The futility of continued surveillance of epididymal cysts – A study of the prevalence and clinico-demographics in pre- vs. post-pubertal boys

Introduction: The first description of epididymal cysts in children appears from a 1976 case study. Since then, there have been a total of 24 indexed publications relating to pediatric epididymal cysts. Risk factors that may exist for children presenting with epididymal cyst remain unknown, as has the best method of management. And there have not been any studies looking at the cost implications of this diagnosis. The aim of this study was to assess the incidence, clinico-demographics, outcomes, and costs of epididymal cysts in pre-pubertal boys compared with a post-pubertal epididymal cyst cohort, and to assess whether this cohort requires continued surveillance. Methods: Our institutional ultrasound (US) database was searched for all scrotal US. From these, a filtered, institution review board-approved search was performed for any reports containing the word “cyst.” These were then cross-referenced with a retrospective chart review (October 2006 to September 2017). Clinico-demographics, cyst characteristics, and outcomes were analyzed for both pre- and post-pubertal boys using descriptive and non-parametric statistical methods. Results: Of 4508 boys undergoing scrotal US during the study period, 191 were indicated to contain cysts. This was manually reduced to 109 scans (2.4%) that met inclusion criteria (85 pre-pubertal; 24 post-pubertal). Thirty-one scans were ordered by urology, including all those with abnormal testicular echotexture (n=5). The average age of the post-pubertal cohort was 15.8 years, compared with 3.8 years in the pre-pubertal cohort. Most (70.5%) epididymal cysts were incidental. There was no difference between the pre- and post-pubertal cohorts in terms of presence of hydrocoeles (p=0.9), symptoms (p=0.9), ordering service (p=0.61), rate of resolution (4.2% vs. 8.2%; p=0.68), or length of followup (4 vs. 4.5 years; p=0.44). Pre-pubertal cysts were significantly smaller in size (3.35 vs. 14.52 mm; p=0.025) and more likely to trigger repeat scanning (67 vs. 10; p=0.008). There were no operative interventions and no subsequent clinical deterioration occurred with observation. At a cost of $71.10 CAD per US, $15 002.10 CAD was expended on epididymal cyst surveillance in direct cost to the healthcare system. Conclusions: Epididymal cysts are comparable in both pre- and post-pubertal boys and can be safely managed non-operatively without the use of continued US surveillance or urological referral. The higher than expected rate of detection may be a result of the improved ultra-resolution of modern scanners. These children should not require continued followup with repeat surveillance imaging solely for epididymal cysts and could be managed in the primary care setting as part of routine clinical examination

Effect of gluten-free diet on cerebellar MR spectroscopy in gluten ataxia

Objective:To evaluate the effect of gluten free diet (GFD) on magnetic resonance spectroscopy (MRS) of the cerebellum in patients with gluten ataxia (GA).Methods:Patients with GA, defined as sporadic ataxia with positive antigliadin antibodies in the absence of an alternative cause, routinely undergo MRS at baseline and after the introduction of GFD as part of their clinical care. We present our experience of the effect of GFD on MRS of the cerebellum.Results:A total of 117 consecutive patients with GA were included in this report. Sixty-three were on strict GFD with elimination of antigliadin antibodies, 35 were on GFD but were still positive for antigliadin antibodies, and 19 patients opted not to go on GFD. The N-acetylaspartate (NAA)/creatine (Cr) area ratio from the cerebellar vermis increased in 62 out of 63 (98%) patients on strict GFD, in 9 of 35 (26%) patients on GFD but positive antibodies, and in only 1 of 19 (5%) patients not on GFD. The NAA/Cr ratio decreased in all 14 ataxia control patients (cerebellar variant of multisystem atrophy). There were no differences in the MRS results between those patients who had and those who did not have enteropathy (celiac disease) within each group.Conclusions:The demonstration of increased NAA/Cr ratio on repeat scanning following strict GFD strengthens previous findings of clinical improvement of the ataxia in patients with GA. The presence of enteropathy is not a prerequisite for such improvement; therefore patients with positive serology and negative duodenal biopsy should still be treated with strict GFD.

Repeat duplex ultrasound scanning in suspected Deep Vein Thrombosis (DVT): putting the onus back on the referring clinician

Duplex scanning is utilised by many departments in the investigation of suspected Deep Vein Thrombosis (DVT). NICE Guideline CG144 recommended repeat scanning for patients in whom the initial Wells score was ‘likely’ in the presence of a raised D-Dimer, following a normal first scan. Following implementation of this recommendation in our department there was a dramatic rise in the number of repeat scans being undertaken, all of which were negative for DVT. Introduction of an electronic message to the report, placing the onus back on the referring clinician to arrange repeat scan if deemed appropriate resulted in a fall in the number of scans being undertaken without impacting on patient outcome.

Effect of Laser Pulse Fatigue on the Mechanical Characteristics of a CFRP Plate

A laser ultrasonic based nondestructive evaluation (NDE) technique has been widely used in aerospace industries for inspecting parts and structures made of composite materials. The thermoelastic regime is used for the ultrasonic generation, so no plasma is formed on the surface of composite structure. Generally, the service lifetime for an aircraft could be more than 25 years. Thus, the composite structures of the aircraft could be susceptible to laser pulse fatigue damage caused by the laser pulse energy of a laser ultrasonic generator in the long-term periodic maintenance inspection. In this paper, the effect of laser pulse fatigue on the mechanical characteristics of a carbon-fiber-reinforced polymer (CFRP) plate (USN175BX Carbon UD preprag) with the stacking sequence of [0/45/-45/90]s is investigated to verify the reliability of the use of a laser ultrasonic based NDE technique on the CFRP plate specimen inspection. A high-speed laser ultrasonic scanning system (400mm/s at the intervals of 0.4 mm) was setup to perform repeat scanning of 1300 times on a CFRP plate specimen with the scanning area of 70 mm x 60 mm. These repeat scanning times were set in consideration of the periodic maintenance inspection scheduled to be 1 time/week x 52 weeks/year x 25 years. A 532nm Q-switched continuous wave laser (QL) was used and set at the laser pulse energy levels of 0.6 mJ and 1.2 mJ. Lamb wave assessment based on pitch-catch method was proposed in this paper to monitor the mechanical characteristics of a composite specimen. In each completion of 100 times repeat scanning, the Young’s modulus of the scanning area was evaluated based on the group velocity of S0 Lamb wave mode. In addition, the surface condition of the scanning area was investigated by using a microscope.

Delayed Epidural Hemorrhage in Hypotensive Multiple Trauma Patients

Despite the availability of high resolution computed tomography, severely head-injured patients often present diagnostic dilemmas. An initially negative computed tomographic scan in the presence of severe multiple trauma does not predict an uncomplicated course. Early repeat scanning should be considered. We present three cases of delayed epidural hemorrhage in multiple trauma patients who initially were hypotensive secondary to hypovolemia. Possible etiologies for the hemorrhage as well as a list of indications for repeat scanning in the posttraumatic period are discussed.