The association of postnatal urinary tract dilation risk score with clinical outcomes.

BACKGROUND: There are limited data on the predictive value of the consensus urinary tract dilation (UTD) score with respect to subsequent clinical diagnoses. We sought to define the relationship between postnatal UTD risk score and clinical outcomes during childhood. METHODS: Complete ultrasound image sets from a random selection of infants aged 0-90 days undergoing initial ultrasound at a single institution for prenatal hydronephrosis between 2012 and 2014 were assigned a UTD score by 1 pediatric urologist and 1 pediatric radiologist. Urinary tract dilation risk score was analyzed for association with a composite outcome comprising urinary tract infection, vesicoureteral reflux (VUR), ureteropelvic junction obstruction, non-refluxing megaureter (NRM), ureterocele, bladder outlet obstruction (BOO), and chronic kidney disease. Surgical intervention and resolution of UTD were evaluated separately. Descriptive and survival analyses were performed. RESULTS: Urinary tract dilation scores for 494 subjects were P0 in 23.5%, P1 in 26.5%, P2 in 23.5%, and P3 in 26.5%. Seventy-four percent were male. Median age at initial imaging was 28 days; median follow-up was 19.8 months. The composite outcome occurred in 138 of 494 patients (27.9%) and varied significantly (p < 0.001) by UTD score: 11.2% for P0, 10.7% for P1, 29.3% for P2, and 58.8% for P3. On survival analysis (Summary Figure), higher UTD grade was significantly associated with the composite outcome (hazard ratio for P3 vs. P0 was 7.4 [95% CI: 3.44-15.92, p < 0.001]). Urinary tract infection and VUR diagnosis varied by UTD score (p = 0.03 and p < 0.001, respectively). Ureteropelvic junction obstruction was diagnosed (based on MAG3 results) in 6.3% of patients, 84% of whom were P3. Non-refluxing megaureter was diagnosed in 7.7%. Ureterocele and BOO were uncommon (1.4%, and 0.6%, respectively). Surgical intervention was also associated with UTD risk, with 46% of P3 undergoing surgery vs. 1% of P0, 1% of P1, and 6% of P2 (p < 0.001). Resolution of UTD occurred in 41% (median 10.1 months) and varied significantly by UTD risk (p < 0.001). DISCUSSION: Urinary tract dilation risk score is associated with clinical events, although ascertainment bias may influence some of the differences in outcomes, particularly for VUR, because VCUG utilization varied by the UTD group. The lack of any significant difference in outcomes between patients with UTD P0 versus P1 suggests that the P1 category could be eliminated as it does not meaningfully distinguish between outcome risk. CONCLUSIONS: Higher UTD risk scores are strongly associated with genitourinary diagnoses during the first two years of life.

Outcome of pregnancies in women with uterine leiomyomas identified by sonography in the first trimester.

PURPOSE: We assessed the outcome of pregnancies in women with uterine leiomyomas (fibroids) documented by sonography in the first trimester of pregnancy. METHODS: We collected cases of women who had undergone first-trimester sonography and had uterine fibroids and singleton pregnancies with documented fetal heartbeats. We compared pregnancy loss rates and modes of delivery in these cases to a maternal-age-matched and gestational-age-matched control group of women who had normal uteruses and first-trimester pregnancies with documented fetal heartbeats. Sonograms in patients with fibroids were reviewed to determine the number of fibroids, their sizes, and their locations. Within the group of patients with fibroids, the pregnancy loss rate was also compared based on the number of fibroids and fibroid size and location. RESULTS: Our study population consisted of 143 women with leiomyomas, and our control group comprised 715 patients with a normal uterus. Among patients with fibroids, 14.7% of pregnancies resulted from assisted conception; in the control group, 6.4% of pregnancies resulted from assisted conception. The rate of spontaneous pregnancy loss in women with fibroids was almost twice the rate in women with normal uteruses (14.0% versus 7.6%; p < 0.05), and the loss rate was higher in women with multiple fibroids than in women with a single leiomyoma (23.6% versus 8.0%, p < 0.05). The loss rate was not significantly associated with fibroid size or location. The rate of cesarean-section delivery was higher in patients with fibroids than in patients with normal uteruses (38% versus 28%, p < 0.05). CONCLUSIONS: Uterine fibroids are associated with an elevated risk of spontaneous pregnancy loss. The loss rate is higher in patients with multiple fibroids than with a single fibroid. The cesarean-section rate is also higher in patients with fibroids than in patients with a normal uterus.

Frequency of a monochorionic pair in multiple gestations: relationship to mode of conception.

OBJECTIVE: To determine whether the mode of conception affects the frequency of monochorionicity in multiple gestations. METHODS: Our study population consisted of all women with multiple gestations who had a first-trimester sonogram at our institution between May 1998 and April 2000. The frequency of monochorionicity in pregnancies conceived naturally was compared with the frequency in pregnancies achieved via any form of assisted reproductive technology and among the different types of assisted reproductive technology. RESULTS: Our study consisted of 464 multiple gestations comprising 332 twin, 113 triplet, 16 quadruplet, and 3 quintuplet pregnancies. The higher the fetal number, the more likely the pregnancy resulted from assisted reproductive technology (72.6% of twins, 84.1% of triplets, 92.8% of quadruplets, and 100% of quintuplets; P < .05, Fisher exact test). Monochorionic pairs were found more commonly in naturally conceived pregnancies than in those resulting from assisted reproductive technology (28.2% versus 5.4%; P < .000001, chi2 test). The frequency of monochorionic pairs after in vitro fertilization with blastocyst transfer on day 5 (10.5%) was double the frequency from in vitro fertilization with cleavage stage transfer on day 3 (4.9%), but the difference was not statistically significant (P = .24, Fisher exact test). CONCLUSIONS: Monochorionic pairs are relatively common in naturally conceived twins and in higher-order multiple gestations with more than 3 fetuses arising from assisted reproductive technology, but they are uncommon in twins and triplets arising from assisted reproductive technology There is a trend toward a higher frequency of monochorionic pairs after day 5 blastocyst transfer than day 3 transfer, but a larger study population is needed to confirm this finding.

Case report: galactography-guided wire localization of an intraductal papilloma.

Galactography is used to evaluate spontaneous unilateral nipple discharge by catheterization of the duct orifice and instillation of radiopaque contrast material. The most common cause of a bloody discharge is an intraductal papilloma which appears as a smooth lobulated intraluminal filling defect or a solitary obstructed duct on galactography. Carcinomas may be the cause of up to 13% [1] of abnormal nipple discharge and cannot be reliably distinguished from papillomas at galactography. Thus any intraductal filling defect or irregularity in symptomatic patients should be surgically evaluated to obtain a tissue diagnosis. Unfortunately, the histologic examination of the biopsy specimen does not always identify the lesion seen at galactography [2]. A potentially more reliable method of locating lesions identified on galactography is described. Chow, J. S. (2001). Clinical Radiology56, 72-73.

Outcome of pregnancies with rapid embryonic heart rates in the early first trimester.

OBJECTIVE: We conducted a study to determine the upper limits of normal embryonic heart rate at or before 7.0 weeks' gestational age and to assess outcome of pregnancies in which the early embryonic heart rate is rapid. SUBJECTS AND METHODS: We recorded embryonic heart rates in 2817 sonograms at or before 7.0 weeks' gestation performed between January 1993 and June 1998. The upper limit of normal heart rate in two gestational age ranges (before 6.3 weeks and 6.3-7.0 weeks) was computed as the average of two values: mean heart rate + 1.96 standard deviations and the rate above which 2.5% of embryos in our population were measured. Pregnancy outcome in cases with rapid embryonic heart rates was compared with pregnancy outcome in a control group with normal rates. RESULTS: The upper limit of normal heart rate was 134 beats per minute before 6.3 weeks' gestation and 154 beats per minute at 6.3-7.0 weeks' gestation. Forty-one embryos had rapid early heart rates and known first-trimester outcome, of which 37 (90.2%) were alive at the end of the first trimester. Pregnancy outcome was available in 33 of the 37 first-trimester survivors (four were lost to follow-up before delivery), and 30 of these 33 (90.9%) were healthy neonates. These short- and long-term outcomes were not significantly different from those of the control group of embryos with normal early heart rates (p > 0.20, Fisher's exact test). CONCLUSION: A rapid early embryonic heart rate is one that is at least 135 beats per minute before 6.3 weeks or at least 155 beats per minute at 6.3-7.0 weeks. Pregnancies in which the embryo has a rapid early heart rate have a good prognosis, with a high likelihood of normal outcome.

Long-term prognosis of pregnancies complicated by slow embryonic heart rates in the early first trimester.

Slow embryonic heart rates at gestational age 7 weeks or less are associated with high risk of first trimester death. Our goal was to determine the prognosis for those embryos with slow early heart rates who survive the first trimester. We prospectively recorded embryonic heart rates for all obstetrical sonograms obtained on singleton pregnancies at or before 7.0 weeks' gestation since 1993. We collected information about pregnancy outcome, including date of live birth or in utero death and presence and nature of congenital anomalies. First trimester survival rate was 61.6% among 531 embryos with slow early heart rates (< 100 bpm at < or = 6.2 weeks, < 120 bpm at 6.3 to 7.0 weeks), lower than the survival rate of 91.5% among 1501 embryos with normal heart rates (p < 10(-8), Fisher's exact test). Among 299 pregnancies in which the early heart rate was slow and the fetus was still alive at the end of the first trimester, 277 (92.6%) resulted in liveborn infants without congenital anomalies, similar to the frequency of 95.1% in cases with normal early heart rates (p > 0.10, Fisher's exact test). Structural and chromosomal anomalies, however, occurred more than twice as frequently in cases with slow early heart rates: 5.4% (16 of 299) of the first trimester survivors with slow early heart rates proved to have anomalies, as compared to 2.4% (31 of 1281) of cases with normal early heart rates (p < 0.05, Fisher's exact test). In conclusion, a pregnancy in which the embryo has a slow heart rate at or before 7.0 weeks' gestation and which continues beyond the first trimester has a high likelihood (> 90%) of resulting in a liveborn neonate without congenital anomalies. Embryos with slow early heart rates do, however, have a greater risk of having anomalies than embryos with normal early heart rates.

Frequency and nature of structural anomalies in fetuses with single umbilical arteries.

Published studies differ concerning the rate of anomalies occurring in the presence of a single umbilical artery and the significance of the single umbilical artery as an isolated sonographic finding. We assessed the frequency, nature, and sonographic detection of structural anomalies in fetuses with a single umbilical artery. We identified all cases in which prenatal sonography diagnosed a single umbilical artery. Cases were excluded if postnatal physical or pathologic examination demonstrated a three-vessel cord, yielding a study population of 167 cases. For each case, we recorded the gestational age at diagnosis of single umbilical artery and the findings of the sonographic fetal anatomic survey. We recorded postnatal clinical and pathologic information when available. Gestational age at time of diagnosis ranged from 16.8 to 41.1 weeks (mean, 29.2 +/- 6.5 weeks). Twenty of the 167 fetuses (12%) were twins, and the remainder were singletons. Among 118 cases with postnatal information, 37 (31%) had structural abnormalities, often involving multiple organs. The most common organ systems involved were the heart (19 cases) and the gastrointestinal (14 cases) and central nervous systems (nine cases). Five of the anomalous fetuses had abnormal karyotypes. The sonographic survey was abnormal in 31 of the 37 anomalous fetuses (84%). Among 85 cases with apparently isolated single umbilical artery at sonography and known fetal outcome, six (7%) proved to be anomalous at birth. We had two sonographic false-positive results (mild hydronephrosis, suspected skeletal dysplasia). In summary, approximately one third of fetuses with single umbilical artery have structural anomalies, most often cardiac. Even when the single umbilical artery is an apparently isolated sonographic finding, the likelihood that the neonate will prove to have structural anomalies is considerable (7% in our series).

A population-based study of the incidence of malignant small bowel tumours: SEER, 1973-1990.

BACKGROUND: Little is known about the incidence of cancers of the small bowel. METHODS: Data from cancer registries participating in the Surveillance, Epidemiology, and End-Results (SEER) Program from 1973 to 1990 were analysed to determine the incidence of the four major histological types of cancer occurring in the small intestine: adenocarcinomas, malignant carcinoid tumours, lymphomas and sarcomas. In addition, the incidence rate of lymphomas arising from the small intestine and stomach and adenocarcinomas from the small intestine, stomach and colon were compared over time. RESULTS: Small bowel tumours occurred rarely, with an average annual incidence rate of 9.9 per million people. Carcinoid tumours and adenocarcinomas were the most common histological subtypes, with average annual incidence rates of 3.8 and 3.7 per million people respectively, followed by lymphomas (1.1 per million people) and sarcomas (1.3 per million people). For all histological subtypes, men had higher rates than women. Most tumours occurred in older adults; over 90% of cases occurred in people over the age of 40. During the 18-year study period, the incidence of small bowel tumours has risen slowly. In white men, black men and black women, rises in the incidence of adenocarcinomas, malignant carcinoids and lymphomas contributed to this trend. In white women, the incidence of adenocarcinomas, was stable while malignant carcinoids and lymphomas rose. The incidence of sarcomas was steady for all groups except black women, for which it fell. The histological types were distributed by anatomical subsite: adenocarcinomas were distributed more proximally on average whereas lymphomas were more common distally. In addition, there was an association between the incidence trends of adenocarcinomas occurring in the duodenum and colon suggesting similar risk factors for cancers in these regions. There was no similar correlation for tumours in the jejunum and ileum. The incidence of lymphomas over time rose in all areas of the small intestine, paralleling a similar rise in lymphomas of the stomach. CONCLUSIONS: Cancers of the small bowel are rare despite a slow increase over the past two decades, especially among lymphomas. Higher rates in males and whites deserve further investigation.

Two years experience with the Palmaz-Schatz coronary stent in a heterogeneous patient population.

Between January 1991 and December 1992, 136 Palmaz-Schatz coronary stents were implanted in 113 native coronary arteries in 106 patients. Forty-seven patients presented with stable angina, 50 with unstable angina, 7 with congestive cardiac failure and unstable angina and 2 were asymptomatic. Stenting was carried out in 15 patients for restenosis after coronary angioplasty (PTCA), 32 for significant dissection during PTCA (with 19 acute and 13 threatened closure), 10 for suboptimal PTCA results and 56 for de novo lesions, 52 (92.9%) of which were either ACC/AHA type B or C. Successful delivery was achieved in 97.2% (103/106) of patients or 97.3% (110/113) of vessels. Percent diameter stenosis was reduced from 78 +/- 13% to 4 +/- 11%. There were two subacute stent thromboses (1.9%), resulting in Q-Wave myocardial infarction. Three deaths (2.9%) occurred, all from the group with congestive cardiac failure and unstable angina. Major bleeding/vascular complications occurred in 4 patients (3.9%). All patients were followed up for a mean of 18 months (6 months to 30 months). Eighty-five patients were asymptomatic. Three patients were angina-free but continued to have, albeit improved, congestive cardiac failure. Ten patients had recurrence of angina, all within 6 months of the stenting procedure. Four were treated medically and 4 had PTCA of whom one eventually had coronary bypass surgery. Two patients had new lesions, successfully treated by PTCA or stenting. In conclusion, a high rate of successful delivery of the Palmaz-Schatz coronary stent can be achieved in a wide spectrum of patients with few complications which are mostly related to anticoagulation. It offers very effective bailout for acute closure during PTCA. Despite the presence of unfavorable pre-procedure patient and lesion characteristics, the acute and long term clinical results are encouraging.

Combined use of warfarin and adjusted subcutaneous heparin during pregnancy in patients with an artificial heart valve.

Adjusted subcutaneous heparin was used for thromboembolism prophylaxis during 18 pregnancies in 16 women with an artificial heart valve. Oral warfarin was replaced by subcutaneous heparin as soon as pregnancy was confirmed. The dosage of heparin was adjusted to maintain a partial thromboplastin time at 1.5 times the control value and treatment was administered during the first trimester and the last 3 weeks of gestation. Warfarin was used between the 13th and 37th week. There were no maternal thromboembolic complications and none of the live-born infants showed congenital malformations, indicating that this regimen is effective. However, there were nine spontaneous abortions, including five that occurred in the first 12 weeks. The early abortions were probably related to warfarin exposure at the beginning of pregnancy. The preconception replacement of warfarin by heparin in these patients may be indicated.

Percutaneous transfemoral catheterization in aortic stenosis with a USCI Sones catheter curve A type 1 (7540).

We report our experience with the use of a USCI Sones catheter curve A type 1 (7540) to cross the aortic valves of 45 patients with clinically significant aortic stenosis. The technique was successful in all our patients with a fluoroscopic time of less than 3 min. A gradient of up to 200 mmHg across the aortic valve area was recorded, and the smallest valve area calculated was less than 0.2 cm2. The method obviated the need for a guidewire and satisfactory left ventriculograms were obtained. No major complication was observed. We conclude that the technique is a simple, rapid, and safe means of obtaining left ventricular hemodynamic and angiographic information in patients with aortic stenosis of various degrees of severity.

Acute haemodynamic and myocardial metabolic effects of intravenous urapidil in severe heart failure.

The acute haemodynamic and myocardial metabolic effects of intravenous urapidil were evaluated in 12 patients with severe congestive heart failure due to coronary heart disease. Urapidil was given intravenously (0.5 mg kg-1 min-1 as a bolus) followed by infusion at a rate of 4 micrograms kg-1 min-1 for 120 min. Following urapidil administration, cardiac index increased by 29%, mean pulmonary artery wedge pressure fell by 35% and systemic vascular resistance by 33%. The fall in mean arterial pressure was moderate. No significant alterations in coronary sinus blood flow, myocardial oxygen consumption and myocardial lactate extraction occurred. No untoward effect was observed. This study shows that intravenous urapidil produces beneficial haemodynamic effects without a deleterious effect on myocardial metabolism in patients with heart failure due to coronary heart disease.

A case of hemorrhagic dengue without hypovolemia in an adult.

Dengue hemorrhagic fever, though prevalent in South East Asia was diagnosed for the first time in Hong Kong. The subject in this report made frequent visits to endemic areas including the Philippines. Hypovolemia was not evident at the time of presentation. The nature and the status of the disease in this area are discussed.

Efficacy of low-dose, subcutaneously administered heparin in treatment of pregnant women with artificial heart valves.

Between 1979 and 1982, the efficacy of fixed low-dose heparin, administered subcutaneously as thromboembolic prophylaxis, was studied during 14 pregnancies in 10 patients with mechanical heart valves. Calcium heparin (5000 units every 12 hours) was substituted for warfarin during the first trimester and the last month of pregnancy. Although the regimen was well tolerated and was associated with only 14% of first-trimester abortions, five episodes of thromboembolism occurred in four patients. Thus, this fixed, low-dose heparin regimen did not provide adequate thromboembolic prophylaxis in patients with prosthetic heart valves during pregnancy.

Familial occurrence of mitral valve prolapse: is this related to the straight back syndrome?

Familial prevalence of mitral valve prolapse in a Chinese population was determined in 22 propositi of whom 10 had straight back (group A), three had abnormally high metacarpal index (group B), and nine had neither (group C). Of 71 (32 male and 39 female subjects) first degree relatives screened, mitral valve prolapse was found in 19 (seven male and 12 female subjects) (26.8%). The familial prevalence among groups A, B, and C was 20%, 30%, and 38.5%, respectively. Our study indicates that the familial occurrence of mitral valve prolapse does not depend on its association with the straight back syndrome.

Intravenous ranitidine has no hemodynamic effects in subjects with normal lung function and patients with chronic obstructive airway disease.

Ten patients with Chronic Obstructive Airway Disease (COAD) and five subjects with duodenal ulcers and normal lung function were given 50 mg ranitidine as a single intravenous bolus injection. Hemodynamic responses were continuously monitored. There were no significant alterations in systemic and pulmonary pressures, systemic and total pulmonary vascular resistances or cardiac output. Continuous ECG recordings did not reveal arrhythmias. Ranitidine does not appear to cause any significant disturbance of hemodynamic function in COAD patients. This contrasts with alterations in hemodynamics previously observed following administration of cimetidine.

Skeletal abnormalities in mitral-valve prolapse.

One hundred and fifteen Chinese patients with mitral-valve prolapse were evaluated for skeletal abnormalities, to determine their prevalence and interrelation. Measurements of thoracic dimensions from radiographs differed significantly from the normal population. The commonest thoracic abnormality was the straight back, being present in 37.5% of the male and 26.9% of the female patients. Accurate quantitation of thoracic kyphosis was difficult. Either the ratio between antero-posterior and transverse thoracic diameters or a vertebral index characterised the straight back. Other abnormalities included scoliosis, sternal and rib deformities. The mean of metacarpal indices for the patients was also significantly higher than the normal mean. An abnormal metacarpal index was present in 20.9%. There was dissociation between peripheral and thoracic skeletal abnormalities. The diagnostic, aetiological and prognostic implications of associated skeletal abnormalities were discussed.