Typical signs of acute appendicitis in ultrasonography mimicked by other diseases?

BACKGROUND: The diagnosis of acute appendicitis in pediatric patients is difficult. There are patients with positive ultrasonography without clinical or histological confirmation of acute appendicitis. It is essential to recognise these patients to avoid unnecessary surgery. METHODS: During 1 year, we compared the patients with 'false-positive' ultrasonography with those with 'true-positive' and those with 'true-negative' ultrasonography. RESULTS: Eighty-two patients were admitted to our inpatient ward for suspected appendicitis. Ultrasonography was performed on 68 patients. In sixteen cases, the ultrasonography showed typical signs of acute appendicitis though the patients turned out to be negative for acute appendicitis either by an observation period (n = 13) or by negative histology (n = 3). We could not find any significant differences between the groups in terms of age, gender or laboratory inflammation markers, though the latter tended to be elevated in patients with confirmed appendicitis. CONCLUSIONS: There are patients with clearly visible typical signs of acute appendicitis that do not need surgery and cannot be distinguished from others by age, gender or laboratory values. In conclusion, the clinical presentation still is the determining indicator for need of surgery. The underlying cause of the visible changes of the appendiceal area remains unclear, but there are several presumptions.

Easy Pulsatile Phantom for Teaching and Validation of Flow Measurements in Ultrasound.

PURPOSE: To build a simple model to teach and validate non-pulsatile and pulsatile flow quantification in ultrasound. MATERIALS AND METHODS: The setting consists of the following connected components: (1) medical syringe pump producing an adjustable constant flow (ml/min), (2) modulator modifying constant flow to a reproducible pulsatile flow, (3) water tank containing a diagonal running silicone tube (0.5 mm inner diameter), and (4) a fixated ultrasound probe (L9 Linear Array 9 MHz, GE Logiq E9) measuring the flow inside the tube. Commercially available microbubbles suspended with physiological saline solution were used for ultrasonic visibility. Spectral Doppler of different flow profiles is performed. RESULTS: The syringe pump produces an adjustable, constant flow and serves as the reference standard. The filling volume of the tube system is 1.2 ml. Microbubbles are very well detected by ultrasound and can be used as an easy and clean blood mimicking substance. The modulator generates different physiological and pathological flow profiles. Velocities are similar to those found within human blood vessels. Thus, it is possible to train and validate flow measurements in ultrasound. CONCLUSION: The model produces non-pulsatile and various pulsatile flow profiles and allows validation of flow measurements. The compact size permits easy and economic setup for flow measurements in research, skills lab and continuing education.

[Increased signal intensity of velocity measurements in duplex sonography by using the contrast agent levovist: a prospective, randomized study in a fetal sheep model]. / Verbesserte Signalintensität durch kontrastverstärkte Duplexsonographie mittels Levovist: Eine prospektive randomisierte Untersuchung beim Schaf-Feten.

PURPOSE: To evaluate the potential diagnostic advantages of the contrast agent Levovist for signal enhancement of small adjoining fetal vessels and to study the effect of Levovist before and during acute fetal hypoxia on the fetal circulation and the fetal blood flow velocities. MATERIALS AND METHODS: A prospective, randomized study was performed in 12 fetal sheep before and during acute fetal hypoxia produced by complete occlusion of the maternal common iliac artery. Two groups of animals were studied, comprising animals with (study group, n = 6) and without (control group, n = 6) Levovist. In the study group, Levovist was administered intravenously by a pump (modified IVAC P 4000, Schering, Berlin). Duration and intensity of signal enhancement were measured in the fetal aorta, the common carotid artery and the ophthalmic artery of both groups before and during hypoxia. Concurrently, fetal heart rates as well as systolic and diastolic blood flow velocities in all three vessels were recorded in both groups. RESULTS: The increased signal intensity of up to 15 dB in the study group resulted in improved differentiation and imaging quality of adjoining small fetal vessels when compared with the control group. Neither before nor during acute hypoxia, significant differences of the fetal heart rate and the systolic and diastolic blood flow velocities were observed between the two groups (p > 0.05). In the study group, no emboli were caused by Levovist in any fetal tissue or in the placenta. CONCLUSION: The contrast agent Levovist improves the detection and accuracy of monitoring flow velocities in small fetal vessels by increasing the intensity of the Doppler signal without affecting fetal heart rate or fetal blood flow velocities.

[Angiographic control of treatment of femur head necrosis with a pedicled pelvic bone graft]. / Angiographische Therapiekontrolle der mit einem gefässgestielten Beckenspan versorgten Hüftkopfnekrose.

A new operative method is introduced in the therapy of the idiopathic necrosis of the femoral head. This operation is based on the idea, that ischaemic processes play an important role in the origin of the idiopathic necrosis of the femoral head. The transplantation of a pedicle bone graft should provide a good arterial supply. 28 Preoperative superselective angiographies of the A. circumflexa femoris medialis showed pathological findings in 17 cases. A good supply of the bone graft was found in 4 from a total of 7 postoperative angiographies of the reset A. circumflexa ilium profunda.

[Status of sonography versus roentgen and computed tomography in the diagnosis of nephrocalcinosis]. / Stellenwert der Sonographie gegenüber Röntgen und Computertomographie bei der Diagnose von Nephrokalzinosen.

Sonography proves a highly sensitive instrument in recognition of nephrocalcinosis (nc). We demonstrate four cases of cortical and medullary nc of different etiology. While abdominal x-rays were unsuspective sonography demonstrated typical findings of nc. In the medullary type of nc the sonographic findings are typical. On the other hand cortical hyperechogenity does not prove nc but in extreme cases. Computerized tomography is able to measure Hounsfield Units and to demonstrate by this deposits of calcium without necessity of histology. We discuss the differential diagnosis of highly echogenic cortical and medullary renal tissue.

[Sonography in callus distraction of the hypoplastic mandible]. / Einsatz der Sonographie bei der Kallusdistraktion am hypoplastischen Unterkiefer.

OBJECTIVES: Since the early 1990's when callus distraction of hypoplastic mandibles was developed, surgeons have been looking for a reliable method to monitor distraction treatment. X-rays films resulted in insufficient quality of images of low calcified structures and are only of little support in follow-up. Therefore, a standardised protocol using ultrasound was introduced. METHODS: 24 patients were included (aged 4 - 29 years with hemifacial microsomy [19], mandibulary micrognathia [5]), 20 intraoral (Howmedica-Leibinger/Mühlheim) and 9 extraoral distractors (Normed/Tuttlingen). Standard procedures for intra- and extraoral distraction were carried out and all postsurgical treatment steps were monitored by ultrasound. RESULTS: The mineralisation of the neocallus shows the following sequence: echogenic dots, needles directed along the distraction direction, bands, plaques, and modulation of the neocompacta. Additional therapeutically relevant questions of distraction distance, inflammation or occurrence of pus, arising during treatment were answered by sonography. Distance measurements could be performed reliably. CAT scan and MRI cannot be carried out because of metal artefacts. X-ray pictures like orthopantomogram and Clementschisch projection cannot show the early mineralisation and do not allow an exact distance measurement. CONCLUSIONS: Sonography is a effective, method to investigate the callus field without using X-rays and supports monitoring and decision making in distraction treatment of hypoplastic mandibles.

[Pharmacokinetic aspects of excretory urography in children]. / Pharmakokinetische Aspekte der Ausscheidungsurographie im Kindesalter.

Contrast media able to pass through the kidney were a major advance in the field of radiodiagnostics. Excretory urography is usually performed using metabolically-inactive substances which accumulate in the kidney and kidney-pelvis. A two-compartment model has always been used so far for pharmacokinetic evaluation of this. However, in doing so, the kidney pelvis was not taken in account. A further compartment was therefore added to this model which enables all the physiological processes demonstrated by excretory urography to be included in the evaluation. With this model, blood and urine levels can be used at the same time to calculate pharmacokinetic variables, as shown in 6 pediatric patients. In addition to the cumulative excretion of urine and blood levels of the contrast medium, the concentrations of the latter in the renal pelvis are shown. Particular attention is paid to the effects of two important factors in investigations using contrast medium--diuresis and total body fluid volume.

[Cranial sonography for newborn screening: a 10-year retrospective study in 11,887 newborns]. / Schädelsonographisches Neugeborenenscreening: Eine retrospektive 10-Jahresstudie an 11 887 Neugeborenen.

We retrospectively analyzed the results of a sonographic cranial screening study, performed between 1985 and 1994 to determine the incidence of intracranial hemorrhage and cerebral anomalies based on obstetrical risk factors. In the Department of Obstetrics and Gynecology of the University Giessen, Giessen, Germany, 94.6 % (n = 11,887) of all children born during the study period were included and underwent sonographic cranial screening within the first 10 days after birth. Cerebral abnormalities were found in 653 (= 5.5 %) cases, and peri-/intraventricular hemorrhages (PIVH, grade I-IV) in 303 cases. Periventricular leucomalacia, porencephaly, subarachnoidal hemorrhage and hydrocephaly were rare (< or = 0.2 %). The Apgar index proved to be a good prognostic factor, particularly at 1 and 5 minutes after birth (p < 0.0001). In contrast, correlation between PIVH and cardiotocography, arterial cord blood gases, and pH was poor. We did not observe a higher incidence of PIVH in newborns with growth retardation, preeclampsia and premature ruptures of membranes or prolonged labor. With decreasing gestational age, the frequency of PIVH increased progressively from 0.4 % at 39 weeks to 53.2 % at 27 weeks (p < 0.001). We also found a higher risk of intracranial hemorrhage in preterm newborns with amniotic infections (38.1 %, p < 0.001). In mature babies, we did not find a difference between the incidence of PIVH and delivery-modes; however, we noted a higher risk of PIVH Grade IV in preterm newborns with breech presentation for vaginal delivery versus caesarean section (38.5 % versus 7.4 %, p = 0.005). The incidence of PIVH over this 10 year time period did not increase despite an increasing number of preterm newborns over time. In conclusion, this study, which represents one of the largest patient cohorts studied for PIVH, indicates that neonatal sonographic cranial screening is an important tool to define quality control in obstetrics.

Peri/intraventricular haemorrhage: a cranial ultrasound study on 5286 neonates.

OBJECTIVE: We launched a prospective cranial ultrasound study at the Department of Obstetrics and Gynaecology of the University of Giessen. In this study we examined the incidence and severity of brain damage in neonates and related them to various obstetrical risk factors. STUDY DESIGN: More than 90% of all neonates born between 1984 and 1988 were included in the study (n = 5286) and were screened by ultrasound for cerebral abnormalities on 5-8 days post-partum. The relation between the incidence of peri/intraventricular haemorrhages (PIVH) and obstetrical risk factors were analyzed by contingency tables. RESULTS: The most frequent abnormality was PIVH (3.6%) of various degrees (grade I-III). Periventricular leucomalacia, porencephalia, subarachnoidal haemorrhages, and hydrocephali were rare (< or = 0.2%). The incidence of PIVH increased progressively with decreasing gestational age, e.g. from 1.6% at 38-43 weeks up to 50.0% at 24-30 weeks of gestation. A large percentage of babies with PIVH were clinically normal. In immature neonates there was a close inverse relationship between Apgar score at 1, 5 and 10 min and both incidence and severity of PIVH. This was in contrast to findings in mature neonates where a marked increase in the incidence of PIVH was found only with Apgar scores as low as 0-4 points. The relation between the incidence of PIVH and both cardiotocography and arterial cord blood pH was poor, independent of the gestational age. The incidence of PIVH was increased in growth retarded fetuses (pH < or = 7.29), premature rupture of membranes, fever sub partu and gestosis. It is interesting to note that in mature fetuses there was no difference in the incidence of PIVH between vaginally delivered (0.8%) and sectioned breech presentations (2.1%). In preterms at 35-37 weeks with prolonged labour and secondary cesarean section, the incidence of PIVH was very high (11.2%). CONCLUSION: From the present study we conclude that the incidence of PIVH especially in immature neonates is highly associated with low Apgar scores at birth. Since the Apgar score reflects the clinical condition and the degree of circulatory centralisation of neonates that is influenced by various ante- and intranatal risk factors, a protective obstetrical management is necessary to reduce the incidence of PIVH in neonates.

[What significance does superselective angiography of the hip joint have in femur head necrosis of the adult before and after management with a vascular pedicled ileal crest graft?]. / Welche Bedeutung hat die superselektive Angiographie des Hüftgelenkes bei der Hüftkopfnekrose des Erwachsenen vor und nach Versorgung mit dem gefässgestielten Beckenspan?

The use of microsurgical techniques in orthopaedics makes it possible to revascularize the necrotic femoral head in adults. Superselective angiography improves preoperative planning. Furthermore, using this method postoperative perfusion control of the pedicle bone graft can be carried out. This paper reports on a special way of positioning the pelvis, as well as on the results of angiography in various functional positions of the hip joint.

[Superselective electronic subtraction angiography. Experience in 6 surgically treated hips using the double cup prosthesis]. / Angiographie supersélective par soustraction électronique. Expérience dans six hanches opérées par double cupule.

Six hips in five patients with Wagner double cup surface replacement prostheses were examined by superselective angiography of the medial femoral circumflex artery to determine a possible relationship between a lesion of the artery and loosening of one or other components of the prosthesis. Electronic subtraction of the angiographic images allowed a precise appreciation to be made of the condition of the vessels. No relationship was found. Lesions of the medial femoral circumflex artery were found, even when the prosthesis was firmly in place. This finding is contrary to that of authors who consider that an extra-osseous vascular lesion always leads to bone necrosis and loosening in double cup surface replacement prostheses.

[Preliminary examinations on the effects of the breed characteristic feature "feather crest" on skull and brain anatomy of domestic ducks (Anas platyrhynchos f. dom.)]. / Voruntersuchungen zur Auswirkung des Rassemerkmales "Haube" auf die Schädel- und Hirnstruktur bei Hausenten (Anas platyrhynchos f. dom.).

As mentioned in older sources, the crested breed of the domestic duck is described as variety with high pre- and postnatal mortalities, malformations in skull and brain anatomy, and several central nervous deficiencies in affected birds. Therefore this breed is to be called defective and abnormal in the sense of section 11b of the German protection of animals legislation. Poultry fanciers reject these findings as incorrect, but accurate scientific examinations that bear out this allegation are not available. Preliminary examinations have demonstrated that brain and skull anatomy of living animals can be described by using non-invasive diagnostic techniques (magnet-resonance-imaging, computerized tomography, radiography). The use of this progressive methods enables to expressive findings on present stocks of domestic ducks. Many of the test animals investigated in preliminary examinations by using magnet-resonance-imaging and radiography showed abnormal tissue deposits in the tentorium cerebelli, meningo-encephalocele, cranial malformations, and variable bone formations in the thickened hypodermis of the crest. If crested ducks are mated against each other, numerous offspring show malformations of upper beak and cranium, encephalocele, as well as craniopagal parasites in form of rudimentary legs.