Mini-thoracotomy and chest tube insertion for children with empyema.

In contrast to the two prior decades, empyema in children has become a rare disease during the past 10 years. Thirty-two children with empyema from all causes were treated at The Children's Memorial Hospital in Chicago in the 11 years between 1970 and 1982. Twenty cases followed postinfectious pneumonia, most commonly due to Staphylococcus aureus. The remaining patients had either an esophageal leak or a pleural infection following an intrathoracic operation. Fourteen of our patients were managed with a "mini-thoracotomy," which allowed accurate drainage of purulent material, débridement of fibrinous exudate, and rapid expansion of the lung with prompt relief from fever and toxicity. In our hands, this procedure provided results which were superior to those obtained with simple closed chest tube drainage. In addition, during this period of time, ultrasound examination of the chest has provided a rapid, accurate technique for the early detection and localization of fluid accumulations within the pleural cavity. Pre-drainage thoracentesis can be accurately guided by ultrasonic imaging.

Intracranial complications of pediatric hematologic disorders: computed tomographic assessment.

Computed tomography (CT) findings in the intracranial complications of leukemia, hemophilia, and sickle cell anemia were reviewed in 19 children with these hematologic disorders. CT demonstrated intracranial hemorrhage, infarction, intracerebral mass, and post-therapeutic atrophy and leukoencephalopathy in leukemic children. Intracerebral, subarachnoid, subdural, and epidural hemorrhage was documented in patients with hemophilia. Bland and hemorrhagic infarctions were identified in children with sickle cell anemia. CT proved valuable in documenting the presence and extent of these abnormalities, titrating factor replacement in hemophiliac patients, and monitoring therapeutic toxicity in leukemic patients.

Radiological approaches in the evaluation of joint disease in children.

In summary, the newer technologies in radiology have allowed us to visualize more clearly the manifestation of joint disease in children. The presence of small erosions and cartilage damage can be seen much better with magnetic resonance imaging than with any other modality short of arthrography, a much more invasive examination. Joint effusion, although sometimes visualized with conventional radiography, is probably best recognized with ultrasound or magnetic resonance imaging, although it can be detected with computed tomography as well. For the evaluation of avascular necrosis that can be associated with steroid use in joint disease, bone scintigraphy is a simple, sensitive method. Magnetic resonance may be as or more sensitive and gives additional information as well. In the detection of change with time, conventional radiography probably will remain the standard as it is still the simplest, least expensive examination; however, it has many limitations in specific cases. Bone scintigraphy may be of value in selected cases. Although we have still not had enough experience with magnetic resonance imaging to use it as a way of evaluating progress of joint disease, it promises to be the most sensitive radiologic measure of evaluating progress as small anatomical changes can be detected within the cartilage, which cannot be done easily with other means.

Ultrasound prior to amniocentesis for genetic counseling.

Ultrasonic placental and fetal head localization, although not mandatory, may minimize the risks of amniocentesis for use in genetic counseling. It permits choosing a site other than low midline with a low-lying anterior placenta; with a posterior placenta, the insertion within the amniotic cavity should stop short of the placenta. Although complications of amniocentesis in the second trimester without ultrasound have been very few, it seems worthwhile to try to decrease even this small risk by the use of ultrasound.

Eight-minute excretory urographic film: once is enough.

A film reading exercise was developed to test the advisability and accuracy of using one "postinfusion" roentgenogram instead of a series of films for a complete antegrade urographic evaluation. The experience of the radiologist making the interpretations was also considered. In most cases a singly eight-minute postinfusion delayed film showed enough detail to rule out pathology when none existed and adequately revealed either specific abnormal findings or suggested an abnormality existed when such was indeed present. No false negative call was made by and of the radiologists, but experience did aid in detailing the pathology.

Ultrasonography and diagnosis of pediatric genitourinary rhabdomyosarcoma.

Rhabdomyosarcoma is the most common tumor of the lower genitourinary tract in children during their first two decades of life. Four patients with genitourinary rhabdomyosarcoma are presented, with ultrasonographic and radiographic findings. The utility of ultrasound in the diagnosis of this pediatric tumor is emphasized.

Sonographic evaluation of caudal spine anomalies in children.

Retrospective analysis of B-mode spinal sonography in 15 pediatric patients with spinal dysraphism and caudal anomalies documents a high degree of accuracy in identifying the presence, site, size, and configuration of meningoceles; and slightly less accuracy in identifying extension of neural tissue into the meningocele and presence of concurrent lipoma. B-mode sonography is capable of displaying spinal anatomy clearly enough to permit accurate retrospective interpretation of pathologic changes. When radiologists learn to interpret sonographic images well enough to achieve equal accuracy in prospective diagnosis, then B-mode spinal sonography will supplant computed tomography and myelography as the preferred screening procedure in the initial evaluation of children with selected anomalies of the caudal spine.

Applications of ultrasound in the neonatal abdomen.

In this article, the uses of real-time sonography relative to evaluation of the neonatal abdomen are presented. Included are some of the more recent applications that, to a great extent, have evolved because of the ease with which portable real-time examination of the fragile or compromised infant can be accomplished.

Intracardiac Wilms' tumor: diagnosis and management.

Complete excision of Wilms' tumor may require resection of adjacent organs and removal of intracaval tumor propagation. Extension of tumor to the right atrium can be determined preoperatively guiding a direct and safe approach to intracardiac tumor at the time of nephrectomy. Preoperative ultrasonography of two children with Wilms' tumor demonstrated caval and right atrial tumor. Laparotomy for nephrectomy and abdominal caval exposure was combined with cardiopulmonary bypass and atriotomy. In both patients, tumor contiguous with the renal pelvis extended from the iliac bifurcation into the right atrium with a large atrial mass. In one patient nephrectomy was performed first, and she was then placed on cardiopulmonary bypass. Caval tumor was easily removed through the atriotomy and open renal vein. In the second patient, bypass was instituted first because of cardiac instability. The large right atrial mass extended through an atrial septal defect into the left atrium. The cardiac tumor and a large amount of caval tumor were removed. Bypass was discontinued after repair of the ASD. Tumor remained in the IVC below the renal veins necessitating a separate venotomy. Combined abdominal and cardiac exploration allows safe and complete excision of all gross tumor. Ultrasonography is a sensitive and noninvasive method of diagnosing retrohepatic and atrial tumor extension and can be obtained easily even on very sick patients.

Aberrant (ectopic) adrenocortical tissue along the spermatic cord.

Aberrant adrenocortical tissue along the spermatic cord is a far more common finding than has previously been reported. During a period of 12 consecutive months, 360 children, aged 13 days to 13 yr, underwent 386 operations for common inguinoscrotal pathology at the Soroka Medical Center. In 12 cases ectopic adreno-cortical tissue was found along the spermatic cord, an overall incidence of 3.8%. None was found in females. Considering the group operated upon for undescended testis, in which by nature of the procedure the spermatic cord was dissected throughout its length, the frequency of ectopic adrenal tissue found rose to 9.3%, the highest figure cited for this location. The nature of aberrant adrenocortical tissue is briefly discussed, including its embryology, histology, and clinical implications. It usually appears as an incidental finding during surgery. Its removal is indicated whenever found although no special attempt should be made to search for it.

Ultrasound of the distal pouch in infants with imperforate anus.

Optimal surgical management of the newborn with imperforate anus depends on accurate determination of the level of the rectal pouch. Eighteen children with imperforate anus were evaluated with ultrasound. The distance from the end of the pouch to the perineum was measured. Ultrasound correctly predicted the level of the distal pouch in all 12 children who had confirmation of the pouch level by surgery or by distal contrast stomagrams. Six children have not yet had definitive surgery. Five children with a pouch to perineum (P-P) distance of less than or equal to 10 mm and three of six children with a P-P distance of 10 to 15 mm had successful correction by a simple perineal anoplasty. Three of six children with a P-P distance of 10 to 15 mm and all of those (seven) with a P-P distance greater than 15 mm were diverted with colostomies.

Dehydration and rehydration in donkeys: the role of the hind gut as a water reservoir.

Body fluid distribution was measured in three donkeys, fully hydrated, following dehydration and after being rapidly rehydrated. In twenty other donkeys that were slaughtered to supply food for predators in a safari zoo, the water content in the different compartments of the gastrointestinal tract (GIT) was assessed. Prior to being slaughtered, four of the animals were fully hydrated, four dehydrated and 12 dehydrated, rehydrated and then slaughtered and examined, four at 1, for at 3 and four at 5 hours following drinking. When the body mass of dehydrated donkeys dropped to 75.4 +/- 2.4% of their initial value, total body water of the animals (HTO space), extracellular volume (SCN space) and plasma volume (EB space) were reduced to 76.6 +/- 5.3%, 80.9 +/- 10.6% and 73.2 +/- 8.3% of their initial values, respectively. The amount of water retained in the GIT of the fully hydrated donkeys amounted to 15.9 +/- 3.4 1, 19% of total body water. In the dehydrated donkeys it was only 7.4 +/- 1.3 1. The calculated total intracellular volume in the dehydrated donkeys was only 14% lower than in the fully hydrated animals. When drinking was allowed, dehydrated donkeys consumed 17.6 +/- 2.4 1 of water. The increase in the water content in the gut of newly rehydrated donkeys matched this volume, 80% of which was retained in the hind gut. During the five hours after drinking, only slow and moderate changes in the volume of the hind gut were recorded. Changes in plasma volume were also suppressed. It is suggested that the hind gut of the donkey, similar to the rumen of goats and sheep, plays a role as a water reservoir that helps maintain the osmotic stability of the body.

B-mode ultrasound and the nonvisualizing kidney in pediatrics.

Ultrasonic definition of the kidney is independent of renal function and therefore capable of imaging impaired or dysplastic renal tissue, In 28 cases, B-mode scanning delineated one or both kidneys which failed to visualize during intravenous pyelography. Similar imaging of both kidneys was obtained in 10 cases of renal failure in which intravenous pyelography was not attempted. The presence and relative severity of hydronephrosis was established. In three cases of multicystic kidney, a diagnostic appearance was elicited. In these instances, in one additional case of renal dysplasia, and in three cases of severe obstructive uropathy, sonography provided the only presurgical definition of the abnormal kidney. Suspected kidney enlargement was rapidly confirmed in a case of renal vein thrombosis and excluded in a case of chronic renal failure. In both instances hydronephrosis was excluded. In 12 of the 38 cases, ultrasonic guidance was utilized for percutaneous renal biopsy.

Milk composition and yield of the black Bedouin goat during dehydration and rehydration.

Milk composition and yield were measured in the black Bedouin goat during 4 d of dehydration followed by 2 d of rehydration. During this time the goats were exposed to strong solar radiation with no access to shade; all of these conditions occur commonly in the desert. Milk yield, initially similar to that found in the desert, was maintained during the first 2 d of dehydration, fell to 35% of the initial value over the third and fourth days and recovered fully during 2 d of rehydration. As yield fell, milk osmolality, and milk fat and protein concentrations rose. During rehydration all 3 fell once more, but whereas osmolality finished below initial values the concentrations of fat and protein remained higher than before dehydration. The milk remained isosmolar with plasma throughout. Total yields of milk solids and milk water during the whole experimental period were 70 and 67% of normal respectively and normal growth of the young was not disturbed.