Three-dimensional assessment of umbilical vein deviation angle for prediction of liver herniation in left-sided congenital diaphragmatic hernia.

OBJECTIVES: To introduce a new sonographic marker of intrathoracic liver herniation in fetuses with left-sided congenital diaphragmatic hernia (CDH). METHODS: In a consecutive series of fetuses with isolated CDH, an ultrasound volume of the fetal abdomen was acquired. On this volume, offline calculation of the angle formed by the midline of the abdomen (joining the center of the vertebral body to the abdominal insertion of the umbilical cord) and a second line joining the center of the vertebral body to the intra-abdominal convexity of the umbilical vein was carried out to give the umbilical vein deviation angle (UVDA). The UVDA was measured in a group of normal fetuses selected as controls. At follow-up, the presence of liver herniation was investigated in all cases of CDH. UVDA values were compared between the CDH group and controls, and between CDH 'liver-up' vs 'liver-down' cases. A receiver-operating characteristics (ROC) curve was constructed to identify a cut-off value of the UVDA with the highest accuracy in predicting liver herniation in the CDH group. RESULTS: Between 2009 and 2015, 22 cases of left-sided CDH were included in the study group, of which nine cases had liver herniation. Eighty-eight normal fetuses were recruited as controls. The UVDA was significantly higher in the cases vs controls (15.25 ± 7.91° vs 7.68 ± 1.55°; P < 0.0001). Moreover, the UVDA was significantly increased in CDH fetuses with liver-up vs liver-down (21.77 ± 8.79° vs 10.75 ± 2.10°; P < 0.0001). On ROC curve analysis the UVDA showed good prediction of liver herniation (area under the ROC curve, 0.94; P < 0.0001) with the best cut-off of 15.2°, yielding a sensitivity of 89% and a specificity of 100% (P < 0.0001). CONCLUSIONS: In fetuses with CDH, umbilical vein bowing may be quantified by measuring the UVDA using three-dimensional ultrasound. This sonographic marker seems to be an accurate predictor of liver herniation in left-sided CDH. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

The code of conduct of the volunteer.

Voluntary service has experienced a considerable expansion and a substantial change over the last two decades. The role of the volunteer has gradually come to interact with activities undertaken by other professionals, but without interfering. Since the role of the volunteer naturally involves autonomy and discretion on his/her behalf, the associations concerned increasingly feel the need to refer to standards defining a voluntary service ethic. Within a refresher course with a set number of places for non-profit-making organisations, which was arranged by the Italian League against Cancer, Milan, a consensus conference for the ratification of a code of conduct on voluntary service was held. The aim was to reach a consensus together with others who work in an "organised" manner every day, on ethical concepts that should inspire voluntary service: the common good, mutual respect, freedom of choice, a non-profit-oriented vision. After exhaustive discussions by three panels, the text of a code of conduct unanimously approved was elaborated. All concerned with this code tried to avoid giving it a "sanitary" imprint. It is in fact our opinion that whatever the area covered by voluntary service, its aim and its final objective is to ensure the wellbeing of mankind and his environment.