” به ترتيب تاريخ برگزاري “

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چهارمين سمينار سراسري انجمن صرع ايران   (تهران)  13-15 آذرماه 1386

تلفن: 88463355-021

iranepi@gmail.com

http://www.iranepi.org/

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  اولین سمینار فیتوشیمی ایران (تهران) 20-22 آذرماه 1386

تلفن: 22431969-021

isp2007@sbu.ac.ir

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  دومین کنگره سراسری سرطان های گوارش(کولون و رکتوم) (تهران)  21-22 آذر ماه 1386

تلفن: 22748001-021

فاکس: 22748002-021

crc@sbmu.ac.ir

http://www.crc.sbmu.ir/

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  همايش سراسري راهكارهاي ارتقاء سلامت و چالشها   (مازندران)  27-29 آذرماه 1386

تلفن: 2267342-0151

nmhc@mazus.ac.ir

http://www.research.mazums.ac.ir/

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  پنجمین کنفرانس بین المللی مدیریت  (تهران)  27-29 آذرماه 1386

تلفن: 88342900-021

info@irimc.org

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  کنگره میان دوره ای جراحی مغز و اعصاب   (اهواز)  27-29 آذرماه 1386

تلفن: 3367562-0611

insc@ajums.ac.ir

www.ajums.ac.ir/insc

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  ششمین همایش سراسری علوم پزشکی   (یزد) 28-30 آذرماه 1386

تلفن: 8219734-0351

info@ymsc.ir

http://www.ymsc.ir/

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  چهارمین جشنواره آسیایی بهداشت خانواده  (تهران)  دیماه 1386

تلفن: 88677478-021

info@paknamaward.com

http://www.paknamaward.com/

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  دومين همايش ملي پژوهشهاي قرآني حوزه و دانشگاه  (مشهد) زمستان 1386

تلفن: 2217814-0511

Bonyad_pajoheshha@yahoo.com

http://www.quranresearchs.org/

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  سومین سمینار شبکه علمی کشور  (تهران)  4-5 دی ماه 1386

تلفاکس: 88937117-021

info@itseminar.ir

http://www.itseminar.ir/

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  اولین سمینار دانشجویی بهداشت روان با محوریت پرستاری بهداشت روان  (لارستان)  5-6 دیماه 1386

تلفن: 2250335-0781

larnurse@sums.ac.ir

http://larnurse.sums.ac.ir/

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  اولین کنگره کشوری دخانیات و سلامت  (بندرعباس)   12-14 دیماه 1386

تلفن: 3335794-0761

thc@hums.ac.ir

http://www.thc.hums.ac.ir/

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  اولین همایش ارتقاء سلامت ایثارگران  (تهران) 12-13 دیماه 1386

تلفن: 88984158-021

info@Isarhamayesh.ir

http://www.isarhamayesh.ir/

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  نخستین همایش نانوبیوتکنولوژی (مازندران) 19-20 دیماه 1386

تلفن:8-3231104-0124

فاکس:3228990-0124

Dr_ebadi2000@yahoo.com

http://ntechno2007.blogfa.com/

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  کنگره سراسری بیماریهای کلیه در اورلوژی اطفال   (تهران) 19-21 دیماه 1386

تلفن: 88054415-021

razicc@iums.ac.ir

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  سومین سمینار درماتولوژی مبتنی بر شواهد  (تهران) 10-11 بهمن ماه 1386

iro@sina.tums.ac.ir

http://iro.tums.ac.ir

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  همایش دین و دانش پزشکی  (ساری)  3-4 بهمن ماه 1386

تلفن: 2262341

فاکس: 2260393

nmums@nmums.com

http://www.mazums.ac.ir/

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  اولین کنفرانس ملی مدیریت دانش  (تهران)  13-14 بهمن ماه 1386

تلفن: 6-88556492-021

فاکس: 88719960-021

http://www.kmiran.com/

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  سومین کنگره بین المللی سرطان پستان (تهران)  24-26 بهمن ماه 1386

تلفن:22748001-021

فاکس: 22748002-021

crc@sbmu.ac.ir

http://www.crc.ir/

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  اولین کنگره سراسری پزشکی قانونی  (تهران)  24-26 بهمن ماه 1386

تلفن: 66955454-021

NCFM@tums.ac.ir

http://ncfm.tums.ac.ir/

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  همایش پیامبر اسلام(ص) عرفان و معنویت نو  (تهران)  اسفند ماه 1386

تلفن: 66953148-021

erfan@payambarazam.ir

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  اولین همایش اخلاق در علوم بهزیستی و توانبخشی  (تهران)  اسفند ماه 1386

تلفن: 22180139-021

Ethics@uswr.ac.ir

http://www.uswr.ac.ir/

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  چهارمین سمپوزیوم پیشگیری و درمان عوارض عصبی، روانی ناشی از جنگ  (تهران)  1-2 اسفند ماه 1386

تلفن: 23992196-021

info@isaarmhc.ir

http://www.isaarmhc.ir/

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  اولین همایش سراسری عفونت در معتادان به مواد مخدر   (اصفهان)   1-2 اسفندماه 1386

تلفن: 7923081-0311

دورنگار: 6687898-0311

www.seminars.mui.ac.ir/ivda

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  چهاردهمین کنفرانس مهندسی پزشکی ایران ICBME 2008 (دانشگاه شاهد تهران) 1-2 اسفند ماه 1386

تلفن: 55277560-021

icbme2008@shahed.ac.ir

http://www.icbme2008.org/

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  همایش دوروزه ارولوژی کودکان  (تهران) 1-2 اسفندماه 1386

تلفن: 22908282-021

fat_gorji@yahoo.com

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  چهاردهمین کنگره سراسری باروری و ناباروری ایران (یزد) 3-1 اسفند ماه 1386

تلفن: 88525512-88525513

فاکس: 88743478

info@isrm.ir

http://www.isrm.ir/

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  دهمين كنگره سراسري اپتومتري ايران    (زاهدان)  1-3 اسفندماه 1386

تلفن: 2442185-0541

opto@zdmu.ac.ir

http://www.zdmu.ac.ir/

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 چهاردهمين كنگره سراسري باروري و ناباروري ايران   (يزد)   4-6 اسفندماه 1386

تلفن: 8247085-0351

info@yazdivf.org

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  سومین کنگره بررسی مسایل سالمندی در ایران و جهان  (تهران)  6-8 اسفند ماه 1386

تلفن: 22180077و 22678525-021

congress_ageing3@yahoo.com

Aging.rct@uswr.ac.ir

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  چهارمین سمینار شبکه علمی کشور  (تهران)  7-8 دی ماه 1386

تلفاکس: 88937117-021

info@itseminar.ir

http://www.itseminar.ir/

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  اولین همایش ملی حفاظت محیط زیست و توسعه پایدار روستایی  (تهران) 7-8 اسفند ماه 1386

تلفن: 7835511-0251

envrosta@yahoo.com

www.envrosta.blogfa.com

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  سومین کنگره بررسی مسائل سالمندی در ایران و جهان   (تهران)   7-8 اسفندماه 1386

تلفن: 22180077-021

http://irca.uswr.ac.ir/

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  پنجمین کنگره سراسری مراقبتهای پرستاری و مامایی «ارتباطات انسانی»  (تهران)  11-13 اسفند ماه 1386

تلفن: 88054415-021 و 82942715-021

دورنگار: 88054414

razicc@iums.ac.ir

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  همایش ملی پرستاری و مامایی در بیماری های مزمن مغز و اعصاب (آستارا) 14 اسفند ماه 1386

تلفن: 5250051-0182

neuro@iau-astara.ac.ir

http://www.iau.astara.ac.ir/

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  همایش بازیهای رایانه ای و اثرات روانی اجتماعی آن   (قزوین)   نیمه دوم اسفندماه 1386

تلفن: 3780034-0281

Psyc_Games@conf.ikiu.ac.ir

http://conf.ikiu.ac.ir/Games

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  دومین سمینار سراسری بارداری ایمن  (تهران)  14-15 اسفندماه 1386

تلفن: 88883133 -021

ir.hamayesh@yahoo.com

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  نهمین همایش کشوری آموزش پزشکی؛ روش های نوین در آموزش پزشکی  (یزد)  14-16 اسفند ماه 1386

تلفن: 6233178-0351

فاکس: 6249779-0351

mec@ssu.ac.ir

http://mec.ssu.ac.ir/

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  نهمین کنگره سراسری میکروب شناسی ایران   (کرمان)  14-16 اسفندماه 1386

تلفن: 3224619-0341

nicm@kmu.ac.ir

http://microcongress.kmu.ac.ir/

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  اولین همایش سراسری علم سنجی در علوم پزشکی (اصفهان)  15-16 اسفند ماه 1386

تلفن: 7922036-0311

www.seminars.mui.ac.ir/itmed

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  همایش سراسری سرطان از پیشگیری تا نوتوانی  (قزوین)  15-16 اسفندماه 1386

تلفن: 2237268-0281

nursing@qums.ac.ir

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  كنگره سراسري اخلاق پزشكي  (ايلام)  4-6اردیبهشت ماه 1387

تلفن: 2222404-0841

http://www.medilam.ac.ir/

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  سومين كنگره ملي و اولين كنگره بين المللي آسيب شناسي خانواده   (تهران)  ارديبهشت ماه 1387

تلفن: 22431813-021

فاکس: 22902368-021

info.fri@mail.sbu.ac.ir

http://fri.sbu.ac.ir/

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  چهارمين كنگره سراسري اعتياد   (زاهدان)  24-26 ارديبهشت ماه 1387

تلفن: 2442185-0541

ics@zdmu.ac.ir

drugcong4@zdmu.ac.ir

http://www.zdmu.ac.ir/

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  پنجمین کنگره آسیا و اقیانوسیه آناتومی و هشتمین کنگره سراسری آناتومی ایران

27-30 اردیبهشت ماه 1387

تلفن: 88054415-021

www.iums.ac.ir/5thapica-tehran

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  سومین همایش روانپزشکی فرهنگی و اجتماعی   (تهران)   7-9 خردادماه 1387

تلفن: 66551655-021

csp@tehranpi.org

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  اولین سمینار انتریک پاتوژن    (سنندج)  9-10خردادماه 1387

تلفن: 3286508-0871

entericpathogens@muk.ac.ir

http://www.muk.ac.ir/

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11-th Congress of the Middle East Society for Organ Transplantation   MESOT

November 2008- 17-20

 سومین نشست هم اندیشی مدیران مسئول نشریات دانشجویی دانشگاه آزاد اسلامی واحد مشهد در محل مرکز رفاهی دانشگاه آزاد اسلامی مشهد برگزار شد . در این نشست که مدیران مسئول بیش از 20 نشریه از بین 35 نشریه دانشجویی فعال دانشگاه آزاد اسلامی   شرکت داشتند ، موضوعاتی از جمله لزوم پرداختن نشریات دانشجویی واحد مشهد به موضوع نماز ، وحدت و انسجام ملی و امر به معروف و نهی از منکر ، ایجاد بانک اطلاعات نشریات دانشجویی واحد مشهد ، ایجاد نشریه الکترونیک و وب سایت نشریات دانشجویی واحد مشهد ، لزوم تشکیل شورای مدیران مسئول نشریات دانشجویی مورد بحث و تبادل نظر قرار گرفت .

در پایان مدیران مسئول نشریه های سیگنال ، مکانیزم و تا صبح به عنوان نمایندگان نشریات دانشجویی دانشگاه آزاد اسلامی واحد مشهد در کمیته تدوین اساس نامه خانه نشریات دانشجویی دانشگاه آزاد اسلامی واحد مشهد انتخاب شده و مدیران مسئول نشریات دانشجویی بر لزوم تدوین هرچه سریعتر اساس نامه این تشکل تاکید نمودند .

کنفرانس یک روزه با موضوع چاقی در تالار بیمارستان آریا وابسته به دانشگاه آزاد اسلامی واحد مشهد برگزار گردید . در این کنفرانس آقایان دکتر عباسی و سرافراز یزدی از اساتید گروه داخلی دانشکده پزشکی دانشگاه آزاد اسلامی مشهد به بررسی آخرین یافته های پزشکی در زمینه تشخیص ، درمان و کنترل چاقی و نیز عوارض ناشی از چاقی در اطفال و بزرگسالان پرداختند .

سخنران:

جناب آقاي دكتر احمدي

زمان: چهارشنبه 15/9/86 – ساعت 8:15 صبح

مكان: سالن كنفرانس بيمارستان 22 بهمن   

مراقبت هاب پرستاري در جراحي اطفال 1

آترزي مري

انسداد پيلور

هيرشپرونگ

استاد راهنما:

جناب آقاي دكتر محمد علي رئيس السادات

فوق تخصص جراحي اطفال

 ارائه دهندگان:

سركار خانم شريفان

سركار خانم فرقاني 

زمان: چهارشنبه 28/9/86 – ساعت 8:30 صبح

مكان: سالن كنفرانس بيمارستان 22 بهمن 

جهت مشاهده Full Text مقاله ي دكتر خزاعي بر روي continue reading  كليك نماييد.

Pediatric Nephrology Journal of the International Pediatric Nephrology Association

© IPNA 2007

10.1007/s00467-007-0637-5

Original Article

Renal length discrepancy by ultrasound is a reliable predictor of an abnormal DMSA scan in children

Mahmood R. Khazaei1, Fiona Mackie2, 3, Andrew R. Rosenberg2, 3 and Gad Kainer2 

(1)	Pediatrics, Mashad Azad University, 22 Bahman Hospital, Pediatrics, Mashad, Iran

(2)	Department of Nephrology, 4th Floor Emergency Wing, Sydney Children’s Hospital, High Street, Randwick, NSW, 2031, Australia

(3)	University of New South Wales, Sydney, NSW, Australia

Gad Kainer Email: g.kainer@unsw.edu.au

Received: 6 June 2007  Revised: 16 August 2007  Accepted: 20 August 2007  Published online: 26 October 2007

Abstract  A renal length discrepancy (RLD) of more than 10 mm by ultrasound (US) is accepted as a potential indicator of an underlying renal pathology; however, there are few supporting data for this in children. Our objective was to determine a cutoff at which RLD on US is a reliable predictor of dimercaptosuccinate acid (DMSA) scan abnormality. We present data from 90 patients who had both renal US and a DMSA scan, as well as DMSA scan results compared with bipolar RLD by US. Positive (PPV) and negative (NPV) predictive values were calculated for renal RLD from 6 to >10 mm. The left kidney was longer in 56%, whereas the right kidney was longer in 37%; their lengths were equal in 8%. For children at all ages, a left kidney longer than the right by ≥10 mm or a right kidney longer than the left by ≥7 mm gave a PPV for DMSA abnormality of 79% and 100%, respectively. In children older than 4 years, if the right kidney was longer by ≥7 mm or if the left kidney was longer by ≥10 mm, the PPVs for DMSA abnormality were 100% and 63%, respectively. In children younger than 4 years, when the right kidney was longer by ≥6 mm or the left was kidney longer by ≥10 mm, the PPV were 86% and 100%, respectively. Thus, children with a right kidney longer than the left by even <10 mm is a reliable predictor of an abnormal DMSA scan.

Keywords  Kidney size - Renal length - Ultrasonography DMSA - Child - Length discrepancy - Prediction

Introduction

Renal tract imaging by ultrasonography (US) is an integral component in the evaluation of children with kidney disease. The safety and noninvasive nature of US make it the imaging modality of first choice in congenital and acquired renal diseases. Renal tract evaluation with US should include assessment of the length and shape of the kidneys, the thickness and echogenicity of the cortex and the presence of corticomedullary differentiation. The appearance of the renal pelves, ureters and bladder should be reported. Measurement of renal size should be compared with data from published charts [1–3]. In general, normal renal size and echotexture is suggestive of a normal kidney. Renal length has been shown to correlate well with renal volume [4] and glomerular filtration rate (GFR) [5]. Similarly, maximum parenchymal surface area has also been shown to correlate with functioning renal mass by radionuclide scintigraphy [6]. Unfortunately, these methods are too complex for routine clinical use. In clinical practice, ultrasound determination of maximum bipolar renal length is generally used as a measure of kidney size and growth.

A difference of more than 10 mm in the length between the kidneys is found in less than 6% of children [7]. However, “acceptable” renal length differences may be smaller in the younger child. There are no published data that correlate renal length discrepancy (RLD) with objective evidence of renal function or dysfunction to confirm the utility of a 10-mm RLD cutoff in children. Available data in children of different ages, height and sex that compare renal length by US with functioning renal mass do not assist in answering the clinical question as to what constitutes a “significant” RLD. Uptake of radionuclide-labelled dimercaptosuccinate acid (Tc99m-DMSA) is a reliable, noninvasive method for assessing differential renal function and is currently the most sensitive way of detecting renal scars [8].

The aims of this study were to (1) determine whether in children an RLD of 10 mm or more by US correlates with an abnormal DMSA scan and (2) determine whether there is an RLD cutoff by US that is a reliable predictor for DMSA scan abnormality, and if so, what that cutoff is at different ages. Additionally, we wondered whether the significance of RLD varies depending on whether the right or left kidney is smaller.

Methods

In this retrospective study, we evaluated the results from 167 children at Sydney Children’s Hospital who had both renal US and DMSA scan from January 2000 to June 2003. For each child, the US report in closest chronological proximity to the DMSA scan was chosen, with a mean interval between tests (± SD) 69 (55.5) days. The US report was used to extract data on maximum longitudinal renal length, pelvicalyceal system dilatation and existence of cysts, masses or abscesses for each kidney. From the nuclear medicine department report of the DMSA scan, differential renal function, existence or absence of kidney scars and the reasons for referral were obtained. All DMSA scans were performed at least 3 months following urinary tract infection (UTI) [8]. Patients’ gender, age, weight and height at time of US and also their principal diagnoses were extracted from their hospital medical files. Body surface area (BSA) was calculated using the formula .

Exclusion and inclusion criteria

Patients were excluded if they had a solitary or horseshoe kidney; renal cyst ≥10 mm, mass or abscess; or when pelvicalyceal dilation (maximal anteroposterior midpelvic diameter) was ≥10 mm or defined by terms in the radiologist’s report describing pelvicalyceal dilatation as marked, severe, significant or prominent dilatation. From the initial 167 children, 26 patients were excluded because the interval between DMSA scanning and US was more than 6 months. A further 51 patients were excluded due to: severe hydronephrosis (15), single kidney (seven), kidney transplantation (five), cyst or abscess (four), horseshoe kidney (one) and incomplete data (19). A total of 90 patients met the inclusion criteria: 51 girls and 39 boys, age range 1 week to 212 months. Body weight ranged from 3.0 to 74.25 kg, height from 48 to 177 cm and BSA from 0.2 to 1.84 m2. In 62 (69%) patients, a history of UTI was the main reason for the DMSA scan. Other reasons for referral were antenatal hydronephrosis in eight (9%), hypertension in five (6%), ureteral reflux in four (5%), renal infarction and renal vein thrombosis in four (5%), renal failure in three (3%), haemoglobinuria and/or proteinuria in two (2%), urinary tract anomaly in one (1%) and kidney hypoplasia in one (1%). No patient was referred to DMSA scanning primarily because of RLD, but it was noted on the request form in eight patients.

Patient categorisation

In order to determine whether a RLD of ≥10 mm was predictive of DMSA abnormality in children, the 90 patients were divided into various groups either according to RLD (G1a,b) or by age (G2a,b), or by the larger kidney (see Fig. 1). We evaluated results for those with ≥10 mm RLD (G1a) and those with <10 mm RLD (G1b) . Based on age, younger (G2a) or older (G2b) than 48 months, we determined the optimal predictive cutoff for RLD. Finally, we determined whether the cutoff varied depending on whether the right or left kidney was longer by US (Fig. 1).

Fig. 1 Patient categorisation

Kidneys with differential kidney function in the range of 50% ± 5% and absence of scarring by DMSA were considered to be normal. Differential renal function below 45% and/or an unequivocal scar by DMSA scan was considered abnormal. Based on the above criteria for DMSA findings, groups with normal and abnormal DMSA findings were assigned for statistical analysis.

Statistical analysis

Normality of distribution of demographic parameters was examined by Shapiro-Wilk test. χ2 and unpaired Student’s t test were used to compare DMSA finding between groups G1a and G1b with <10 mm or ≥10 mm RLD. Linear regression analysis was used to examine the correlations between RLD and demographic parameters. Pearson’s correlation coefficients were determined for nonlinear data. Receiver operating characteristic (ROC) curves were used [9, 10] to determine the RLD that best predicted an abnormality by DMSA scan. Positive predictive values (PPV) were calculated for 6-mm through 11-mm RLDs as candidate cutoffs for all kidneys and for right or left longer kidneys. PPVs were also calculated for 6- to 11-mm RLD for the two age groups (younger or older than 4 years) and their related subgroups. P values <0.05 were considered significant. Analyse-It® statistical software package was used for statistical analysis.

Results

Renal length discrepancy

The left kidney was longer by US in 50/90 (56%) children and the right in 33/90 (37%). They were of equal length in 7/90 (8%). DMSA abnormalities ranged from discrete scars to global reduction in differential function. Because the main question we wanted to answer was whether <10-mm or ≥10-mm renal size discrepancy correlated with abnormal DMSA findings, all patients with DMSA abnormalities (scars or abnormal differential function) were analysed as a group. Abnormal DMSA findings were noted in 82% (18/22) of patients with US RLD ≥10 mm and in 32% (22/68) of patients with renal discrepancy <10 mm (χ2; p < 0.0005).

Forty patients (22 males) had abnormal DMSA. These were noted in 40% of patients with longer left kidneys and 60% with longer right kidneys (Table 1). Children with kidneys of equal length had normal DMSA scans. Of those with a normal DMSA scan, 17 were boys. Analysis of data from all 90 children showed that RLD by US for kidneys with abnormal DMSA scans was significantly larger than for kidneys with normal DMSA scans (mean ± SD) 12.4 ± 9.7 mm vs 3.9 ± 3.9 mm (unpaired t test; p < 0.0001). When data were analysed by DMSA abnormality in children younger than 48 months (G2a) and older than 48 months (G2b), the difference in RLD is also significant (Table 2). RLD by US did not correlate significantly with age, height and BSA. Correlation coefficients (r 2) for age, height, weight and BSA were 0.03, 0.01, 0.02 and 0.02 (not significant), respectively.

Table 1 Comparison of renal length discrepancy (RLD) in millimetres in children with normal or abnormal dimercaptosuccinate acid (DMSA) scan

	Abnormal DMSA n (%)	Abnormal DMSA mean RLD ± SD	Normal DMSA mean RLD ± SD	P value b

SD standard deviation

aIncludes 7 children who had kidneys of equal size bComparison between mean RLD in normal and abnormal DMSA scan

Table 2 Comparison by age groups of mean renal length discrepancy (RLD) in children with abnormal and normal dimercaptosuccinate acid (DMSA) scans

	Abnormal DMSA	Normal DMSA	P value

SD standard deviation

ROC curves for all kidneys and for longer right or left kidneys revealed an area under the ROC curve of >0.8 [10], suggesting that RLD is a useful measurement in predicting renal abnormality on DMSA scan (Fig. 2). The RLDs that resulted in the best PPVs were ≥10 for longer left and ≥6 mm for longer right kidneys. The predictive values, sensitivity and specificity data are presented in Table 3, and the data for the ‘cutoffs’ at the two age groups and their related subgroups are presented in Tables 4, 5 and 6, 7.

Fig. 2 Receiver operating characteristic (ROC) curves for all (a), longer left (b) and longer right (c) kidneys

Table 3 Renal length discrepancy at any age and an abnormal dimercaptosuccinate acid (DMSA) scana

Kidneys	Numberb	Cutoff	Sensitivity	Specificity	PPV	NPV

aWith <45% differential function and/or a scar b Number of patients; 7 had kidney with identical lengths

PPV Positive predictive value, NPV Negative predictive value

Table 4 Analysis of renal length discrepancy (RLD) by cutoff as a predictor for dimercaptosuccinate acid (DMSA) abnormality in children younger than 4 years when the left kidney is longer than the right (n = 29)

RLD (mm)	Sensitivity % (CI)	Specificity % (CI)	Positive predictive value %	Negative predictive value %

Table 5 Analysis of renal length discrepancy (RLD) by cutoff as a predictor for dimercaptosuccinate acid (DMSA) abnormality in children younger than 4 years when the right kidney is longer than the left (n = 23)

RLD (mm)	Sensitivity % (CI)	Specificity % (CI)	Positive predictive value %	Negative predictive value %

Table 6 Analysis of renal length discrepancy (RLD) as a predictor for dimercaptosuccinate acid (DMSA) abnormality in children older than 4 years when the left kidney is longer than the right (n = 26)

RLD (mm)	Sensitivity % (CI)	Specificity % (CI)	Positive predictive value %	Negative predicitve value %

Table 7 Analysis of renal length discrepancy (RLD) as a predictor for dimercaptosuccinate acid (DMSA) abnormality in children older than 4 years when the right kidney is longer than the left (n = 12)

RLD	Sensitivity % (CI)	Specificity % (CI)	Positive predictive value %	Negative predictive value %

Discussion

The relationship between kidney length and age is biphasic. There is rapid growth during the first year of life and a more gradual enlargement thereafter up to 12–18 years of age [1, 2]. Kidney length in adult men is larger than that in women, but in children up to the age of 16 years, renal length does not vary between the sexes after correction for height [3, 4, 11–14]. The maximum bipolar renal length by US has become the standard parameter measured because it is simple to obtain [11] and correlates well with renal volume [4]. Although renal volume correlates well with renal length [4], renal mass [6] and glomerular filtration rate [5], determination of renal volume needs a renal longitudinal measurement and at least two renal transverse dimensions. Calculation of volume is not clinically practical [11] and is prone to significant inaccuracy because the errors in each measurement are compounded [13, 15].

Determining whether the length of a kidney is abnormal by US requires knowledge of the expected length for age and sex of the patient and of potential variations in size and shape of normal kidneys. Normal renal length averages 11 cm in adults of average height [11], and a range of 10–12 cm is considered normal [16]. Miletic et al. concluded that in adults, an RLD is likely to be abnormal if the longitudinal measurement of the right kidney is greater than that of the left by >4 mm; however, the left can be up to 9 mm longer [17]. Difference between left and right kidney length has previously been described in children; the left kidney is usually longer and larger in volume than the right [2–4, 7, 13, 14, 16–21] and on postmortem examination is longer [22]. Postulated explanations for this may be simply the availability of a larger space for growth because of the relatively smaller size of the spleen compared with the liver, or perhaps increased blood supply for left kidney from the short and straight left renal artery [11]. The variation in the length of the left kidney by US may be exaggerated, as the spleen does not provide as good an acoustic window as does the liver, making it technically more difficult to measure the left kidney accurately [23]. Some have argued for a standardisation of methods for evaluating the length of both kidneys by US; however, others contend that this may introduce a different set of measurement errors [24].

Our results in 90 children referred to a renal clinic revealed that the left kidney was longer by US in 56%, whereas the right kidney was longer in 37% and equal in length in 8%. Although the patients were referred for evaluation of potential renal disease, our study confirms previous data that show that normally, the left kidney is longer than the right [2–4, 7, 11–14, 16–21]. Hence, when the right kidney is longer, a smaller RLD could be significant.

A ≥10-mm RLD is considered an acceptable cutoff for further investigation in adults. This magnitude of RLD was noted as a significant discrepancy in the US report of only eight of our patients and was not the stated reason for referral to the nuclear medicine department. Most children were referred for DMSA scans because they had a history of UTIs and/or high-grade vesicoureteric reflux. We showed that an RLD cutoff of 10 mm for longer left kidneys and as low as 6 mm for longer right kidneys predicts abnormality on DMSA scan. We confirmed the clinical impression that in children, a smaller difference in kidney length by US is predictive of abnormality on DMSA scan, especially if the right kidney is longer. However, our data cannot rule out the possibility that a lower cutoff could be used, especially in younger children, as the number of children in the study was too small.

There was no clear correlation between RLD and age, BSA, height and weight. We chose 48 months of age for group assignment because renal growth slows after that age. It is likely that predictive accuracy would increase with larger studies.

Our study suffers from the disadvantages inherent in retrospective data analysis and the relatively small study population. Although our imaging department routinely performs renal tract US in children, errors in measurement of renal length may occur. Our report reflects findings in a clinical setting rather than a controlled experimental protocol. In our hospital, we delay DMSA scans for at least 3 months from an identified UTI. It may be argued that some changes found in a DMSA scan 3 months after a UTI may resolve if scanning is delayed beyond 6–12 months. Characteristically, most DMSA scan abnormalities of acute pyelonephritis are unlikely to persist beyond 3 months, but resolution of minor residual changes may occur [8, 25, 26]. The time interval between renal US and DMSA scan in our study was up to 6 months. A shorter interval is unlikely to have greatly affected the interpretation, as RLD is more likely to increase with time due to hypertrophy of the less affected kidney. Thus, if RLD by US was smaller, this could have resulted in a reduced rather than an increased correlation with DMSA abnormalities.

Our findings agree with those of Klare et al. [7] who used intravenous urography measurements to show that RLD is not as large in children as in adults and that acceptable RLDs increase with age. In the older children (>48 months), we found that the cutoff for RLD was not different from adults, but for younger children, (≤48 months) the cutoff was as low as 6 mm. In our study, especially in younger children, we demonstrated the importance of using different cutoffs according to whether the left or right kidney was longer.

Conclusion

RLD is a useful measurement for making decisions regarding further investigations including a DMSA scan, but what constitutes an abnormal discrepancy in renal length must be defined further in prospective studies. Our data revealed that a different RLD cutoff for age and for the left or right kidney correlates well with and is predictive of abnormal DMSA scans, the gold standard for parenchymal damage. Overall, in children and adults, an RLD (>10 mm) alone is sufficient for further investigation, but a smaller size discrepancy of only ≥6 mm may be significant in children, especially when the right kidney is longer than left.

Our study shows that RLD increases with age. An “acceptable” renal discrepancy in children younger than 4 years is up to 6 mm. In older children, RLD of 10 mm or larger is sufficient reason to refer for further evaluation, but importantly, this cutoff falls to ≥6 mm if the right kidney is longer.

Acknowledgements  We thank the staff of the departments of medical imaging and Prof. M. A. Rossleigh and staff of the nuclear medicine department for the excellent performance and reporting of renal ultrasounds and nuclear scans.

References

1.	Han K, Babcock DS (1985) Sonographic measurements and appearance of normal kidneys in children. AJR Am J Roentgenol 145:611–614

هدف درماني در ديابت دستيابي به سطح گلوكز خون بدون ايجاد هيپوگليسمي و بدون ايجاد وقفه جدي و شديد در فعاليت و زندگي روزمره بيمار است.

اقدامات درماني در درمان ديابت

      •رژيم غذايي

      •ورزش

      •پايش و كنترل

      •دارودرماني

      •آموزش

آموزش بيمار و خانواده وي بخش بسيار مهم و اساسي در درمان است و اهميت آن برابر با اهميت كليه موارد ديگر است.

رژيم غذايي

       •فراهم كردن كليه مواد غذايي مورد نياز بدن (شامل ويتامين‌ها و مواد معدني)

       •رسيدن به وزن ايده‌آل و حفظ وضعيت بدست‌آمده، در مبتلايان به ديابت نوع دوم كاهش وزن كليد درمان ديابت است.

       •تأمين انرژي مورد نياز بدن

       •پيشگيري از نوسان سطح گلوكز خون

       •كاهش سطح ليپيدهاي سرم در صورت بالابودن

شاخص گليسميك

هنگام توصيه‌هاي غذايي پيوري از اصول زير مهم است:

             •تركيب غذاهاي حاوي نشاسته با مواد پروتئيني و چربي براي كندكردن جذب گلوكز

             •مصرف غذاهاي خام و خردنشده

             •خوردن ميوه بجاي آب‌ميوه

             •استفاده از قند ساده

يك نگراني و مسئله بسيار مهم در ديابت عدم مصرف الكل است

استفاده از شيرين‌كننده‌ها

دو نوع شيرين‌كننده داريم:

تغذيه‌اي كه داراي كالري بوده، باعث افزايش سطح گلوكز خون شده و خاصيت مسهل دارند مثل فروكتوز يا قند ميوه، سوربيتول و گزيليتول.

غيرتغذيه‌اي كه كالري آنها اندك يا هيچ است مثل ساخارين و اسپارتام و سوكرالوز. خاصيت‌شيرين‌كنندگي اين دسته با حرارت از بين مي‌رود.

دو نكته مهم ديگر در خصوص رژيم غذايي در ديابت عبارتند از:

            •توجه به برچسب غذايي و هشدار نسبت به برچسب‌هاي گمراه كننده.

            •آموزش در مورد رژيم غذايي و اهميت پيروي از آن

ورزش

ورزش اهميت زيادي در ديابت دارد چون باعث كاهش سطح گلوكز، كاهش ريسك‌فاكتورهاي قلبي عروقي و تسهيل تأثير انسولين مي‌گردد، جذب گلوكز را فزايش داده و باعث ارتقاي گردش خون و تن عضلات مي‌شود، در ادامه با كاهش وزن و كاهش استرس شادابي به همراه دارد. اثر ديگر آن افزايش سطح ليپوپروتئين‌هاي با دانسيته بالا HDL و كاهش سطح كلسترول و تري‌گليسريدها است.

با اين وجود بايد توجه داشت كه در بيماراني كه سطح كلوكز بالاتر از 250 دارند در ادرار آنها كتون وجود دارد و در اين افراد ورزش منع دارد.

در بسيار از بيماران پياده‌روي ورزش بسيار سودمندي است كه فقط به يك جفت كفش راحت نياز دارد.

نكاتي كه بايد در ورزش كردن رعايت كرد:

             •استفاده از كفش راحت و وسايل محافظتي.

             •خودداري از ورزش در هواي بسيار سرد و يا بسيار گزم.

             •معاينه پاها بعد از ورزش و پياده‌روي.

             •در سالمندان فعاليت جسمي بايد يكنواخت و واقع‌بينانه باشد.

پايش و اندازه‌گيري سطح گلوكز و كتون‌ها
خود پايش گلوكز خون Self Monitoring of Blood Glucose

اين عمل افراد مبتلا به ديابت را قادر مي‌سازد تارژيم‌درماني خود را جهت كنترل مطلوب سطح قند خون تنظيم نموده و از بروز هيپر و هيپوگليسمي پيشگيري نمايند.

مزايا و معيب سيستم خود پايش گلوكز خون

             •نياز به مقدار بسيار كم خون دارد.

             •تميزكردن ونگهداري مناسب دستگاه اندازه‌گيري مهم است.

             •در صورت صدمه به كيت (سرما، گرما و رطوبت) و يا تاريخ گذشته بودن آن نتايج صحيح نمي‌دهد.

لازم است تا نتايج حاصله از دستگاه اندازه‌گيري را در برگه مشخصي ثبت نمود تا در موقع نياز به آن مراجعه كرد.

فاكتورهاي مشخص‌كننده تحت كنترل بودن قند خون

هموگلوبين گليكوزيلاته يا HbA1c

اندازه‌گيري سطح كيفي گلوكز ادرار

اندازه‌گيري سطح كتون‌هاي ادرار

دارودرماني ديابت

داروي تزريقي در درمان ديابت انسولين است.

انسولين شكل‌هاي متفاوتي دارد كه فرق آنها در سه ويژگي است:

              •دوره اثر

              •منبع آن

              •سازنده آن

انسولين سريع‌الاثر هيومالوگ

با شروع اثر 10 الي 15 دقيقه

اوج اثر يك ساعت

طول اثر 3 ساعت

كاربرد:

كاهش سريع قندخون و پيشگيري از هيپوگليسمي شبانه

      •انسولين كوتاه‌الاثر رگولار

      •با شروع اثر 30 الي 60 دقيقه

      •اوج اثر 2 الي 3 ساعت

      •طول اثر 4 الي 6 ساعت

      •كاربرد:

تركيب با ساير انواع انسولين مثل NPH، 20 تا 30 دقيقه قبل از غذا تجويز مي‌گردد.

      •انسولين متوسط‌الاثر NPH

      •با شروع اثر 3 الي 4 ساعت

      •اوج اثر 4 الي 12 ساعت

      •طول اثر 16 الي 20 ساعت

      •كاربرد:

                        بعد از غذا داده مي‌شود

      •انسولين طويل‌الاثر الترالنت

      •با شروع اثر 4 الي 8 ساعت

      •اوج اثر 12 الي 16 ساعت

      •طول اثر 20 الي 30 ساعت

      •كاربرد:

عموماً جهت كنترل سطح گلوكز ناشتا استفاده مي‌شود.

روش‌هاي تجويز انسولين

سرنگ

قلم انسولين

تزريق‌كننده جت

پمپ انفوزيون

روش‌هاي جدي كه تحت مطالعه است مثل پمپ كاشتني و انسولين استنشاقي.

پيوند پانكراس كه در مدل‌هاي تجربي تحت بررسي است.

عوارض انسولين‌تراپي

             •واكنش آلرژيك موضعي

             •واكنش الرژيك سيستميك

             •ليپوديستروفي (به دو شكل ليپوهيپرتروفي و ليپوآتروفي)

             •مقاومت به انسولين.

لازم به ذكر است كه تزريق انسولين در نواحي دچار اسكار باعث تأخير در جذب آن شده و به همين دليل توصيه مي‌شود كه تزريق آن به صورت چرخشي باشد تا محل تزريق قبلي ترميم گردد.

داروهاي خوراكي ضد ديابت

              •سولفونيل‌اوره‌ها: با اثر تحريك مستقيم پانكراس مانند كلرپروپاميد و گليبن‌گلاميد. برخي داروهاي با اين دسته دارويي تداخل اثر داشته و باعث افزايش اثر آن مي‌شوند مثل سولفوناميدها، كلرامفنيكل، اندرال، كلوفيبرات،  و برخي باعث كاهش اثر آنها مي‌شوند مثل ديورتيك‌هاي دافع پتاسيم، كورتيكواستروئيدها و استروژن‌ها.

              •بي‌گوآنيدها: مثل متفورمين با اثر تسهيل عملكرد انسولين در مواضع گيرنده‌هاي محيطي. اين دارو همراه با انسولين نيز مصرف مي‌شود. اين دارو با برخي داروهاي ديگر تد اخل دارد مثل: كورتيكواستروئيدها، ديورتيك‌ها، داروهاي ضدبارداري. در اختلالات كليوي وانفاركتوس ميوكارد منع مصرف دارد.

              •مهاركننده‌هاي آلفاگلوكوزيدازها: مثل آكاربوز كه با تأخير در جذب گلوكز اثر مي‌كند.

              •تيازوليدين‌ديون‌ها: مثل رزولين كه با ارتقاي اثر انسولين در سطح گيرنده‌هاي انسولين بدون افزايش ترشح انسولين از سلول‌هاي بتا عمل مي‌كند.

آموزش

      •ديابت مليتوس يك بيماري مزمن است كه مستلزم رفتارهاي خوددرماني ويژه در تمام عمر است. چون رژيم غذايي، فعاليت جسمي و استرس جسمي و عاطفي مي‌توانند روي كنترل ديابت اثر بگذارند لذا بيمار بايستي ايجاد تعادل بين اين عوامل را ياد بگيرد.

مراقبت‌هاي پرستاري

مراقبت و درمان پرستاري دربرگيرنده طيف وسيعي از مشكلات و مسائل فيزيولوژيك است كه به وضعيت بهداشتي فرد و اين موضوع كه بيماري به تازگي تشخيص داده‌شده است دارد.

Pediatrics Intern

Islamic Azad University Of Mashhad

Faculty Of Medicine

Ludwig’s angina was described initially by Wilhelm Frederick von Ludwig in 1836. Five patients had marked swelling of the neck that progressed to involve the tissues covering the muscles between the larynx and the floor of the mouth. Ludwig described indurated edema of the submandibular and sublingual areas with minimal throat inflammation but without lymph node involvement or suppuration. At that time, the condition was almost always fatal.(1,2 )

Illustrative Cases

Case 1

A 14-month-old girl was admitted to the hospital because of swelling below the chin that had increased during the previous two days. Fever developed on the day of admission, and she had reduced fluid intake and urine output.

On physical examination, a tender, indurated, warm swelling that spread laterally was seen in the submental area (Figure 1). An excoriated oval lesion was present on the chin. The child was uncomfortable and preferred to keep her mouth open. She had no respiratory distress or cyanosis. Her temperature (taken rectally) was 38.8°C (101.8°F); respiratory rate was 34 breaths per minute; and heart rate was 166 beats per minute. The oxygen saturation, in room air, was 95 percent.

Neck radiographs revealed marked submandibular soft tissue prominence that was characteristic of Ludwig’s angina. No abscess was seen on ultrasonogram.

The white blood cell count was elevated, with a shift to the left. Blood culture was sterile. The illness resolved following initial treatment with intravenous oxacillin followed by oral dicloxacillin.

FIGURE 1. Marked submental swelling in the patient in illustrative case 1; note open mouth.

FIGURE 2. Tender swelling in patient in illustrative case 2. Patient is unable to open mouth.

FIGURE 3. Note spread of swelling laterally and abrasion on nose in same patient as shown in Figure 2.

Case 2

A boy aged 33 months presented to the emergency department because of progressive enlargement under the chin for one day and inability to swallow. Three weeks earlier, he had fallen and injured his nose.

On examination, the patient had swelling, erythema and tenderness in the submandibular area. Pain prevented him from opening his mouth (Figures 2 and 3). His temperature was 38.8°C (101.8°F); cardiac and respiratory rates were normal; and no respiratory distress was noted.

The white blood cell count was 14,600 cells per mL (14.6 × 109 per L), with elevated band forms. Radiographs of the neck showed marked soft tissue prominence; no foreign body was present. Ludwig’s angina was diagnosed clinically, and treatment with intravenous nafcillin was started.

The greatest threat resulting from Ludwig’s angina is:

respiratory compromise as a consequence of swelling

By the third day of treatment, the submental tenderness, erythema and induration began to resolve. Incision and drainage produced approximately 10 mL of purulent material. Culture was sterile, as was the initial blood culture.

Improvement was obvious within 24 hours of the surgical treatment. The boy was discharged after seven days of treatment with intravenous nafcillin and was continued on a course of oral penicillin for an additional 10 days.

Anatomic Considerations

A knowledge of neck spaces and fascial relationships is important in diagnosing and treating neck infections. Spaces created by various fasciae of the neck are potential areas of infection. Invasion by bacteria produces cellulitis or abscess, and spread occurs by continuity along these paths of least resistance, rather than by lymphatic channels.(3,4)

The submandibular space is composed of two spaces separated anteriorly by the mylohyoid muscle: the sublingual space, which is superior, and the submaxillary space, which is inferior. The spread of infection is halted anteriorly by the mandible and inferiorly by the mylohyoid muscle(5) (Figure 4). The infectious process expands superiorly and posteriorly, elevating the floor of the mouth and the tongue. The hyoid bone limits the process inferiorly, and swelling spreads to the anterior aspect of the neck, causing distortion and a “bull neck” appearance(5) (Figure 5). This then evolves to an infectious compartment syndrome of the submandibular and sublingual spaces.(6 )

FIGURE 4. Sublingual space, superior to mylohyoid muscle. The submandibular space is inferior to the mylohyoid muscle.

FIGURE 5. Spread of process superiorly and posteriorly elevates floor of mouth and tongue. In anterior spread, the myoid bone limits spread inferiorly, causing a “bull neck” appearance

.

Clinical Features

In a study spanning a 13-year period,(7) Ludwig’s angina was diagnosed in 41 patients, of whom 10 (24 percent) were children. Another study,(8) involving 110 patients who had deep neck abscesses, included 21 children aged 10 years and younger. Ludwig’s angina has been reported in infants as young as 12 days(.9-12)

Predisposing factors include dental caries, recent dental treatment, sickle cell disease, a compromised immune system, trauma and tongue piercing.(13) Ludwig’s angina in children can occur de novo, without any apparent precipitating cause.(7)

The signs and symptoms of Ludwig’s angina are the result of a rapidly expanding cellulitis. Severe pain and neck swelling occur in virtually all patients.(14) Fever, toothache, malaise, dysphagia and fetid breath are common. Trismus also occurs, as experienced by the child in the second illustrative case.(15 )

Characteristic symptoms of Ludwig’s angina include:

 severe pain, neck swelling and dysphagia.

A child may sit leaning forward to maximize the airway. Examination may reveal carious molar teeth, neck rigidity or drooling. The presence of stridor, dyspnea, decreased air movement or cyanosis requires prompt attention because it may indicate an impending airway crisis.

The bacterial isolates vary and are often mixed. Alpha-hemolytic streptococci, staphylococci and bacteroides are commonly reported. Other anaerobes such as peptostreptococci, peptococci, Fusobacterium nucleatum, Veillonella species and spirochetes are also seen. A foul breath odor usually indicates the presence of an anaerobe. Gram-negative organisms such as Neisseria catarrhalis, Escherichia coli, Pseudomonas aeruginosa and Haemophilus influenzae have also been reported(6). A beta-hemolytic streptococcus was isolated in 18 percent of a large series of patients with deep neck abscesses.(8) Antibiotic treatment before hospital admission often results in sterile cultures.

Treatment

Treatment includes assessment and protection of the airway, use of intravenous antibiotics, surgical evaluation and, if necessary, operative decompression. Recommended initial antibiotics are high-dose penicillin G, sometimes used in combination with an antistaphylococcal drug or metronidazole (Flagyl I.V.). In penicillin-allergic patients, clindamycin hydrochloride (Cleocin HCl) is a good choice.

Alternative choices include cefoxitin sodium (Cefoxil) or combination drugs such as ticarcillin-clavulanate (Timentin), piperacillin-tazobactam (Zosyn) or amoxicillin-clavulanate (Augmentin).(8) Intravenous dexamethasone sodium phosphate (Decadron), given for 48 hours, has been beneficial in reducing edema, which helps maintain airway integrity and enhances antibiotic penetration.(6)

Surgical drainage may be indicated if no clinical improvement is seen within 24 hours. In one series of 41 patients, including 10 children, seven were treated successfully with conservative medical management. Incision and drainage were necessary in three patients. Tracheostomy was necessary in only one child. One of the 10 children died.(7) The airway remains the major concern because it can be compromised with little warning.

Final Comment

Ludwig’s angina can be fatal. Failure to diagnose deep neck infections promptly may be caused by a clinical picture that is altered by previous antibiotic use. With early diagnosis, aggressive intravenous antibiotic therapy and management in an intensive care unit, the process should resolve without complications.

REFERENCES

1. Burke J. Angina ludovici. Bull Hist Med 1939; 7:1115-26.

2. Arnon SS. Anaerobic infections. In: Nelson WE, Behrman RE, Kliegman R, eds. Nelson Textbook of pediatrics. 15th ed. Philadelphia: Saunders, 1996: 821.

3. Lindner HH. The anatomy of the fasciae of the face and neck with particular reference to the spread and treatment of intraoral infections (Ludwig’s) that have progressed into adjacent fascial spaces. Ann Surg 1986;204:705-14.

4. Patterson HC, Kelly JH, Strome M. Ludwig’s angina: an update. Laryngoscope 1982;92:370-8.

5. Nicklaus PJ, Kelley PE. Management of deep neck infection. Pediatr Clin North Am 1996;43:1277-96.

6. Busch RF, Shah D. Ludwig’s angina: improved treatment. Otolaryngol Head Neck Surg 1997;117:S172-5.

7. Kurien M, Mathew J, Job A, Zachariah N. Ludwig’s angina. Clin Otolaryngol 1997;22:263-5.

8. Har-El G, Aroesty JH, Shaha A, Lucente FE. Changing trends in deep neck abscess. A retrospective study of 110 patients. Oral Surg Oral Med Oral Pathol 1994;77:446-50.

9. Steinhauer PF. Ludwig’s angina: report of case in a 12-day-old boy. J Oral Surg 1967;25:251-4.

10. Barkin RM, Bonis SL, Elghammer RM, Todd JK. Ludwig angina in children. J Pediatr 1975;87:563-5.

11. Finch RG, Snider GE Jr, Sprinkle PM. Ludwig’s angina. JAMA 1980;243:1171-3.

12. Schulman NJ, Owens BM. Ludwig’s angina following dental treatment of a five-year-old male patient: report of a case. J Clin Pediatr Dent 1992; 16:263-5.

13. Perkins CS, Meisner J, Harrison JM. A complication of tongue piercing. Br Dent J 1997;182:147-8.

14. Sethi DS, Stanley RE. Deep neck abscesses–changing trends. J Laryngol Otol 1994;108:138-43.

15. Schulman NJ, Owens B. Medical complications following successful pediatric dental treatment. J Clin Pediatr Dent 1996;20:273-5.

1. فيزيولوژي و فارماكولوژي درد
2. ارزيابي درد
3. روانشناسي درد
4. درمان هاي داروئي درد
5. فيزيوتراپي درد
6. درد هاي عضلاني – استخواني
7. سر درد
8. روش هاي جراحي كنترل درد
9. درد هاي سرطاني
10. آنستزيولوژي و درد
11. درد هاي نوروپاتيك
12. درد در كودكان
13. درد در سالمندان
14. طب جايگزين و درد
15. عوامل اجتماعي درد
16. هزينه هاي اقتصادي درد

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