Biomedical subjects
Publications and source records attributed to S M Goldman.
Early use of manual disk reduction procedures was significant in providing a functional disk-condyle relationship. Ninety-three percent of the 41 patients with anterior medial displaced disk without recapture did not require surgical correction using manual disk reduction procedures. All reductions were done within a six- to eight-week time period from the date of onset.
Thirty-eight patients undergoing a cardiac operation randomly received either tranexamic acid, a potent inhibitor of plasminogen, or placebo in an effort to determine whether prophylactic antifibrinolytic therapy reduces chest tube drainage. Twelve-hour blood loss was 750 +/- 314 (standard deviation) ml in the placebo group and 496 +/- 228 ml in the drug group (p = 0.0057). Fibrin split products were present more frequently in patients in the placebo group (17 of 20 compared with four of 18 in the drug group; p = 0.0002). Tranexamic acid markedly decreased plasminogen availability (112 +/- 104 units in the placebo group versus 36 +/- 18 units in the drug group, p = 0.0058). Plasma fibrinogen concentrations were similar in the placebo and drug groups. Patients in the placebo group received more fresh-frozen plasma and more mediastinal shed blood than those in the drug group. No coagulation-related complication occurred in the group receiving tranexamic acid. We conclude that prophylactic tranexamic acid can be administered safely to inhibit fibrinolysis during cardiac operations, decrease postoperative bleeding, and possibly decrease the frequency of blood product transfusion.
Recently, there has been considerable interest in plasma concentrations of homovanillic acid (HVA) in various psychiatric disorders. Homovanillic acid is a weak organic acid, and its excretion probably resembles that of other organic acids (eg, p-aminohippuric acid) that are actively secreted by the kidney. Alterations in renal plasma flow can affect clearance of organic acids, resulting in changes in plasma concentrations. In our study, concentrations of plasma HVA and urinary HVA (from 24-hour urine collections) were measured in 20 prepubescent boys who received 3 weeks of placebo, dextroamphetamine sulfate, and fenfluramine hydrochloride in a randomized, double-blind, counterbalanced study of the treatment of attention-deficit disorder. Plasma HVA concentrations were significantly lower during fenfluramine treatment than during amphetamine treatment. This difference, however, seemed to be caused by alterations in renal clearance of HVA rather than changes in production. Whole-body production of HVA, as indexed by total urinary HVA excretion, was unaffected by the different treatments, while renal clearance of HVA did differ significantly between amphetamine and fenfluramine treatment. It seems that alterations in renal clearance can affect plasma HVA concentrations, which should be taken into account when plasma HVA is studied.
The computed tomographic (CT) findings in four cases of seminal vesicle abscess are presented. The predominant infectious organism in two cases was Escherichia coli, one case was probably caused by Mycobacterium tuberculosis, and another by atypical mycobacterium. The CT findings included unilateral (three cases) or bilateral involvement (one case), seminal vesicle enlargement with hypodense areas within the gland (three cases), adjacent perivesicle inflammation (three cases), and associated bladder wall thickening (three cases). Although the diagnosis of seminal vesicle abscess is often overlooked clinically, CT may help suggest the correct diagnosis early thereby helping to initiate therapy.
Renal tumors both benign and malignant have two basic growth patterns. One pattern is that of appositional growth in which a round mass is shown displacing the normal kidney. The other is that of infiltrative growth. In this situation, the tumor cells grow between the scaffolding of the normal glomerulae and tubules. Thus, in this situation, kidney function appears normal until late in the disease. The kidney thus keeps its reniform shape but does increase in size (bean or orange to grapefruit pattern).
Between 1981 and 1985, 6 patients with transitional cell carcinoma in bladder diverticula had preoperative computerized tomography (CT). CT suggested no invasion through the wall of the diverticulum in all 5 patients who had pathologic confirmation. CT is a useful staging procedure and is helpful in determining the management of patients with transitional cell carcinoma.
The imaging studies done on 62 patients hospitalized for acute renal infections were retrospectively reviewed. Thirty-six (58%) had one or more abscesses, 17 (27%) had focal or diffuse acute bacterial nephritis, five (8%) had pyonephrosis, and four (6%) had pyelonephritis. All had prolonged fever (greater than or equal to 72 hours) and leukocytosis. Among 25 patients examined with both ultrasound (US) and computed tomography (CT), US failed to depict three of five (60%) cases of acute bacterial nephritis and seven of 15 (47%) intrarenal and extrarenal abscesses. One renal abscess was misdiagnosed as a tumor at CT. US is not an adequate screening test for detecting lesions that may require invasive therapy. CT is more sensitive for the detection of acute renal inflammatory disease and for defining the extent of disease for planning of radiologic or surgical intervention.
The authors retrospectively evaluated radiologic, clinical, and pathologic findings in 23 cases of mature teratoma arising within peri- or pararenal spaces. Radiologic studies--including abdominal radiographs (21 cases), excretory urograms (12 cases), sonograms (17 cases), and computed tomographic (CT) scans (18 cases)--were evaluated for tumor location, mass effect, calcification, fat, tumor invasion, echo pattern, and tissue characteristics. Most patients were female (3.4:1), younger than 6 months (50%), and asymptomatic. Abdominal radiography demonstrated a mass in 95%, calcium in 92%, and fat in 60% of cases in which CT revealed these components. Similarly, sonography showed uncomplicated fluid in 76% and calcium in 50% of cases. Fat was not reliably distinguished from other soft-tissue components on sonograms. The most characteristic radiologic findings of mature teratoma of the retroperitoneum are a complex mass containing a well-circumscribed fluid component of variable volume, adipose tissue and/or sebum in the form of a fat-fluid level, and calcification in either a congealed or linear strand pattern. These findings are better demonstrated by CT than by sonography.
Seventeen patients with upper urinary tract infection who underwent 51 computed tomographic studies (two to five per patient; mean, three) were retrospectively evaluated. Five to 10 days after the initial examination, there was little change in parenchymal abnormalities, but perirenal inflammation worsened and then subsided over 2-8 weeks. Enlargement of the affected kidney, present initially in 12 patients, persisted up to 6 weeks and resolved by 10-16 weeks. Abnormalities of parenchymal contrast material enhancement persisted for 1-2 months. New cortical scars appeared in six of 12 patients with an initially normal renal contour and in one of five patients who had scars initially. Three patients with a renal abscess developed a new calyceal diverticulum, presumably by rupture of the abscess into the collecting system. The present study shows that abnormalities of renal size and enhancement persist for weeks to months after clinical signs of infection resolve and that scarring in adults with urinary tract infection occurs more frequently than was previously realized.
The current approaches to diagnosing the various renal inflammatory diseases are briefly reviewed. Terminology is varyingly used by different individuals. Our current understanding of these disease processes is discussed in an effort to review the current status of both the mundane and the esoteric infections of the kidney.
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Six hundred forty-five cases of transitional cell carcinoma (TCC) of the bladder, ureter, and/or kidney were reviewed retrospectively to determine the frequency of synchronous and metachronous lesions elsewhere in the urinary tract. Among 597 patients with TCC of the bladder, 23 (3.9%) developed an upper-tract lesion, after an average delay of 61 months. Metachronous upper-tract tumors developed in 13% of 38 patients with primary ureteral TCC and in 11% of 63 with renal TCC, after average delays of 28 and 22 months, respectively. Synchronous TCC was found in 2.3% of patients with bladder TCC, 39% of those with ureteral TCC, and 24% of those with renal TCC. Seventeen percent of the subsequent upper-tract lesions would have been demonstrated by intravenous or retrograde urography performed 1 year after the initial onset of primary bladder cancer, and 61% would have been demonstrated by studies performed within 2 years. Therefore, the authors recommend annual radiologic evaluation of the upper urinary tract for 2 years after initial diagnosis and treatment of an upper-tract or bladder TCC.
Seventeen cases of hemangiopericytoma of the retroperitoneum were retrospectively analyzed for demographic, morphologic, and radiologic features. These tumors were found in all age groups (2 months to 72 years) and occurred in similar numbers of male and female patients. The tumors tended to be large (11 were greater than 8 cm), were well encapsulated, and occurred less frequently in the pelvic retroperitoneal space (six cases) than in abdominal retroperitoneum (11 cases). All tumors were bulky enough to displace part of the gastrointestinal tract, with only two being inoperable. The most distinctive radiologic feature was hypervascularity (found on 11 of 11 angiograms). Other nondiscriminating radiologic features included well-defined margins and necrosis, with nondistinctive amorphous calcification identified in one case. Angiographic or computed tomographic demonstration of hypervascularity in a retroperitoneal tumor is more suggestive of hemangiopericytoma than of a liposarcoma or malignant fibrous histiocytoma, two of the more common tumors of this region.
The CT and sonographic findings in 23 cases of renal lesions in which the abnormality was infiltrative, as opposed to expansile, were analyzed (invasive transitional cell carcinoma [seven], renal lymphoma [six], metastasis to the kidney [three], acute bacterial nephritis [three], mesoblastic nephroma [two], squamous cell carcinoma of the renal pelvis [one], and renal cell carcinoma [one]). CT scans were evaluated for shape and density of the mass, pelvocaliceal displacement, effect on the renal sinus fat, and the presence of perirenal involvement. Sonograms were evaluated for the shape and echogenicity of the mass and for the effect on the renal sinus echoes. Findings of infiltrative growth included poorly defined margins of the mass; trapped, nondisplaced infundibulae; and calices with occasional calicectasis, diminished contrast enhancement, occasional nephrographic striations, replacement of central sinus fat, loss of central sinus echoes, and variable renal parenchymal echogenicity. The reniform shape was usually preserved and was present in 19 of 20 cases with CT and 13 of 15 cases with sonograms. These observations indicate that analyses of the margins, architecture, and effects on the collecting system and renal sinus by the mass are helpful in the diagnosis of those diseases that characteristically infiltrate the kidney.
A new computed tomographic and sonographic appearance of renal metastatic melanoma is described. Bilateral cystic masses with thick walls, many with mural nodules, were noted. Sonography also demonstrated complex echopenic masses with irregularly thickened walls and mural nodules.
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Intravesical small bowel herniation is a rare complication of bladder perforation, with only 1 case reported previously. We describe 2 additional patients in whom the diagnosis of bladder perforation was delayed or made difficult because the herniated small bowel presented as a filling defect without significant extravasation of contrast medium on cystography. In both patients additional investigative procedures were necessary to establish the diagnosis preoperatively.
1. Many diverse disease processes may result in a multiloculated renal mass. 2. The term "multilocular cyst" is purely descriptive and should not be used as a specific diagnosis. 3. The management of this diverse group of diseases is controversial. There is insufficient information concerning the accuracy of percutaneous biopsy to permit one to base management decisions on such a biopsy in most of these masses. The cystic diseases (septated cyst, localized cystic disease, segmental multicystic kidney) should be managed conservatively. Most cases of arteriovenous communication are readily diagnosed angiographically and managed by vascular occlusive techniques or by surgery. The remaining multiloculated renal masses usually require surgical removal for histologic diagnosis or definitive therapy or both.