Minimally invasive radiologic techniques in the treatment of uretero-enteric fistulas.

OBJECTIVES: The goal of this study was to assess the efficacy of minimally invasive interventional radiologic (IR) techniques in the management of uretero-enteric fistulae in comparison to established surgical modalities. MATERIALS AND METHODS: Twenty-five patients (16 men, 9 women) with a mean age of 47 (range: 19-77 years) with uretero-enteric fistulae were treated with percutaneous nephrostomy, double "J" stent, radiologic uretero-neocystostomy, and radiologic uretero-pyelocalicostomy. All patients had a single fistula each. Uretero-enteric fistulas were due to direct or iatrogenic trauma in 14 patients (uretero-ileal fistulas, n=6; uretero-colonic fistulas, n=4; uretero-duodenal fistulas, n=2; uretero-pancreatic fistula, n=1; uretero-fallopian tube, n=1), complications of pelvic neoplasms in 4 patients (uretero-sigmoid fistulas, n=4), inflammatory disease in 4 patients (uretero-ileal fistulas, n=2; uretero-sigmoid fistulas, n=2), and avascular necrosis of renal transplants in 3 patients (uretero-sigmoid fistulas, n=3). RESULTS: Drainage by percutaneous nephrostomy and double "J" stent resulted in closure of 8 uretero-enteric fistulae over 7-16 weeks. Four uretero-enteric fistulae obliterated after re-routing urine flow using 3 radiologic uretero-neocystostomies and one IR pyelocalicostomy. In other patients, flow through the fistulae was substantially decreased by five double "J" stents and 3 percutaneous nephrostomies. The duration of inpatient hospitalization was significantly less for patients managed successfully by IR procedures than those treated by surgical modalities, 5.07 versus 10.5 days mean (P<0.05). CONCLUSIONS: IR procedures provided definitive treatment in 48% of uretero-enteric fistulae at significantly reduced inpatient hospitalization and cost. As palliative treatment, it improved the quality of life.

The acute effect of oral acetazolamide on macular blood flow.

Acetazolamide has been shown to be beneficial in the treatment of macular edema. To investigate whether this effect is associated with changes in the retinal circulation, the acute effect of oral acetazolamide on macular blood flow was studied in 20 healthy volunteers. The blue-field simulation technique, a noninvasive method enabling the quantitation of the number (N) and mean velocity (Vm) of leukocytes flowing in the subject's own macular capillaries was used in this study. On two different occasions, separated by 3 or more days, 20 subjects adjusted Vm and N of computer-simulated leukocytes moving on a video screen to match those of their own entoptically perceived leukocytes before and 3 hr after a double-blind, randomized administration of 500 mg acetazolamide or placebo capsules. Ten trials were done, and the velocities were averaged. After acetazolamide ingestion, there was a nonsignificant average change from baseline in Vm (2.5 +/- 23% [+/- one standard deviation]; P greater than 0.1, by paired student t-test) and N (6.9 +/- 25%, P greater than 0.1). After placebo ingestion, the average changes from baseline in Vm and N also were not statistically significant (-1 +/- 18% and 14.9 +/- 30.3%, respectively). Furthermore, when compared with the changes measured after placebo intake, acetazolamide ingestion was associated with a nonsignificant 4.3 +/- 28.7% change in Vm (P greater than 0.1) and a -8 +/- 30.9% change in N (P greater than 0.1). With 20 subjects tested, the calculated average minimum change in leukocyte velocity that could have been detected with this technique (P less than 0.05, by paired student t-test) is about 9%.(ABSTRACT TRUNCATED AT 250 WORDS)

Long-term survivors of fetal cardiac bypass in lambs.

The initial experience with cardiac bypass in fetal lambs resulted in early fetal death from placental insufficiency. Subsequent work in our laboratory indicated that vasoactive cyclooxygenase products were released as mediators of this response. The placental dysfunction could be blocked by the administration of indomethacin, allowing longer fetal survival. This unmasked a more subacute (but fatal) problem: fetal surgical stress resulted in diminished fetal cardiac output and progressive metabolic acidosis and contributed to the placental vasoconstriction. In acute studies, when indomethacin was given and the stress response was inhibited by the use of total spinal anesthesia, the fetus maintained normal blood gas levels, cardiac output, placental blood flow, and acid-base status for several hours after bypass. We hypothesized that beyond this point, no further fetal or placental compromise would occur and that this management technique would thus allow long-term fetal survival. With the use of total spinal anesthesia and sterile technique for long-term study, 12 fetal lambs at 120 days (80%) gestation underwent exposure, line placement, and cannulation for fetal cardiac bypass. Indomethacin was given intravenously on obtaining venous access. After 20 minutes of normothermic cardiac bypass at flow rates of 250 to 300 ml/kg/min, the fetus was weaned from bypass, the cannulas and lines were removed, the uterus and abdomen were closed, and the ewe and fetus were allowed to recover. There was one maternal death (pneumonia) and one early abortion (of twins); the remaining 10 ewes progressed to term. At term, five healthy lambs that had undergone fetal cardiac bypass were delivered (including one twin), four ewes delivered a mummified study fetus and one or two healthy siblings, and one delivered a dead term fetus. With the use of techniques that inhibit fetal stress and block placental vasoconstriction, cardiac bypass can be performed in single-gestation fetal lambs with a high degree of recovery and survival (80% in this study). The cause of the elevated abortion rate associated with twin gestation is unclear.

Diagnostic imaging in pediatric AIDS.

The manifestations of acquired immune deficiency syndrome (AIDS) in children are mainly secondary to opportunistic infection, lymphoproliferative diseases, and AIDS-related neoplasms. This article reviews the pathologic findings of various disorders afflicting children with AIDS and emphasizes the imaging of these disorders. Although many of the radiologic findings are not specific for a particular infection or neoplasm, the differential diagnostic possibilities for an abnormality can be narrowed down significantly with proper clinical correlation and knowledge of the imaging findings and pathologies specific to children with AIDS.

[The value of lymphography of malignant testicular tumors]. / Der Stellenwert der Lymphographie bei malignen Hodentumoren.

Between 1965 and 1968, 6500 lymphograms were performed at the University of Göttingen. Amongst these, there were 412 patients with malignant testicular tumours. In 81 patients the results of lymphography could be checked histologically. There was agreement between the lymphographic and histological findings in 65 patients (80.3%), sensitivity of 98.1% (51 out of 52) and specificity of 48.3% (14 out of 29). In 50 patients CT was performed in addition. The findings agreed in 31 cases; in eight patients lymphangiography resulted in a false positive finding and CT was incorrect in 12 patients. In all patients with proven retroperitoneal metastases, one or the other method produced a correct diagnosis.

Transient bilateral ovarian enlargement associated with large retroperitoneal lymphoma.

Bilateral ovarian enlargement may reflect benign or malignant processes of the ovary. Benign causes of ovarian enlargement include luteomas, tumors such as mature cystic teratomas, fibrothecomas, cystadenomas and rare conditions including capillary hemangioma and massive edema of the ovaries. Ovarian malignancies include epithelial, stromal and germ-cell tumors. Primary malignancies that may exhibit metastases to the ovaries include gastrointestinal, breast and soft tissue tumors such as lymphoma. We present an unusual case in which a patient presenting with weakness and mild lower abdominal and pelvic pain was noted at sonography to have bilaterally enlarged ovaries with features similar to those of massive ovarian edema as described previously, which has been associated with venous and lymphatic obstruction. Subsequent computerized tomography (CT) imaging depicted a large retroperitoneal tumor, CT-guided biopsy of which revealed diffuse large B cell lymphoma. The patient responded well to chemotherapy with significant shrinkage of the tumor, and reappearance of normal findings on ovarian sonography. This case demonstrates that bilaterally enlarged ovaries may be the first clinical evidence of a large retroperitoneal tumor and that in such cases CT imaging may be warranted.

Transvaginal sonographic findings of a large intramural uterine hematoma associated with iatrogenic injury sustained at termination of pregnancy.

We report a case in which a patient presented with severe right lower abdominal pain associated with nausea and vomiting 3 days after termination of pregnancy. Transvaginal ultrasonography showed a large intramural mass in the anterior aspect of the lower segment of an acutely retroflexed uterus. Computed tomography and magnetic resonance imaging findings were consistent with an intramural hematoma as a result of iatrogenic injury sustained during the preceding termination of pregnancy. The patient was managed expectantly. Systematic review of the literature confirmed that this is the first report of sonographic findings associated with an intramural uterine hematoma some days after the injury sustained at termination of pregnancy. This case supports utilization of real-time ultrasound guidance during intrauterine surgery of selected cases to decrease procedure-related morbidity.

Peripelvic cysts simulating hydronephrosis.

Peripelvic cysts can have a sonographic appearance that is similar to hydronephrosis. Two cases are described where the initial sonogram suggested the diagnosis of pelvicalyceal obstruction, and on subsequent intravenous urography the correct diagnosis of peripelvic cysts was made.

Renal manifestations of AIDS in children.

Renal abnormalities in pediatric AIDS patients are common. The most common renal abnormality is HIV nephropathy, which usually progresses to end-stage renal disease. Other disorders discussed are related to infection, malignancy, and medications. This review illustrates several of the imaging findings seen in the kidneys of these patients.

Ultrasonographic diagnosis of ectopic pregnancy: importance of transabdominal imaging.

Endovaginal sonography has greatly improved the diagnostic evaluation of suspected ectopic pregnancy. Some authors suggest imaging solely by endovaginal technique for diagnosis. We perform both a transabdominal scan for a global view of the pelvic and abdominal contents and an endovaginal sonographic examination for a higher resolution and focused view of the gynecologic structures. We report three patients with negative endovaginal examinations who had obvious ectopic pregnancies on our subsequent transabdominal examination. These cases remind us of the valuable information that can be obtained with the transabdominal approach and the complementary role it plays with endovaginal sonography.

Stimulating equity of services to nonwhites in community mental health centers.

This paper describes a special date-based approach by the National Institute of Mental Health (NIMH) and the Health, Education and Welfare (HEW) regional offices to improve mental health service utilization nationwide for nonwhites and equalize these services with those available to whites.

Macromastia in a newborn with Alagille syndrome.

We present a case of macromastia in a newborn with Alagille syndrome. A review of the literature failed to find any prior reports of this findings in Alagille syndrome patients. We propose that this patient's macromastia may be related to her liver failure and abnormal estrogen metabolism.

[Lymphography in Hodgkin's lymphoma. Diagnostic value based on the current status of experience and knowledge]. / Die Lymphographie beim Hodgkin-Lymphom. Der diagnostische Stellenwert aufgrund des heutigen Erfahrungs- und Wissensstandes.

Lymphography was carried out at least once in 355 patients with Hodgkin's lymphoma (HL). In 229 patients, there was a histological subclassification: 26 LP, 63 NS, 122 NC and 18 LD cases. The lymphographic manifestations could be subdivided empirically into two superordinate groups: 1. lymph nodes closely linked together in chains (LC) with dense structures as well as LC destructions, LC debris and 2. LC of varying size with pathological internal structure. Apart from in the NS type, a correlation between the lymphological appearance and the histological subtype could not be discerned in any other histological subgroup. After lymphography, 61.6% of stages I and II were assigned to stage III. The staging of the lymphography was: stage I 24.5%, stage II 47.3%, stage III 10% and stage IV 9%, and after lymphography: stage I 9.9%, stage II 17.7%, stage III 63.1% and stage IV 9.3%. From a qualitative point of view, lymphography is superior to all other methods in the diagnosis of malignant lymphomas and should hence be carried out obligatorily in suspicion of a malignant lymphoma.

[Lymphography in malignant testicular tumors]. / Die Lymphographie bei malignen Hodentumoren.

Experience and results are reported on the basis of more than 380 lymphographic investigations in patients with a malignant testicular tumor. In 61% of these patients, there was suspicion of a metastatic infiltration of the retroperitoneal lymph nodes. In 75 patients, histological checking of the lymphographic finding was possible on the basis of a retroperitoneal lymphadenectomy. Lymphography was shown to have a precision of 81%. Lymphography is obligatory as a complement to other techniques of investigation such as sonography and computer tomography in patients with malignant testicular tumor, since the greatest diagnostic information can be expected from combined application of all three methods.

Simple renal cysts in children with AIDS.

Simple renal cysts are very uncommon among children. Of 50 children with AIDS that underwent computed tomography at our hospital, 4 had radiographically simple cysts. The incidence of simple renal cysts in this group of children is thus approximately 45 times that seen in normal children. To our knowledge, simple renal cysts have never been reported as a manifestation of AIDS in children. It is unknown whether or not these cysts are a manifestation of HIV nephropathy (HIVN), in which microcysts are seen pathologically. We suggest that simple renal cysts may be a finding compatible with the diagnosis of HIVN.