TU-E-BRB-02: A Decision Support Tool for SBRT Planning Using a Searchable DVH Database.

PURPOSE: Develop a decision support tool that aids dosimetrists, physicians, and physicists in assessing and improving plan quality through comparison to plans previously used in similar clinical situations. METHODS: Software was developed to capture and store DVHs and other clinically relevant treatment plan characteristics in a database. In addition to the plan DVH, the database contains a total of 24 plan characteristics including fractionation, prescribed dose, treatment volume, prior surgery, tumor position, and smoking history. DVH and other plan data was captured from the treatment planning system via exported dicom RT files. Structures in the plan were automatically matched by name to a list of standard structures using a system of regular expressions. Additional fields were entered manually using a simple java interface. As a support tool, a plan under development can be quickly compared to similar plans in the database based on selected plan characteristics. A plot displaying the current and historical DVHs provides an easy visual comparison. Our interface also provides statistics for comparison for each dose/volume level such as average, minimum, maximum and standard deviation. RESULTS: DVHs from 111 lung SBRT plans treated from 2009-2011 were imported in accordance with an approved IRB protocol. As an example of data comparisons that can be easily performed to guide plan evaluation, we examined plans prescribing 5400cGy in 3 fractions and found that tumors >7.5cc (n=34) had an average PTV coverage of 94.2% (range: 73.5-95.0%), and tumors =7.5cc (n=35) had an average PTV coverage of 94.9% (range: 81.6-99.6%). CONCLUSION: A searchable DVH database was constructed to provide planners, physicists, and physicians with a straightforward means of comparing plans against historic distributions of DVHs. In the future, outcome data will be included in the database to strengthen its functionality as a decision support and research tool.

SU-E-J-148: Fabrication of an Anatomically Realistic Dynamic Respiratory Phantom.

PURPOSE: The purpose of this project was to design an anatomically correct respiratory phantom that allows for accurate dose measurement within thoracic structures that move in a realistic fashion allowing for a more accurate simulation of in vivo measurements. METHODS: The basis for this phantom is The Dynamic Breathing Phantom (TBP), an Alderson Phantom by Radiology Support Devices (RSD). The phantom was disassembled, removing the proprietary pneumatic lung apparatus as well as the motor driven tumor mount. A CT of the phantom at rest in the exhale position was acquired with 0.25 cm slice thickness. Every sixteenth slice was printed out to scale. The lung cavity was segmented on the images. These were used to cut out 4.0 cm thick slabs of foam rubber matching the contour of the lung. These were assembled along with other thoracic structures manually imbedded in the foam rubber. The organs were then placed within the chest cavity of the phantom. A purpose-built diaphragm chamber made of a rubber bladder was inserted under the lung material. The manufacturer-provided air compressor system was re-tasked to drive the diaphragm chamber. RESULTS: The foam rubber used as lung material has comparable density to human lung (-800 HU). The phantom is capable of producing realistic respiratory motion. This phantom will easily accommodate a variety of dosimeters and can be adapted for a variety of tumor/critical structure shapes, sizes and locations. CONCLUSIONS: The creation of this versatile humanoid phantom opens the door for a multitude of experiments to investigate dose to organs within the chest cavity for different planning techniques, under different respiratory condition, while using a more anatomically correct experimental setup.

SU-E-T-401: Evaluation of Initial Setup Accuracy and Intra-Fraction Motion for Spine SBRT Using Stereotactic Body Frames.

PURPOSE: Quantify initial setup accuracy and intra-fraction motion using stereotactic body frames (SBF) for spine SBRT. METHODS: 10 patients (11 sites, 31 fractions) treated with spine SBRT using SBF immobilization were evaluated for initial setup accuracy and intra-fraction motion. Either the commercial Elekta SBF or an in-house developed SBF (BHS-SBF) were used. The BHS-SBF uses the same setup/immobilization principle as the Elekta but with increased interior space and couch indexing. Both frames include sidewalls to conform the vac-loc rigidly to the patient's sides. All patients were setup using the Brainlab ExacTrac system which includes IR and stereoscopic kV x-ray based positioning. Patients were initially positioned in the frame using skin tattoos then shifted to treatment isocenter based on IR markers affixed to the frame with known geometry relative to isocenter. kV imaging was acquired and automatic 6-D bony fusion performed. Resulting translations and rotations give the initial setup accuracy. Calculated shifts and rotations were performed using a robotic couch and verification imaging acquired. The imaging/fusion process was repeated multiple times during treatment providing intra-fraction motion data. RESULTS: Mean initial setup error in the VRT, LNG and LAT directions was 0.1+/-3.0 mm (0.1+/-0.6 deg), 0.5+/-5.2 mm (0.1+/-1.1 deg) and -0.3+/- 3.7 mm (0.4+/-0.8 deg) respectively. Mean 3-D error magnitude was 6.6 mm with a 95% certainty of 11.2 mm. Mean intra-fraction shifts observed in the VRT, LNG and LAT directions were -0.1+/-0.4 mm, -0.1+/-0.4 mm and 0.1+/-0.3 mm respectively. Mean 3-D intra-fraction shift magnitude was 0.6 mm with a 95% certainty of 1.4 mm. No significant difference was observed between the SBFs. CONCLUSIONS: Patient positioning is not sufficiently reproducible with the evaluated SBF to allow non-image guided treatment. However, provided image guidance is used for patient positioning, these frames provide excellent immobilization which is on par with mask based cranial radiosurgery.

Endoscopic hyaluronic acid/dextranomer gel implantation is effective as first-line treatment of vesicoureteral reflux (VUR) in children: a single centre experience.

PURPOSE: Aim of the study was to analyse the success rate of endoscopic treatment (ET) using Dx/HA for primary vesicoureteral reflux (VUR) in children and to assess the incidence of postoperative urinary tract infections (UTIs). METHODS: We retrospectively reviewed the charts of 103 children with VUR grade II-V who underwent ET, including children with additional urogenital malformations. Outcomes were verified with voiding cystourethrography (VCUG) and periodical urinalysis. RESULTS: 103 children with a total of 174 ureters underwent ET. 71 patients presented with bilateral VUR. Additional malformations were: duplex ureters (19 patients), posterior urethral valves (PUV) (12 patients), diverticulum (4 patients), neurogenic bladder and ectopic orifice. VUR grade was II in 52, III in 74, IV in 41 and V in 7 ureters, respectively. Postoperative VCUG demonstrated no VUR in 140 ureters (80%) and diminished VUR grade in an additional 18 ureters (total 91%). After a second ET, VCUG was negative in 28 ureters. The overall success rate was 98%. 30 patients had had more than 3 febrile and 67 patients had had 1-3 febrile UTIs before ET. 4 out of 103 patients (3.9%) had 1 febrile UTI within the first year of follow-up. Serious complications after ET were not noted. CONCLUSION: ET is effective at eliminating VUR in children, even in patients with high-grade reflux, as well as in patients with VUR and additional malformations. Early intervention may reduce the incidence of UTIs and prevent long-term renal damage.

[Laparoscopic "single-port" appendectomy in children]. / Laparoskopische "Single Port"-Appendektomie im Kindesalter.

BACKGROUND: In contrast to the laparoscopic three trocar-technique and to the single incision laparoscopic surgery (SILS), the "single-port" appendectomy (SPA) requires only one port with one integrated instrument channel. We report on our experience with this half-open surgical technique. PATIENTS / MATERIALS AND METHODS: Between September 2006 and August 2008 a total of 285 children underwent an appendectomy, 265 in SPA technique. Through a 10 mm subumbilical inserted ballon trocar, diagnostic laparoscopy was routinely performed and, afterwards, the appendix was grasped with a 450 mm forceps, exteriorised and dissected outside the abdomen as in open surgery. Patients with perforated appendicitis detected by preoperative ultrasonography were operated by open appendectomy. RESULTS: 94 % of the SPA were performed successfully with no conversion. In six patients (2.3 %), a second trocar was inserted, in seven children (2.6 %), an extension of the incision became necessary. There were three conversions (1.1 %) to open surgery. The median operating time was 50 min and the median length of hospital stay 4 days. Three children had postoperative wound infections (1.1 %). CONCLUSIONS: SPA is a safe alternative to conventional appendectomy techniques, in part also in cases of perforated appendicitis. The minimal scarring guarantees an attractive cosmetic result. The diagnostic laparoscopy enables one to obtain additional information. In the case of extended adhesions, an extension of the incision and / or the use of a second trocar may be helpful.

Immediate hip spica for unstable femoral shaft fractures in preschool children: still an efficient and effective option.

INTRODUCTION: Despite the increasing use of flexible intramedullary nailing for the treatment of femoral shaft fractures during growth, the use of acute or delayed plaster fixation is still a widely practised alternative in preschool children. The purpose of this retrospective study was to analyse outcome following acute casting in preschool children with a focus on acceptable initial leg length discrepancy and angulation. MATERIAL AND METHODS: A retrospective study was performed of 46 children with femoral shaft fractures treated conservatively. It was possible to verify the outcome in 22 children with an average follow-up time of 7.5 years. We compared initial shortening and mal-angulation to radiographic data at the time of consolidation and clinical outcome. RESULTS: Most children sustained their fracture by falling out of bed or from their parent's arm. A hip spica including the foot of the injured side, a pelvic ring and the thigh of the uninjured leg was applied under sedation and manual traction. Mean time of hospital stay was 1.4 days (range, 2 h-20 days). The average immobilisation time was 16.7 days (range, 0-30 days). At follow-up, on average 7.5 years after trauma, only one patient showed a leg length discrepancy greater than 2 cm. One patient showed a minor valgus and rotational deformity. CONCLUSION: The long-term outcome for conservatively treated femoral shaft fractures in preschool children is very good, even in severely dislocated fractures. Our data show that even initial shortening of up to 2.5 cm can be treated successfully with a spica cast.

DLR MiroSurge: a versatile system for research in endoscopic telesurgery.

PURPOSE: Research on surgical robotics demands systems for evaluating scientific approaches. Such systems can be divided into dedicated and versatile systems. Dedicated systems are designed for a single surgical task or technique, whereas versatile systems are designed to be expandable and useful in multiple surgical applications. Versatile systems are often based on industrial robots, though, and because of this, are hardly suitable for close contact with humans. METHOD: To achieve a high degree of versatility the Miro robotic surgery platform (MRSP) consists of versatile components, dedicated front-ends towards surgery and configurable interfaces for the surgeon. RESULTS: This paper presents MiroSurge, a configuration of the MRSP that allows for bimanual endoscopic telesurgery with force feedback. CONCLUSIONS: While the components of the MiroSurge system are shown to fulfil the rigid design requirements for robotic telesurgery with force feedback, the system remains versatile, which is supposed to be a key issue for the further development and optimisation.

Improvement of renal split function in hydronephrosis with less than 10 % function.

PURPOSE: The split function (SF) of hydronephrotic kidneys may dramatically decrease in the presence of severe and persistent obstruction, necessitating surgical correction. The indication for pyeloplasty versus nephrectomy is mainly based on the results of repeated renal ultrasonography (US) and MAG3-diuretic nephrography (DNG) with SF. Nephrectomy is usually recommended if SF is less than 10 %. However, recent studies with long-term follow-up indicate that even with an initial SF of < 10 %, a significant improvement of SF may be seen when pyeloplasty is performed so that nephrectomy may not be justified. PATIENTS AND METHODS: Case histories of 32 children with pre- or postnatally diagnosed severe hydronephrosis were retrospectively analyzed. Surgical correction was indicated if US revealed progredient hydronephrosis (anteroposterior diameter > 20 mm) and/or DNG demonstrated a loss of SF < 40 % and/or severe obstruction, respectively. Postoperative follow-up examinations included renal US after 3, 6 and 12 months, as well as DNG after 12 months. RESULTS: Thirty-two children (25 male, 7 female) underwent Anderson-Hynes pyeloplasty (AHP). At the time of operation, the mean age of the patients was 33 months (1 - 156 months). Patients were divided into 3 groups according to the initial SF: group I, 21 patients with SF > 40 %; group II, 7 patients with moderately impaired SF between 10 - 40 %; group III, 4 patients (aged 1 - 137 months) with a SF of < 10 %. In 2 patients, percutaneous nephrostomy (PCN) was performed, followed by AHP. Thirty patients underwent AHP without preceding PCN. In group III, SF increased from < 10 % preoperatively to 21 %, 27 %, 45 %, and 53 % postoperatively, respectively. In all patients, postoperative DNG demonstrated a significant improvement of SF from 41 %, on average, preoperatively (range 0 - 64 %) to 47 %, on average, postoperatively (range 17 - 60 %). CONCLUSION: Long-term follow-up confirms that the prognosis for renal function is excellent in patients with moderately reduced SF. The significant improvement of SF 12 months after AHP in all patients with a poor SF of less than 10 % supports our approach of performing pyeloplasty in patients even with an initial SF of < 10 %, which is in contrast to common practice.

Pulmonary function following completion of Minimally Invasive Repair for Pectus Excavatum (MIRPE).

UNLABELLED: Pulmonary function testing remains part of the routine preoperative investigations in patients with pectus excavatum, although there is evidence that reduced exercise capacity is predominantly due to impaired cardiovascular performance rather than ventilatory limitation. AIM OF THE STUDY: To evaluate the change of pulmonary function in patients after completion (metal bar removal) of minimally invasive repair for pectus excavatum compared to the preoperative functional results. PATIENTS AND METHODS: All patients who underwent minimally invasive repair for pectus excavatum (MIRPE) between February 2000 and June 2006 and subsequently had their metal bars removed were examined. Pulmonary function tests were performed as part of the routine pre- and postoperative protocol. Vital capacity (VC), forced expiratory volume in one second (FEV1), total lung capacity (TLC), residual volume (RV) and maximal expiratory flow rate at 25 % (MEF25) were evaluated. In addition, comparisons were made between patients with a low ( 6) pectus severity index (PSI) to establish the relative pre- to postoperative change of the above-mentioned lung function parameters. RESULTS: Fifteen patients were included in the study (14 males, 1 female). The median age at surgery was 15.9 years. The metal bar(s) were removed after a median of 37 months following the initial operation. Lung function tests were performed at a median of 32 days preoperatively and 129 days after completion of the procedure. Preoperative lung function values lay below population averages. The majority of patients had either a restrictive, obstructive or combined pulmonary disorder. Improvement was observed in all lung function parameters after metal bar removal compared to preoperative values and was significant for VC, FEV1 and the RV/TLC ratios. With regard to the severity of the deformity, although not statistically significant, patients with a higher PSI (> 6) appeared to benefit particularly from the operation. CONCLUSION: Our findings indicate that pulmonary function improves in patients after completion of minimally invasive repair of pectus excavatum. However, a review of the literature suggests that, in all probability, following surgery, patients benefit more with regard to enhanced cardiovascular performance than from improved pulmonary limitations. The value of routine testing of pre- and postoperative lung function in patients with pectus excavatum is questionable.

The relevance of surgical therapy for bilateral and/or multiple pulmonary metastases in children.

PURPOSE: Pulmonary surgery is frequently used for the treatment of metastases in children with various malignant diseases. The benefit of an aggressive surgical treatment in children with bilateral and/or multiple pulmonary metastases is still discussed controversially. METHODS: A retrospective analysis of 10 children (7 girls, 3 boys; age range from 2 to 16.5 years) who underwent thoracotomy for bilateral and/or multiple pulmonary metastases was performed. The primary malignancies were osteosarcoma (n = 4), hepatoblastoma (n = 3), malignant peripheral nerve sheath tumor (n = 1), adrenocortical carcinoma (n = 1) and alveolar rhabdomyosarcoma (n = 1). Unilateral but multiple pulmonary metastases were found in 3 children. 7 patients showed bilateral pulmonary metastases. Preoperative induction chemotherapy with tumor regression and a subsequent decrease in the size and number of pulmonary metastases was mandatory for the surgery of metastases. RESULTS: Standardized bilateral thoracotomy was performed in 4 patients in 1 operation (in 1 patient combined with a hemihepatectomy), and in 3 patients, in 2 operations on different days. 5 children underwent re-thoracotomy due to recurrent pulmonary metastases (2 patients: unilateral; 3 patients: bilateral; 1 patient: twice bilateral). All visible and palpable metastases (1 - 25) were excised, either by wedge resection, by segment resection or by lobectomy. Postoperative artificial ventilation was necessary for 0 to 24 hours. Postoperative complications included intrathoracic secondary hemorrhage in 3 cases and pneumonia in 1 patient. 2 patients (20%) died of recurrent metastatic disease (osteosarcoma: 1; adrenocortical carcinoma: 1). During a mean follow-up period of 49 months (14 to 66 months after the last thoracotomy), 8 patients (80%) remained in complete remission without clinically relevant respiratory restrictions. CONCLUSION: Complete surgical resection of pulmonary metastases after response to induction chemotherapy may increase survival in carefully selected children, even in cases with multiple and recurrent metastatic disease. In children, bilateral thoracotomy within a single operation is possible without an increased complication rate.

Perceptual responses in the heat after brief intravenous versus oral rehydration.

PURPOSE: The purpose of the study was to compare the effects of a brief period (20 min) of intravenous (IV) fluid rehydration and oral (ORAL) rehydration on ratings of perceived exertion (RPE), thirst, and thermal sensation (TS) during exercise in the heat. METHODS: After dehydration (-4% of body weight), eight nonacclimated highly trained cyclists (age = 24 +/- 1 yr; VO2 = 61.4 +/- 0.8 mL.kg.min-1) performed three experimental trials. Rehydration (randomized, cross-over design) included: 1) ORAL (0.45% NaCl) equal to 50% of prior dehydration; 2) IV (0.45% NaCl) equal to 50% of prior dehydration; and 3) a control (CON), no fluid trial. Subjects then cycled at 74% VO2peak until volitional exhaustion in a hot environment (37 degrees C). RESULTS: Central (C-), local (L-), and overall-RPE (O-RPE) were significantly higher in CON compared to ORAL and IV at minutes 5 and 15 of exercise. C-RPE responses at minute 5 of exercise were lower (P < 0.05) during ORAL compared with IV, and C-RPE and O-RPE responses at minute 15 were lower (P < 0.05) during ORAL compared with IV. TS responses during CON were higher (P < 0.05) than ORAL and IV at minute 5, and TS was higher (P < 0.05) during IV versus ORAL at minute 15. TS were significantly correlated with all RPE responses at minute 15 in all trials. Thirst ratings were lower (P < 0.05) during ORAL compared with CON and IV at minutes 0, 5, and 15. CONCLUSION: It was concluded that ORAL resulted in lower RPE, thirst, and TS compared with CON and IV during exercise in the heat.

Intravenous versus oral rehydration during a brief period: stress hormone responses to subsequent exhaustive exercise in the heat.

The purpose of this study was to determine if intravenous fluid rehydration, versus oral rehydration, during a brief period (20 min) differentially affects plasma ACTH, cortisol, and norepinephrine concentrations during subsequent exhaustive exercise in the heat. Following dehydration (DHY) to Eth 4% of body weight, 8 nonacclimated highly trained males (age = 23.5 +/- 1.2 years, VáO2peak = 61.4 +/- 0.8 ml á kg á min-1, % body fat = 13.5 +/- 0. 6%) cycled to exhaustion at 74% VáO2peak in 36.8 C on three different occasions. These included: (a) no fluid (NF), where no fluid was provided during the rehydration period; (b) DRINK, where oral rehydration (0.45% NaCl) was provided equal to 50% of the prior DHY; and (c) IV, where intravenous infusion (0.45% NaCl) was provided equal to 50% of the prior DHY. Exercise time to exhaustion was not different (p =.07) between the DRINK (34.86 +/- 4.01) and IV (29.48 +/- 3.50) trials, but both were significantly (p <.05) longer than the NF (18.95 +/- 2.73) trial. No differences (p >.05) were found for any of the hormone measures among trials. The endocrine responses at exhaustion were similar regardless of hydration state and mode of rehydration, but rehydration prolonged the exercise time to exhaustion.

Intravenous versus oral rehydration during a brief period: responses to subsequent exercise in the heat.

PURPOSE: The purpose of this study was to assess whether a brief period (20 min) of intravenous (i.v.) fluid rehydration versus oral rehydration differentially affects cardiovascular, thermoregulatory, and performance factors during exhaustive exercise in the heat. METHODS: Following dehydration (-4% of body weight), eight nonacclimated highly trained cyclists (age = 23.5 +/- 1.2 yr; VO2peak = 61.4 +/- 0.8 mL x kg x min(-1); body fat = 13.5 +/- 0.6%) rehydrated and then cycled at 70% VO2peak to exhaustion in 37 degrees C. Rehydration (randomized, cross-over design) included: 1) CONTROL (no fluid), 2) DRINK (oral rehydration, 0.45% NaCl) equal to 50% of prior dehydration, and 3) IV (intravenous rehydration, 0.45% NaCl), equal to 50% of prior dehydration. Thus, in the DRINK and IV treatments subjects began exercise (EX) at -2% of body weight. RESULTS: Exercise time to exhaustion was not different (P = 0.07) between DRINK (34.9 +/- 4 min) and IV (29.5 +/- 3.5 min), but both were significantly (P < 0.05) longer than CONTROL (18.9 +/- 2.7 min). Plasma volume was better (P < 0.05) restored during IV than CONTROL and DRINK at pre-exercise and 5 min EX, but different (P < 0.05) from only CONTROL at 15 min EX. Plasma lactate during DRINK was lower (P < 0.05) than IV at 15 min EX and postexercise. Heart rate during CONTROL was greater (P < 0.05) than DRINK and IV from 0-8 min EX, and greater (P < 0.05) than DRINK from 10-14 min EX. Rectal temperature during DRINK was less (P < 0.05) than IV from 0-24 min EX. Mean weighted skin temperature during DRINK was less (P < 0.05) than IV from 4-12 min EX. CONCLUSIONS: Thus, despite no statistically significant performance differences between DRINK and IV, it appears that certain physiological parameters were better maintained in the DRINK trial, and the trend toward performance differences may be important to elite athletes.

Urinary indices during dehydration, exercise, and rehydration.

This investigation evaluated the validity and sensitivity of urine color (Ucol), specific gravity (Usg), and osmolality (Uosm) as indices of hydration status, by comparing them to changes in body water. Nine highly trained males underwent a 42-hr protocol involving dehydration to 3.7% of body mass (Day 1, -2.64 kg), cycling to exhaustion (Day 2, -5.2% of body mass, -3.68 kg), and oral rehydration for 21 hr. The ranges of mean (across time) blood and urine values were Ucol, 1-7; Usg, 1.004-1.029; Uosm, 117-1,081 mOsm x kg-1; and plasma osmolality (Posm), 280-298 mOsm x kg-1. Urine color tracked changes in body water as effectively as (or better than) Uosm, Usg, urine volume, Posm, plasma sodium, and plasma total protein. We concluded that (a) Ucol, Uosm, and Usg are valid indices of hydration status, and (b) marked dehydration, exercise, and rehydration had little effect on the validity and sensitivity of these indices.

Beam shaping for conformal fractionated stereotactic radiotherapy: a modeling study.

PURPOSE: The patient population treated with fractionated stereotactic radiotherapy (SRT) is significantly different than that treated with stereotactic radiosurgery (SRS). Generally, lesions treated with SRT are larger, less spherical, and located within critical regions of the central nervous system; hence, they offer new challenges to the treatment planner. Here a simple, cost effective, beam shaping system has been evaluated relative to both circular collimators and an ideal dynamically conforming system for effectiveness in providing conformal therapy for these lesions. METHODS AND MATERIALS: We have modeled a simple system for conformal arc therapy using four independent jaws. The jaw positions and collimator angle are changed between arcs but held fixed for the duration of each arc. Eleven previously treated SRT cases have been replanned using this system. The rectangular jaw plans were then compared to the original treatment plans which used circular collimators. The plans were evaluated with respect to tissue sparing at 100%, 80%, 50%, and 20% of the prescription dose. A plan was also done for each tumor in which the beam aperture was continuously conformed to the beams eye view projection of the tumor. This was used as an ideal standard for conformal therapy in the absence of fluence modulation. RESULTS: For tumors with a maximum extent of over 3.5 cm the rectangular jaw plans reduced the mean volume of healthy tissue involved at the prescription dose by 57% relative to the circular collimator plans. The ideal conformal plans offered no significant further improvement at the prescription dose. The relative advantage of the rectangular jaw plans decreased at lower isodoses so that at 20% of the prescription dose tissue involvement for the rectangular jaw plans was equivalent to that for the circular collimator plans. At these isodoses the ideal conformal plans gave substantially better tissue sparing. CONCLUSION: A simple and economical field shaping device has been shown to provide all of the beam shaping advantage of a hypothetical ideal dynamically conforming system at the prescription level. This system may be immediately implemented in the clinic. It offers a substantial advantage over the currently used circular collimators in the high dose region with equivalent performance in the low dose region.

[Endosonographic determination of the volume of anal sphincter muscles as a parameter for continence outcome in childhood]. / Endosonographisch bestimmtes Volumen der analen Kontinenzmuskulatur als Parameter für die Kontinenzleistung im Kindesalter.

The volumes of the external and internal anal-sphincter muscles, determined by three-dimensional (3d) endosonography, are linear to each other and to the body-height and body-surface ratios in normal children. In patients with an operation of the sphincter muscles, the reduced volume of the external sphincter system permits a differentiation of incontinent children; the volume of the internal sphincter muscles, however, doesn't give a significant difference nor does the muscle-thickness. An acceptable estimation of the sphincter muscles volume can be made with conventional endosonography by planimetry of the muscle tissue in four representative axial cut-planes and by measuring of the sphincter-length.

[Hospital ambulatory pediatric surgery]. / Krankenhausambulante Kinderchirurgie.

Since 1990, we have been conducting ambulatory pediatric surgery in an unit established solely for this purpose, supported by a team of kindergarten teachers, pediatric nurses, anesthesiologists and pediatric surgeons. This prospective investigation includes all ambulatory pediatric operations performed in our department from 1990 to 1995. In this time 3665 infants and children between the ages of 6 weeks and 18 years underwent an ambulatory operation. The ratio male to female was 4.1 to 1. The series consists of 1400 inguinal hernias, 722 inguinal testes, 191 hydroceles/funiculoceles, 75 umbilical hernias, 667 phimoses, 70 meatotomies, 59 hemangiomas, 217 endoscopies and 264 other surgical procedures. Postoperative complications defined as secondary hemorrhage, fever, obvious vomiting, urine retention and laryngospasm upon terminating anesthesia accompanied by subsequent vomiting occurred in 59 (1.6%) of all infants and children. Wound infections were seen in 0.48% (17/3517) of all patients. The recurrence rate for inguinal hernias were 0.79% and 1.12% for inguinal testes. Our experience enables us to summarize that a variety of pediatric operations can be performed today as ambulatory procedures. Nevertheless one must be prepared for the occurrence of complications and always have capacities free for inpatient care where adequate observation and treatment are available. Further improvement is necessary in quality management. In the last 20 years only a few data have been published about recurrence rates after pediatric ambulatory operations for inguinal hernias and inguinal testes. Therefore we started a prospective long- term study.

Reactions to disaster at a distance. The first week after the earthquake in Soviet Armenia.

Armenian-American adolescents from a Los Angeles school were interviewed during the first week after the massive earthquake in Soviet Armenia in December 1988. The authors describe their observations: All the adolescents strongly identified with the victims and felt that the catastrophe personally affected them; they all rushed into hectic activities to escape intolerable grief reactions; there was strong group pressure to accelerate helping efforts; the catastrophe was experienced as fortifying group cohesion; and there was a distinct preference to preserve and strengthen communal values, even over and above helping the earthquake victims. In particular, the authors observed the phenomenon of "participation envy," a special form of survivor guilt involving envious resentment at being excluded from a unique and rallying communal experience.

Pharmacokinetics of sulfamethazine in male, female and castrated male swine.

The concentration of sulfamethazine in plasma and sulfamethazine and its metabolites in urine were compared in male, female and castrated male swine. A surgical technique for placement of catheters in the urinary bladder was used to facilitate the collection of urine in males and castrated males. The elimination rate of sulfamethazine from plasma and the excretion of parent drug and metabolites into urine did not differ significantly among females, males and castrated male swine.