[Left flank tumor of fluctuating size in a 5-week-old boy: perirenal urinoma caused by urethral valves]. / Perirenales Urinom durch Urethralklappen bei einem Säugling mit fluktuierender Flankenschwellung.

BACKGROUND: Flank swelling and pseudotumors of the kidney are unusual manifestations of obstructive uropathies in small children. Our case illustrates typical problems and briefly reviews management options. CASE REPORT: A 5-week-old boy presented with a large, palpable urinoma due to posterior urethral valves. Sonography and voiding cystourethrogram led to the diagnosis and immediate suprapubic transcutaneous urinary diversion was performed. However, the urinoma did not resolve. Thus, in addition to suprapubic urinary diversion, indirect drainage - instead of percutaneous puncture - was performed by retrograde insertion of a double-J catheter. Urethral valves were resected 4 weeks later and follow-up demonstrated an uneventful further development with normal renal function as assessed by regular ultrasound studies, a repeat cystourethrogram and a renal scan. CONCLUSION: Perirenal urinomas may be the first symptom in patients with posterior urethral valves. Drainage via double-J stenting offers a promising alternative to percutaneous puncture. A renoprotective "pop-off" mechanism by which intrarenal pressure may be relieved is discussed.

[Conventional thorax diagnostics in neonates and children]. / Konventionelle Thoraxdiagnostik im Neugeborenen- und Kindesalter.

Advances in neonatal medicine have led to an increasing number of premature infant patients and to an improved survival rate of these children. Chest X-rays of premature infants, newborns, and older children with respiratory difficulties provide information leading to diagnosis and help decide on further clinical management. Diagnostic findings and their appreciation by the radiologist require knowledge of the specific anatomy of the infant chest, and also of common diseases in early and later childhood, congenital or acquired. Radiologic findings in pediatric patients may differ significantly from those in adults. Close collaboration between the neonatologist and radiologist is essential for reaching the right diagnosis.

Using receiver operating characteristic methodology to evaluate the diagnostic quality of radiography on paper prints versus film.

OBJECTIVE: The aim of this study was to compare the diagnostic quality of paper prints with film copies in a sample of observers who were trying to detect small coin lesions on radiographs of a phantom. MATERIALS AND METHODS: The phantom consisted of 60 high-contrast and 60 low-contrast test objects, half of which had holes in them. Diameter and depth of the holes varied from 0.5 mm to 2 mm. Fifteen radiographs were obtained from different areas of the test objects. Film copies and paper prints were made using high-quality printers. Five observers independently evaluated 1,800 high-contrast and 1,800 low-contrast images. Data were evaluated using the well-established receiver operating characteristic methodology. RESULTS: The mean area under the curve rated 0.863 for paper prints (0.859 for high contrast and 0.860 for low contrast) and 0.926 for laser films (0.937 for high contrast and 0.913 for low contrast). The difference between the two imaging techniques was statistically significant for both high- and low-contrast lesions (p < 0.05). CONCLUSION: Detection of small coin lesions on radiographs of a phantom was significantly less sensitive on paper prints than on film. We found paper prints less acceptable for the diagnosis of small-sized lesions.

Rescue of the mineralocorticoid receptor knock-out mouse.

The mineralocorticoid receptor knock-out mouse (MR-/-), resembling inborn pseudohypoaldosteronism, dies 8-12 days after birth in circulatory failure with all the signs of terminal volume contraction. The present study aimed to examine the functional defects in the kidney and colon in detail and to attempt to rescue these mice. In neonatal (nn) MR-/- the amiloride-sensitive short-circuit current in the colon was reduced to approximately one-third compared to controls (MR+/+ and MR+/-). In isolated in vitro perfused collecting ducts the amiloride-induced hyperpolarization of the basolateral membrane (Vbl) of nn MR-/- was similar to that of controls, but urinary Na+ excretion was markedly increased to 4.3 micromol/day.g (BW). Based on this measured urinary Na+ loss we tried to rescue nn MR-/- mice by injecting NaCl twice daily (3.85 micromol/g BW), corresponding to 22 microliter of isotonic saline/g BW subcutaneously. This regimen was continued until the animals had reached a body mass of 8.5 g. Thereafter, in addition to normal chow and tap water, NaCl drinking water (333 mmol/l) and pellets soaked in 333 mmol/l NaCl were offered. Unlike the untreated nn MR-/- most of these mice survived. The adult animals were examined between days 27 and 41, some were used for breeding. When compared to age-matched controls the growth of MR-/- was delayed until day 20. Then their growth curve increased in slope and reached that of controls. MR-/- retained their Na+-losing defect. Amiloride's effect on urinary Na+ excretion was not significant in MR-/- mice and the effect on Vbl in isolated cortical collecting ducts was attenuated. The renin-producing cells were hypertrophic and hyperplastic. Plasma renin and aldosterone concentrations were significantly elevated in MR-/- mice. These data indicate that MR-/- can be rescued by timely and matched NaCl substitutions. This enables the animals to develop through a critical phase of life, after which they adapt their oral salt and water intake to match the elevated excretion rate; however, the renal salt-losing defect persists.

Contact B-scan echography in the assessment of optic nerve cupping.

We determined the reliability of high-resolution contact B-scan echography for estimating the optic cup size in 56 eyes of 28 patients with glaucoma or ocular hypertension. Two trained observers independently evaluated horizontal and vertical cup/disk ratios in stereophotographs, and two skilled echographers independently estimated optic cup size in photoechograms in a masked fashion. The reliability of echographic interpretation varied (kappa 0.29 to 0.71), but it always exceeded that expected by chance alone, even for cups of 0.3 disk diameter or less. Subtly saucer-shaped cups (three of 50 eyes) and deep cups with intact neuroretinal rims (two of 50 eyes) were misinterpreted echographically. High-resolution contact B-scan echography may provide a useful and reliable estimate of the optic cup size in eyes with opaque media.

Coronary angioplasty versus coronary bypass. Three-year follow-up of a matched series of 250 patients.

Two hundred fifty consecutive patients treated for one or two vessel coronary artery disease with either balloon angioplasty or surgical bypass were monitored for 3 years in a study designed to determine the comparative long-term effectiveness of each treatment. The 125 patients having angioplasty were matched with the 125 patients having bypass, so that both groups had a similar number of patients with single or double vessel disease. The two groups did not significantly differ in age, male:female ratio, New York Heart Association class, or risk factors. The ejection fraction was 54 +/- 11 in the angioplasty group and 49 +/- 12 mmHg in the surgical patients (p = 0.0031). Angioplasty was deemed initially successful in 88% (110/125), unsuccessful in 10% (12/125), and in 2% (3/125) the lesion could not be crossed. Emergency bypass was performed in 10% (12/125). Four of the 125 angioplasty patients (3%) died within 30 days. Coronary artery bypass grafting was successfully performed on the matched set of surgical patients with 99% (124/125) discharged well. There was one (1%, 1/125) surgical death. The average hospital stay per patient was 4.8 +/- 3.1 days for angioplasty and 12.1 +/- 4.2 days for bypass grafting (p = 0.0000). Three-year postprocedure follow-up was obtained on 96% (236) of the 245 patients discharged alive. A second angioplasty was required in 18%, and 11 angioplasty patients subsequently required surgical bypass. Overall, 19% (23/121) of the angioplasty patients ultimately required bypass. Four late deaths occurred in the angioplasty group, which brought the early and late mortality rates to 7% (8/121). There were two late surgical deaths, which brought the combined surgical mortality to 2.5% (3/120), p = 0.1263. Patient evaluation reveals that 63% (76/121) of the angioplasty group are alive and in New York Heart Association class I or II 3 years after one or two angioplasty procedures. This figure compares with 92% (110/120) of surgical patients alive and in the same two New York Heart Association classes (p = 0.0000).

Emergency operation after failed angioplasty.

A group of patients with failed angioplasty who then required emergency coronary bypass was compared with a historically matched group of patients who had had elective bypass grafting. The two groups were well matched in age, sex, ejection fraction, and New York Heart Association classification and in the incidence of diabetes and hypertension. Significant differences were found in the prevalence of mortality (12% versus 1.5%), hemorrhage (28% versus 13%), cardiac tamponade (10.5% versus 1.5%), myocardial infarction (28% versus 9%), and length of hospital stay (15.3 days versus 13.4 days). Cardiogenic shock carries the worst prognosis; four of the five patients with this condition died. Because emergency operation after failed angioplasty carries with it significant postoperative morbidity and mortality, this procedure cannot be considered equivalent to elective coronary bypass grafting.

Pulmonary inactivation of vasopressors following cardiac operations.

Vasoactive drugs were infused through catheters in the right atrium and then the left atrium of 34 patients who required either vasopressor or vasodilator support following cardiac operation to determine if the route of infusion affected the aortic blood concentration of these agents. Drugs were given through the right atrium for one hour and then the left atrium for an hour. Both central aortic and pulmonary arterial blood were assayed for drug concentrations, and hemodynamic measurements were made. Sixteen patients receiving dopamine hydrochloride through the left atrium had a 36 +/- 12% (+/- standard error of the mean) increase in aortic concentration of the drug (p less than 0.005) and a 37 +/- 14% increase in cardiac index (p less than 0.005) compared with administration through the right atrium. Seven patients receiving epinephrine showed a 59 +/- 21% increase in aortic concentration (p less than 0.05) and a 21 +/- 10% increase in cardiac index (p greater than 0.05, not significant). Eleven patients receiving sodium nitroprusside achieved a 99 +/- 25% increase in aortic concentration (p less than 0.005) and a 20 +/- 7% increase in cardiac index (p less than 0.05). In all instances, significantly higher central aortic blood concentrations were achieved during left atrial (LA) versus right atrial (RA) infusions. Changes in blood concentration of the drug between the pulmonary artery and the aorta during RA infusion suggest removal or inactivation of these drugs in the pulmonary vasculature.(ABSTRACT TRUNCATED AT 250 WORDS)

Timing of coronary revascularization after acute myocardial infarction. Early and late results in patients revascularized within seven weeks.

Evidence of ischemia after acute myocardial infarction is a serious complication. If angiography reveals significant coronary artery disease, the precise timing of myocardial revascularization may be of critical importance. From 1978 through 1982, 174 patients underwent myocardial revascularization within 7 weeks of a documented myocardial infarction. The male:female ratio was 138:36, the average age was 58 +/- 1 (SEM) years; and the ejection fractions averaged 41% +/- 1%. Forty-four (25%) patients required preoperative intra-aortic balloon pump support, and an additional 18 (10%) required intra-aortic balloon pumping to be separated from cardiopulmonary bypass. An average of 2.9 +/- 0.1 vessels per patient were bypassed. The hospital mortality for these 174 patients was 16%. When mortalities were categorized according to the postinfarction week in which operation was performed, hospital mortality fell from 46% for those patients operated upon within 1 week of infarction to 6% for those patients operated upon 7 weeks after infarction. Of those patients operated upon within the first week after infarction, 23% were in cardiogenic shock and 62% required preoperative balloon pumping. Clearly the most critically ill patients were operated upon during the early postinfarction period. However, there was a marked difference in survival when patients in each of the seven weekly groups were classified according to ejection fraction. All patients with an ejection fraction greater than or equal to 50% (50 patients) operated upon at any time after infarction survived their hospital course, with only one late death. Conversely, among the 124 patients with an ejection fraction less than 50% operated upon during this 7 week interval, there were 27 (22%) hospital deaths. In this latter group, survival rates steadily improved if revascularization was performed at a time more remote from the infarction. The difference in early and late survival rates of patients operated upon with an ejection fraction greater than or equal to 50% compared to patients with an ejection fraction less than 50% is highly significant (p less than 0.001). We conclude that myocardial revascularization is safe at any time after myocardial infarction for those individuals with an ejection fraction greater than or equal to 50%. However, if the ejection fraction is less than 50%, then operation after myocardial infarction should be delayed at least 4 weeks.

Hemodynamic effects of intravenous 20% soy oil emulsion following coronary bypass surgery.

Because of its high caloric density, intravenous fat emulsions have been suggested as useful sources of calories and essential fatty acids in patients with serious heart disease in whom fluid restriction must be closely monitored. Previous studies in the experimental animal have suggested a myocardial depressant effect of intravenous fat emulsions at high infusion rates. In the present study, 19 adult patients, following uncomplicated isolated coronary artery bypass surgery, were divided into two groups. A constant infusion of 2 ml/min of soy oil emulsion (20% Intralipid) was administered to the first group. The second group received 20% Intralipid at 1 ml/min followed by a 2 ml/min infusion. In the group receiving the 2 ml/min infusion (averaging 5.25 mg/kg/min), significant decreases in cardiac output and increases in pulmonary capillary wedge pressure occurred. One patient suffered an adverse side effect which may have been related to myocardial ischemia. The second group of patients received an initial infusion of 1 ml/min (averaging 2.35 mg/kg/min) following which the rate was doubled. No significant hemodynamic changes or adverse side effects occurred in the second group. It is concluded that 20% soy oil emulsion can be administered safely to the recently postoperative cardiac surgical patient recovering from coronary bypass grafting, but the rate should not exceed the maximum clearance rate of 1 ml/min (2.67 mg/kg/min).

Should nutritional status be assessed routinely prior to cardiac operation?

One hundred consecutive adult patients undergoing cardiac operations at a single institution were evaluated preoperatively with regard to their nutritional status. Anthropometric, biochemical, and immunologic characteristics were evaluated in addition to cardiac biopsy specimens to determine right atrial glycogen concentration. Although some positive anthropometric, biochemical, and cell-mediated immunity characteristics were observed to have "statistically significant" correlations with morbidity and mortality for the group as a whole, nearly all of the values remained near or at normal limits. Lighter weight men with a smaller arm muscle circumference and lower concentration of total body fat had more complications than their heavier counterparts. Serum transferrin and cell-mediated immunity also formed weakly positive statistical correlations. Anthropometric correlations in women were of no value. Myocardial glycogen concentrations did not correlate with postoperative morbidity and mortality. Because nearly all of the patients had arteriosclerotic heart disease, the series as a whole may have been skewed toward a group with values too close to normal to differentiate them adequately. It is concluded that routine nutritional assessment is of no value in guiding nutritional management for individual patients, although when patients are analyzed as a group, interesting epidemiologic observations can be made.

Hemodynamic effects of intravenous fat emulsions in patients with heart disease.

Two intravenous fat emulsions (Liposyn 10%, Abbott Laboratories, North Chicago, IL, and Intralipid 10%, Cutter Laboratories, Berkeley, CA) were evaluated in 13 adult patients following cardiopulmonary bypass procedures in a randomized, prospective, double-blind study to determine their overall hemodynamic effects. The fat emulsions were administered for 30 minutes, and each patient was his own control. Neither intravenous fat emulsion was observed to exert significant changes in left ventricular stroke work, left ventricular filling pressure, cardiac output, systemic vascular resistance, mean systemic arterial blood pressure, central venous pressure, or mean pulmonary artery pressure. This study confirmed that the administration of 10% fat emulsions available in the United States does not exert significant untoward hemodynamic changes, even in patients with severe cardiac impairment recovering from recent open heart surgery.