Feasibility of a school reintegration programme for children with acute lymphoblastic leukaemia.

Despite children with acute lymphoblastic leukaemia missing a significant amount of school, little empirical literature guides the optimal content, setting and timing of a school reintegration programme. We examined the feasibility of a 4-month school reintegration intervention by: (1) developing collaboration with a community-based advocacy organisation; (2) developing intervention modules and observable end points; and (3) determining how the study achieved recruitment expectations. Eight families with children aged 6-12 years diagnosed with acute lymphoblastic leukaemia and parents were enrolled in the study. An experienced advocate implemented a series of eight modules over a 4-month period (twice per month) with the families. Participants completed pre-post measures. Successful collaboration with the advocacy organisation and the development of an intervention module series were achieved. Recruitment aims proved more difficult: enrolment was extended when recruitment for the original 1- to 6-month post-diagnosis window proved difficult. The advocate was able to complete between three and seven of the modules (mean = 5.2, standard deviation = 1.5). Families preferred clinic-based intervention. Challenges faced and lessons learned include: (1) advocacy organisations may be useful resources for school reintegration interventions; (2) school reintegration interventions must be flexibly applied; and (3) measurement end points constructed to gauge programme effectiveness.

Defense mechanisms and adjustment in normal adolescents.

OBJECTIVE: This study compared self-perception of defense patterns with objective and independent ratings of general adjustment in normal adolescents. METHOD: Self-perception of defense utilization by 140 high school students was measured by an adolescent version of Bond's Defense Style Questionnaire. The DSM-III-R Global Assessment of Functioning Scale was used by clinicians in determining general adjustment. RESULTS: Defense style and adjustment were significantly related; greater maturity of defense style was associated with better global adjustment, and conversely, greater immaturity of defense style was associated with a lower level of functioning. CONCLUSIONS: Adolescents' self-perceived defense patterns have conscious correlates associated with general adjustment. This study extends the validity of the defense mechanism paradigm to the adolescent age group.

Are overweight children unhappy?: Body mass index, depressive symptoms, and overweight concerns in elementary school children.

BACKGROUND: It is commonly believed that overweight children are unhappy with their weight. However, population-based data addressing this association are lacking. OBJECTIVES: To evaluate the association between obesity and depressive symptoms in a diverse, school-based sample of preadolescent children, and to examine whether overweight concerns play a role in this association. DESIGN, SETTING, AND PARTICIPANTS: Third-grade students (N = 868, mean age, 8.4 years) attending 13 public elementary schools in Northern California were measured for weight and height, and were asked to complete self-report assessments of depressive symptoms and overweight concerns. RESULTS: A modest association between depressive symptoms and body mass index (BMI; calculated as weight in kilograms divided by the square of height in meters) was found for girls (r = 0.14, P<.01), but not for boys (r = 0.01, P<.78). Among girls, depressive symptoms were strongly associated with overweight concerns (r = 0.32, P<.001). After controlling for level of overweight concerns, BMI was no longer significantly associated with depressive symptoms among girls. In contrast, after controlling for BMI, overweight concerns remained significantly associated with depressive symptoms. CONCLUSIONS: This study provides cross-sectional evidence for a relationship between depressive symptoms and BMI in preadolescent girls, but not in preadolescent boys. This relationship seems to be explained by an excess of overweight concerns. Assessing overweight concerns may be a useful method to identify those overweight girls who are at highest risk for associated depressive symptoms.

Are perceived neighborhood hazards a barrier to physical activity in children?

BACKGROUND: We hypothesized that children's perceptions of more neighborhood hazards would be associated with less physical activity, less aerobic fitness, and a higher body mass index. OBJECTIVE: To examine the association between a hazardous neighborhood context and physical activity in children. METHODS: Fourth-grade students (n = 796) of diverse ethnic and economic backgrounds completed measures of neighborhood hazards, self-reported physical activity, physical fitness, height, and weight. Parents (n = 518) completed telephone interviews and provided data on their education level and occupation. RESULTS: As expected, children from families of lower socioeconomic status perceived significantly more neighborhood hazards. Contrary to our hypothesis, the perception of more hazards was significantly associated with more reported physical activity. This finding was not explained by school heterogeneity, alteration of the hazards measure, or differences in socioeconomic status. CONCLUSION: To further examine the relationship between neighborhood hazards and physical activity, we suggest that future studies include assessments of sedentary behavior, parental fear of violence, parental regulation of children's leisure activities, and cost and quality of available play areas and organized sports.

MR imaging of the ankle and foot.

Optimal MR imaging of the ankle and foot demands attention to coil selection, patient positioning, and prescription of the imaging parameters. Though useful in the evaluation of many osseous conditions, MR imaging is perhaps most frequently used in the evaluation of osteochondral lesions and suspected osteomyelitis. Soft-tissue masses with a predilection for the foot and ankle include plantar fibromatosis, ganglion cysts, and interdigital neuromas.

In vivo proton (H1) magnetic resonance spectroscopy for cervical carcinoma.

Proton magnetic resonance spectroscopy (MRS) may be a useful tool in both the initial diagnosis of cervical carcinoma and the subsequent surveillance after radiation therapy, particularly when other standard diagnostic methods are inconclusive. Single voxel magnetic resonance (MR) spectral data were acquired from 8 normal volunteers, 16 patients with cervical cancer before radiation therapy, and 18 patients with cervical cancer after radiation therapy using an external pelvic coil at a 1.5-T on a Signa system. The presence or absence of various resonances within each spectrum was evaluated for similarities within each patient group and for spectral differences between groups. Resonances corresponding to lipid and creatine dominated the spectrum for the eight normal volunteers without detection of a choline resonance. Spectra from 16 pretreatment patients with biopsy-proven cervical cancer revealed strong resonances at a chemical shift of 3.25 ppm corresponding to choline. Data acquired from the 18 posttreatment setting studies was variable, but often correlated well with the clinical findings. Biopsy confirmation was obtained in seven patients. H1 MRS of the cervix using a noninvasive pelvic coil consistently demonstrates reproducible spectral differences between normal and neoplastic cervical tissue in vivo. However, signal is still poor for minimal disease recurrence. Further study is needed at intervals before, during, and after definitive irradiation with biopsy confirmation to validate the accuracy of MRS in distinguishing persistence or recurrence of disease from necrosis and fibrosis.

Normal magnetic resonance imaging anatomy of the ankle and foot.

The normal anatomy of the ankle and fore-foot is quite complex and presents a challenge for both MR imaging and interpretation. Many of the critical ligaments and tendons require imaging in several planes for greatest diagnostic accuracy. We hope this article serves as a solid foundation and a reference for the excellent articles that follow.

Medial and lateral supporting structures of the knee. Normal MR imaging anatomy and pathologic findings.

The supporting structures of the knee can be divided into several layers: fascial boundaries, the collateral ligaments and tendons, and the joint capsule. MR imaging's ability to demonstrate these findings has helped to validate this anatomic concept. An appreciation for the organization of the medial and lateral compartments facilitates MR imaging interpretation.

Normal MR imaging anatomy of the elbow.

This article discusses the normal, clinically relevant MR imaging anatomy of the elbow. A compartmental approach is utilized to help simplify this anatomically complex region. Imaging techniques, common anatomic variants, and imaging pitfalls are also briefly discussed.

Cirsoid aneurysm treatment by percutaneous injection of sodium tetradecyl sulfate.

BACKGROUND: Cirsoid aneurysms are uncommon arteriovenous fistulas of the scalp. Surgery for these lesions can be difficult; transarterial embolization is rarely curative, while embolization of the venous pouch with permanent agents usually necessitates subsequent surgical removal of the embolic material. The ideal embolic agent would be one that is safe and effective, commercially available, and would not require subsequent removal. METHODS: We treated an arteriovenous fistula of the scalp with direct puncture and injection of sodium tetradecyl sulfate, a commercially available sclerosing agent. RESULTS: Control angiography immediately following percutaneous injection of sotradecol into the fistula showed decreased flow but not complete closure of the lesion. However, within several days of the embolization, the patient's scalp pain and mass resolved. Four months after embolization, MRA demonstrated no evidence of residual or recurrent fistula. Color doppler flow imaging demonstrated only slightly decreased vascular resistance in the distal superficial temporal artery, possibly indirect evidence of persistent micro-fistulae. Twenty-three months after the procedure, the patient continued to be asymptomatic and had no palpable lesion. CONCLUSIONS: Percutaneous injection of sotradecol can be considered as one of the treatment options for arteriovenous fistula of the scalp. Further experience is needed to compare the safety and effectiveness of sotradecol with other agents currently used in the treatment of scalp arteriovenous fistulae.

Cancer immunotherapy for prostate cancer.

Our approach to prostate cancer immunotherapy involves two components dendritic cells as antigen-presenting cells; and the antigen used to target T-cell attack, HLA-A0201-associated peptides from prostate specific membrane antigen (PSMA). We have conducted a phase I dose-ranging study in 51 men with advanced prostate cancer, using dendritic cells pulsed with a PSMA peptide. no significant toxicity was observed. In that study, T-cell response was enhanced, with seven men meeting NCPC and PSA criteria for partial response. We are now conducting a phase II study with 67 men, who will receive 6 infusions of dendritic cells that have been pulsed with 2 PSMA peptides, at 6-week intervals. The phase II study design and rationale is described in this paper.

Fast gradient echo magnetic resonance imaging of the normal diaphragm.

To determine the ability of fast gradient-recalled echo (GRE), breath-hold magnetic resonance imaging (MRI) to depict all regions of the diaphragm, 13 volunteers were scanned in coronal and sagittal planes. The central to anterior left hemidiaphragm and the posterior lumbar portions were each demonstrated in 12 subjects (92%). The crura were visible crossing anterior to the aorta in the sagittal plane in eight subjects (62%) and in the coronal plane in six subjects (46%). In the sagittal plane, the right crus was evident in eight subjects (62%). Muscular portions of the diaphragm in contact with the liver or body wall were less frequently discernible, and the central tendon could not be confidently resolved. Several artifacts occurred that interfered with visualization of the diaphragm. These observations indicate that many regions of the diaphragm can be seen with fast GRE, breath-hold MRI, but there are some limitations in depicting the diaphragm in its entirety.

Detection of osteomyelitis in the neuropathic foot: nuclear medicine, MRI and conventional radiography.

The diagnostic efficacy of (1) combined three-phase bone scintigraphy and In-111 labeled WBC scintigraphy (Bone/WBC), (2) MRI, and (3) conventional radiography in detecting osteomyelitis of the neuropathic foot was compared. Conventional radiography was comparable to MRI for detection of osteomyelitis. MRI best depicted the presence of osteomyelitis in the forefoot. Particularly in the setting of Charcot joints, Bone/WBC was more specific than conventional radiography or MRI.

Sonography of the foot and ankle.

Sonography of the foot and ankle is a quick, relatively inexpensive imaging modality that can be used to diagnose a variety of pathologic conditions. Sonography is particularly well suited for the assessment of tendons, soft-tissue masses, and suspected foreign bodies. Visualization of internal structural detail typically equals or exceeds that of MR imaging. Diagnostic accuracy, however, requires meticulous attention to technical parameters and proficiency with the transducer.

Magnetic resonance imaging in the evaluation of heel pain.

This study demonstrates magnetic resonance findings in 16 patients (25 heels) with heel pain. Sixteen of 25 (64%) studies demonstrated abnormalities which could be related to the etiology of their heel pain. Eleven of 16 abnormal scans demonstrated thickening of the plantar aponeurosis with associated fibrosis (7 of 11), and a tear of the flexor digitorum brevis (1 of 11). One study demonstrated changes in the heel pad consistent with fluid. The other four abnormal studies demonstrated changes thought to be consistent with bilateral fibrous calcaneonavicular coalitions, subtalar arthrosis and tenosynovitis of the posterior tibial, flexor digitorum longus, and flexor hallucis longus tendons.

Color Doppler flow imaging.

The performance requirements and operational parameters of a color Doppler system are outlined. The ability of an operator to recognize normal and abnormal variations in physiologic flow and artifacts caused by noise and aliasing is emphasized. The use of color Doppler flow imaging is described for the vessels of the neck and extremities, upper abdomen and abdominal transplants, obstetrics and gynecology, dialysis fistulas, and testicular and penile flow imaging.

Trauma and personality correlates in long-term pediatric cancer survivors.

To explore the relationship between PTSD and trauma-spectrum symptoms, including personality and functional correlates, in long term pediatric cancer survivors (N = 40), we assessed these constructs with a structured interview for PTSD, a clinical interview, and self-report questionnaires. Thirty-five out of 40 participants (88%) currently met at least one trauma symptom at a functionally significant level. These survivors demonstrate high levels of restraint and low levels of distress, representative of a repressive adaptive style. After more than 5 years since treatment completion, the relatively high levels of current trauma-spectrum symptoms may reflect the long-term deleterious impact of childhood cancer.

CT-guided injection of the stellate ganglion: description of technique and efficacy of sympathetic blockade.

Stellate ganglion blockade, typically performed by using palpable osseous landmarks, is an accepted method in the diagnosis and treatment of sympathetically maintained pain and other conditions. The authors present the results of stellate ganglion injection performed with computed tomographic (CT) guidance. Thirteen CT-guided procedures were performed in seven patients. Lidocaine, bupivacaine, and buprenorphine were used to achieve the blockade. Successful blocks were achieved in all 13 cases as evidenced by production of Horner syndrome and ipsilateral hand temperature elevations. The average ipsilateral and contralateral hand temperature changes following the procedure were 7.5 degrees C and 0.5 degrees C. The ipsilateral hand temperature changes and the differences between the ipsilateral and contralateral hand temperature changes exceeded 1.5 degrees C in every case. Five patients preferred the CT-guided procedure over the conventional technique, and two patients noted no substantial difference between the approaches. With the CT-guided technique, a highly effective sympathetic block is achieved with a substantially reduced volume of anesthetic compared with the conventional approach.

Clonidine poisoning--an emerging problem: epidemiology, clinical features, management and preventative strategies.

OBJECTIVE: To ascertain whether the incidence of clonidine poisoning in children has increased given the probable increase in clonidine use for treatment of childhood behavioural disorders. METHODS: Cases of clonidine poisoning requiring hospital admission between 1985-95 inclusive were reviewed and demographic data pertinent to each admission were recorded. A literature review was also performed, with particular emphasis on incidence, clinical presentation and management of clonidine poisoning. RESULTS: There were 14 cases of clonidine poisoning during the specified period eight cases presenting in the last 2 years. These eight children or their siblings had been prescribed clonidine for behavioural disorders. The most common signs at presentation were alteration of conscious state (71%) and bradycardia (50%). Nine children were given activated charcoal while seven cases underwent gastric lavage or induced emesis. Although six children were admitted to intensive care, length of hospital stay was less than 24 h in all cases and all had a favourable outcome. CONCLUSION: We concluded that the incidence of clonidine poisoning had increased over the specified period and that, based on our results, this was likely to be due to an increase in clonidine use in childhood behavioural disorders. Based on our data and that from literature review it was evident that there are inconsistencies in the management of clonidine poisoning and that safety measures, namely packaging and education, are inadequate given the increasing profile of clonidine use.