Orthotic devices. Custom-made, prefabricated, and material selection.

Orthotic use has become a common adjunct to medical treatment for foot and ankle pathology. For pain and discomfort from overuse to pathology-specific problems, interventions involving foot orthoses are widely accepted. A wide range of accommodative, functional, and prefabricated orthoses is available. With the emergence of technology in the manufacture of raw materials and prefabricated orthoses and the training and expertise of technicians and practitioners, the quality and accuracy of foot orthoses have improved vastly, justifying their role in the treatment and rehabilitation of patients with simple and complex foot problems.

Chest radiographs of limited utility in the diagnosis of blunt traumatic aortic laceration.

BACKGROUND: The radiographic diagnosis of blunt traumatic aortic laceration (BTAL) remains problematic. We reviewed our experience with chest radiographic signs of BTAL at a single trauma center. METHODS: The chest radiographs of 188 consecutive blunt trauma patients with suspected BTAL who underwent portable chest radiography and aortography were retrospectively reviewed by a thoracic radiologist. The presence or absence of 15 radiographic findings were recorded, and the sensitivity and specificity of individual radiographic signs and combinations of signs were determined. RESULTS: There were 10 patients with BTAL. Although three signs showed greater than 90% sensitivity for BTAL, these signs showed low specificity, and no significant improvement in overall accuracy was achieved by combining radiographic findings. CONCLUSION: The experience at our institution suggests that chest radiographs have limited utility in the accurate diagnosis of blunt traumatic aortic laceration. Cross-sectional imaging techniques will likely become the preferred imaging procedures for evaluating patients with suspected BTAL.

Preschoolers doing arithmetic: the concepts are willing but the working memory is weak.

The study of early mathematical development provides important insights into young children's emerging academic competencies and, potentially, a basis for adapting instructional methods. We presented nonverbal forms of two- and three-term arithmetic problems to 4-year-olds to determine (a) the extent to which certain information-processing demands make some problems more difficult than others and (b) whether preschoolers use arithmetic concepts spontaneously when solving novel problems. Children's accuracy on simple arithmetic problems (a + b and a - b) was strongly related (r2 = .88) to representational set size, the maximum number of units that need to be held in working memory to solve a given problem. Some children also showed spontaneous use of procedures based on the arithmetic principle of inversion when solving problems of the form a + b - b. These results highlight the importance of identifying information-processing and conceptual characteristics in the early development of mathematical cognition.

Transthoracic needle biopsy.

Transthoracic needle biopsy (TNB) has emerged as the semi-invasive technique of choice for the diagnosis of localized intrathoracic lesions. Using CT, fluoroscopic, or sonographic guidance, TNB is highly accurate and safe when combined with expert pathologic interpretation of the aspirated specimen. This article details the preprocedural evaluation of the patient referred for TNB and discusses the technical aspects of performing the biopsy and processing and interpreting the material obtained. The reported results and complications of TNB are reviewed and followed by a brief description of the cost effectiveness of the technique and a comparison with alternative semi-invasive diagnostic techniques including bronchoscopic and video-assisted thoracoscopic biopsy.

Interventional techniques in the thorax.

Transthoracic needle biopsy (TNB) has become the diagnostic procedure of choice in evaluation of focal chest lesions. Both advances in cross-sectional image guidance and cytopathologic techniques allow TNB to accurately diagnose malignancy and characterize a spectrum of benign conditions. Image-guided percutaneous drainage of intrathoracic collections has developed as an extension of similar procedures in the abdomen and pelvis. The ability of CT and ultrasound to accurately detect and characterize parenchymal and pleural collections, and advances in interventional techniques and catheter design, have made percutaneous catheter drainage the treatment of choice for a variety of intrathoracic collections. This article provides an updated review of the spectrum of image-guided diagnostic and therapeutic procedures in the thorax.

High-resolution computed tomography of the chest in children with cystic fibrosis: support for use as an outcome surrogate.

BACKGROUND: Outcome surrogates are indicators that reflect, rather than directly measure, patient benefit. In order to provide useful results, however, outcome surrogates must be carefully chosen and must meet specific criteria. OBJECTIVE: To support development of high-resolution computed tomography (HRCT) as an outcome surrogate in cystic fibrosis (CF) by demonstrating the ability of HRCT to show short-term improvement in the appearance of the lungs in children with CF. MATERIALS AND METHODS: HRCT was performed at admission and after discharge on 8 children during 15 admissions for acute pulmonary exacerbation of CF. Three radiologists scored each study separately, then compared admission and discharge pairs. RESULTS: HRCT scores improved in 13/15 admissions. Mean score decreased from 25 to 22. The decrease was significant (P = 0.014). Comparison of admission and discharge scans showed improvement in peribronchial thickening (P = 0.007), mucous plugging (P = 0.002), and overall appearance (P = 0.025). CONCLUSION: HRCT has the potential to be a useful outcome surrogate in CF. A necessary attribute of an outcome surrogate is that it improves rapidly with effective therapy. Despite widespread belief among radiologists and pulmonologists that HRCT meets this criterion, no previous report has demonstrated this ability in children. These findings support further development of HRCT as an outcome surrogate in children with CF.

Epidemiology of anaphylaxis in Olmsted County: A population-based study.

BACKGROUND: Awareness of the clinical features of anaphylaxis and its causative triggers is important if recurrent episodes are to be avoided. The incidence of anaphylaxis in the general population is often underreported, and epidemiologic studies are few. Because an accurate profile of anaphylaxis could heighten awareness of this problem, we investigated the epidemiology of anaphylaxis in the general population of Olmsted County, Minn. OBJECTIVE: The purpose of this study was to describe the epidemiology of anaphylaxis in Olmsted County residents from 1983 through 1987. METHODS: This was a retrospective population-based cohort study. The medical records of 1255 Olmsted County residents identified by computer-linked, medical diagnostic indices (the Rochester Epidemiology Study) were reviewed retrospectively to identify residents whose clinical episodes met the criteria for anaphylaxis. We determined the incidence and rate of occurrence of anaphylaxis, rate of recurrence, prevalence of atopy, cause of anaphylaxis, frequency of referral to an allergy specialist, hospital admission rate, and case-fatality rate. RESULTS: There were 133 residents who experienced 154 anaphylactic episodes during the 5-year period: 116 residents had 1 episode of anaphylaxis, 13 residents had 2 episodes, and 4 residents had 3 episodes. The anaphylaxis occurrence rate was 30 per 100,000 person-years (95% confidence interval, 25-35). There were 110 residents who had a first lifetime episode of anaphylaxis (that was medically evaluated) during the years 1983 to 1987. The average annual incidence rate of anaphylaxis was 21 per 100,000 person-years (95% confidence interval, 17-25). Atopy was present in 53% of the cohort, and allergy consultation was obtained in 52%. A suspect allergen was identified in 68% of the cohort, most frequently a food, medication, or insect sting. The hospitalization rate was 7%, and 1 patient died. CONCLUSION: The incidence of anaphylaxis is less than 1%, and death rarely occurs. People with atopy experience anaphylaxis more frequently than people without atopy. Anaphylaxis frequently is not recognized by patients and physicians.

Imaging techniques for pleural space infections.

Radiology plays a central role in the evaluation and management of pleural space infections. Conventional radiographs, including decubitus films, remain the primary radiological study in the detection of parapneumonic pleural effusions. Loculated collections develop as a result of visceral-to-parietal pleural adhesions and appear radiographically as longitudinally oriented, lenticular-shaped opacities. Contrast-enhanced computed tomography scans accurately distinguish lung abscess from loculated empyema and provide a global view of the extent and complexity of the pleural collection. Sonography allows portable bedside examination of critically ill patients and is useful in the detection and sampling of small effusions. Real-time ultrasound evaluation of pleural collections accurately determines the size and nature of the effusion and may be useful in predicting the success of thoracentesis. As cross-sectional studies are obtained in the majority of patients with complex pleural space infection and provide valuable information, the precise clinical utility of computed tomography scans and ultrasound in these patients remains undetermined.

Proinflammatory cytokines differentially modulate their own expression in human intestinal mucosal mesenchymal cells.

BACKGROUND & AIMS: Intestinal homeostasis is coordinated through the response of different cell types, including the interaction of immune with nonimmune cells. This study investigated the effect of immune cell-derived proinflammatory cytokines on mesenchymal cell proliferation and gene product expression. METHODS: Primary cultures of human mucosal mesenchymal cells were activated with interleukin (IL)-1 beta, IL-6, and tumor necrosis factor alpha (TNF-alpha). Proliferation was measured by thymidine incorporation, messenger RNA (mRNA) expression was assessed by Northern blot analysis, and IL-1 receptor type was identified by reverse-transcription polymerase chain reaction. RESULTS: Mesenchymal cells dose-dependently proliferated in response to IL-1 beta, IL-6, and TNF-alpha. Each cytokine differentially induced mRNA expression in a dose-dependent and selective fashion: IL-1 beta was the most potent inducer, TNF-alpha was weaker, and IL-6 induced little or no mRNA; in contrast, IL-6 mRNA was the most abundantly induced, followed by IL-1 beta mRNA, whereas TNF-alpha mRNA was weakly and infrequently expressed. The IL-1 receptor antagonist inhibited cytokine mRNA expression, and mesenchymal cells expressed the type II, but not the type I, IL-1 receptor. CONCLUSIONS: The ability of intestinal mesenchymal cells to express proinflammatory gene products implicates them as regulators of local immune cells through immune-nonimmune interactions. Thus, mesenchymal cells should be considered as active regulators of intestinal immunity under normal and inflammatory conditions.

Transthoracic needle biopsy: an overview.

The parallel development of cross-sectional detection and characterization of thoracic lesions with advances in biopsy needle design and increased access to expert cytopathology has led to an expanded role for image-guided transthoracic needle biopsy (TNB) in the diagnostic evaluation of thoracic lesions. There is a growing list of indications for TNB, the most important of which is the evaluation of a solitary pulmonary nodule. A key preparatory step in planning TNB is conducting a preprocedural consultation with the pathologist, which maximizes the likelihood of a positive diagnostic outcome. Computed tomography (CT) has rapidly become the guidance modality of choice for performing TNB. While TNB is highly sensitive in the diagnosis of carcinoma, methods used to enhance the diagnostic yield for other neoplasms and benign conditions include coaxial needle placement for multiple samplings, selective use of core biopsy needles to obtain histologic specimens, and the performance of ancillary tests on the aspirated material. The complications of TNB are well recognized and include pneumothorax, hemorrhage, and systemic air embolism. Although the results of recent cost-analysis studies suggest a central role for TNB in the diagnosis of the indeterminate lung lesion, the availability and yield of alternative diagnostic and therapeutic techniques including positron-emission tomography scanning and video-assisted thoracoscopic surgery will determine its true utility.

Interventional procedures in the AIDS patient.

The detection and characterization of radiologic abnormalities in the AIDS population are frequently adequate to suggest which opportunistic infection or malignancy is affecting the patient. In addition, tissue sampling for more specific diagnosis and therapeutic interventions is often guided by the results of the imaging studies. This article discusses the various diagnostic and therapeutic options that may be applicable to the AIDS patient.

RadNotes: a novel software development tool for radiology education.

RadNotes is a novel software development tool that enables physicians to develop teaching materials incorporating text and images in an intelligent, highly usable format. Projects undertaken in the RadNotes environment require neither programming expertise nor the assistance of a software engineer. The first of these projects, Thoracic Imaging, integrates image teaching files, concise disease and topic summaries, references, and flash card quizzes into a single program designed to provide an overview of chest radiology. RadNotes is intended to support the academic goals of teaching radiologists by enabling authors to create, edit, and electronically distribute image-oriented presentations. RadNotes also supports the educational goals of physicians who wish to quickly review selected imaging topics, as well as to develop a visual vocabulary of corresponding radiologic anatomy and pathologic conditions. Although Thoracic Imaging was developed with the aim of introducing chest radiology to residents, RadNotes can be used to develop tutorials and image-based tests for all levels; create corresponding World Wide Web sites; and organize notes, images, and references for individual use.

Disparate CD4+ lamina propria (LP) lymphokine secretion profiles in inflammatory bowel disease. Crohn's disease LP cells manifest increased secretion of IFN-gamma, whereas ulcerative colitis LP cells manifest increased secretion of IL-5.

In this study, we investigate whether human inflammatory bowel disease (IBD) (ulcerative colitis and Crohn's disease) is associated with altered lymphokine secretion profiles, as recently found in various animal models of chronic intestinal inflammation. In initial studies, we determined the proliferative responses of purified lamina propria (LP) CD4+ T cells from patients with IBD under defined conditions of T cell stimulation. We found that IBD LP CD4+ T cells in comparison with control LP CD4+ T cells have diminished TCR/CD3 pathway proliferative responses, whereas CD2/CD28 accessory pathway proliferative responses are relatively preserved. In further studies centering on lymphokine production, we showed that LP T cells from inflamed Crohn's disease mucosa manifest increased IFN-gamma secretion compared with control LP T cells, particularly when stimulated via the CD2/CD28 pathway. Subsequent ELISPOT analysis indicated that this was due to an increased number of IFN-gamma-secreting CD4+ T cells. In contrast, IL-4 and IL-5 production by Crohn's disease LP T cells was decreased compared with that of control LP T cells. Of interest, IL-2 production by Crohn's disease LP T cells was also reduced, as was IL-2 production by peripheral blood T cells. In parallel studies, LP T cells from inflamed ulcerative colitis mucosa stimulated via either the TCR/CD3/CD28 or CD2/CD28 produced increased amounts of IL-5, again when measured either as secreted IL-5 or by ELISPOT analysis. Such increased IL-5 production was not associated with increased IL-4 secretion and, in contrast to Crohn's disease, ulcerative colitis LP T cell production of IL-2 and IFN-gamma was normal. Taken together, these studies provide strong evidence that the immunopathologic process characteristic of the two major forms of IBD is associated with very different cytokine secretion patterns. These different patterns may determine the type of inflammatory process present.

Interleukin 4 in inflammatory bowel disease and mucosal immune reactivity.

BACKGROUND & AIMS: Interleukin (IL) 4 has immunoregulatory and anti-inflammatory activities, but little is known about IL-4 in the human gut. We investigated production of IL-4 by isolated lamina propria mononuclear cells (LPMCs) from normal and inflamed intestine and its capacity to modulate local immune responses. METHODS: IL-4 levels were measured by enzyme-linked immunosorbent assay in cultures of control and inflammatory bowel disease LPMCs, and the effect of IL-4 on LPMC proliferation and interaction with IL-2, IL-1 beta, lipopolysaccharide, bacterial antigens, superantigen, and antibodies to various T-cell receptors was investigated. RESULTS: Various stimuli induced LPMCs to produce IL-4, but inflammatory bowel disease cells expressed IL-4 messenger RNA and secreted protein in significantly lower amounts than control cells. IL-4 failed to stimulate proliferation by fresh LPMCs, but a vigorous dose-dependent response was observed after preactivation by phytohemagglutinin, IL-2, or IL-4. When added to fresh LPMCs, IL-4 inhibited IL-2-induced proliferation. IL-4 amplified proliferation to IL-1 beta, lipopolysaccharide, peptidoglycan-polysaccharide complexes, staphylococcus enterotoxin A, and antibodies to the CD3 and CD28 receptors but not to tetanus toxoid. CONCLUSIONS: Decreased production of IL-4 in inflammatory bowel disease may cause defective immunosuppressive and anti-inflammatory mechanisms and may contribute to disease pathogenesis. The ability of IL-4 to differentially modulate LPMC reactivity probably influences mucosal immune homeostasis.