Supervisor versus self-assessment of trainee competence: Differences across developmental stages and competency domains

OBJECTIVES

This research aimed to systematically examine supervisor-trainee differences in assessments of trainee competencies across domains and developmental stages.

METHODS

Trainees and supervisors (N = 141 dyads) independently rated trainee performance at the end of placements using the Clinical Psychology Competencies Rating Scale. Based on the number of placement hours completed at the time competence was assessed, the 141 trainees were assigned to three developmental levels (61, 42, and 31 in the groups, respectively). Trajectories of 10 different competencies and trainee-supervisor differences for these competencies were examined across three developmental levels.

RESULTS

Compared to their supervisor ratings, trainees underestimated their competence during early stages of training, with this discrepancy reducing at Level 2 and reversing into an overestimation at Level 3. Compared to their own ratings for overall competence, trainees rated Relational and Communication, Reflective Practice, and Professionalism domains as relative strengths, and rated their competence on assessment and intervention domains as relative weaknesses.

CONCLUSION

Growth trajectories derived from supervisor assessments were much flatter than trajectories derived from trainee assessments. As predicted by the impostor theory of practitioner development, trainees significantly underestimated their competence early in training. The trend for trainees to overestimate their competence toward the end of their training is a potential concern that warrants further research.

[Subcutaneous annular granuloma: a differential diagnosis not to be forgotten in expansive lower leg (soft-tissue) lesions of young children]

PURPOSE

Expansive lower leg lesions in children include numerous, even malignant, entities. Good differential diagnostic knowledge is extremely important in those conditions in order to prevent unnecessary biopsy. Therefore, our own observations of a not particularly rare pseudotumorous soft-tissue disease are presented and the value of ultrasonography is emphasized.

MATERIALS AND METHODS

The imaging material (sonograms in all, MRI and radiograms in the first 4 and 3 patients, respectively) and the clinical charts of 7 young children (4 females, 3 males; aged 28 - 65 months) were analyzed retrospectively.

RESULTS

All lesions were pretibial, firm, indolent, non-movable, and without inflammatory signs. They had developed spontaneously. Laboratory tests were normal. Ultrasound demonstrated all lesions located subcutaneously, homogeneously echopoor with indistinct borders and only little increased perfusion. On MRI they presented with low signal in T 1, high in T 2 and marked contrast enhancement. No intraosseous changes or calcifications were found. Histological proof in the first 2 patients disclosed subcutaneous annular granuloma. Based on an identical clinical and sonographic initial presentation, biopsy and additional imaging were dispensed in the later patients. Their clinical course with only sonographic controls was as expected.

CONCLUSION

When dealing with expansive lower leg soft-tissue lesions in young children, the presented typical clinical and sonographic findings should give rise to consideration of the benign entity of subcutaneous annular granuloma and primary monitoring of those patients with only ultrasound.

Ultrasound in abdominal and soft-tissue childhood PTLD (post-transplant lymphoproliferative disease)

AIM

Post-transplant lymphoproliferative disease (PTLD) is a rare condition, which should be well known to all paediatric medical facilities dealing with bone marrow and solid organ transplantation. The spectrum and the primary detecting modality of the initial imaging findings in paediatric transplant recipients with abdominal and soft-tissue PTLD should be studied retrospectively.

METHOD

7 children/adolescents (female: 4, male: 3; age: 3 - 19 yrs.; study period: 7 yrs.) after heart (5), kidney (1) or liver (1) transplantation were evaluated regarding their initial clinical and imaging findings of PTLD.

RESULTS

6 patients had a latent Epstein-Barr virus (EBV) infection. PTLD presented with clinical symptoms in only 5 patients (ileus: 2, soft-tissue swelling: 2, intussusception: 1) and was detected on routine abdominal ultrasound (US) controls in the remaining patients. US was the primary imaging modality in all children and led to suspecting PTLD in 6 patients. In the seventh case, US had been misinterpreted first. Compared to US, additional magnetic resonance imaging (MRI) and/or computed tomography (CT) better demonstrated the extent of the disease in 3 children, but were even inferior in another 3. There was no completely false-negative US examination during the study period.

CONCLUSION

US is reliable for detecting as well as excluding abdominal and soft-tissue PTLD in paediatric patients after solid-organ transplantation and might even be superior to MRI/CT. Therefore, all patients with an increased risk of developing PTLD should be closely monitored by ultrasound. MRI/CT may be reserved for supplementary imaging in cases incomplete or equivocal on US, but are primarily essential in all patients with a localisation of PTLD not accessible by US.

[Infradiaphragmatic extralobar pulmonary sequestration]

PURPOSE

To demonstrate characteristic imaging findings in infradiaphragmatic extralobar pulmonary sequestration (IEPS) with special emphasis on ultrasound (US).

MATERIALS AND METHODS

The imaging material (pre- and postnatal US in all cases, magnetic resonance imaging (MRI) in 2 cases) for 4 infants (3 girls, 1 boy) was reviewed. 2 patients underwent surgery (after birth and at 4 months of age, respectively) and the diagnosis of IEPS was confirmed. The other 2 patients were monitored conservatively using US for up to 15 months.

RESULTS

All 4 left-side suprarenal masses exhibited the same characteristic sono-morphology, leading to the suspected diagnosis of IEPS. The masses were small (max. 10 ml), hyperechoic with cystic components and without calcifications, well demarcated and separate from the normal kidney and the suprarenal gland, and without any change in prenatal and directly postnatal size. Doppler US showed low-grade perfusion in all cases and an aberrant systemic artery originating from the abdominal aorta in 2 cases. MRI did not add any fundamental information. Despite the suspected imaging diagnosis of IEPS and negative urinalyses for neuroblastoma, 2 patients underwent surgery for histological confirmation. The lesions in the other 2 patients were monitored via US. A complete disappearance after 4 months in one patient and a continuous decrease in size over 15 months in the other patient were documented.

CONCLUSION

Based on the characteristic findings of prenatal and postnatal US, IEPS can be diagnosed reliably. With the knowledge of its benign spontaneously regressing behavior, suspected suprarenal lesions should be treated conservatively via US monitoring.

Parvovirus B19 infection associated with unilateral cervical lymphadenopathy, apoptotic sinus histiocytosis, and prolonged fatigue

This report describes the case of a 16 year old girl with a history of high fever, prolonged fatigue, and cervical lymphadenopathy of the right side. In addition, the patient showed neutropenia, thrombopenia, and pronounced reticulopenia. Cervical ultrasound showed unilateral hypoechoic lymph nodes up to 23 mm in diameter suspicious for malignant lymphoma. Histology of a cervical lymph node specimen revealed massive nodular histiocytic proliferation and prominent apoptosis without necrosis. Parvovirus B19 was detected by polymerase chain reaction and immunohistochemistry in the lymph node. In summary, this case is an unusual presentation of parvovirus B19 infection. The virus was identified as the potential causative agent of unilateral cervical lymphoma and apoptotic sinus histocytosis, thus broadening the clinicopathological spectrum of parvovirus B19 induced diseases.

[The VIP-secreting tumor as a differential diagnosis of protracted diarrhea in pediatrics]

BACKGROUND

Vasoactive intestinal peptide (VIP) can be produced by mature neurogenic tumors. Pathologically elevated VIP plasma levels cause secretory diarrhea with excessive loss of water and electrolytes. Despite the clinical severity diagnosis of a VIP-secreting tumor is often delayed and subsequently its extirpation as the mainstay of therapy.

PATIENTS

We report on two patients with ganglioneuroblastoma and secretory diarrhea. We contrast the case of a 13-month-old boy with advanced symptoms of secretory diarrhea, high VIP plasma levels, and late diagnosis to the case of a 14-month-old boy with mild secretory diarrhea and normal VIP plasma levels but positive proof of VIP in tumor tissue. Reviewing the literature we found 57 cases of pediatric VIP-secreting tumors.

RESULTS

The clinical situation is characterized by the typical symptoms of secretory diarrhea with hypokalemia and metabolic acidosis. Histopathology predominantly reveals ganglioneuroblastoma or ganglioneuroma. The symptoms mostly stop after complete resection of the tumor whereas lack of resection is associated with elevated mortality rates.

CONCLUSIONS

In case of prolonged therapy-resistant secretory diarrhea the existence of a VIP-secreting tumor should be considered. Diagnostic work-up should include the assessment of VIP plasma levels, catecholamines in urine, and appropriate imaging techniques in order to rule out or confirm the possibility of a VIP producing tumor.

[Currarino syndrome: variability of imaging findings in 22 molecular-genetically identified (HLXB9 mutation) patients from five families]

PURPOSE

The imaging documents, obtained in connection with a primarily molecular genetic study on Currarino syndrome, should be evaluated with special respect to the constancy resp. the variability of findings in patients with proven HLBX9 mutations.

METHODS

In five female non-related index patients with clinico-radiologically diagnosed Currarino syndrome and further 53 members of their families, changes of the homeobox gene HLXB9 had been analysed. Variable mutations of this gene were found in a total of 23 individuals including the five index patients. In 22 of them the preexisting radiological documents could be collected as well as further imaging (plain sacrococcygeal radiography and/or lumbosacral MRI at least) initiated. This was followed by a detailed evaluation of pathological findings in the os sacrum/coccyx as well as in the presacral, the intraspinal, the anorectal, and the urogenital region, finally.

RESULTS

Imaging investigations revealed concomitant phenotypic abnormalities in all and even nine clinically asymptomatic individuals with proven HLXB9 mutations. A sacrococcygeal defect of varying intensity was depicted in every case. Complete Currarino triad (i. e. sacrococcygeal defect, presacral mass = anterior meningocele and/or tumor, anorectal malformation) was only found in the five index patients and three further relatives. In all other cases, one or more of the following anomalies were detected with variable combination and with decreasing frequency: anterior meningocele (12), presacral tumor (11), tethered cord (10), intraspinal lipoma (8), anorectal stenosis/atresia (8), syringocele (5), rectal fistula (3), urogenital (2).

CONCLUSION

Currarino syndrome should be considered as a differential diagnosis in all patients with chronic constipation since early infancy and its imaging index finding, i. e. a sacrococcygeal defect, should be looked for with plain radiography, first. In positive cases or other phenotypic suspicious constellations molecular genetic analysis for HLBX9 mutations should be the next step. If positive again, this should be followed by complete adequate imaging in the patient as well as by plain sacrococcygeal radiography in, at least, symptomatic family members.

[A rare location for extratruncular vascular malformation]

We report on an undefined tumor of the right ulnar side of the elbow in a 15-year-old boy. The clinical examination showed painful swelling in the area of the ulnar nerve at the right elbow as well as sensory and motor deficits of the right hand corresponding to distribution of the ulnar nerve. Ultrasound examination and magnetic resonance imaging showed a tumor along the nerve. Subsequent surgical therapy included tumor decompression by division of the fascia. The histological examination demonstrated a capillary hemangioma that infiltrated the ulnar nerve.After surgery, oral glucocorticoid therapy with cortisone (5 mg/kg per day) was administered over a period of 4 weeks, alternating between 1 week of therapy and 1 week without medication. The result of this combined therapy was a rapid diminution of the tumor and an almost complete restitution of the neural function.

[Sonographic detection of a "VIPoma" in a small child with intractable gastroenteritis]

As case report we describe a rare cause of intractable "gastroenteritis" detected by ultrasonography. The 14 months-old boy was admitted to hospital because of intensive dehydration due to massive vomiting and diarrhoea. A salmonella enteritis with intractable hyponatraemia and hypokalaemia was thought to be the cause. After a dramatic relapse during oral treatment measures, further extensive laboratory tests finally disclosed an elevated serum level of vasoactive intestinal polypeptide ("VIP"). The VIP secreting tumor ("VIPoma") was detected ultrasonographically in a retroperitoneal localization mediocaudally of the right kidney. Diffuse distinct calcifications and an increased perfusion could be demonstrated. Intraspinal tumour spread was excluded by magnetic resonance imaging. After complete surgical removal of the tumour the clinical symptomatology normalized promptly and permanently. A VIP-excreting ganglioneuroblastoma with low grade growth fraction ("VIPoma") was diagnosed histologically. Common gastroenteritis in childhood represents no indication for ultrasound. In cases of unclear and therapy-resistant symptomatology, however, diagnostic work-up should include ultrasonography to search for retroperitoneal or pancreatic VIP-excreting tumours.

Ultrasonographic late results after surgically treated cryptorchidism

BACKGROUND

Because uncorrected cryptorchidism is accompanied by the high risk of later disturbed testicular function and cancer, early surgery in the second year of life is recommended.

OBJECTIVE

To evaluate testicular morphology, the sonomorphologic testicular long-term outcome and additional complications, as well as possible differences depending on varying ages at surgery.

MATERIALS AND METHODS

Seventy-five previously maldescended testes in 68 boys were studied with US, 2-11 years after intrascrotal orchidopexy. Nineteen had been operated on in the first or second year of life, while the other 49 boys underwent surgery at a later age (up to 7 years). Each examination utilised conventional B-mode and colour Doppler (7-MHz linear ART probe, Acuson XP 128) to examine the scrotal and inguinal regions on both sides; testicular volume and perfusion were assessed. Ultrasound changes in testicular volume, architecture and Doppler flow rates were regarded as the most valid indirect indices of testicular damage. Histopathological correlation was not obtained, for ethical reasons, in any of the probands.

RESULTS

Thirty-five of the surgically fixed testes were normal with regard to position, volume, structure and perfusion. The other 40 (53%) showed abnormalities of one or more of these parameters without any correlation with the patient's age at surgery or the time interval between surgery and US. Additional relevant findings, which were also found on the non-operated side, were: microlithiasis (n = 6), inguinally retained testis (n = 6), hydrocoele (n = 5), hydatid (n = 5) and varicocoele (n = 1).

CONCLUSIONS

Ultrasound, including colour Doppler, enables an exact morphological analysis of the late results after surgically corrected cryptorchidism. The spectrum of findings does not show any correlation with the time of surgery. Thus, the value of even early surgery has to be questioned. Pre-existent primary damage (dysplasia) seems more important for long-term outcome of the testis. Additionally, US was of high value in demonstrating additional unexpected anomalies, the majority of which needed sonographic follow-up or even surgery.

[Sonographic course of systemic echinococcosis in a 10 year old girl (with cardiac, hepatic, renal and muscular involvement)]

PURPOSE

To present the predominantly ultrasonographic (initial and follow-up) imaging in a disease that is rare among the Central European paediatric population--and to evaluate the role of ultrasound for initial staging and follow-up under antihelmintic therapy.

METHOD

The imaging documents as well as the clinical record of a 10-year old Armenian girl with systemic hydatid disease (cystic echinococcosis) were analysed retrospectively.

RESULTS

By means of ultrasound, the complete initial systemic spread of the disease with at least 11 cysts within the liver, 1 cyst in the left kidney, 1 peri-/2 intracardiac cysts, and 1 cyst in the dorsal musculature was detected. Repeated sonographic examinations allowed the estimation of successful medical treatment by the following criteria: size reduction of all cysts with changing internal structures from an initially echo-free to an increasingly homogeneous echodense character; no developing new cysts. In addition, CT and MRI enabled a more complete demonstration of especially the intra- and pericardiac lesions (preoperatively) and the exclusion of further intracranial cysts.

CONCLUSION

In paediatric hydatid disease, ultrasonography yields important information not only with regard to the initial staging, but also to the antihelmintic therapeutic effects and thus helps to determine when to discontinue medical treatment.

The spectrum of imaging in Currarino triad

The aim of this study was to evaluate the spectrum of findings and the efficacy of different imaging modalities in order to formulate recommendations for diagnostic imaging of Currarino triad (ASP syndrome), including screening of relatives. The imaging films of five female patients (age range 6 weeks to 12 months) were analysed retrospectively. The studied material consisted of US and MRI of the lower spine (5 patients each), lumbosacral plain radiography (4 patients), contrast enema (4 patients), urinary US (2 patients), genitography (1 patient) and myelo-CT (1 patient). Depiction of pathological findings with different imaging modalities was reviewed and validated with special respect to their demonstrability by US. Ultrasonography detected the sacral bony defect as well as the presacral pathology (meningocele and/or tumour) and thereby gave the basic diagnosis in all of the cases. It also depicted tethered cord and urinary tract abnormalities correctly. Magnetic resonance imaging gave a more distinct visualization of pre- and intraspinal pathology with additional demonstration of intraspinal lipoma in two cases. Regarding anorectal and genital malformations, radiographic contrast agent studies had been used in all patients. Two blind-ending retrorectal fistulas, depicted by enema, were missed by MRI. Patients with congenital or early infancy obstipation, anorectal malformations and complex urinary tract malformations should have spinal and pelvic sonography first. A plain film of the sacrum is recommended in equivocal cases. The need for MRI and contrast agent studies depends on the individual pathology, whereas presently MRI has made further radiographic imaging increasingly dispensable. A screening program with lumbosacral US or plain radiography for families with Currarino triad should be obligatory.

Recessively inherited multiple epiphyseal dysplasia with normal stature, club foot, and double layered patella caused by a DTDST mutation

We have observed over 25 different mutations in the diastrophic dysplasia sulphate transporter gene (DTDST) in association with the recessive disorders achondrogenesis 1B, atelosteogenesis 2, and diastrophic dysplasia. The c862t (R279W) transition is the most common mutation in non-Finnish patients, but in these disorders it is usually combined with other DTDST mutations. We had not seen a case of homozygosity for c862t (R279W) until we analysed DNA from a 36 year old male with tall-normal stature (180 cm) who asked for genetic counselling for suspected multiple epiphyseal dysplasia. He was treated for club foot and hip dysplasia at birth. Skeletal changes consistent with multiple epiphyseal dysplasia, with the peculiar finding of a double layered patella, were recognised during childhood. Cleft palate, swelling of the ear pinna, and hitch hiker thumb were absent. He was found to be homozygous, and both healthy parents heterozygous, for the R279W mutation in DTDST, and his fibroblasts showed a sulphate incorporation defect typical of DTDST disorders. Counselling was given for a recessive disorder, thereby considerably reducing the probability of affected offspring. Multiple epiphyseal dysplasia is more frequently caused by dominant mutations in the COMP (EDM1, McKusick 132400) and COL9A2 genes (EDM2, McKusick 600204). A few other patients and families with features similar to our proband have been described previously and considered to have autosomal recessive MED (EDM4, McKusick 226900). This observation confirms the existence of this entity and assigns it to the phenotypic spectrum associated with mutations at the DTDST locus.

[Vaginal atresia as a rare cause of a cyst in the fetal lower abdomen. Pre- and postnatal diagnosis/therapy]

This is a report on the course of a cystic mass in the lower abdomen of a female fetus, which could bei seen by prenatal ultrasound. We are describing differential diagnosis, pre- and postnatal therapy and the origin, as well as the risks of vaginal atresia.

[Experiences with a new film-screen system in pediatric thoracic radiography]

PURPOSE

To compare the x-ray images made by the Kodak InSight Pediatric Imaging System (InSight P) with conventional film-screen systems in pediatric chest radiography.

MATERIAL AND METHODS

The comparison involved chest radiographs made using Quanta-Fast-Detail/Cronex 4 (DuPont), Trimax 16/XDA (3 M) and DuPont UVR/UVL systems. The image quality of critical structures and the physical parameters of quantum interference, contrast and resolution were assessed. The energy path of the system was assessed by preparing density curves. Test conditions were in accordance with the latest guidelines of the Bundesärztekammer (German Physician's Association).

RESULTS

The mediastinal area, retrocardiac and paravertebral spaces and the peripheral vessels of the lung were all displayed more distinctly using InSight P. The reason for this seems to be a lower degree of quantum interference associated with this system. With tube voltages between 60 and 80 kV, InSight P displayed a relatively low degree of sensitivity.

CONCLUSION

InSight P can be used to produce predominantly high quality chest radiographs of infants between one and five years of age. However, this system has limited sensitivity in the tube voltage range recommended by the German Physicians' Association.

[Skull injury in childhood: comparison of ultrasonography with conventional X-rays and computerized tomography]

PURPOSE

The purpose of our study was to compare the value of ultrasound, conventional x-ray diagnosis and CT in detecting skull fractures and intracranial haemorrhage in children suffering from a head injury.

MATERIAL AND METHODS

We examined 210 children who had a head injury. In all cases the calvarium was investigated by ultrasound using a 7.0 MHz linear transducer. In children with an open fontanel (n = 190) the cerebrum was screened additionally by ultrasound following a standard protocol. The sonographic findings were correlated to the x-ray examination (n = 21) and CT (n = 13).

RESULTS

Ultrasound enabled diagnosis of linear calvarial fractures (n = 29), depressed fractures (n = 6) and intracranial haemorrhage (n = 8). X-Ray and CT examination confirmed the diagnosis of linear calvarial fractures in 16 cases, of depressed fractures in 6 cases. CT confirmed the sonographic diagnosis of intracranial haemorrhage in 8 cases.

CONCLUSION

Ultrasound as a primary method can replace the conventional x-ray in detecting calvarial fracture and posttraumatic sequelae. Additional CT examination depends on the sonographic and neurological status.

[Ultrasound of extremity lesions caused by birth trauma]

With regard to injuries of the extremities caused by birth trauma, ultrasound allows simultaneous direct evaluation of the surface of osseous elements and of cartilaginous and soft-tissue structures as well. Thus, not only fractures, but also concomitant articular fluid collections, respectively haematomas and/or dislocation of an epiphysis are demonstrated in their initial extent and in their course of healing. Additionally, closed repositions, for instance of a displaced epiphysis, can be exactly monitored by ultrasound. A reduced number of roentgenograms as well as renunciation of other imaging modalities are the consequence. Own experiences in 4 patients with birth trauma to the humerus confirm the high validity of ultrasound in this area as well.

Meningothelial hamartoma of the scalp. A case report with immunohistochemical studies

An unusual and, apparently, hitherto undescribed congenital lesion of the scalp which proved to be heterotopic meningothelial tissue is reported, and its clinical, morphological, and theoretical implications are reviewed. A 14-month-old male infant exhibited a soft tissue lesion on the midline of the parietal scalp since birth. The lesion had grown in size since birth. Histological examination showed an admixture of mature adipose tissue, bands consisting of bundles and small nodules of dense collagen, both enclosed and bordered by rests and strands of meningothelial cells. A network of vessel-like channels lined by plump hyperchromatic cells with spindle-shaped nuclei and occasionally multinucleated giant cells was one of the prominent features. Immunohistochemically, these cells were positive for vimentin, but staining was negative for EMA and all other antibodies tested. A fibrocollagenous stalk via bony defect showed no arachnoid cell rests. The authors believe that the herein described lesion and the hamartoma of the scalp described by Suster and Rosai (1990) may represent varying morphological expressions of a pathogenetically related process. Precautions appropriate to the possibility of intracranial extension must be taken at the time of surgery.

Hyperechoic lesions in the basal ganglia: an incidental sonographic finding in neonates and infants

Cerebral ultrasound (US) imaging was performed as a screening procedure in approximately 3,600 neonates and infants over a period of 18 months. Hyperechoic lesions in the basal ganglia and thalamic region were detected incidentally in 15 of these patients. Clinical diagnoses included cytomegalovirus infection, asphyxia, rotavirus infection, prematurity, amniotic infection, dysmorphic stigmata, hyperbilirubinemia, congenital heart disease, and diabetic fetopathia. Lesions showed a single punctate (n = 5), multiple punctate (n = 8), or stripe-like pattern (n = 2), with no disease-specific distribution. Computed tomography performed in two of the 15 patients was normal. Lesions resolved within four to seven months in four of eleven cases who had follow-up studies, whereas echogenicities persisted in the remaining seven patients over a period of observation ranging between one to 15 months. Our results indicate that hyperechoic lesions in the basal ganglia and thalamic region may be associated with congenital infections and asphyxia, but could indicate some other unknown pathology. No correlation was found between the morphology of foci and both clinical diagnosis and results of follow-up studies.

Choroid plexus cysts: a normal finding on ultrasound

Within a period of 2.5 years, cystic structures in the choroid plexus were encountered at cerebral sonography in 70 neonates and babies (45 male, 25 female; 18 premature babies). Their prevalence in patients examined during the first 4 weeks of life (n = 55) was 3%. The size of the cysts ranged from 1-4 and, rarely, up to 7 mm. They were mostly solitary and unilateral. Follow-up sonograms over periods up to 13 months showed that most of the cysts persisted unchanged. A few disappeared (n = 7), while distinct increase in size was observed in 1 case. Since no additional sonographic changes were observed and none of the patients displayed any neurological abnormalities and no association existed with any other, particularly chromosomal, disease, such plexus cysts are postulated to represent a normal sonographic finding and do not require follow-up.

[Deterioration of clinical findings in hip joint follow-ups in neonatal screening]

6 per cent out of 4290 hips checked by neonatal ultrasound screening could be reexamined later on. 7 of 200 hips (i.e. 4 per cent), primarily categorized as type IIa, showed an unexpected severe deterioration to type D (n = 3) or even to type IIIa (n = 4) after a mean-time of 9 weeks. Additional 5 cases with similar unfavourable courses from IIa to IIc, D or IIIa, and even 3 initially normal hips, changing to type IIa, were seen in another screening material (not yet systematically analyzed). Reasons for possible initial misinterpretation (purely visual evaluation in most cases, uncertainties in measuring suboptimal sonographic cuts, deficiencies in technical equipment and documentation), equivocal classification of border-line sonograms as well as possible influence of additional risk factors are discussed. Routine sonographic re-examinations after 6 (to 12) weeks are recommended as obligatory for all hips.

Use of non-ionic contrast media for tracheobronchography in neonates and young infants

The paper describes the experience gained with tracheobronchography in 11 neonates and young infants with severe pulmonary disease--most of them on artificial respiration--using isotonic solutions of iopromide (17 series) and iotrolan (14 series). Both contrast agents were tolerated without any obvious problems when instilled into the lungs. Because of its higher content of iodine and greater viscosity, iotrolan was superior to iopromide as regards both the demonstration even of the more peripheral bronchial morphology and the duration of the contrast coating.

Spermatic venography in undescended testes

In patients with undescended testes the demonstration of the pampiniform plexus (i.e. venous network surrounding the testis) by selective retrograde contrast filling of the internal spermatic vein gives exact information about the existence and localization of the gonadal tissue. Especially with small hypoplastic testes and/or an intraabdominal position of the gonad the results of this technique are superior to those of ultrasound and computed tomography. The venographic information often helps to reduce the extent of the surgical exploration, most of all in those cases in which after an ineffective first procedure a second operation is planned. Venography can be done on an outpatient basis in children from an age of about 6 years upwards without general anesthesia and serious complications. Personal experiences with the spermatic venography in 11 patients (age: 7-32 years) with 18 undescended testes are demonstrated. Comparing the roentgenologic and surgical findings in 7 patients with 12 explored veins the results corresponded completely in 75%. In the remaining cases roentgenologic demonstration of one of the testicular veins with its pampinifom plexus suggested important information about the localization of the contralateral testis, surgically confirmed later.

[Vascular supply of the rectum in anal atresia. Angiography studies in newborn swine]

In 15 piglets with anorectal malformations (high and low anomalies) we performed angiographies of the pelvic arterial system. 3 healthy animals were used as control group. None of the animals had isolated rectal atresia which is assumed to be due to vascular disorders. In all animals we could demonstrate normal superior and inferior rectal arteries. Thus our results support the hypothesis that anorectal malformations, with the exception of isolated rectal atresia, are not associated with vascular malperfusion during embryogenesis.

[Comparative x-ray and nuclear medical studies of osteosarcomas to evaluate the effectiveness of preoperative chemotherapy]

In 16 patients with a long bone osteosarcoma treated after the therapy regimen of COSS 80/82 (Cooperative Osteosarcoma Study) the tumour response to preoperative chemotherapy was assessed by conventional roentgenograms (plain films, tomograms, angiograms). The histological grade of regression determined in the operative specimen was used as a reference for the extent of tumour devitalisation. By their different typical roentgenological course the osteosarcomas with a very good and those with a rather poor response could be correctly identified (100%). On following the clinically used differentiation between "good responders" (histological grades I to III) and "poor responders" (grades IV to VI) the corresponding classification of these tumours by roentgenograms and functional scintigraphic imaging was found to be correct in 94% of the cases. The coincidence of the correct as well as the false results in both radiological methods was as high as 100% if those osteosarcomas showing only a "medium response" in their roentgenograms were added to the clinical group of good responders. There were no fundamentally discrepant results obtained by each of the two radiological techniques. With the combined workup of the roentgenological and the scintigraphic material any incorrect preoperative estimation of tumour regression with a harmful influence on therapy (date and type of surgery, mode of postoperative chemotherapy) could be avoided.

De Barsy syndrome--an autosomal recessive, progeroid syndrome

We report two families with seven siblings with de Barsy syndrome. Characteristic features include severe mental retardation, hypermobility with athetoid movements, grimacing, muscular hypotonia, laxity of small joints and brisk deep tendon reflexes, progeroid aspect with cutis laxa, atrophy of skin with hyperpigmentation, isolated depigmentations, reduction of subcutaneous fatty tissue, translucent vein pattern, short stature, frontal bossing in the young child, large prominent ears with dysplastic helices and corneal clouding or cataracts. The syndrome probably has autosomal recessive inheritance.

[Comparison of x-ray and histological findings in osteosarcomas following preoperative chemotherapy]

Since the introduction of pre-operative chemotherapy, osteosarcomas have shown a more favourable prognosis. Reaction of the tumour due to chemotherapy is judged pre-operative primarily by radiology (plain films, angiography, CT, scintigraphy). There is little evidence concerning the radiological appearances after pre-operative chemotherapy and morphological changes, particularly in respect of tumour regression. Specific radiological changes were therefore compared with pathological findings following chemotherapy and operation in 17 patients with osteosarcomas. Tumours were examined which showed radiological evidence of intra-and extra-osseous sclerosis or lysis and which still were classified as vital tumour tissue. Tumour planes were reconstructed from large histological sections of the operative specimen and compared with the radiological appearances. Sclerosis was found to be due to reactive new bone formation or to mineralisation of the osteosarcomatous tissue. Lysis correlated with persistent vital tumour, or in connective tissue. Nine out of ten cases, regarded as vital on radiological evidence, showed vital tumour cells on histological section. Lyses and scleroses were not reliable indications of the pre-operative state of the osteosarcoma following chemotherapy. On the other hand, combined qualitative radiological criteria for assessing tumour vitality, proved to be helpful.

[Torsion of a wandering spleen]

The torsion of an ectopic (= wandering) spleen is a rare entity especially in children. Clinically it presents either with signs of an "acute abdomen" or as a fairly painful abdominal "tumor" of the chronic recurrent type. Ultrasonography, arteriography, and additional scintigraphy in special cases are of greatest value in the preoperative diagnostic management. Splenopexy, sometimes after resecting parts of a very enlarged organ, is the therapy of choice. The complete exstirpation of the ectopic spleen should be reserved only for exceptional cases. By presenting a case report, the etiologic factors, the clinical signs, the diagnostic steps, the differential diagnostic considerations as well as the mode of therapy for this rare disease are described and discussed.

[Comparison of x-ray plain films, x-ray tomograms and computed tomograms in lung nodules in children and adolescents]

A comparison was carried out of the value of plain radiographs, tomography and CT in 37 patients aged between five and 24 years. The majority of these patients had an osteosarcoma. Thirty-five CT examinations were performed on 16 patients and about 300 foci were demonstrated. Plain radiographs only showed 50%, and tomograms only 70% of these lesions. Surgery was carried out in 34 patients and there was agreement between the findings at thoracotomy and radiology in about half the cases. Frequently, more metastases were found at operation than could be demonstrated radiologically, in a few cases there were fewer.

[Sonography for monitoring kidney transplants]

Ultrasonography is very useful for judging the position and course of renal transplants. With this method extra- and intrarenal complications can be detected very accurately. The sonographic examination is quite harmless and puts little strain on the patient. It can be carried out a few days after the operation. This initial sonogram, obtained as early as possible, makes it easier to recognize and to interpret later changes more promptly and correctly. The results of sonographic examinations in 18 patients with renal transplants are presented. They show that a normal sonogram reliably excludes extrarenal complications such as fluid collection or obstruction as well as rejection of the transplant. All cases of rejection correlated to clearly abnormal sonographic findings.

[Sterile vesiko-ureteral reflux. Radiological kidney surface measurements as follow-up criteria]

33 patients with 46 sterile vesicoureteral refluxes were followed by repeated clinical-urological and radiological studies over a period from 1 to more than 6 years. The results of the evaluation, obtained by only looking at the urograms, were compared with the following measurements: the length of each kidney, the length ratio right to left, and the parenchymal area. At the end of the follow-up period, 2 out of 32 initially normal kidneys (about 6%) had pathologically low values, whereas 3 out of 14 already initially damaged kidneys (21,5%) showed a further decrease of these values. Preceding urinary tract infections with consecutive pyelonephritis, leading to a progressive shrinkage of the organ over many years, are thought and discussed to be more responsible for these results than the sterile reflux itself.

[Pulmonary sequestration (author's transl)]

Pulmonary sequestration is a rare condition both in children and as in adults. A portion of the lung malformed during early embryological development receives an anomalous systemic arterial supply. The intralobar form is surrounded by normal lung within the visceral pleura and drains its blood into the pulmonary venous system. Extralobar sequestration has its own pleural investment and a systemic venous drainage. Intermediate forms are only partially embedded in normal lung with otherwise separate pleural embedded in normal lung with otherwise separate pleural investment, and classified as hybrid sequestrations. Clinical symptoms are secondary recurrent pulmonary infections especially with intralobar sequestration. The pathologic changes are regularly discovered already on plain roentgenograms of the chest. Extralobar sequestrations may be detected as incidental radiological findings. Angiography is of great diagnostic value to demonstrate the anomalous arteries. The usual treatment consists of excision of the sequestration, segmental resection, or lobectomy. For thoracotomy for a local and long lasting pulmonary process it is recommended to look for anomalous vessels in order to prevent their accidental cut with possible dangerous hemorrhage.

Bilateral femoral dysgenesis with micrognathia, cleft palate, anomalies of the spine and pelvis, and foot deformities. Clinical and radiological findings

Two girls afflicted with bilateral femoral hypoplasia, micrognathia, cleft palate, anomalies of the spine and pelvis, and foot deformities are reported. Based on 10 cases reported in the literature the following points are emphasized: 1. Femoral hypoplasia may be bilateral or unilateral. 2. Many patients show asymmetrical changes. 3. To our knowledge, the complete syndrome including a cleft palate has been reported only in females. 4. Femoral hypoplasia without a cleft palate may represent a different entity, of possibly autosomal dominant inheritance, or may occur in children of diabetic mothers.

[Phlebography in children with varicocele (author's transl)]

The condition of varicocele is rare in childhood. Usually it is not observed before puberty, and can cause infertility if not operated upon in time. With the usual examination of the children in supine position the varicocele can be overlooked. The primary idiopathic type with insufficiency of the spermatic vein is distinguished from the rare secondary symptomatic form, mainly caused by renal tumours. A renal mass should be excluded by an intravenous urography in every case. The percutaneous selective phlebography of the spermatic vein--results in two boys with primary idiopathic varicocele are described--is indicated, if clinical symptoms are still existing despite high ligature of the vein. Further open branches of the spermatic vein and collateral circulation can be shown by this method, the way and type of the second operation better planned, and the patients saved from the threatening infertility.

[Tuberculous stenosis of the transverse colon]

A 14 year old Turkish girl presented with unspecific abdominal symptoms and barium enema showed an almost complete obstruction in the region of the splenic flexure. The picture was that of a neoplasm and a left hemicolectomy was performed. Histological examination revealed ulcerating hypertrophic tuberculosis of the colon. The incidence, pathology and symptomatology of colonic tuberculosis are discussed.

[Thoraco-omphalopagus: importance of angiocardiography for clarification of operability (author's transl)]

The article reports on a case of thorako-omphalopagus with conjoinment from the sternum to the umbilical region. Radiological and especially angiocardiographic examinations revealed considerable fusion and complex malformation of the hearts of Siamese twins. This specific diagnosis proved the inoperability of the otherwise largely regularly developed children who died on the sixth day of their life.

[Viscerocutaneous Haemangiomatosis (author's transl)]

The article describes a case of viscerous haemangiomatosis in a 3 1/4-year old girl. Unusually extensive changes in the skin and soft parts, progressing since birth, are shown. Radiological findings for localising visceral haemangiomas are underlined, especially in connection with frequent posthaemorrhagic anaemia as a result of intestinal involvement. Typical x-ray findings: Phleboliths and soft-part "tumours" in plain roentgenograpy (abdomen, soft parts of the skin, cranium); involvement of the walls and disturbances of motility through intestinal haemangiomas in oral and rectal examination with contrast medium; changes in osseous structures and internal organs caused by adjacent angiomatous space-occupying growths.