Multicenter Analysis of Acquired Undescended Testis and Its Impact on the Timing of Orchidopexy.

OBJECTIVE: To assess whether late orchidopexy for undescended testis represents delayed treatment of primary undescended testis or later-occurring acquired undescended testis. STUDY DESIGN: We examined boys undergoing orchidopexy for cryptorchidism regarding age at surgery and entity of undescended testis. We characterized differences between primary undescended testis and acquired undescended testis and evaluated the knowledge regarding the diagnosis and management of acquired undescended testis among practicing physicians. We conducted an observational study using a mixed-method multicenter cross-sectional design. A total of 310 consecutive boys undergoing orchidopexy for undescended testis at 6 pediatric medical centers in Germany between April 2016 and June 2018 were investigated regarding testicular position at birth and age at surgery. In addition, a survey on acquired undescended testis management was carried out in 1017 multidisciplinary physicians and final-year medical students. RESULTS: Only 13% of all patients were operated on in their first year of life. Among patients with known previous testicular position (67%), primary undescended testis (n = 103) and acquired undescended testis (n = 104) were equally frequent. More than one-half (56%) of orchidopexies performed after the first year of life were due to acquired undescended testis. Remarkably, only 15% of physicians considered acquired undescended testis as an indication for late surgery. CONCLUSIONS: Acquired undescended testis is more common than previously perceived and accounts for a significant proportion of "late" orchidopexies in patients with undescended testis. Acquired undescended testis needs to be better recognized in clinical practice and screening should continue in older children with previously descended testes. TRIAL REGISTRATION: German Clinical Trials Registry: DRKS00015903.

A flow sensor suitable for use with split-flow ventilation--first preclinical data.

Volutrauma caused by artificial ventilation represents a major morbidity risk for premature infants. Our working group has recently developed an innovative "split-flow ventilation" system aiming at the reduction of tidal volumes (TVs). The main problem for the practical use of this system is the fact that conventional measurements of commercially available flow sensors are distorted by the split flow. In this study, we present the first preclinical data from testing an adapted flow sensor combination recognizing the split flow. A preterm infant test lung was conventionally ventilated, modified by insertion of a split-flow line. In addition to the customary flow sensor (FS-1), a second flow sensor (FS-2) was integrated into the split-flow line, and a third (FS-3) was placed at the exit of the test lung for reference measurements. The signals of all three flow sensors were read and processed by a computer. The program was set to graphically add up flow curves 1, 2, and 3 during one ventilation loop. After 10 runs, a mean curve of FS-1+2 was calculated and compared to the mean curve of FS-3. Furthermore, the mean TV of 10 runs measured by FS-1+2 was calculated and compared with the mean TV calculated by FS-3. The summation curve FS-1+2 proved identical to the reference curve FS-3. FS-1+2 yielded a TV of 6.6 +/- 0.01 mL (inspiratory) and 6.7 +/- 0.02 mL (expiratory). The corresponding values of FS-3 were 6.5 +/- 0.20 mL and 6.6 +/- 0.09 mL, respectively. According to our results, the presented flow sensor constellation allows exact flow measurements in the experimental setting and appears suitable for usage in a split-flow ventilation circuit under clinical conditions.

Effect of the Y-piece of the ventilation circuit on ventilation requirements in extremely low birth weight infants.

OBJECTIVE: Volutrauma caused by high tidal volumes contributes considerably to the development of bronchopulmonary dysplasia. Yet high tidal volumes are required to overcome dead space. In an experimental arrangement we tested whether reduction of dead space might reduce ventilation requirements and thus reduce volutrauma in preterm infants. MATERIALS AND METHODS: The time required to eliminate CO2 by standardized mechanical ventilation from a preterm infant's test lung flooded with CO2 was measured. Four different Y-pieces and flow sensor combinations were tested with and without a device for closed suction: Y-piece without flow sensor; integrated flow sensor; small dead-space flow sensor; and a new dead-space free-flow sensor for preterm infants. CO2 concentrations were measured by a capnograph. Mean CO2 elimination times (+/-SD) were compared. RESULTS: Mean CO2 elimination time was 37.5 s (+/-1.18 s) with and 37.4 s (+/-0.97 s) without closed suction device for the Y-piece without flow sensor, 47.7 s (+/-0.82 s) and 45.5 s (+/-1.18 s) for the integrated flow sensor, 42.5 s (+/-1.27 s) and 41.1 s (+/-0.99 s) for the small dead-space flow sensor and 38.3 s (+/-1.16 s) and 36.8 s (+/-0.79 s) for the dead-space free-flow sensor. CONCLUSION: CO2 elimination time with and without closed suction device was nearly identical for the Y-piece without flow sensor and for the dead-space free-flow sensor. With both systems, ventilation requirements were significantly lower than for the integrated flow sensor and for the small dead-space flow sensor (integrated flow sensor vs dead-space free-flow sensor 23.6 and 24.5%, respectively, small dead-space flow sensor vs dead-space free flow sensor 11.7 and 10.9%, respectively); thus, we think that introduction of the innovative dead-space free-flow sensor into clinical practice might reduce incidence and severity of bronchopulmonary dysplasia by reduction of volutrauma.

Dead-space washout by split-flow ventilation. A new method to reduce ventilation needs in premature infants.

OBJECTIVE: Chronic lung disease caused by volutrauma is one of the most important consequences of preterm delivery. In this pilot study a new method is presented that consists of flushing part of the dead space with fresh gas in order to reduce high tidal volumes, the chief cause of volutrauma. The aim of the study was to evaluate if the new method could reduce ventilatory effort in preterm infants by diminishing dead space. DESIGN AND SETTING: In split-flow ventilation, gas required for dead-space washout is split off from the regular ventilation circuit. The split flow bypasses the apparatus dead space and fills it retrogradely with fresh breathing gas, mainly in the pause between exhalation and inspiration. The mean per-minute ventilation and ventilation index after 12 h of conventional ventilation were compared with corresponding mean values after 12 h of split-flow ventilation in 17 preterm infants weighing <2,000 g. Statistical analysis was performed using the T -test for matched pairs. RESULTS: After switching from conventional ventilation to split-flow ventilation, the mean per-minute ventilation per kilogram of body weight decreased significantly from a mean value of 0.314+/-0.097 l/kg/min to 0.190+/-0.043 l/kg/min ( p <0.001), while the ventilation index decreased significantly from 28.47+/-7.48 to 16.10+/-4.13 ( p <0.001). CONCLUSION: Split-flow ventilation significantly reduces apparatus dead space during ventilation in preterm infants. This leads to reduced ventilatory effort.

Fatal air embolism in an extremely low birth weight infant: can it be caused by intravenous injections during resuscitation?

OBJECTIVE: A preterm infant with a birth weight of 384 g who succumbed to vigorous resuscitation for sudden respiratory failure on the third day of life is presented. Postmortem examination revealed, apart from extensive pulmonary hemorrhage, a fatal amount of air mainly in the right ventricle. We believe that this air had been introduced via peripheral venous cannulas due to inadvertent and unavoidable air admixture to each injection volume administered with a syringe, and we develop an experimental model to confirm that fatal amounts of air can indeed accumulate with frequent change over of syringes within a short period of time. DESIGN: An empty 50-ml syringe was connected to a 15-cm-long connection line via a three-way tap. With a 1 ml syringe 100 doses of 0.5 ml aqua were injected into the connection line. The amount of air which had collected in the 50 ml syringe after the 100 injection cycles was measured. This process was repeated three times each by three of the authors and the average air volume introduced with 100 injections calculated for each investigator. RESULTS: The average amounts of air which had entered the closed system after 100 acts of syringe assembly and aqua administration were 1.84, 1.95, and 2.0 ml. This corresponds to an average volume of almost 0.02 ml per injection.

Glucagon therapy as a possible cause of erythema necrolyticum migrans in two neonates with persistent hyperinsulinaemic hypoglycaemia.

UNLABELLED: Erythema necrolyticum migrans (ENM) usually presents as a cutaneous paraneoplastic phenomenon which is in most cases associated with a glucagon-producing tumour. Here it is for the first time described as a side-effect of glucagon treatment in persistent hyperinsulinaemic hypoglycaemia of infancy (PHHI). In both patients, the skin lesions disappeared after discontinuation of glucagon administration. In the first child the erythema resolved without scarring within 10 days after glucagon was substituted with other medication while in the second patient healing followed subtotal pancreatectomy which rendered glucagon infusion unnecessary. Initially the clinical resemblance to atopic dermatitis is prone to cause diagnostic errors, especially in this age group. CONCLUSION: erythema necrolyticum migrans should be considered as a differential diagnosis in patients who develop erythematosquamous skin lesions under glucagon treatment.