Rigler Sign in a Child With Posttransplant Lymphoproliferative Disease: A Sign That Should Not Be Missed.

Rigler sign is a double wall sign suggesting pneumoperitoneum and intestinal perforation, and it needs emergency surgical treatment. Early diagnosis of intestinal perforation by clinical symptoms, presence of Rigler sign in abdominal radiography, and then early surgical treatment can reduce mortality. Here, we report a patient with Crigler-Najjar syndrome who underwent liver transplant and then developed posttransplant lymphoproliferative disease and received chemotherapy with cyclophosphamide, doxorubicin, vincristine, and prednisone plus rituximab. She was referred to the emergency department due to abdominal distension with positive Rigler sign in abdominal radiography; intraoperative findings revealed intestinal perforation. Pediatricians and surgeons should be aware of Rigler sign so that it is diagnosed early and emergency surgical treatment can be performed.

Ultrasound for Localization of Central Venous Catheter: A Good Alternative to Chest X-Ray?

BACKGROUND: Chest radiography after central venous catheter (CVC) insertion is the main method of verifying the catheter location. Despite the widespread use of radiography for detecting catheter position, x-ray may not always be readily available, especially in the operating room. OBJECTIVES: We aimed to compare contrast-enhanced ultrasonography (CEUS) and chest radiography for detecting the correct location of CVCs. METHODS: One hundred sixteen consecutive patients with indications for CVC before cardiac surgery were enrolled in this observational study. After catheter insertion, CEUS was performed. Portable radiography was obtained postoperatively in the intensive care unit. Sensitivity, specificity, and predictive values were determined by comparing the ultrasonography results with radiographic findings as a reference standard. RESULTS: Chest radiography revealed 16 CVC misplacements: two cases of intravascular and 14 cases of right atrium (RA) misplacement. CEUS detected 11 true catheter malpositionings in the RA, while it could not recognize seven catheter placements correctly. CEUS showed two false RA misplacements and five falsely correct CVC positions. A sensitivity of 98% and specificity of 69% were achieved for CEUS in detecting CVC misplacements. Positive and negative predictive values were 95% and 85%, respectively. The interrater agreement (kappa) between CEUS and radiography was 0.72 (P < 0.001). CONCLUSIONS: Despite close concordance between ultrasonography and chest radiography, CEUS is not a suitable alternative for standard chest radiography in detecting CVC location; however, considering its high sensitivity and acceptable specificity in our study, its usefulness as a triage method for detecting CVC location on a real-time basis in the operating room cannot be ignored.

Complementory Value of Sonography in Early Evaluation of Necrotizing Enterocolitis.

BACKGROUND: Despite the widespread use of plain films to detect necrotizing enterocolitis (NEC), it is considered a time-consuming method, which exposes patients to radiation. We aimed to assess changes in ultrasonographic variables and to compare sonograhy and chest radiography in detecting early stages of NEC in suspected premature infants. MATERIAL/METHODS: This case-control study was carried out in the years 2012-2013. We enrolled 67 premature neonates using a simple sampling method and divided them into the study and control groups. All patients underwent plain abdominal radiography, gray-scale and color Doppler sonography. RESULTS: 34 and 33 neonates were assigned to the study and control groups. No significant gender differences were found between the two groups (P=0.549). The mean bowel wall thickness ranged from 1.2 to 3.2 mm in the control group (132 abdominal quadrants) and 1-3.3 mm in the study group (136 abdominal quadrants, P=0.502). Intra-mural echogenic dots were seen in one neonate in the study group in favour of pneumatosis intestinalis. The mean ±SD bowel wall perfusion in the study and control groups were 3.117±0.975 and 2.878±0.538 dots or lines/cm(2), respectively (P=0.218). One neonate in the study group showed internal echoes within the mild amount of free fluid. Twelve neonates in the control group had minimal amounts of intra-abdominal free fluid. CONCLUSIONS: The two groups differed regarding bowel wall thickness, echogenicity, and perfusion in sonograhy and color Doppler evaluation. Although those differences were not statistically significant, considering the time-consuming nature of abdominal X-ray, the use of sonograhy and color Doppler can improve diagnosis and treatment of NEC as a triage method.

The effects of low and high dose oral calcium and phosphor supplementation on nephrocalcinosis diagnosed by sonography in premature and low birth weight neonates.

UNLABELLED: Nephrocalcinosis is defined as calcium deposition in the renal interstitium. One of the major causes of neonatal nephrocalcinosis is the use of calcium and phosphor supplements for premature neonates. This study aims at assessing the effects of calcium and phosphor supplementation in neonatal nephrocalcinosis by renal ultrasonography. In this randomized controlled trial, 37 premature neonates with birth weights <1500 g or a gestational age of <34 weeks were considered. Two different doses of calcium 75 vs. 230 mg/kg/day and phosphor 50 vs. 110 mg/kg/day were prescribed and laboratory and sonographic data were then documented and evaluated. The incidence of nephrocalcinosis was 47.8% in group 1 and 28.6% in group 2. There was a significant association between NC and positive family history of renal stones, shorter duration of TPN and NICU stay. The amount of calcium dosage, gestational age, birth weight, sex, use of surfactants, and mechanical ventilation did not have any significant association with NC. In this study, the neonates with NC were mostly the white flake type (8 cases) and the majority of the lesions were 1-2 mm. All the lesions were located in the pyramid and papilla areas, acoustic shadows were not prevalent and stones were not observed in any of the patients. TRIAL REGISTRATION NUMBER: IRCT2013060810441N3.

Evaluation of thymic changes after median sternotomy in children.

In patients who undergo median sternotomy to treat congenital heart diseases, a thymectomy is performed to yield better access to the cardiac system. In this study we have used MRI to evaluate the changes in size, shape and location of the thymus after midsternatomy. This case-control study was performed during 2011-2012 in Shiraz, Iran. Eligible participants between 5-17 years of age were divided into case and control groups (n=13 per group). Each participant underwent a median sternotomy at least one year prior to study entry. Participants were initially examined by a cardiologist and then referred for MRI. A radiologist examined all MRI images. The thymus was observed in all control group patients and in only 7 (53.8%) patients in the case group. There was a significant relationship noted in terms of mean age in the group whose thymus was visible and the group in which the thymus was not visible. We have observed no significant difference in thymic visibility between these two groups based on the mean age at midsternatomy. In pediatric patients undergoing cardiac surgery the possibility of remaining or regenerated thymic tissues may be evaluated by MRI. The remaining portion of the thymus may have any shape, size or location. Therefore, it can be misinterpreted as a mass if a patient's previous surgical history and age at the time of surgery are not taken into consideration.

Benefit of urinalysis.

OBJECTIVE: In the pilot Iran school screening programme, the minimal cost of screening dipstick urinalysis in 1601 asymptomatic school children was determined. METHODS: The cost of screening dipstick urinalysis was calculated by reviewing the literature for the prevalence of asymptomatic proteinuria, hematuria, bacteriuria, and glucosuria determined by an initial dipstick urinalysis. The minimal cost utilizing data of 3 general physicians was calculated. Costs were determined by using current charge for supplies ordered to perform tests, charges for tests performed by a commercial laboratory, and the cost of a final evaluation by a pediatric nephrologist. RESULTS: 4.7% (76/1601) of patients were calculated to have an initial abnormal urinalysis. Upon retesting 1.37% (22/1601) of patients were calculated to have a persistent abnormality. The calculated cost was $167 to initially screen all 1601 patients with a dipstick urinalysis or $0.092 per patient. The calculated cost to evaluates the 22 patients with any persistent abnormality on repeat dipstick urinalysis was $0.02 or $0.001 per patient. This is the calculated cost for a single screening of 1601 asymptomatic pediatric patients. CONCLUSION: Multiple screening dipstick urinalysis in asymptomatic pediatric is costly and should be discontinued. We propose that a single screening dipstick urinalysis be obtained at school entry age, between 6 and 7 years, in all asymptomatic children.

Determination of the incidence and severity of hoarseness after cardiac surgery.

BACKGROUND: The aim of the study was to determine the incidence and severity of hoarseness and vocal cord dysfunction in 200 patients undergoing open heart surgery in Shiraz-Iran. MATERIAL/METHODS: This study involved prospective evaluation of 200 patients who underwent open heart surgery during the year 2003 in Shiraz University hospitals. All patients received the same standard anesthetic technique. In post-operative course, all patients were electively ventilated for variable periods depending on several factors, at least until the morning after surgery. All patients underwent direct laryngoscopy immediately after extubation by the otolaryngologist, and the existence and grade of hoarseness was evaluated on a four-point scale 6 and 12 hours after extubation. RESULTS: Two hundred patients, 64.5% male and 35.5% female, with a mean age of 56.7 (S.D. = 5.2) were evaluated. CABG was performed most frequently and the mean duration of cold perfusion was 122 minutes (S.D. = 15). CVP insertion, endotracheal intubation, sternotomy, and hypothermia were performed in all patients. Hoarseness was found to be present in 17% of patients; all but one were rated to be grade one on the four-point scale. However, laryngoscopy did not reveal anything specific. CONCLUSIONS: The incidence of hoarseness in this study was 17%; similar series reported as high as 32%. Vocal cord dysfunction never occurred in our study and hoarseness probably resulted from intubation trauma. Although we found no case of nerve injury and cord dysfunction, vocal cord palsy as a rare cause of respiratory insufficiency in chest and neck surgeries must never be overlooked.