Hyperpolarized 3He MR lung ventilation imaging in asthmatics: preliminary findings.

Asthma is a disease characterized by chronic inflammation and reversible obstruction of the small airways resulting in impaired pulmonary ventilation. Hyperpolarized 3He magnetic resonance (MR) lung imaging is a new technology that provides a detailed image of lung ventilation. Hyperpolarized 3He lung imaging was performed in 10 asthmatics and 10 healthy subjects. Seven asthmatics had ventilation defects distributed throughout the lungs compared with none of the normal subjects. These ventilation defects were more numerous and larger in the two symptomatic asthmatics who had abnormal spirometry. Ventilation defects studied over time demonstrated no change in appearance over 30-60 minutes. One asthmatic subject was studied twice in a three-week period and had ventilation defects which resolved and appeared in that time. This same subject was studied before and after bronchodilator therapy, and all ventilation defects resolved after therapy. Hyperpolarized 3He lung imaging can detect the small, reversible ventilation defects that characterize asthma. The ability to visualize lung ventilation offers a direct method of assessing asthmatics and their response to therapy.

Follow-up abdominal computed tomography after splenic trauma in children may not be necessary.

Nonoperative management of splenic injuries in children is well accepted. However, the need for follow-up abdominal CT to document splenic healing has not been well studied. We retrospectively reviewed initial and follow-up abdominal CT examinations of pediatric patients admitted to our institution with documented splenic trauma who were managed nonoperatively. Eighty-four patients were admitted to our pediatric surgical service with splenic injury documented by CT from 1994 through 1998. The standard approach for splenic injury was bedrest for 5 to 21 days and limited activity for up to 90 days at the discretion of the attending surgeon. Thirty-five of the 84 had follow-up CTs during outpatient follow-up to evaluate and document splenic healing by CT criteria. The initial and follow-up studies were randomized and read blindly by pediatric radiologists using a modified American Association for the Surgery of Trauma grading system (I-V). The age range of the patients was 6 months to 17 years (mean +/- SE; 11 +/- 1 years). Nineteen (54%) were male and 16 (46%) were female. Causes of splenic trauma included motor vehicle accident (22), fall (seven), assault (four), pedestrian versus vehicle (one), and sports injury (one). Eight children (23%) had grade II injuries, 14 (40%) had grade III injuries, and 13 children (37%) had grade IV injuries on initial CT scan. Seven (88%) of the grade II splenic injuries were healed by 64 +/- 11 days. The remaining grade II injury had healed by 210 days. Thirteen (93%) of the grade III splenic injuries were healed by 76 +/- 7 days. The remaining grade III injury was healed by 140 days. Spleens in 10 (77%) of the 13 patients with grade IV injuries were healed by 81 +/- 8 days. Of the three remaining grade IV injuries two were healed by 173 +/- 14 days. The remaining patient's spleen was radiologically considered to have a grade III defect 91 days from the time of injury, and no further CTs were obtained. Of the 34 patients who underwent follow-up CT imaging until splenic healing was demonstrated the mean time to complete healing was 87 +/- 8 days postinjury (range 11-217 days). These data suggest that routine follow-up abdominal CTs may not be necessary to allow children to resume their normal activities after an appropriate time of restricted activity.

Processes of clinical change and resistance. A theoretical synthesis.

Evidence from both experimental laboratory studies and clinical observation supports the behavioral principle that immediate (compared with delayed) consequences are most influential in shaping future actions. This presents the theoretical possibility of conflicts of consequences (e.g., short-term positive vs. long-term negative). As one example, resistance to completing therapeutic homework assignments that instruct clients to approach feared situations may result in short-term positive outcomes, such as freedom from negative emotional experience (emotional avoidance), but is dysfunctional over time. Thus, temporal conflicts of consequences is one theoretic source of resistance in clinical treatment. In this article, the authors articulate how the activation of the metacognitive level theoretically mediates conflicts between short-term (immediate) and long-term (delayed) consequences, thereby facilitating therapeutic change and reducing resistance. This synthesis unifies principles of behaviorism and contemporary clinical cognitive theory.

Cervical spine anomalies and tumors in Weaver syndrome.

Weaver syndrome is an autosomal dominant disorder comprising accelerated growth rate and rapidly advancing skeletal maturation. Previous reports suggest that the phenotype in adults may be sufficiently subtle to make diagnosis difficult. Half brothers with classical childhood findings of Weaver syndrome and their father with minimal clinical findings showed cervical spine anomalies that likely represent a consistent radiographic finding in this disorder. One of the children represents the third occurrence of neoplasia in Weaver syndrome.

An approach to the asymmetric neonatal chest radiograph.

Conditions causing respiratory distress in the neonate, which may require surgery or an interventional procedure, typically have asymmetric radiographic findings. The findings are conveniently categorized from the plain radiographs as those producing a large lucent-appearing hemithorax, those producing a large cystic-appearing hemithorax, and those producing a large opaque-appearing hemithorax. Additional imaging with ultrasound, CT, MR imaging, or fluoroscopy can be planned based on the initial radiographic appearance.

Chondrodysplasia punctata stemming from maternal lupus erythematosus.

The finding of stippled epiphyses on a neonatal radiograph generates a wide differential diagnosis, including genetic and teratogenic causes. We report the case of a male infant with stippled epiphyses evident on neonatal radiographs in whom a typical rash of lupus erythematosus developed. The skin abnormalities in the infant resulted in a diagnosis of systemic lupus erythematosus in his mother. Over a 3-year follow-up period, the child has demonstrated strikingly short stature, midface hypoplasia, anomalous digital development, slow resolution of the stippled epiphyses, and near normal cognitive development. The differential diagnosis of chondrodysplasia punctata and the literature supporting maternal lupus as one cause are reviewed.

Radiographic measurements of dysplastic adult hips.

Hip dysplasia is a not uncommon feature in adults and can vary from subtle acetabular dysplasia to complex sequelae of developmental dysplasia of the hip. This review article describes the most useful radiographic measurements used to evaluate the adult hip. The frontal projection of the pelvis permits measurement of the center-edge angle (CE angle) and "horizontal toit externe" angle (HTE angle), both of which assess the superior coverage of the acetabulum. The femoral neck-shaft angle (NSA) is also measured on this view. The false profile radiograph of the pelvis is described. It allows measurement of the vertical-center-anterior angle (VCA angle), which determines the anterior acetabular coverage and detects early degenerative hip joint disease. When surgery is contemplated, computed tomography (CT) is useful to better determine the anterior acetabular coverage by use of the anterior acetabular sector angle (AASA), and the posterior acetabular coverage by use of the posterior acetabular sector angle (PASA). CT also permits measurement of femoral anteversion. These measurements are particularly useful in the evaluation of acetabular dysplasia and for the preoperative assessment of the dysplastic hip.

Prevalence of deep venous thrombosis in the lower extremities of children in the intensive care unit.

PURPOSE: To determine the prevalence of lower extremity deep venous thrombosis (LE-DVT) in children who spent at least 72 h in the pediatric intensive care unit (ICU). MATERIALS AND METHODS: Children up to the age of 17 years who spent at least 72 h in the ICU underwent lower extremity venous ultrasound at the end of their stay. Prevalence range for the sample size was calculated with a confidence interval of 95%. RESULTS: Among 76 children who spent 3-141 days in the ICU, the prevalence of acute (and silent) DVT was 4% (confidence interval 0-9%). All three affected children had femoral venous catheters in that leg during their ICU stay (17 unaffected children also had catheters). CONCLUSION: Children in an ICU setting are at significantly lower risk for thrombosis than adults in the same setting.

Hopelessness predicts future depressive symptoms: a prospective analysis of cognitive vulnerability and cognitive content specificity.

Beck's content specificity hypothesis predicts distinct cognitive content within specific psychological disorders. We evaluated whether the third component of the "cognitive triad", negative view of the future (hopelessness), would be related 4 weeks later to depressive symptoms, but not to anxiety. University student participants (83 females, 71 males) were tested on the Beck Depression Inventory and the Beck Anxiety Inventory at two points in time, separated by 4 weeks. The Hopelessness Scale was administered at time 1 and a Life Events Inventory at time 2. Concurrent cognitive content specificity was replicated. For males only, hopelessness predicted future depression severity scores, but not anxiety. Hopelessness predicted depressive symptoms over and above life event stressors, but not vice versa.

The specificity of sociotropy-autonomy personality dimensions to depression vs. anxiety.

Previous cognitive vulnerability studies have identified sociotropy/dependency as a personality characteristic related to depression. We evaluated sociotropy in differential prediction of depression vs. anxiety. Participants (70 females, 42 males) were tested on the Beck Depression Inventory (BDI) and the Beck Anxiety Inventory (BAI) at two points in time (T1 and T2), separated by an interval of 4 weeks. The Sociotropy-Autonomy Scale (SAS) was administered at T1. Sociotropy was related moderately to the BDI at T1 and T2, but also to the BAI. Autonomy was related to neither. Hierarchical multiple regression analyses found sociotropy to predict anxiety at T2, but not depression. The issue of cognitive vulnerability marker specificity is discussed.

Cognitive therapy of delusional beliefs.

The present article articulates a cognitive theoretical perspective of delusional beliefs. In contrast to the focus of psychoanalytic therapy (theoretically-derived phenomena beyond personal awareness), the cognitive therapist focuses primarily on the conscious cognitive-experiential level in the treatment of delusional beliefs, thereby emphasizing a 'common-sense' level of analysis or reasoning shared by the delusional patient. Unlike noncognitive behavioral approaches, which focus on topographical 'verbal behavior' as such, cognitive therapy directly targets specific delusional beliefs which theoretically give rise to the disordered verbal behavior. In this article, the adaptation of cognitive therapy to the treatment of delusions is described, with special attention to the following issues: special problems in collaboration; difficulties in obtaining conviction ratings; how to avoid and reduce confrontation through the Socratic method; the collaborative design of homework experiments; distancing strategies; interpersonal relationship issues; and the necessity to identify and explore the emotions associated with the various delusions, especially feelings about the possibility that the delusions may be incorrect.

Asymmetric radiographic findings in the pediatric chest: approach to early diagnosis.

Several conditions in children produce a mass effect within one hemithorax, which may be life threatening. The different radiographic appearances of these conditions provide a basis on which they can be classified. The three major categories include a large cystic hemithorax, a large lucent hemithorax, and a large opaque hemithorax. Some disorders may be seen within more than one major group. Within the large cystic hemithorax group, congenital cystic adenomatoid malformation and congenital diaphragmatic hernia may be life-threatening conditions that require emergency surgery. The large lucent hemithorax is usually caused by pneumothorax, partial bronchial occlusion, or compensatory hyperinflation of the unobstructed lung. The majority of cases within the large opaque hemithorax group involve pleural fluid collections. Because many conditions that cause a mass effect require intervention or surgery, accurate interpretation of the plain chest radiograph is essential for an early diagnosis. Classification of radiographic features into these three groups often allows accurate diagnosis without additional studies.

Lung tumor incidence after intrabronchial administration of the nonionic contrast agent metrizamide.

RATIONALE AND OBJECTIVES: Metrizamide has been used for examination of the gastrointestinal tract and tracheobronchial tree of infants. Contrast agents may enter the lungs during such examinations. The current study was undertaken to determine whether there would be any later pulmonary effects when metrizamide was administered to the lungs of weanling mice. METHODS: One hundred fifty mice (18-21 days old), divided into groups, received either 75 microL of metrizamide, using the manufacturer's diluent (190 mg iodine [I]/mL), or saline solution administered to the lungs by injection into the trachea. The mice were observed for the duration of their lives. Moribund animals were killed. At death, all animals underwent necropsy. The lungs were fixed in formalin, and histologic sections were examined for pathologic changes. RESULTS: The incidence of lung tumors was increased (P less than .05) in the lungs of mice receiving metrizamide compared with those receiving saline. Eighteen percent of the lung tumors in the metrizamide-treated mice were lymphomas, a histologic type not found in the saline-treated controls. CONCLUSIONS: A hypothesis proposing that metrizamide may be an initiator of carcinogenic transformation rather than a carcinogen was developed.

The child with acute abdominal pain and vomiting.

Evaluation of the child who presents with abdominal pain and vomiting is difficult. Close cooperation between pediatricians, surgeons, and radiologists is necessary to identify situations requiring urgent intervention. Close attention to history and physical findings will allow appropriate, judicious use of modern imaging techniques to arrive at an early diagnosis and initiate proper treatment when necessary.

Integration of scientific criteria into the psychotherapy integration movement.

Psychotherapy integration has recently received considerable attention among behavior therapists. Although the wisdom of ecumenicism has been questioned, behavior therapy has often been credited with flexibility and modification of practice based on experimental and clinical research. From this perspective, the two central criteria for psychotherapy integration are inclusion of proven therapeutic elements and exclusion of unproven ones. Rationales for the importance of both criteria are discussed, and an analogy to the development of modern medicine is suggested. Formal acceptance of the proposed criteria would place psychotherapy integration in a proactive position to censor fee-for-service clinical practice not grounded in basic clinical or experimental research.

Renal atrophy or infarction in children with neuroblastoma.

Twelve children with adrenal or upper abdominal paraaortic neuroblastoma developed unilateral or bilateral renal atrophy or infarction. At presentation, the children ranged in age from 2 weeks to 9.7 years. Neuroblastomas were stage II (n = 1), III (n = 2), IV-S (n = 2), and IV (n = 7). Treatment varied but included surgery, chemotherapy, localized abdominal irradiation, and/or bone marrow transplantation. Six children developed ipsilateral renal atrophy, five experienced ipsilateral or bilateral acute perioperative renal infarction, and one developed contralateral renal infarction unrelated to surgery. During treatment, two patients required hemodialysis; both subsequently died. Creatinine concentrations in eight patients have been in the normal range. Two patients have had mildly but persistently elevated creatinine levels. Renal damage from primary effects of the tumor can develop in children with adrenal or upper abdominal neuroblastoma. Treatment, especially surgical resection of the primary tumor, chemotherapy, and radiation therapy, can compound such damage.

Behavioral design of a positive verbal community: a preliminary experimental analysis.

Behaviorists have theorized (and experimental analyses suggest) the potential clinical application of verbal behavior modification. This study evaluated therapeutic effects of behavioral intervention to modify the intact verbal community. The setting was an adolescent operant treatment center for behavioral disorders. All residents within the center, 16 females and 22 males, participated in the study. A within subjects experimental design compared effects of a positive verbal community (PVC) plus the ongoing operant treatment program to the operant program alone. Conceptually, these were dual-level and single-level operant programs, respectively. Dependent measures included rates of positive goal-relevant verbalizations of residents, and clinical measures of self-control and psychiatric symptoms. Preliminary evidence supported the feasibility of the PVC as a potential novel therapeutic intervention.

Spondylometaphyseal dysplasia, corner fracture type: a heritable condition associated with coxa vara.

The authors present the radiographic features of a previously incompletely delineated bone dysplasia, which they call spondylometaphyseal dysplasia, corner fracture type. This is a dominant heritable condition associated with short stature and developmental coxa vara. The progressive hip deformity usually causes significant disability requiring surgical correction. Developmental coxa vara, simulated corner fractures of long tubular bones, and vertebral body abnormalities result in a diagnostic constellation. Knowledge of these distinctive radiologic features allows accurate diagnosis, which in turn should lead to appropriate genetic counseling and possibly to earlier, more efficacious surgical treatment of the coxa vara.

Doppler evaluation of renal transplants in children: a prospective analysis with histopathologic correlation.

Duplex Doppler sonography recently has been used to evaluate renal transplants. Some authors have stated that high resistive indexes (RIs) occur in the presence of acute renal transplant rejection. RIs less than 0.7 are considered as probably excluding acute transplant rejection. We performed a prospective study of duplex sonographic examinations of pediatric patients (mean age, 8 years; 13 boys, two girls) with renal allografts and clinically suspected transplant disease. The results of 22 duplex studies were correlated with histopathologic data obtained between July 1987 and June 1988. RIs of the arcuate arteries in patients with acute rejection (n = 14) averaged 0.62 (range, 0.50-0.80). The RI in patients with chronic rejection (n = 1) was 0.59. RIs in patients with acute tubular necrosis (n = 3) averaged 0.66 (range, 0.59-0.72). RIs in patients with cyclosporine A toxicity (n = 4) averaged 0.66 (range, 0.58-0.79). Tubulointerstitial rejection was predominant, with only two patients showing minimal acute vascular rejection. Thirteen of 14 pediatric patients with histologically proved renal transplant rejection had a resistive index of less than 0.70. This study refutes the concept that resistive indexes of less than 0.7 exclude acute rejection.

The role of ultrasound in the management of vein of Galen aneurysms in infancy.

Ultrasonography can be the key imaging modality for neonatal patients with vein of Galen aneurysms. Ultrasound can be used to diagnose the condition, monitor transtorcular embolization procedures, and follow-up these patients after embolization to assess the effectiveness of embolization and to check for complications.