Asynchronous Bilateral Ovarian Torsion: Three Cases, Three Lessons.

BACKGROUND: Ovarian torsion (OT) is a serious condition, and delay in surgical intervention may result in loss of the ovary. Children and adolescents who have suffered from ovarian torsion may be at risk for asynchronous torsion of the contralateral ovary. STUDY OBJECTIVE: Three cases of asynchronous bilateral ovarian torsion were reported to analyse clinical history of three patients, to review the current literature, and to draw a conclusion for future treatment. DESIGN: Case reports and review of the literature. RESULT: When a prepubertal girl presents with an ovarian torsion, several considerations have to be taken in account in order to preserve her future fertility; in particular, the pediatric surgeon/gynecologist has to preserve as much as possible the twisted ovary in addition to considering the fate of the contralateral ovary. SUMMARY AND CONCLUSIONS: Pelvic pain in a young girl has always raised the clinical suspect of an ovarian torsion; the possibility of asynchronous bilateral ovarian torsion is rare, but it is described in the literature and has catastrophic consequences; this condition has to be known and treated in the proper way by pediatric surgeons as well as by gynecologists in order to maximize the future fertility of the young patients.

Relationship between socio-economic features and health status in elderly hospitalized patients.

We aimed at investigating the relationship between socioeconomic (SES) and health status in the context of an observational multicenter study of elderly hospitalized patients. Our series consisted of 473 patients aged 70 years or more. K-means cluster analysis was used to generate 3 clusters on the basis of age, gender, education, perception of personal economic situation, difficulty to reach health services, need for formal or informal support, family arrangement, and population density of residence municipality. Logistic regression analysis was used to identify correlates of "negative" SES. Correlates of "negative" SES cluster were older age (odds ratio=OR=5.19, 95% Cl=2.28-11.8), cognitive impairment (OR=6.36, 95%CI=3.11-13.0), emergency hospital admission (OR=3.11; 95%CI=1.52-6.35), and dependency in at least 1 BADL (OR=4.36, 95%CI=1.53-12.4). In conclusion, "negative" SES is associated with age and selected indices of frailty in elderly hospitalized patients. The evaluation of socio-economic problems should be routinely addressed in elderly hospitalized patients in order to tailor appropriately post-discharge use of health care resources.

Metabolic syndrome, psychological status and quality of life in obesity: the QUOVADIS Study.

OBJECTIVE: We aimed to investigate the association of the clinical variables of the metabolic syndrome (MS) and psychological parameters on health-related quality of life (HRQL) in obesity. In particular, our aim was to investigate the relative impact of physical symptoms, somatic diseases and psychological distress on both the physical and the mental domains of HRQL. DESIGN: Cross-sectional study. SUBJECTS: A cohort of 1822 obese outpatients seeking treatment in medical centers. MEASUREMENTS: HRQL was measured by the standardized summary scores for physical (PCS) and mental (MCS) components of the Short Form 36 Health Survey (SF-36). Patients were grouped according to tertiles of PCS and MCS. Metabolic and psychological profiles of PCS and MCS tertiles were compared by discriminant analysis. RESULTS: The profile of metabolic and psychological variables was tertile-specific in 62.4 and 68.3% of patients in the lowest and highest tertiles of PCS, respectively, while concordance was low in the mid-tertile (32.8%). Concordance was very high in the lowest (74.4%) and in the highest (75.5%) tertiles of MCS, and was fair in the mid-tertile (53.2%). The main correlates of PCS were obesity-specific and general psychological well-being, BMI, body uneasiness, binge eating, gender and psychiatric distress. Only hypertension and hyperglycemia qualified as correlates among the components of MS. The components of MS did not define MCS. CONCLUSIONS: Psychological well-being is the most important correlate of HRQL in obesity, both in the physical and in the mental domains, whereas the features of MS correlate only to some extent with the physical domain of HRQL.

Herlyn-Werner-Wunderlich syndrome: uterus didelphys, blind hemivagina and ipsilateral renal agenesis. Sonographic and MR findings in 11 cases.

BACKGROUND: Uterus didelphys with obstructed hemivagina and ipsilateral renal agenesis is a rare entity, sometimes referred to as Herlyn-Werner-Wunderlich syndrome (HWW). It usually presents after menarche with progressive pelvic pain, sometimes with regular menses, and a palpable mass due to hemihaematocolpos. The diagnosis is generally made only if the suspicion of this genitourinary syndrome is raised. OBJECTIVE: To highlight the imaging diagnostic clues in this rare condition. MATERIALS AND METHODS: We report on 11 adolescents with this condition. RESULTS: Sonography mostly allowed the correct diagnosis by showing uterovaginal duplication, haematocolpos or haematometrocolpos, and the absence of the ipsilateral kidney. MRI provided more detailed information regarding uterine morphology, the continuity with each vaginal channel (obstructed and nonobstructed), and the bloody nature of the contents. CONCLUSION: Early and accurate diagnosis of this syndrome is important so that adequate and prompt surgical therapy (excision of the vaginal septum) can provide relief of pain and prevent further complications. It is also advisable to look for an obstructed Müllerian system whenever a multicystic dysplastic kidney or the absence of a kidney is discovered in a fetus, or girl postnatally.

Relationship between metabolic syndrome and platelet responsiveness to leptin in overweight and obese patients.

OBJECTIVE: To verify whether platelet responsiveness to leptin is associated with metabolic syndrome risk factors. DESIGN: Cross-sectional study. SUBJECTS: We studied 169 consecutive patients, mean age=43.6+/-9.9 years, with overweight (N=57) or obesity (N=112). MEASUREMENTS: Cluster analysis was used to generate three clusters based on platelet responsiveness to increasing doses of leptin. Profiles of metabolic syndrome risk factors of the three clusters were compared by discriminant analysis. RESULTS: Platelet responsiveness to leptin was absent in cluster 1, whereas cluster 3 had the greatest platelet aggregation response to leptin pre-incubation. Plasma leptin levels significantly decreased from cluster 1 to cluster 3 in both gender. Patients in cluster 2 had an intermediate profile of leptin responsiveness. Highest body mass index (BMI) values were more frequent in non-responders, whereas the prevalence of high waist circumference, as well as hypertriglyceridemia and hypertension, increased with increasing responsiveness to leptin from cluster 1 to cluster 3. Pattern of metabolic syndrome risk factors qualified as group specific in 69.0% of the cluster 1, 54.9% of the cluster 2 and 55.8% of the cluster 3. Circulating leptin, waist circumference, plasma triglycerides and BMI defined distinctive patterns of metabolic syndrome risk factors in the clusters. CONCLUSIONS: In overweight and obese outpatients, metabolic syndrome risk factors parallel to some extent platelet responsiveness to leptin. Such a correlation involves plasma leptin levels, waist circumference, plasma triglycerides and BMI, and may contribute to the excess risk of cardiovascular events in overweight and obese patients.

Isolated tubal torsion: a rare cause of pelvic pain at menarche. Sonographic and MR findings.

Isolated torsion of the fallopian tube is a rare clinical entity, especially in adolescents and at menarche. The diagnosis is essentially made at laparoscopy or at laparotomy because of nonspecific clinical signs. We present a case of isolated tubal torsion in a 12-year-old girl a few days after menarche, highlighting the sonographic and MR findings. Both techniques demonstrated the enlarged and tortuous fallopian tube with normal ovaries and uterus, but MR was also able to characterize contained blood and absent vascular supply. Although this condition is uncommon it should be considered as a cause of acute pelvic pain in adolescents because of the possibility of salvage surgery with early diagnosis. Sonography and MRI have a complementary role in this diagnosis.

A surgical method to preserve testicular function and restore cosmetic appearance in hypogonadal men.

PURPOSE: Maintenance of spermatogenesis in hypogonadotropic hypogonadal patients is possible and is an objective to be actively pursued. Gonadotropin releasing hormone and gonadotropin/ testosterone therapy can develop and maintain sex characteristics and spermatogenesis such that even small gonads should be preserved. An empty scrotum, like any other congenital or acquired condition compromising the size of the genitalia, can produce serious psychosexual problems and have an extremely negative effect on normal social life. MATERIALS AND METHODS: In 2 adolescents affected by Kallmann's syndrome with testes of infantile volume 1 gonad was transferred to the contralateral hemiscrotum and replaced by an adult testicular prosthesis. RESULTS: There were no postoperative complications. The cosmetic results were considered satisfactory by the patients and their parents. CONCLUSIONS: When possible and when there is no risk of physiological repercussions, every effort should be made to normalize the appearance of the genital area for strong psychological reasons.

Impalpable testis and laparoscopy: when the gonad is not visualized.

The diagnostic accuracy of laparoscopy for impalpable testis is well recognized. However, in some cases, laparoscopic findings may be misleading, and a viable gonad may be missed with significant medico-legal implications. From January 1993 to December 2000, 202 patients with 219 impalpable testes were evaluated. In 95 cases, the gonad was immediately visualized, and in 5, the presence of a testis was documented by inserting the scope into the processus vaginalis. In the 119 remaining cases, no gonad was seen while entering the abdomen with the laparoscope. All patients with documented vas and vessels exiting the inguinal ring were surgically explored. Ten testes were found, 8 ectopic, with significant changes in shape and position, and 2 were canalicular. In the absence of hormone stimulation, no testes were found while exploring patients with cord structures coursing a closed inguinal ring and with contralateral hypertrophy. In 1 patient with absent vas and vessels, the testis was found at the lower renal pole while removing a dysplastic kidney. Despite technical refinements and an increase in clinical practice, a small percentage of viable testes may be missed with laparoscopic findings consistent with absent/vanished inguinal testis. Therefore, inguinal exploration is mandatory in all these cases.

Role of electrogastrography in detecting motility disorders in children affected by chronic intestinal pseudo-obstruction and Crohn's disease.

Gastrointestinal motility disorders are frequently found in several pathologies. The aim of this study was to assess, by means of electrogastrography, the presence of gastrointestinal motility abnormalities in children affected by Crohn's disease (CD) or Chronic Intestinal Pseudo-Obstruction (CIPO). Patients and Methods. We studied 34 subjects; 20 control subjects (M = 15, mean age = 10 +/- 3.5 yrs), 8 patients (M = 4, mean age = 18 +/- 7 yrs) with Crohn's disease in a quiescent phase and 6 patients (M = 6, mean age = 10 +/- 3.5 yrs) with Chronic Intestinal Pseudo-Obstruction. Results. Analysis of gastric electrical activity (GEA) parameters demonstrated that in the control group physiological post-prandial changes are represented by an increase of 3 Cycles Per Minute (3 CPM) activity, Period Dominant Power (PDP) and Period Dominant Frequency (PDF) and by the reduction of bradygastria. Crohn patients showed an insignificant increase of 3 CPM and PDP; CIPO patients showed an abnormal variation of 3 CPM, PDP and post-prandial bradygastria. Moreover, CD patients showed a significant difference in post-prandial values of PDP compared to normal subjects. CIPO patients revealed a significant difference in the values of either preprandial PDF with tachygastria or the post-prandial value of 3 CPM, compared to normal subjects. Conclusions. EEG is a non-invasive method to study gut motility related to GEA alterations present in CIPO as well as in CD patients.

Skin graft for 2-stage treatment of severe hypospadias: back to the future?

PURPOSE: Despite the introduction of more refined surgical techniques, the optimal treatment of the most severe forms of hypospadias remains to be determined. Single stage procedures, whether with the use of flaps or grafts, have long been regarded as the best approach, although the complication rate is nonnegligible with all procedures. MATERIALS AND METHODS: We report the use of a 2-stage repair with preputial graft interposition and subsequent tubularization of the urethral plate applied it to all severe cases of hypospadias with significant chordee or small glans. RESULTS: Both stages of the procedure were completed in 34 patients. Complications in 8 cases (23.5%) included 4 glans disruption in 4, coronal grove fistula in 2, urethral diverticulum in 1 and urethral stenosis due to balanitis xerotica obliterans in 1. Two pinhole fistulas also occurred which closed spontaneously. No complete disruptions or postoperative hematomas/bleeding was noted. Cosmetic and functional outcome after a minimum followup of 1 month was optimal in all cases with a normally located "slit" meatus and straight penile shaft. CONCLUSIONS: Although the controversy between use of grafts and flaps will probably continue forever, we believe that our 2-stage approach should be considered as a valid alternative for the most severe forms of hypospadias. Long-term results appear to outnumber the necessity of a learning curve for appropriate graft manipulation.

Paratesticular pilomatricoma: a new location.

The first case of pediatric paratesticular pilomatricoma is reported. Differential diagnosis with other more common lesions in such a site is the main issue. Conservative surgery is the treatment of choice. Follow-up is recommended, since most pilomatricomata are benign, but rarely malignant transformation may occur.

Adolescent varicocele: Tauber antegrade sclerotherapy versus Palomo repair.

PURPOSE: There is general agreement on treatment for varicocele in pediatric patients. Randomized prospective studies have shown that anatomical and functional lesions may be corrected. Due to the impossibility of seminal examination patients with moderate to large varicocele or ipsilateral testicular hypertrophy, characterized by a change in testicular consistency or symptoms, should undergo surgical correction. The best therapeutic approach is still under discussion. MATERIALS AND METHODS: At 2 centers 2 therapeutic approaches to varicocele treatment in pediatric patients were compared, namely the Palomo repair and antegrade sclerotherapy according to Tauber. The 89 patients from the same geographical area elected 1 procedure after an explanation. From the medical records we retrospectively evaluated operative time, postoperative analgesics, postoperative fever onset, complications, convalescence, recurrence and postoperative hydrocele. RESULTS: After Palomo repair in 45 patients there were 2 recurrences (4.4%) and 2 postoperative hydroceles (4.4%). Of 44 antegrade sclerotherapy cases 1 was converted to Palomo repair, there was no hydrocele formation and recurrence developed in 2 (4.5%). Testicular atrophy was not observed in any patient regardless of the method used. The cost of the procedure was lower in the sclerotherapy group. CONCLUSIONS: These data suggest that the failure rate was similar in both groups. The principal advantages of sclerotherapy are simplicity, decreased cost and lack of hydrocele formation.

Abdominoscrotal hydrocele: a reliable surgical technique.

Abdominoscrotal hydrocele (ASH) consists of two large sacs, both abdominal and scrotal, connecting with the inguinal channel. The diagnosis is made only by ultrasound scan. Surgical treatment is mandatory since no spontaneous resolution has been reported. A new surgical procedure used successfully to treat 11 patients with ASH is described.

Ultra-short-bowel syndrome is not an absolute indication to small-bowel transplantation in childhood.

Short-bowel syndrome (SBS) either in adults or in children is considered as an indication to small-bowel transplantation (SBTx), particularly in its most severe form with a residual bowel length below 20 cm. Among factors likely to worsen the prognosis, more recent reports also indicate the number of surgical interventions, early onset sepsis and early development of liver disease. We report six cases of ultra-short-bowel syndrome followed from birth to verify the importance of various prognostic factors. In our case series, the male sex is predominating (5:1). Intestinal resection was indicated in 3 patients for multiple intestinal atresias, in 2 for volvulus and in 1 for necrotizing enterocolitis. The length of intestine remaining was invariably less than 20 cm and 2 patients had a preserved ileocecal valve. In most cases, more than 50% of the colon remained. The number of abdominal operations ranged from 1 to 4. In almost all cases (5 of 6), sepsis and hepatopathy developed early. Our experience suggests that rather than depending on the length of intestine remaining or the presence of the ileocecal valve, the prognosis of patients with the extreme-short-bowel syndrome depends on recurrent neonatal onset sepsis and early onset liver impairment. In addition, our case review shows that the extreme-short-bowel syndrome is not necessarily an indication for bowel transplantation.

Gastroesophageal reflux in neurologically impaired children: partial or total fundoplication?

BACKGROUND: It is difficult to give guidelines when approaching gastroesophageal disease in neurologically impaired children. Indication for surgery has been increasing over recent years, but there is no consensus on the surgical technique of choice. Nothing has been written specifically comparing the results of different procedures in these patients, so far. STUDY DESIGN: We retrospectively compare the short- and long-term results of two different types of fundoplication in a series of children operated on for documented gastroesophageal reflux disease at our institution. RESULTS: One group (group A) of 27 patients, operated on between 1977 and 1993, underwent Nissen fundoplication, the other (group B), formed of 20 patients all of whom were operated on between 1993 and 1995, underwent Thai fundoplication. We compared the results in terms of positive outcome (recovery) and negative outcome (minor and major complication), computing the relative odds of group A versus group B in terms of risk of complication, and we compared the mean operative time and the length of hospital stay by means of a student's t-test analysis. CONCLUSIONS: Our results show that there is no statistical difference between the two procedures in terms of relative risk of complication and success rate. The duration of surgery and hospital stay were significantly shorter in group B. The Thal procedure can, therefore, be proposed as first choice in the management of these patients.

Stenting for caustic strictures: esophageal replacement replaced.

METHODS: From 1983 to 1996, 31 children with caustic esophageal strictures were seen at Bambino Gesù Children's Hospital; they were all treated conservatively except for two cases complicated by tracheoesophageal fistula. The remaining 29 patients were divided into three groups depending on the treatment, which was modified over the years. Group A (1983 to 1987) consisted of seven patients treated by periodic dilatations; group B (1988 to 1992) consisted of 10 children treated by 40 days of esophageal stenting plus dexamethasone, 0.5 mg/kg/d plus ranitidine plus no oral feeding for 7 to 10 days; group C (1993 to 1996) consisted of 12 cases treated by 40 days of esophageal stenting plus dexamethasone, 1 mg/kg/d plus omeprazole plus early oral feeding resumption. RESULTS: No differences were observed between the three groups of patients with regard to the mean age and to the ingested substance, whereas a significant difference (P = .007) was observed in the mean length of the stricture between group A and C (3.4+/-1.3 and 5.6+/-1.6 cm, respectively). In all but one of the patients (96.5%) complete healing of the stenosis was achieved by conservative treatment, with definitive relief of dysphagia. One patient in group C did not improve after a repeated stenting procedure and was surgically treated. However, in group A, resolution of the stricture was obtained after an average of 19.9+/-14.8 dilatations in a mean period of 25.3+/-17.2 months. In group B, a mean of 12+/-11.3 dilatations were required in a mean period of treatment of 14.1+/-10.6 months. In patients in group C, a mean of 3.5+/-3.2 dilatations were necessary in a mean of 5.8+/-4.8 months. A statistically significant difference was observed both with regard to the number of dilatations and to the duration of treatment, between group A and group C (P = .002) and group B and C (P = .03). CONCLUSION: Esophageal replacement should be considered only in cases complicated by tracheoesophageal fistula or in the rare patients who do not respond to repeated esophageal stenting.

Microalbuminuria and associated clinical features among Brazilians with insulin dependent diabetes mellitus.

With the objective to determine the frequency of microalbuminuria, macroalbuminuria and the associated clinic and metabolic features among insulin dependent diabetes mellitus (IDDM) Brazilian patients attending at a general University Hospital, a total of 50 outpatients, aged 21.9 +/- 7 years with IDDM duration of 6.8 +/- 5.8 years were studied cross-sectionally. Urinary albumin excretion rate (AER) was determined in timed overnight urine samples. Microalbuminuria was defined when two out of three urine samples had AER ranging 20-200 micrograms/min. Microalbuminuria was present in 12% of our patients. No macroalbuminuric patient was found. Among patients with diabetes duration < or = 5 years (n = 24), 8.3% (n = 2) had microalbuminuria. Retinopathy was strongly associated with microalbuminuria (P = 0.004) although no proliferative retinopathy was noted. No difference was observed concerning FBG and HBAI between normo and microalbuminuria patients. Univariate analysis has revealed no influence of these variables in AER. Systolic blood pressure (sBP) was high in microalbuminuria patients and stepwise multiple regression analysis has shown that it was the only significant independent variable to influence AER. (R = 0.42 r2 = 0.18 P = 0.002). In conclusion, the frequency of microalbuminuria in this sample of IDDM Brazilian patients was similar to other populational groups and was associated with retinopathy and sBP.

Influence of first morning urine volume, fasting blood glucose and glycosylated hemoglobin on first morning urinary albumin concentration.

The aim of the present study was to evaluate the effect of first morning urinary volume (collected on three different non-consecutive days), fasting blood glucose (determined on the first and third days of urine collection), and glycosylated hemoglobin (determined on the first and third days of urine collection) on the albumin concentration in first morning urine samples collected on three different days. We found 3.6% asymptomatic bacteriuria in the urine samples; therefore, every urine sample must be tested to exclude infection. One hundred and fifty urine samples were provided by 50 IDDM patients aged 21.9 +/- 7 (12-38) years with a disease duration of 6.8 +/- 5.8 (0.4-31) years attending the Diabetes Clinic at the State University Hospital of Rio de Janeiro. There were no differences in albumin concentration (6.1 vs 5.8 vs 6.2 micrograms/ml; P = NS) or urinary volume (222.5 vs 210 vs 200 ml) between the three samples. In addition, there were no differences in fasting blood glucose (181.9 +/- 93.6 vs 194.6 +/- 104.7 mg%; P = NS) or glycosylated hemoglobin (HbA1) (8.4 +/- 1.3 vs 8.8 +/- 1.5%; P = NS) between the first and third blood samples. Six patients (group 1) had a mean urinary albumin concentration of more than 20 micrograms/ml for the three urine samples. This group was compared with the 44 patients (group 2) with a mean urinary albumin concentration for the three urine samples of less than 20 micrograms/ml. No difference was found between groups 1 and 2 in relation to fasting blood glucose (207.1 +/- 71.7 vs 187.6 +/- 84.6 mg/dl), HbA1 (8.1 +/- 0.9 vs 8.6 +/- 1.1%) or urinary volume [202 (48.3-435) vs 246 (77.3-683.3) ml]. Stepwise multiple regression analysis with albumin concentration of first morning urine samples as the dependent variable, and urinary volume, fasting blood glucose and glycosylated hemoglobin as independent variables, showed that only 12% (P = 0.01) of the albumin concentration could be accounted for by the independent effect of morning urine volume on the first day of urine collection. No urine samples showed a change in the cutoff level of 20 micrograms/ml of albumin concentration as the result of volume. Fasting blood glucose and glycosylated hemoglobin did not influence the urinary albumin concentration. Considerable variability in urinary albumin concentration was found in the three morning urine samples with a mean intraindividual coefficient variation of 56%. In conclusion, in the present study, urinary volume had a minimal, though not constant, effect on first morning urinary albumin concentration. Day-to-day metabolic and clinical control of IDDM patients, except probably for ketoacidosis, should not contraindicate microalbuminuria screening in first morning urine samples.

[Lipids, microalbuminuria and systemic blood pressure in patients with insulin-dependent diabetes mellitus]. / Perfil lipídico, microalbuminúria e pressão arterial sistêmica em pacientes com diabetes insulino-dependente.

PURPOSE: To determine the association between lipids, microalbuminuria and systemic blood pressure. Urinary albumin excretion rate (AER) was determined in timed overnight urine samples by radioimmunoassay. Microalbuminuria was defined when two out of three urine samples had AER ranging 20-200 micrograms/min. Lipids were determined by colorimetric methods (total cholesterol, HDL cholesterol and triglycerides). METHODS: Fifty patients with insulin dependent diabetes mellitus (28 females, 22 males) aged 21.9 +/- 7 years and with diabetes duration of 6.8 +/- 5.8 years attending the outpatients diabetes clinic were studied cross-sectionally. RESULTS: Microalbuminuria was present in 12% of our patients. A high systolic blood pressure (SBP) was found in microalbuminuric patients (p = 0.003). No difference concerning serum lipids were found in comparison between normo and microalbuminuric patients, although 20% of all patients had increased cholesterol and LDL cholesterol and 4% had high HDL cholesterol and triglycerides levels. Stepwise multiple regression analysis showed that SBP was the only significant independent variable to influence AER (r = 0.42 r2 = 0.18 p = 0.002). CONCLUSION: Although in our study, microalbuminuria was associated only with SBP, the independent alteration of lipids in young IDDM patients must be considered as a possible additional risk factor for cardiovascular disease.