The role of ultrasonography in the diagnosis and management of idiopathic plantar fasciitis.

OBJECTIVE: To compare ultrasonography with bone scintigraphy in the diagnosis of plantar fasciitis and to compare ultrasound-guided injection with palpation-guided injection in the management of idiopathic plantar fasciitis. METHODS: Twenty-three patients with a clinical diagnosis of idiopathic plantar fasciitis in 28 heels underwent ultrasonography and bone scintigraphy of both heels at baseline. The patients were randomized to ultrasound- or palpation-guided injection of triamcinolone hexacetonide and xylocaine into the plantar fascia. The 100 mm visual analogue scale (VAS) of pain, the heel tenderness index (HTI), and ultrasonography were performed at baseline and follow-up (mean=13.4 weeks). RESULTS: The mean thickness (+/-standard error of the mean) of the plantar fascia, measured by ultrasonography, was 5.7+/-0.3 mm in symptomatic heels as compared with 3.8+/-0.2 mm in asymptomatic heels (P<0.001). Ultrasonography findings correlated with bone scintigraphic findings in the diagnosis of plantar fasciitis (P<0.001). Fourteen heels were randomized to ultrasound-guided injection, 10 heels were randomized to palpation-guided injection and four heels were not injected. Ultrasound- and palpation-guided injection resulted in significant mean improvements in VAS [39.6+/-9.2 (ultrasound) vs 41.5+/-8 (palpation)] and HTI [1.35+/-0.2 (ultrasound) vs 1.3+/-0.4 (palpation)]. There was no significant difference in the response rate following corticosteroid injection by either modality (ultrasound=13/14, palpation=8/10). Following injection, the mean thickness of the plantar fascia decreased from 5.7+/-0.3 mm to 4.65+/-0.4 mm (P<0.01). CONCLUSION: Ultrasonography and bone scintigraphy are equally effective in the diagnosis of plantar fasciitis. Ultrasound-guided injection is effective in the management of plantar fasciitis but is not more effective than palpation-guided injection. Ultrasonography may be used as an objective measure of response to treatment in plantar fasciitis.

Value of double-contrast barium enema performed immediately after incomplete colonoscopy.

OBJECTIVE: The purpose of this study was to evaluate the ease, completeness, and clinical utility of double-contrast barium enema (DCBE) performed immediately after incomplete colonoscopy. SUBJECTS AND METHODS: During a 30-month period, a prospective study was performed in 103 patients (79 women, 24 men) to determine the ease and completeness of DCBE immediately after failed colonoscopy and any additional useful information provided by the enema. The ease with which DCBE was performed was graded from 1 (easy) to 10 (difficult). RESULTS: DCBE revealed the entire colon in 97 patients (94%). Incomplete DCBE was a result of obstruction and incontinence in three patients each. The mean score for ease of performing DCBE was 5.0. In 14 patients (14%), significant additional diagnostic information was provided by the immediate DCBE. In eight patients, abnormalities were identified on DCBE that had not been seen at colonoscopy (five malignant neoplasms, one diverticular mass, two extrinsic masses, and multiple strictures). In four patients, a suspected colonoscopic abnormality was excluded with DCBE findings; and in two patients, a colonoscopic abnormality was further characterized with DCBE. CONCLUSION: Immediate DCBE after incomplete colonoscopy allows complete colonic evaluation in most cases, often adds vital diagnostic information, and eliminates repeated bowel preparation and unnecessary delay in diagnosis.

Ultrasonography in the diagnosis and management of psoriatic dactylitis.

OBJECTIVE: To determine the ultrasonographic features of dactylitis in psoriatic arthritis (PsA). METHODS: Seventeen patients with PsA presenting with a total of 25 dactylitic fingers and toes underwent ultrasonographic examination of the digits with a 7.5 or 10 MHz transducer. RESULTS: Flexor tenosynovitis was present in 96% (24/25) of dactylitic digits. Articular synovitis was present in 52% (13/25) of dactylitic digits. Subcutaneous soft tissue enlargement was present in all digits. The presence of articular synovitis in a dactylitic finger on ultrasonography correlated with the presence of joint space narrowing and periostitis on plain radiography. CONCLUSION: Dactylitis in PsA is due to both flexor tenosynovitis and articular synovitis. Dactylitis in PsA has an increased incidence of articular synovitis, which was associated with the development of articular damage as assessed by plain radiography.

Multiple gastric polyps in familial amyloid polyneuropathy.

Amyloid masses of the gastrointestinal tract are very rare. A previously undescribed finding of multiple gastric polyps due to systemic amyloidosis is outlined in a patient with familial amyloid polyneuropathy. The relevant literature pertaining to gastric amyloidosis and mucosal masses is reviewed. Amyloidosis should be included in the differential diagnosis of target lesions in the stomach.

Ultrasound guided injection of recalcitrant plantar fasciitis.

OBJECTIVE: To determine the effect of ultrasound guided injection in recalcitrant idiopathic plantar fasciitis. METHODS: Four patients with a clinical diagnosis of idiopathic plantar fasciitis, who were unresponsive to palpation guided injection with triamcinolone acetonide and local anaesthetic, underwent ultrasonographic examination of the heel. RESULTS: The following ultrasonographic features were noted:- (a) increased thickness of plantar fascia in symptomatic heels compared with asymptomatic heels, (b) loss of distinction of the distal plantar fascia borders, (c) reduced echogenicity of the plantar fascia. Ultrasound guided injection of the enlarged, hypoechoic plantar fascia resulted in complete relief in four of five heels (mean duration of follow up = 24 months) in three cases. One patient developed a recurrence of symptoms after six months. CONCLUSION: Ultrasound allows for confirmation of the clinical diagnosis and ultrasound guided injection produces a good clinical response when unguided injection is unsuccessful. The technique is quick, inexpensive, and entails no radiation exposure.

A comparison of a non-ionic dimer, iodixanol with a non-ionic monomer, iohexol in low dose intravenous urography.

A prospective, double-blind study of 392 patients randomized into four groups was performed to establish whether diagnostic intravenous urograms could be obtained with a lower dose of iodine when using the dimeric, non-ionic contrast medium iodixanol compared with the monomeric, non-ionic iohexol. Patients received iodixanol or iohexol containing either 9 or 12 g of iodine (gI). The primary parameter was the diagnostic quality of the 6 min film, assessed in a blinded fashion, by consensus, by four radiologists. Iodixanol at both doses was diagnostic in over 90% of cases. Iohexol was only diagnostic in 74% (9 gI) and 81.8% (12 gI). Pairwise comparisons revealed that iodixanol 9 gI was significantly better than both iohexol 9 gI (p = 0.0005) and 12 gI (p = 0.014). No significant difference was present for different doses within the same contrast medium group. Iodixanol resulted in poorer bladder distension than iohexol. Iodixanol caused significantly less discomfort than iohexol.

Comparison of an asymmetric screen-film combination with a conventional screen-film combination for chest radiography in 51 patients.

Comparison is made between a new asymmetric screen-film combination and a conventional screen-film combination for use in chest radiography. Seven anatomical features were assessed by three consultant radiologists in each of 51 film pairs. A preference was indicated if one system better demonstrated a particular feature. Alternatively, no preference was indicated if the feature was equally demonstrated by both systems or not demonstrated at all. Any pathology incidentally noted which remained unchanged between the two films was localized to lung, mediastinum or bone and marked in the same way. The asymmetric high contrast system scored higher than the conventional system for demonstration of anatomy in both mediastinum and lungs, but no difference emerged between the two systems in the demonstration of pathology. The asymmetric screen-film system showed improved mediastinal and, to a lesser degree, improved lung detail. Further assessment in necessary to define any associated improvement in diagnostic yield.

An assessment of the anticompetitive effects of preferred provider organizations.

Although preferred provider organizations (PPOs) sponsored by third parties are likely to offer benefits to society through increased competition, those sponsored by providers may generate a risk of anticompetitive collusion. Such cartellike collusion could result in price fixing, less aggressive utilization review, and restrictions on entry and innovation in the market. In this article, we provide guidance on the potential risks posed by provider-sponsored PPOs. We suggest that public policy should generally promote PPOs and remove regulatory barriers to their growth because of their cost containment potential. Policy design should, however, reflect an awareness of the potential anticompetitive outcomes of provider-sponsored PPOs and should promote antitrust oversight of their activities.