Biomedical subjects
Publications and source records attributed to R A Filly.
A case of choledochal cyst in a 17 month old child is described. The ultrasonographic findings were felt to be specific in this case since the dilated common bile duct was noted to enter directly into a large right upper quadrant cyst. The clinical history, ultrasonographic findings, and differential diagnostic features are discussed.
Gray scale ultrasonography has made it possible to identify hepatic and portal venous structures. Single sector sweep scanning is important in depicting these structures. Identification of venous structures is discussed as well as methods for distinguishing large veins from pathologic structures.
Gray scale ultrasonography has made it possible to identify the major systemic arteries and veins in the upper abdomen. Identification of these vascular structures is discussed as well as their value as anatomic landmarks.
Two hundred seventy-eight female children with urinary tract infections have been evaluated at Stanford division of urology. All children were followed up for a period of not less than twelve months. Age of onset of infection, clinical presentation, and nature of infecting organisms were observed. The group consisted of 144 children without ureteral reflux and 134 children with ureteral reflux. Sixty-one of the female children with ureteral reflux had ureteral reimplantation, while 73 received medical treatment alone. A study of infection rates in each of the three groups of children indicated a similar infection rate, although those children with reflux experienced a higher incidence of clinical pyelonephritis. Correction of ureteral reflux did not alter the infection rate; however, infections after surgical correction were generally of a type usually associated with children without reflux. Twenty-nine children had urethral dilatation, and the infection rate prior to and following urethral dilatation indicated a similar rate of infection pre- and posturethral dilatation. One hundred nonrefluxing kidneys were observed radiologically: 97 were normal and 3 showed clubbing and scarring. Of 110 refluxing renal units observed, 62 were clubbed and scarred and 48 were normal. Following surgical correction of reflux, renal clubbing and scarring were not observed in previously normal renal units. Of those renal units found to be abnormal at time of surgery, 66 per cent showed progression of clubbing and scarring after surgical correction of reflux. It was observed that the greater the degree of reflux present, the higher the incidence of renal damage. This study suggests that children who experience recurrent urinary tract infections who do not have ureteral reflux are seldom at renal risk; similar children who do have ureteral reflux are at risk unless the infections are controlled or the reflux either disappears or is corrected surgically.
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Roentgen findings in 107 girls under the age of ten years who had proven recurrent urinary tract infections were analyzed. From the excretory urograms done on these children, renal and pelvocalyceal outlines were accurately traced. Subsequently, renal length and parenchymal thickness at multiple points were measured. The presence or absence and grade of reflux were determined by voiding cystourethrography. Finally, the clinical history was correlated with the roentgen findings. With three exceptions, scarring and clubbing in the presence of infection occurred only in refluxing renal units. Kidneys exposed to a higher grade of reflux more frequently showed scarring and clubbing (p<0.001). Seventeen out of 40 renal units either developed or had increase in clubbing and scarring while the patients were being followed. After surgical correction of reflux, 16 of 24 previously clubbed and scarred kidneys showed progression of the lesions, usually within 24 months after operation. All children whose kidneys showed progression after surgical operation had experienced an episode of acute urinary infection with chills and fever before operation. No significant difference existed in the age at clinical onset of infection in patients with ureteral reflux with or without roentgen evidence of clubbing and scarring. This study documents the close relationship between clubbing and scarring and reflux in the presence of urinary infection in infants and children.
Of 134 girls with demonstrable ureterovesical reflux, 61 (105 ureters) had the reflux surgically corrected with an overall surgical cure rate of 97 percent. In the remaining 73 children (112 ureters), the reflux was treated conservatively with medical management alone. During the follow-up period no significant differences were demonstrated in the overall incidence of urinary tract infection; two years following corrective operation or medical treatment more than 50 percent of both medically and surgically treated children were still experiencing infections. A pronounced decrease, however, occurred in the incidence of clinical pyelonephritis among the surgically treated group. Following correction of reflux, the incidence of pyelonephritis was similar in both medically and surgically treated cases and was approximately the same as that found in a comparable group of children without reflux. In approximately two-thirds of refluxing renal units in which there was evidence of clubbing and scarring before medical or surgical therapy, deterioration progressed during the follow-up period. In most of these cases infection control was felt to be inadequate with episodes of clinical pyelonephritis occurring during the period of medical management, or, in the surgically treated group, occurring just before corrective operation and the scar appearing within two years after operation. The majority of renal units in which calyceal clubbing and parenchymal scarring was present had the most severe grades of reflux.
This paper is the study of 144 girls with histories of urinary tract infection followed at the Stanford Medical Center who were found to be free of ureterovesical reflux. The mean age at onset of infection for the entire group was about four years and ranged from the first few months of life to age 10. Ninety-two percent of the 505 infection episodes in these children presented with symptoms referable to the lower tract, and bacterial localization studies confirmed that 85 percent of the infections were limited to the bladder. Escherichia coli was the most common organism isolated and most infections were caused by a pure culture of a single bacteria. In only two of the 144 patients studied was there any evidence of upper tract damage related to infection. The possibility that these patients had reflux at an earlier age could not be discounted. In response to short-term antibacterial therapy in 66 of the patients followed closely for an average of 40 months each, 20 percent of the patients had no further infections and 80 percent went on to recurrence. With each succeeding treatment an additional 20 percent of the patients were "cured," but the remainder experienced recurrent infections during the follow-up. This reinfection pattern supports the use of long-term antibacterial prophylaxis in all girls who have more than three or four recurrences of infections. Urethral dilation appeared to have no value in reducing the reinfection rate. While it appears that in the absence of ureterovesical reflux few, if any, of these children will go on to develop upper tract damage, long-term prophylactic suppressive medication can clearly be justified on the grounds of reducing patient morbidity.
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To prove that protein-lipid emulsions can be echogenic, we made two lipid-in-water emulsions. The first emulsion was composed of lipid micelles approximately 10 microns in diameter. The second emulsion was composed of micelles approximately 100 microns in diameter. The first emulsion was anechoic; the second emulsion was echogenic. These results are consistent with the physical laws governing the scatter of ultrasound and demonstrate that collagen containing connective tissue is not necessary for echoes. In addition, these data support the hypothesis that the wide differences in echogenicity of fatty tissues is due to the differences in the thickness of their connective tissue stromata.
Cerebral real-time ultrasound examinations from 35 high-risk premature newborn infants and 25 normal-term infants were reviewed for early signs of ventricular dilation. Measurements of the midbody lateral wall of the lateral ventricle to falx distance and ratio of this distance to the hemispheric width were obtained. Midbody lateral ventricular widths were also measured. Results indicate that displacement of the medial wall of the body of the lateral ventricle toward the midline is an earlier sign of ventricular dilation than is displacement of the lateral wall away from the midline.
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A case in which the diagnosis of anencephaly was missed on a standard obstetrical sonogram performed at 12.5 menstrual weeks is described. Prompted by this case, we retrospectively reviewed the appearance of the cephalic pole of normal fetuses in 47 pregnancies ranging in menstrual age from 11 weeks to 16 weeks. Results indicate that the abnormal cephalic pole in the index case was similar to the appearance of many normal fetuses of similar menstrual age. We conclude that while anencephaly may be diagnosed as early as 11 menstrual weeks to 12 menstrual weeks, this defect may be difficult to diagnose on sonograms using standard sonographic techniques prior to 14 menstrual weeks.
Six cases of sonographically diagnosed fetal sacrococcygeal teratoma (SCT) are presented and illustrate the variable features of fetal SCT. The sonographic findings assisted the parents and perinatal team in making decisions, and in two of the cases the children survived after elective Cesarean section and prompt neonatal resection of the tumors. None of the patients showed signs of malignant degeneration of the teratoma or metastases. Fetal SCT no longer should be considered a uniformly fatal condition. The literature on sacrococcygeal teratoma detected after birth indicates that the mortality rate is correlated with the degree of extension of the tumor. Therefore, the classification of sonographically diagnosed fetal SCT according to its size and position is important for decisions regarding pregnancy management.
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