Incidence and treatment of developmental hip dysplasia in Mongolia: a prospective cohort study

BACKGROUND In Mongolia, adequate early diagnosis and treatment of developmental hip dysplasia (DDH) have been unavailable and its incidence was unknown. We determined the incidence of ultrasonographic DDH in newborns and established adequate procedures for diagnosis and treatment of DDH at the largest maternity hospital in Ulaanbaatar, Mongolia. METHODOLOGY/PRINCIPAL FINDINGS During one year (Sept 2010 - Aug 2011) we assessed the hips newborns using ultrasound and Graf's classification of DDH. 8,356 newborns were screened; median age at screening was 1 day. We identified 14,873 Type 1 (89.0%), 1715 Type 2a (10.3%), 36 Type 2c (0.2%), 70 Type D (0.4%), 14 Type 3 (0.08%), and 4 Type 4 hips (0.02%). Children with Type 1 hips (normal) were discharged. Children with Type 2a hips (physiologically immature) received follow-up ultrasounds at monthly intervals. Children with Type 2c to 4 (DDH; deformed or misaligned hip joint) hips were treated with a Tubingen hip flexion splint and also followed up. The hip abnormalities resolved to mature hips in all children who were followed up. There was no evidence for severe treatment related complications. CONCLUSION/SIGNIFICANCE This study suggests that the incidence of DDH in Mongolian neonates is comparable to that in neonates in Europe. Early ultrasound-based assessment and splinting treatment of DDH led to mature hips in all children followed up. Procedures are feasible and will be continued.

Effect of phrenic nerve palsy on early postoperative lung function after pneumonectomy: a prospective study

BACKGROUND The issue of phrenic nerve preservation during pneumonectomy is still an unanswered question. So far, its direct effect on immediate postoperative pulmonary lung function has never been evaluated in a prospective trial. METHODS We conducted a prospective crossover study including 10 patients undergoing pneumonectomy for lung cancer between July 2011 and July 2012. After written informed consent, all consecutive patients who agreed to take part in the study and in whom preservation of the phrenic nerve during operation was possible, were included in the study. Upon completion of lung resection, a catheter was placed in the proximal paraphrenic tissue on the pericardial surface. After an initial phase of recovery of 5 days all patients underwent ultrasonographic assessment of diaphragmatic motion followed by lung function testing with and without induced phrenic nerve palsy. The controlled, temporary paralysis of the ipsilateral hemidiaphragm was achieved by local administration of lidocaine 1% at a rate of 3 mL/h (30 mg/h) via the above-mentioned catheter. RESULTS Temporary phrenic nerve palsy was accomplished in all but 1 patient with suspected catheter dislocation. Spirometry showed a significant decrease in dynamic lung volumes (forced expiratory volume in 1 second and forced vital capacity; p < 0.05) with the paralyzed hemidiaphragm. Blood oxygen saturation levels did not change significantly. CONCLUSIONS Our results show that phrenic nerve palsy causes a significant impairment of dynamic lung volumes during the early postoperative period after pneumonectomy. Therefore, in these already compromised patients, intraoperative phrenic nerve injury should be avoided whenever possible.

Use of a hand-assisted laparoscopic surgical technique for closure of an extensive mesojejunal rent in a horse

CASE DESCRIPTION A 7-year-old 573-kg (1,261 -lb) Swiss Warmblood gelding was evaluated because of signs of acute abdominal pain. CLINICAL FINDINGS Physical examination revealed a markedly distended abdomen with subjectively reduced borborygmi in all abdominal quadrants. A large, gas-distended viscus was present at the pelvic brim preventing complete palpation of the abdomen per rectum. Ultrasonographic evaluation could not be safely performed in the initial evaluation because of severe signs of abdominal pain. TREATMENT AND OUTCOME Ventral midline celiotomy was performed, and right dorsal displacement of the ascending colon was corrected. Progressive signs of abdominal pain after surgery prompted repeat ventral midline celiotomy, and small intestinal incarceration in a large, radial mesojejunal rent was detected. The incarceration was reduced, but the defect was not fully accessible for repair via the celiotomy. Repair of the mesenteric defect was not attempted, and conservative management was planned after surgery; however, signs of colic returned. A standard laparoscopic approach was attempted from both flanks in the standing patient, but the small intestine could not be adequately mobilized for full evaluation of the rent. Hand-assisted laparoscopic surgery (HALS) allowed identification and reduction of jejunal incarceration and repair of the mesenteric rent. Although minor ventral midline incisional complications were encountered, the horse recovered fully. CLINICAL RELEVANCE HALS techniques should be considered for repair of mesenteric rents in horses. In the horse of this report, HALS facilitated identification, evaluation, and repair of a large radial mesenteric rent that was not accessible from a ventral median celiotomy.

Development of an ultrasound-guided technique for pudendal nerve block in cat cadavers.

The objective of this prospective experimental cadaveric study was to develop an ultrasound-guided technique to perform an anaesthetic pudendal nerve block in male cats. Fifteen fresh cadavers were used for this trial. A detailed anatomical dissection was performed on one cat in order to scrutinise the pudendal nerve and its ramifications. In a second step, the cadavers of six cats were used to test three different ultrasonographic approaches to the pudendal nerve: the deep dorso-lateral, the superficial dorso-lateral and the median transperineal. Although none of the approaches allowed direct ultrasonographical identification of the pudendal nerve branches, the deep dorso-lateral was found to be the most advantageous one in terms of practicability and ability to identify useful and reliable landmarks. Based on these findings, the deep dorso-lateral approach was selected as technique of choice for tracer injections (0.1 ml 1% methylene blue injected bilaterally) in six cat cadavers distinct from those used for the ultrasonographical study. Anatomical dissection revealed a homogeneous spread of the tracer around the pudendal nerve sensory branches in all six cadavers. Finally, computed tomography was performed in two additional cadavers after injection of 0.3 ml/kg (0.15 ml/kg per each injection sites, left and right) contrast medium through the deep dorso-lateral approach in order to obtain a model of volume distribution applicable to local anaesthetics. Our findings in cat cadavers indicate that ultrasound-guided pudendal nerve block is feasible and could be proposed to provide peri-operative analgesia in clinical patients undergoing perineal urethrostomy.

Arthroscopic approaches to the fetlock joint of adult cattle: a cadaver study

The objective of the present study was to describe the arthroscopic anatomy of the bovine fetlock joint using one palmar/plantar and three dorsal joint approaches. A comparative anatomic, ultrasonographic and arthroscopic study using 20 cadaveric feet from 13 non-lame adult dairy cows was performed. Arthroscopy was accomplished using a rigid arthroscope to view the synovial cavities with their synovial villi and parts of the following structures: the distal ends of the metacarpal/metatarsal III/IV bones with their trochleae and sagittal ridges, synovial grooves, the articular surfaces of the proximal sesamoid bones, the proximal aspects of the first phalanges, the lateral and medial collateral ligaments, the suspensory ligament and the interdigital ligaments as parts of the interosseus muscle, the cruciate sesamoidean ligaments, the communication site between the lateral and medial pouch in the palmar/plantar area, and dorsally the septum between the lateral and the medial pouch. The technique allowed a good overall view of most relevant structures in the sound cadaver joint. Further investigations are warranted to evaluate the diagnostic, therapeutic and prognostic applications of these techniques in the treatment of septic arthritis.

Gastrointestinal ultrasonography of normal Standardbred neonates and frequency of asymptomatic intussusceptions.

BACKGROUND Ultrasonographic appearance of the gastrointestinal (GI) tract of equine neonates has not been completely described. OBJECTIVES To describe (1) sonographic characteristics of the GI segments in normal nonsedated equine neonates, (2) intra- and interobserver variation in wall thickness, and (3) the sonographic appearance of asymptomatic intussusceptions, and (4) to compare age and sonographic findings of foals with and without asymptomatic intussusceptions. ANIMALS Eighteen healthy Standardbred foals ≤5 days of age. METHODS Prospective, cross-sectional blinded study. Gastrointestinal sonograms were performed stall-side. Intraobserver variability in wall thickness measurements was determined by calculating the coefficient of variation (CV). The Bland-Altman method was used to assess interobserver bias. Student's t-test and Fisher's exact test were used to test the association among presence of intussusceptions, age, and selected sonographic findings. RESULTS The reference ranges (95% predictive interval) for wall thickness were 1.6-3.6 mm for the stomach, 1.9-3.2 mm for the duodenum, 1.9-3.1 mm for the jejunum, 1.3-2.2 mm for the colon, and 0.8-2.7 mm for the cecum. Intraobserver wall thickness CV ranged from 8 to 21% for the 2 observers for 5 gastrointestinal segments. The interobserver bias for wall thickness measurements was not significant except for the stomach (0.14 mm, P < .05) and duodenum (0.29 mm, P < .05). Diagnostic images of mural blood flow could not be obtained. Asymptomatic intussusceptions were found in 10/18 neonates. Associations between sonographic variables or age and the presence of intussusceptions were not found. CONCLUSIONS AND CLINICAL IMPORTANCE Sonographic characteristics of the GI tract of normal Standardbred neonates can be useful in evaluating ill foals. Asymptomatic small intestinal intussusceptions occur in normal Standardbred neonates.

IMAGING DIAGNOSIS-MUSCULAR HYPERTROPHY OF THE SMALL INTESTINE AND PSEUDODIVERTICULA IN A HORSE.

A 14-year-old Thoroughbred gelding was presented for chronic colic and weight loss. Transcutaneous and transrectal abdominal ultrasonography revealed distended, thickened small intestine with primary thickening of the muscularis and a focally more thickened loop with an echoic structure crossing the wall from the mucosa to the serosa. Visualization of diffuse thickening of the muscularis (muscular hypertrophy of the small intestine) and a focal lesion (pseudodiverticulum) helped clinicians make informed decisions. This case illustrates the importance of transabdominal and transrectal ultrasonography in horses with chronic colic and the relevance of considering the abnormalities in layering pattern of the intestinal wall.

Ceco-cecal intussusception in a Simmental heifer

This report describes the clinical, laboratory and ultrasonographic findings in a Simmental heifer with a ceco-cecal intussusception. The general condition of the heifer was moderately reduced and it showed mild colic signs. Physical examination revealed a firm longish mass visible and palpable in the right flank. Findings upon rectal examination, fecal output und defecation were normal. Ultrasound examination of the mass revealed features typical for an intussusception. Based on the slow development of symptoms, normal fecal output and ultrasonography findings, a ceco-cecal intussusception was diagnosed. Right flank laparatomy was performed under general anaesthesia, and an end-to-side anastomosis between the jejunum and the spiral colon was made after resection of the intussuscepted intestines. Recovery was uneventful.

New osseous soft markers for trisomy 13, 18 and 21

INTRODUCTION For ultrasonographic diagnosis of a fetal trisomy so-called "soft markers" (=ultrasonographically detectable morphological variants) are used. Detection of a certain number of them increases the diagnostic certainty of a fetal trisomy. Up to now there are very few diagnostically accepted osseous soft markers for trisomy. Hence potential osseous soft markers applicable for first and second trimester ultrasound screening for trisomy 21, 18 or 13 were studied. METHODS Postmortal fetal X-rays (ap, lateral) of 358 fetuses (trisomy 21: n = 109, trisomy 18: n = 46; trisomy 13: n = 38, control group: n = 165). RESULTS Not yet described but with trisomy 21 statistically associated soft markers were un-timely os sternale ossification, delayed os sacrum ossification, shortened os maxillare, reduced os maxillare-jaw-corner distance, augmented orbita height, premature os calcaneus ossification, bell-shaped thorax, coronal clefts, trend to wider binocular as well as wider intraocular distances; for trisomy 18: elevated clavicula slope, reduced number of ribs, bell-shaped thorax, coronal clefts, reduced os maxillare-jaw-corner distance, shortened ramus mandibulare, shortened os metacarpale IV and V, augmented ratio between biparietal diameter and (osseus and soft-tissue) shoulder width; for trisomy 13: longer os nasale, elevated clavicula slope, premature sternum, delayed os sacrum ossification, delayed/premature cranium ossification, reduced number of ribs, coronal clefts, reduced os maxillare-jaw-corner distance, shortened ramus mandibulare, augmented orbita height, shortened os metacarpale V and a tendency for a shortened os metacarpale IV. CONCLUSION We found several not yet published osseous soft markers statistically associated with trisomy 21, 18 and 13, which can help to ensure sonographically these aneuploidy diagnoses.

The importance of phrenic nerve preservation and its effect on long-term postoperative lung function after pneumonectomy

OBJECTIVES The importance of phrenic nerve preservation during pneumonectomy remains controversial. We previously demonstrated that preservation of the phrenic nerve in the immediate postoperative period preserved lung function by 3-5% but little is known about its long-term effects. We, therefore, decided to investigate the effect of temporary ipsilateral cervical phrenic nerve block on dynamic lung volumes in mid- to long-term pneumonectomy patients. METHODS We investigated 14 patients after a median of 9 years post pneumonectomy (range: 1-15 years). Lung function testing (spirometry) and fluoroscopic and/or sonographic assessment of diaphragmatic motion on the pneumonectomy side were performed before and after ultrasonographic-guided ipsilateral cervical phrenic nerve block by infiltration with lidocaine. RESULTS Ipsilateral phrenic nerve block was successfully achieved in 12 patients (86%). In the remaining 2 patients, diaphragmatic motion was already paradoxical before the nerve block. We found no significant difference on dynamic lung function values (FEV1 'before' 1.39 ± 0.44 vs FEV1 'after' 1.38 ± 0.40; P = 0.81). CONCLUSIONS Induction of a temporary diaphragmatic palsy did not significantly influence dynamic lung volumes in mid- to long-term pneumonectomy patients, suggesting that preservation of the phrenic nerve is of greater importance in the immediate postoperative period after pneumonectomy.

Une étude cadavérique pour réduire les risques des approches chirurgicales et percutanées de l’artère fémorale

En chirurgie vasculaire, l’accès à l’artère fémorale, qu’il soit par une incision chirurgicale ou par une approche percutanée, est très fréquemment utilisé pour une multitude d’interventions vasculaires ou endovasculaires; pour des pontages divers, le traitement d’occlusions artérielles, la réparation d’anévrismes et la pose d’endoprothèses. L’objectif général de ce projet de recherche est de faciliter et réduire les risques des approches de l’artère fémorale par une meilleure compréhension anatomique du triangle fémoral. La méthodologie a été réalisée grâce à l’utilisation de cadavres spécialement embaumés par la méthode développée par Walter Thiel. Les résultats présentés dans ce mémoire ont permis de proposer des solutions en réponse à des problèmes cliniques en chirurgie vasculaire. Dans un premier temps, l’étude de la vascularisation cutanée du triangle fémoral a mené à proposer de nouvelles incisions chirurgicales afin de limiter la dévascularisation cutanée des plaies et ainsi réduire les problèmes de cicatrisation observés. Ensuite, nous avons validé l’identification radiographique et échographique de l’artère fémorale à son croisement avec le ligament inguinal afin de faciliter l’identification d’un site de ponction artérielle adéquat. Enfin, nous avons développé une méthode échographique simple qui facilite l’approche percutanée de l’artère fémorale, même chez les patients obèses. Les retombées de ce projet de recherche sont multiples pour les cliniciens, l’étude fournit une meilleure compréhension anatomique tridimensionnelle du triangle fémoral et les techniques proposées dans ce mémoire pourront apporter une amélioration de la pratique chirurgicale et faciliter le travail des médecins. Toutefois, ces propositions devront maintenant être validées en clinique.

Ultrasonography of gallbladder abnormalities due to schistosomiasis

After malaria, schistosomiasis remains the most important tropical parasitic disease in large parts of the world. Schistosomiasis has recently re-emerged in Southern Europe. Intestinal schistosomiasis is caused by most Schistosoma (S.) spp. pathogenic to humans and leads to chronic inflammation and fibrosis of the colon as well as to liver fibrosis. Gallbladder abnormalities usually occur in patients with advanced hepatic portal fibrosis due to Schistosoma mansoni infection. Occasionally, gallbladder abnormalities have been seen also in children and occurring without associated overt liver abnormalities.The specific S. mansoni-induced gallbladder abnormalities detectable by ultrasound include typical hyperechogenic wall thickening with external gallbladder wall protuberances. The luminal wall surface is smooth. The condition is usually clinically silent although some cases of symptomatic cholecystitis have been described. The ultrasonographic Murphy response is negative. Gallbladder contractility is impaired but sludge and calculi occur rarely. Contrary to other trematodes such as liver flukes, S. mansoni does not obstruct the biliary tract. Advanced gallbladder fibrosis is unlikely to reverse after therapy.

Suspected hexamine intoxication in a dog

An eight-month-old Labrador Retriever was presented with urinary incontinence and haematuria. Recent history suggested that the dog had access to solid fuel hexamine tablets, ingesting a dose of 6g/kg. Clinical signs, laboratory investigation and ultrasonographic findings were supportive of chemically-induced cystitis and a diagnosis of suspected hexamine intoxication was made. The dog recovered uneventfully and it is unlikely that the insult will be carcinogenic.

PCOS remains a diagnosis of exclusion:a concise review of key endocrinopathies to exclude

Polycystic ovarian syndrome (PCOS) is a heterogenous disorder associated with clinical, endocrine and ultrasonographic features that can also be encountered in a number of other diseases. It has traditionally been suggested that prolactin excess, enzymatic steroidogenic abnormalities and thyroid disorders need to be excluded before a diagnosis of PCOS is made. However, there is paucity of data regarding the prevalence of PCOS phenotype in some of these disorders, whereas other endocrine diseases that exhibit PCOS-like features may elude diagnosis and proper management if not considered. This article reviews the data of currently included entities that exhibit a PCOS phenotype and those that potentially need to be looked for, and attempts to identify specific features that distinguish them from idiopathic PCOS.