Andrew R. Pulito

Testicular regression syndrome: a clinical and pathologic study of 11 cases.

CONTEXT The vanishing or regressed testis is an entity well known to urologists and pediatric surgeons, affecting approximately 5% of patients with cryptorchidism. However, there is little review and discussion of this entity among pathologists with only 2 of 40 published reviews of testicular regression syndrome (TRS) found in the pathologic literature. OBJECTIVES To assess recognition of TRS among a subset of pathologists and to determine the applicability of histologic criteria for TRS as published. DESIGN An 8-year retrospective review of cases submitted as atrophic or regressed testis was performed. Original diagnosis and diagnosis after review were compared to assess pathologic recognition of TRS. Pathologic assessment included identification of vas deferens, epididymis, dystrophic calcification, hemosiderin, dominant vein, pampiniform plexus-like vessels, and vascularized fibrous nodule formation. At minimum, the presence of a vascularized fibrous nodule (VFN) with calcification or hemosiderin or VFN with cord element(s) was required for diagnosis. SETTING AND PARTICIPANTS Medical records and pathologic specimens of patients undergoing surgery for cryptorchidism or with specimens reviewed at a medium-sized university hospital were analyzed. RESULTS The original diagnosis in 3 (23%) of 13 cases was that of TRS. On secondary review, 11 (85%) of 13 cases showed features consistent with TRS. The diagnoses both before and after review showed a concurrence of 23% (3/13 cases). Two (15%) of 13 cases were correctly recognized and diagnosed as TRS at primary review; 1 case originally thought to represent TRS was not confirmed. Pathologic features correlated well with those reported in the literature. Among all 13 cases, the 11 confirmed TRS cases showed VFN in 11 (85%), intranodular calcification in 8 (62%), intranodular hemosiderin in 9 (69%), vas deferens in 9 (69%), epididymal structures in 5 (38%), and a dominant venous structure in 11 (85%). The average size of the VFN was 1.1 cm. CONCLUSION A urologic and pediatric surgical problem, TRS may be unrecognized by many practicing pathologists. In the typical situation in which a blind ending spermatic cord is submitted for tissue analysis, characterization of such cases as consistent with regressed testis is desirable and achievable in a high percentage of cases. Pathologists may play a pivotal role in management of these patients since histologic confirmation of the testis as regressed reassures the surgeon and the family of the correctness of diagnosis and can eliminate the necessity for further intervention.

Locally Invasive Aspergillosis of the Bowel

Locally invasive aspergillosis of the bowel and peritoneal cavity is a rare complication of immunosuppression, broad-spectrum antibiotic therapy, and corticosteroid administration. We present the case of a 9-year-old boy with acute lymphocytic leukemia who presented with a small bowel obstruction. Surgical treatment of the aspergillosis required multiple aggressive resections of all involved bowel segments. Parenteral nutrition and intravenous Amphotericin B and 5-Fluorocytosine therapy were also instituted. Achievement of a hematologic remission is another prerequisite for cure.

Broviac central venous catheters inserted via the saphenous or femoral vein in the NICU under local anesthesia

We present our experience with 92 Broviac central venous catheters inserted into 84 infants over a 31-month period. Our technique specifies placement in the neonatal intensive care unit under local anesthesia, with insertion to the inferior vena caval-atrial junction via the saphenous or femoral vein, with a subcutaneous tunnel to an exist site on the anterior thigh. We conclude this technique to be safe, efficient, convenient, cost-effective, and minimally uncomfortable to the infant, with no increase in morbidity or mortality in comparison to previously described methods.

Faculty evaluation of surgery clerkship students: important components of written comments.

Quiet 0.96 Intelligence 0.93 Clinical reasoning skills 0.91 Fund of knowledge 0.91 Work ethic 0.89 Overall performance 0.88 Future life as a physician 0.85 Role on team 0.85 Will improve in time 0.83 Organization 0.81 Interpersonal skills with patients 0.79 Evidence of study 0.79 Written and/or oral skills 0.75 Professionalism 0.74 Motivation 0.73 Participates during rounds/conferences 0.68 Prepares for and participates in patient care activities 0.62 Initiative 0.60 Clinical skills 0.58 Interpersonal skills with staff 0.49 Miscellaneous; no category 0.20 General comments such as ‘‘nice guy’’ 0.17

Are multiple objective measures of student performance necessary

BACKGROUND This study examines the effect of using multiple modalities to evaluate medical students. METHODS Thirty-four students were evaluated by a complex model utilizing National Board of Medical Examiners (NBME) shelf examination, Objective Structured Clinical Examination (OSCE), Computer Patient Simulation (CPS), faculty and peer evaluation. Results were compared with a traditional model based on NBME and faculty evaluation alone. RESULTS Reliability (coefficient alpha) of the complex and traditional models were 0.72 and 0.47, respectively. Item correlations suggested that NBME was most discriminating (r = 0.75), followed by OSCE (r = 0.52), peer evaluation (r = 0.43), CPS (r = 0.39), and faculty evaluation (r = 0.32). Rank order correlation (Spearmans rho) between scores calculated using each model was 0.87. CONCLUSIONS Although the complex model has improved reliability, both models rank students similarly. However, neither model fully captures and reflects the information provided by each of the specific evaluation methods.

Ischemic extremities due to compartment syndromes in a septic neonate.

The clinical presentation and diagnostic evaluation of a septic neonate with sclerema neonatorum and impending tissue loss secondary to compartment syndromes is presented. Vascular disease leading to tissue loss is uncommon in children. To our knowledge, this is the only reported case of a compartment syndrome leading to tissue loss in a neonate.

Fetal morbidity and mortality following motor vehicle accident: Two case reports

OBJECTIVE:To report two unusual cases of fetal morbidity and mortality following motor vehicle accident (MVA).STUDY DESIGN:The authors retrospectively reviewed two MVA episodes involving pregnant mothers that resulted in unusual mortality and morbidity to the fetus.RESULTS:Of the two infants, one died from complications related to disseminated intravascular coagulation. The other infant survived after surgical repair of a full-thickness tear of the small bowel at the level of the duodenal-jejunal junction. This type of injury is due to acceleration and deceleration forces, a classic mechanism for bowel injury to the restrained passenger in an MVA.CONCLUSION: We report two unusual cases of fetal morbidity and mortality from MVA, including the first case of fetal bowel injury secondary to maternal MVA (a case that demonstrates that the fetus is subjected to similar mechanical forces as any restrained passenger in an MVA).

Separation of complex pygopagus conjoined twins

Pygopagus twins were born with a unique spectrum of anomalies including a conjoined distal spinal cord, single kidney (in twin A), single rectum (in twin A), single vagina (in twin B), and severe central nervous system anomalies in twin B that precluded her independent survival. Separation at 10 weeks of age was tailored toward Twin As survival. This report discusses the surgical modifications necessary in view of the unique anatomy, including salvaging the distal spinal cord and vagina for twin A.