ACR Appropriateness Criteria® Ataxia-Child.

Childhood ataxia may be due to multifactorial causes of impairment in the coordination of movement and balance. Acutely presenting ataxia in children may be due to infectious, inflammatory, toxic, ischemic, or traumatic etiology. Intermittent or episodic ataxia in children may be manifestations of migraine, benign positional vertigo, or intermittent metabolic disorders. Nonprogressive childhood ataxia suggests a congenital brain malformation or early prenatal or perinatal brain injury, and progressive childhood ataxia indicates inherited causes or acquired posterior fossa lesions that result in gradual cerebellar dysfunction. CT and MRI of the central nervous system are the usual modalities used in imaging children presenting with ataxia, based on the clinical presentation. This document provides initial imaging guidelines for a child presenting with acute ataxia with or without a history of recent trauma, recurrent ataxia with interval normal neurological examination, chronic progressive ataxia, and chronic nonprogressive ataxia. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances in which peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

ACR Appropriateness Criteria® Cerebrovascular Disease-Child.

Stroke is an uncommon but an important and under-recognized cause of morbidity and mortality in children. Strokes may be due to either brain ischemia or intracranial hemorrhage. Common symptoms of pediatric acute stroke include headache, vomiting, focal weakness, numbness, visual disturbance, seizures, and altered consciousness. Most children presenting with an acute neurologic deficit do not have an acute stroke, but have symptoms due to stroke mimics which include complicated migraine, seizures with postictal paralysis, and Bell palsy. Because of frequency of stroke mimics, in children and the common lack of specificity in symptoms, the diagnosis of a true stroke may be delayed. There are a relatively large number of potential causes of stroke mimic and true stroke. Consequently, imaging plays a critical role in the assessment of children with possible stroke and especially in children who present with acute onset of stroke symptoms. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

ACR Appropriateness Criteria® Acutely Limping Child Up To Age 5.

Imaging plays in important role in the evaluation of the acutely limping child. The decision-making process about initial imaging must consider the level of suspicion for infection and whether symptoms can be localized. The appropriateness of specific imaging examinations in the acutely limping child to age 5 years is discussed with attention in each clinical scenario to the role of radiography, ultrasound, nuclear medicine, computed tomography, and magnetic resonance imaging. Common causes of limping such as toddler's fracture, septic arthritis, transient synovitis, and osteomyelitis are discussed. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

ACR Appropriateness Criteria® Sinusitis-Child.

Sinusitis is common in children that usually resolves spontaneously. Imaging is not part of the standard of care for initial diagnosis, however may be necessary in cases with persistent or chronic sinusitis to guide surgical intervention, or to rule out intracranial and vascular complications of sinusitis. Computed tomography (CT) and magnetic resonance imaging (MRI) are the leading imaging modalities. In this article, appropriateness in use of imaging modalities are discussed under common/clinically relevant scenarios. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Sulfuric acid-layered ultrafine particles potentiate ozone-induced airway injury.

Urban air pollution in the United States is composed of a complex mixture of particles and gases. Among the most prominent products of the atmospheric pollutants are sulfur oxides and ozone. In this report, we use two exposure protocols to examine the interaction between exposure to these two pollutants. In the first exposure regimen, guinea pigs were exposed to sulfuric acid (pure sulfuric acid mist or sulfuric acid layered on ZnO) for 1 h. Each exposure is followed 2 h later by another exposure to 0.15 ppm ozone for 1 h. Pulmonary function parameters were measured immediately after the ozone exposure. In guinea pigs that were exposed to 300 micrograms/m3 pure sulfuric acid mist, subsequent exposure to 0.15 ppm ozone did not produce additional change in pulmonary functions. In guinea pigs that were exposed to 84 micrograms/m3 sulfuric acid layered on ZnO, subsequent exposure to 0.15 ppm ozone produced more than additive alterations in vital capacity and diffusing capacity. In the second exposure regimen, guinea pigs were exposed to 24 micrograms/m3 sulfuric acid layered on ZnO for 3 h/d for 5 d. On d 8 and 9, animals received two additional daily 3-h exposures to 24 micrograms/m3 sulfuric acid layered on ZnO, and pulmonary functions were measured at the end of the daily exposure. Greater reductions in lung volumes and diffusing capacity were observed in animals on d 9 than would be observed in animals that received no additional exposure. In the third exposure regimen, guinea pigs were exposed to 24 micrograms/m3 sulfuric acid layered on ZnO for 3 h/d for 5 d. On d 9, animals were exposed to 0.15 ppm ozone for 1 h and pulmonary functions were measured at the end of the ozone exposure. Ozone exposure on d 9 induced reductions in lung volumes and diffusing capacity that were not observed in animals receiving exposures to either ozone or sulfuric acid layered ZnO alone. We conclude that single or multiple exposure to sulfuric acid-layered ZnO sensitizes guinea pigs to subsequent sulfuric acid or ozone exposure.

Pulmonary effects of ultrafine coal fly ash inhaled by guinea pigs.

Guinea pigs were exposed to ultrafine coal fly ash produced in a laboratory furnace. The average mass median aerodynamic diameter and the average mass concentration of Illinois no. 6 fly ash produced in all exposure conditions were 0.21 microns and 5.8 mg/m3, respectively. In guinea pigs exposed to Illinois no. 6 fly ash, total lung capacity (TLC), vital capacity (VC), and diffusing capacity for carbon monoxide (DLco) were significantly reduced below the control values immediately, 2 h, and 8 h postexposure. The diffusing capacity was still 10% below the control 96 h after exposure. The total sulfate in the Illinois no. 6 fly ash as determined using ion chromatography is 1105 +/- 120 micrograms/m3. Animals exposed to the Montana lignite fly ash at comparable concentration and particle size did not show alteration in diffusing capacity. The data suggest that part of the sulfate present in the fly ash of Illinois no. 6 could be in the form of sulfuric acid and is responsible for the adverse effects observed in the exposed animals. The sulfuric acid in the fly ash of Montana lignite is neutralized by its high alkali content and produces no change in lung functions.

Pulmonary function of guinea pigs exposed to freshly generated ultrafine zinc oxide with and without spike concentrations.

Exposure of guinea pigs 3 hr/day for 5 consecutive days to freshly formed ultrafine zinc oxide (ZnO) (count median diameter: 0.05 micron; geometric standard deviation: 2.0) at a concentration of 7 mg/m3 produced a gradual decrease in total lung capacity and vital capacity over the course of the exposure period. The carbon monoxide (CO) diffusing capacity (DLCO) was not affected until the fourth day, when it dropped abruptly to 30% below control levels. Wet-lung weight/body weight ratios and wet-lung/dry-lung weight ratios increased, indicating the presence of edema. Exposures to 2.7 mg/m3 ZnO, using the same 3 hr/day, 5 day time frame, did not alter any parameters measured. In 2 experiments a single high peak of ZnO (25-34 mg/m3) occurred. In one experiment exposure was stopped, but pulmonary function measurements were made as scheduled; in the other case, exposures to ZnO were continued. In both, lung volumes were decreased abruptly and to a greater extent than when peaks were absent. Continued exposure caused greater decrements in total lung capacity (TLC) and vital capacity (VC) as well as decrements in functional residual capacity (FRC) and residual volume (RV) than were observed when exposure was stopped. Peak exposures reduced DLCO to 45%-60% below control. These values rose to 25%-30% below control with or without continued exposure. Airway resistance increased and compliance decreased following peak exposures. When exposure was stopped, these changes were reversible; with continued exposure they still were different from control levels on the fifth day.(ABSTRACT TRUNCATED AT 250 WORDS)

Indomethacin and cromolyn sodium alter ozone-induced changes in lung function and plasma eicosanoid concentrations in guinea pigs.

Male Hartley guinea pigs were given either indomethacin (IN), cromolyn sodium (CS), or no drug (ND) and then exposed either to filtered air or to 1 ppm ozone (O3) for 1 hr. At 2 or 24 hr postexposure, ventilation, respiratory mechanics, lung volumes, carbon monoxide-diffusing capacity (DLCO), and alveolar volume (VA) were measured, and in separate groups of animals, plasma eicosanoids (EC) were measured. Both drugs blocked the increase in flow resistance noted at 2 hr after O3 and prevented O3-induced increases in the wet lung weight to body weight ratio seen at 2 and 24 hr in the ND group. In the ND animals O3 also decreased total lung capacity (TLC), vital capacity (VC), functional residual capacity (FRC), and residual volume (RV). IN as well as CS blocked reductions in FRC and RV at both 2 and 24 hr after O3. TLC was reduced by both drug treatments in air- and O3-exposed animals. CS treatment also decreased VC in all groups. IN blocked reductions in VA after O3 but did not prevent decreases in DLCO. CS blocked reductions in both VA and DLCO after O3, but the drug decreased DLCO in air-exposed animals. The prostaglandins PGF2 alpha and 6-keto PGF1 alpha were largely unaffected by O3 exposure or drug treatment. Prostaglandin E1 (PGE1) was not affected by O3, but both drugs significantly increased PGE1 in all exposure groups. Effects on plasma thromboxane B2 (TxB2) were variable although in most groups TxB2 was lower than in the O3-exposed ND groups. Although our findings suggest that both drugs block some effects of O3 exposure on the lungs and on plasma EC concentrations, the degree to which EC contribute to O3-induced pulmonary effects is not clearly apparent.

Functional changes in the lungs of guinea pigs exposed to sodium sulfite aerosols.

Guinea pigs were exposed head only for 1 hr to submicrometer sodium sulfite aerosols (mass median aerodynamic diameter = 0.36 micron, sigma g = 2.96) at 474, 669, and 972 micrograms SO3(2-)/m3. Respiratory mechanics were measured in unanaesthetized animals before, during, and after exposure. Dose-related increases in resistance and decreases in compliance were observed. At 972 micrograms SO3(2-)/m3, the sodium sulfite aerosol caused a 50% increase in resistance and a 19% decrease in compliance. These changes were still present 1 hr after the end of exposure. The results were used to assess the irritant potency of sodium sulfite aerosol. Another group of guinea pigs was exposed whole body for 1 hr to the same aerosol at 0, 204, 395, and 1152 micrograms SO3(2-)/m3. Immediately after the exposures, lung volume, diffusion capacity for carbon monoxide (DLCO), and wet lung weight were evaluated in anesthetized, tracheotomized animals. As compared to controls, total lung capacity, vital capacity, functional residual capacity, residual volume, and DLCO were all decreased with increasing concentrations of sodium sulfite. Dose-related increases in wet lung weights were also observed. These results were compared with the irritant responses of animals exposed to zinc oxide and sulfur dioxide mixed under different conditions of temperature and humidity.

Effect of ozone exposure on lung functions and plasma prostaglandin and thromboxane concentrations in guinea pigs.

Male Hartley guinea pigs were exposed either to filtered air or to 1 ppm ozone (O3) for 1 hr. At 2, 8, 24, or 48 hr after exposure we measured ventilation, respiratory mechanics, lung volumes, diffusing capacity for carbon monoxide (DLCO), and alveolar volume (VA) in anesthetized, tracheotomized animals. Respiratory frequency and tidal volume were unchanged in all groups. Pulmonary resistance was increased 2 hr after O3 but returned to control at 8 hr and thereafter. Prolonged reductions in lung volumes (total lung capacity, vital capacity, functional residual capacity, and residual volume) as well as in DLCO and VA occurred after O3, with maximum decreases at 8 and 24 hr postexposure. Increased ratios of wet lung weight to body weight were seen at 2, 8, and 24 hr. In separate groups of animals, also exposed either to filtered air or to 1 ppm O3, plasma eicosanoid (EC) concentrations were measured at 2, 8, 24, 48, or 72 hr after exposure. Significant increases in thromboxane B2 concentrations were seen at 2, 24, and 48 hr after exposure. Plasma concentrations of 6-keto prostaglandin F1 alpha (PGF1 alpha) and prostaglandin E1 (PGE1) were increased at 24 hr and at 24, 48, and 72 hr, respectively. The nature of this long-term pulmonary response to a short-term exposure to O3 suggests alveolar involvement, including probable alveolar duct constriction and localized pulmonary edema. Although changes in plasma EC concentrations were observed concurrent with impaired lung functions, no simple causal relationship was apparent from these studies.

Functional and morphologic changes in the lungs of guinea pigs exposed to freshly generated ultrafine zinc oxide.

Guinea pigs were exposed by nose only for 3 hr/day for 6 days to freshly formed zinc oxide (ZnO) particles (projected area diameter = 0.05 micron, sigma g = 2.0) at 5 mg/m3, the currently recommended threshold limit value (TLV). Ventilation, lung mechanics, lung volumes, and diffusing capacity for carbon monoxide (DLCO) in anesthetized, tracheostomized animals at 1, 24, 48, or 72 hr after the end of the last exposure were evaluated. At the same time intervals lung weight, lung fluid content, respiratory epithelial permeability to horseradish peroxidase, gross and microscopic appearance, and [3H]thymidine labeling of nuclei of bronchial and bronchiolar epithelial cells in other groups of animals were measured. Vital capacity, functional residual capacity, alveolar volume, and DLCO were all decreased following the last exposure and did not return to normal values by 72 hr. Increases in flow resistance and decreases in compliance and total lung capacity returned to normal by 72 hr. Lung weights were elevated due to inflammation involving the proximal portion of the alveolar ducts and adjacent alveoli. These changes were still present at 72 hr. [3H]Thymidine labeling of bronchiolar epithelial cell nuclei was increased for 48 hr. Respiratory epithelial permeability to horseradish peroxidase was not affected by the exposures. These results suggest that the current TLV for ZnO may not be adequate.

Lung injury in guinea pigs caused by multiple exposures to submicron zinc oxide mixed with sulfur dioxide in a humidified furnace.

Sulfur dioxide, water vapor, and ultrafine particles rich in oxides of zinc and other surface-deposited trace elements are important products of coal combustion. In order to study the toxicity of zinc oxide generated under conditions simulating combustion, guinea pigs were exposed in a nose-only apparatus for 3 h on 6 consecutive days to 6 mg/m3 of submicron zinc oxide particles (count median diameter of 0.05 micron, sigma g 2.0), which were generated in a humid furnace and mixed with 1 ppm sulfur dioxide. The exposures caused increases in lung weight and [3H] thymidine labeling index of terminal bronchiolar cell nuclei and inflammation of the proximal portion of the alveolar duct. The lung weights and labeling index had returned to normal and inflammatory changes had nearly resolved by 72 h after the last exposure. Total lung capacity, vital capacity, functional residual volume, alveolar volume, and diffusing capacity for carbon monoxide were decreased following exposure and had not returned to normal by 72 h after the last exposure. Large airways were not affected by the repeated exposures, as indicated by normal morphology of trachea and bronchi, unchanged secretory cell concentration, and unaltered epithelial permeability to horseradish peroxidase. These results are essentially identical to changes we reported in guinea pigs exposed to zinc oxide alone, suggesting that surface-deposited sulfur compounds, which are important determinants of the response to a single exposure to these ultrafine particles, become less important as exposure progresses.

Pneumoconiotic effects of welding-fume particles from mild and stainless steel deposited in the lung of the rat.

Rats were exposed to single periods of inhalation of fumes generated by arc welding. Two processes were compared: either manual metal arc (MMA) using flux-coated mild steel (MS) electrodes or metal inert-gas (MIG) welding with stainless steel (SS). Widespread but small deposits of fume particles were cleared effectively from alveoli and airways. Peribronchial and subpleural aggregates of particle-laden macrophages remained. More massive and persistent lung-burdens were established by intratracheal administration of suspensions of fume-particles (10 mg and 50 mg, single doses). Initial pneumonitis was attributed to irritant gases or soluble toxic components of particles. MIG-SS particle deposits were more persistent and lesions more severe, inhibition of phagocytosis or clearance and damage to epithelial cells being associated with possible toxic effects in macrophages. Both types of particle caused alveolar epithelial thickening, with proliferation of granular pneumocytes and exudation of lamellar material. Foam cells appeared in alveoli. Long-term effects (80-300 days) involved formation of nodular aggregates of particle-laden macrophages. Giant cells were formed. Nodules containing MIG-SS material were irregular and surrounded by collapsed and thickened epithelium. Soluble chromium or nickel constituents are cited as probable active agents producing effects resembling those of cytotoxic non-fibrogenic dusts, e.g., soluble silicas . MMA-MS particles produced low-grade fibrotic ( collagenised ) changes.

An investigation of fibrogenic and other toxic effects of arc-welding fume particles deposited in the rat lung.

Lung burdens of deposited particles from fumes generated by arc-welding were established in rats by single inhalation exposures, repeated intermittent exposure or by intratracheal injection. Fumes from manual metal arc-welding using flux-coated mild-steel rods (MMA-MS) were compared with those from metal inert-gas welding with stainless steel wire (MIG-SS). After initial rapid clearance of deposited material from the lungs, persistent residual deposits remained. Such residues resulting from single inhalation were small and confined mainly to peribronchial accumulations in macrophage clusters. Deposits remaining after repeated inhalation were larger and more widespread. Intratracheal administration (50 mg) established massive residual deposits, giving nodular accumulations in peribronchial, subpleural and perivascular sites, with substantial alveolar parenchymal involvement. Deposits from both types of fumes contained predominantly iron. Particles from stainless steel also contained chromium, but concentrations of this element were low in deposits from MMA-MS fumes. MMA-MS deposits contained silica, probably amorphous. Long-term studies (up to 450 days) attempted to detect evidence of fibrosis resulting from particle burdens. Low-grade collagen fibre layers developed at margins of MMA-MS nodules. Diffuse reticulin fibre networks occurred within MIG-SS aggregates. Tissue hydroxyproline levels were increased (doubled) in lungs with intratracheal burdens of MMA-MS particles, but no significant increases resulted from MIG-SS. The major lesions were nodular aggregates of particle-laden macrophages with giant-cell formation, and alveolar epithelial thickening with atelectasis.

A comparison of the effects of paraquat and diquat on lung compliance, lung volumes and single breath diffusing capacity in the rat.

Paraquat intoxication in its initial stage is characterized histologically in the lungs by atelectasis, hyaline membrane formation, alveolar edema and vascular hemorrhage often into the interstitium or air spaces. Information on the functional modification of paraquat-damaged lungs has been lacking. We evaluated lung volumes, single breath diffusing capacity of the lungs for carbon monoxide (DLCO) and static lung compliance (Cst(L)) in rats treated with paraquat or diquat. Measurements were made 12, 24, 48, and 72 h after treatment. Paraquat by intratracheal (i.t.) instillation 0.5 mg/kg or by intraperitoneal injection (i.p.) 27 mg/kg significantly decreased (P less than 0.01) the body weight, total lung capacity (TLC), functional residual capacity (FRC), vital capacity (VC), residual volume (RV), DLCO, apparent alveolar volume (VA) and Cst(L). At a lower dose level (13.5 mg/kg), the effects of paraquat peaked at about 24 h following treatment, causing a significantly decreased (P less than 0.01) VC and TLC. Diquat i.t. or i.p. had little effect on the lungs. However, diquat i.p. decreased body weight (P less than 0.01) and caused a slight increase (P less than 0.05) in VC. The data obtained are consistent with the known pathological changes seen in paraquat-damaged lungs in that, by both routes, paraquat caused severe lung damage associated with decreased elasticity of the lungs and thorax, destruction of gas exchanging alveolar surfaces, and edema. These changes were detected reliably by lung function measurements.

An investigation of the experimental induction of hypersensitivity in the guinea pig by material containing chromium, nickel and cobalt from arc welding fumes.

Sensitization of guinea pigs by chromium, cobalt and nickel was compared by four methods. The most effective was the maximization test of Magnusson and Kligman. Sensitizing properties of particles from fumes of either manual metal arc (MMA) or metal inert gas welding were demonstrated. Potent sensitization was attributed to chromium.