Enteroviral infection in patients treated with rituximab for non-Hodgkin lymphoma: a case series and review of the literature.

In recent years, anti-CD20 antibodies have been increasingly used to treat lymphoproliferative and immune disorders. Chronic viral infections are infrequently reported in patients receiving these therapies. Enteroviral infection can cause life-threatening meningoencephalitis and other systemic chronic syndromes in immune deficient patients. We describe the clinical courses and outcomes of 6 patients from 2 tertiary care institutions who developed chronic enteroviral infection with neurological manifestations, after combined chemoimmunotherapy with rituximab for B-cell lymphoma. We review the literature that includes 10 sporadic reported cases of chronic enteroviral meningoencephalitis attributed to rituximab therapy. It is a rare disease, and its diagnosis is often elusive. We propose that low immunoglobulin G levels are the main risk factor for developing chronic enteroviral infection and emphasize the need for a high index of suspicion, early diagnosis, and intervention in this iatrogenic and potentially fatal complication.

Live birth sex ratios and father's geographic origins in Jerusalem, 1964-1976.

OBJECTIVE: To examine whether ancestry influenced sex ratios of offspring in a birth cohort before parental antenatal sex selection influenced offspring sex. METHODS: We measured the sex ratio as the percent of males according to countries of birth of paternal and maternal grandfathers in 91,459 live births from 1964 to 1976 in the Jerusalem Perinatal Study. Confidence limits (CI) were computed based on an expected sex ratio of 1.05, which is 51.4% male. RESULTS: Of all live births recorded, 51.4% were male. Relative to Jewish ancestry (51.4% males), significantly more males (1,761) were born to Muslim ancestry (54.5, 95% CI = 52.1-56.8, P = 0.01). Among the former, sex ratios were not significantly associated with paternal or maternal age, education, or offspring's birth order. Consistent with a preference for male offspring, the sex ratio decreased despite increasing numbers of births over the 13-year period. Sex ratios were not affected by maternal or paternal origins in North Africa or Europe. However, the offspring whose paternal grandfathers were born in Western Asia included fewer males than expected (50.7, 50.1-51.3, P = 0.02), whether the father was born abroad (50.7) or in Israel (50.8). This was observed for descendents of paternal grandfathers born in Lebanon (47.6), Turkey (49.9), Yemen & Aden (50.2), Iraq (50.5), Afghanistan (50.5), Syria (50.6), and Cyprus (50.7); but not for those from India (51.5) or Iran (51.9). The West Asian group showed the strongest decline in sex ratios with increasing paternal family size. CONCLUSIONS: A decreased sex ratio associated with ancestry in Western Asia is consistent with reduced ability to bear sons by a subset of Jewish men in the Jerusalem cohort. Lower sex ratios may be because of pregnancy stress, which may be higher in this subgroup. Alternatively, a degrading Y chromosome haplogroup or other genetic or epigenetic differences on male germ lines could affect birth ratios, such as differential exposure to an environmental agent, dietary differences, or stress. Differential stopping behaviors that favor additional pregnancies following the birth of a daughter might exacerbate these lower sex ratios.

Long-term efficacy of Paula method as compared with pelvic floor muscle training for stress urinary incontinence in women: a 6-month follow-up.

PURPOSE: The purpose of this study was to examine the long-term efficacy of an exercise regimen based on circular muscle strengthening (Paula method) as opposed to pelvic floor muscle training (PFMT) on stress urinary incontinence symptoms at 6 months postintervention. SUBJECTS AND SETTING: Of 240 women who had initially participated in a randomized clinical trial, 143 women suffering from stress urinary incontinence participated in this follow-up study. METHODS: Subjects participated in a randomized controlled clinical trial comparing 2 exercise programs (12 private Paula lessons vs 6 group PFMT lessons) over a 12-week period. Of these, 143 women took part in the follow-up study: 64 from the Paula group and 79 from the PFMT group. Six-month follow-up data were gathered via telephone interviews. RESULTS: No significant deterioration in stress urinary incontinence symptoms occurred 6 months after completion of the interventions in either group. We found a statistically significant difference between the groups with regard to reported frequency of urinary leakage; 25 of subjects (39.7%) allocated to the Paula method reported a low frequency rate of incontinence episodes upon completion of the study as compared to 18 (22.8%) in the PFMT group (P = .03). Forty-nine of the 64 women in the Paula group (76.6%) and 62 of the 79 women in the PFMT group (78.5%) reported that they continued exercising 6 months after completion of the trial (P = .8). CONCLUSIONS: Both intervention methods reduced frequency of urinary incontinence over a 6-month period. Long-term adherence was similar in both groups. Pelvic floor muscle training was associated with fewer sessions and decreased cost and fewer lessons needed as compared with the Paula method. Nevertheless, results also suggest that the Paula method achieves a lower frequency of urinary leakage than PFMT.

Concordance between one-hour pad test and subjective assessment of stress incontinence.

OBJECTIVES: To examine the concordance among the 1-hour pad test results, subjective questions regarding incontinence, and a quality-of-life questionnaire to assess the role of the pad test as a noninvasive measurement tool in clinical trials. The 1-hour nonstandard pad test is one of several quantitative tools used to measure urinary incontinence; however, its utility has been questioned. METHODS: The study subjects were women participating in 2 clinical trials evaluating noninvasive interventions: circular muscle exercises versus pelvic floor muscle training for urinary incontinence. The quantity of urinary leakage according to the pad test and questions regarding subjective urinary leakage from the quality-of-life questionnaire were evaluated for all study subjects combined and in subgroups. RESULTS: A total of 731 clinical pad tests were evaluated from the 2 trials. Significant associations were found between several questions regarding subjective leakage and the pad test results in the study subgroups. A significant correlation was seen between the pad test results and the quality-of-life questionnaire scores (r = 0.14 before intervention and r = 0.42 after intervention in the combined studies; P < .05). CONCLUSIONS: The 1-hour pad test demonstrated concordance with subjective assessment tools for urinary incontinence and should be considered a part of the armamentarium for assessing the severity of this condition.

Risk factors for central venous catheter thrombotic complications in children and adolescents with cancer.

BACKGROUND: The use of central venous catheters (CVCs) has greatly improved the quality of care in children with cancer, yet these catheters may cause serious infectious and thrombotic complications. The aim of this prospective registry study was to assess the host and CVC-related risk factors for CVC-created thrombotic complications. METHODS: Patients undergoing CVC insertion for chemotherapy were followed prospectively for CVC complications. At the time of enrollment, demographic, clinical, and CVC-related data, and family history of thrombosis were collected. Survival and Cox regression analyses were performed. RESULTS: A total of 423 CVCs were inserted into 262 patients for a total of 76,540 catheter days. The incidence of CVC-related deep-vein thrombosis (DVT) was 0.13 per 1000 catheter-days (95% confidence interval [CI], 0.06-0.24). Insertion of peripherally inserted central catheters (PICCs) and insertion in an angiography suite significantly increased the risk of symptomatic CVC-related DVT. The incidence of CVC occlusion was 1.35 per 1000 catheter-days (95% CI, 1.1-1.63). Positive family history of thrombosis significantly increased the risk of CVC occlusion (hazard ratio [HR], 2.16; 95% CI, 1.2-3.8). The CVC-related risk factors were insertion of Hickman catheters, insertion in angiography suite, and proximal-tip location. Patients developing at least 1 episode of both CVC occlusion and infection had an increased risk for developing symptomatic CVC-related DVT (HR, 4.15; 95% CI, 1.2-14.4). CONCLUSIONS: Both patient-related and CVC-related factors are associated with higher risk of symptomatic thrombotic complications. These risk factors could be used in the clinical setting and in developing future studies for CVC thromboprophylaxis.

Randomized trial of circular muscle versus pelvic floor training for stress urinary incontinence in women.

BACKGROUND: Conservative management, such as pelvic floor muscle training (PMFT), is commonly recommended as first-line therapy for women with stress urinary incontinence (SUI). METHODS: We randomly assigned 245 women with SUI to 12 weeks of circular muscle exercises (Paula method) or PMFT in order to assess whether these approaches are equivalent. End points after 12 weeks included urinary leak as measured by a 1-hour pad test, subjective assessment of incontinence, and quality of life (QOL). Cure was defined as urinary leakage of <1 g. RESULTS: The mean decrease in urinary leakage was 7.9 g (SD 12.1) among women in the Paula group and 8.9 g (SD 18.2) in the PFMT group (90% confidence interval [CI] of between-group difference was -4.68 g to 3.0 g). This did not meet the prespecified criterion for equivalence. There were 15.2% (p = 0.04) more cures in those randomized to the Paula method. Improvement in subjective urinary complaints and QOL was observed in both groups. The study was limited by a dropout rate of 26.6%. CONCLUSIONS: Both methods are efficacious in women with SUI. The results suggest superiority of the Paula method in terms of cure rate.

Cancer risk after exposure to treatments for ovulation induction.

Uncertainty continues as to whether treatments for ovulation induction are associated with increased risk of cancer. The authors conducted a long-term population-based historical cohort study of parous women. A total of 15,030 women in the Jerusalem Perinatal Study who gave birth in 1974-1976 participated in a postpartum survey. Cancer incidence through 2004 was analyzed using Cox's proportional hazards models, controlling for age and other covariates. Women who used drugs to induce ovulation (n = 567) had increased risks of cancer at any site (multivariate hazard ratio (HR) = 1.36, 95% confidence interval (CI): 1.06, 1.74). An increased risk of uterine cancer was found among women treated with ovulation-inducing agents (HR = 3.39, 95% CI: 1.28, 8.97), specifically clomiphene (HR = 4.56, 95% CI: 1.56, 13.34). No association was noted between use of ovulation-inducing agents and ovarian cancer (age-adjusted HR = 0.61, 95% CI: 0.08, 4.42). Ovulation induction was associated with a borderline-significant increased risk of breast cancer (multivariate HR = 1.42, 95% CI: 0.99, 2.05). Increased risks were also observed for malignant melanoma and non-Hodgkin lymphoma. These associations appeared stronger among women who waited more than 1 year to conceive. Additional follow-up studies assessing these associations by drug type, dosage, and duration are needed.

Consanguinity and birth defects in the jerusalem perinatal study cohort.

BACKGROUND: While parental consanguinity is known to increase the risk of birth defects in offspring, it is hard to quantify this risk in populations where consanguinity is prevalent. METHODS: To support ongoing studies of cancer and of psychiatric disease, we studied relationships of consanguinity to 1,053 major birth defects in 29,815 offspring, born in 1964-1976. To adjust for confounding variables (geographic origin, social class and hospital), we constructed logistic regression models, using GEE to take into account correlations between sibs. Odds ratios (ORs) and 95% confidence limits were estimated in comparison to a reference group of offspring with grandfathers born in different countries. RESULTS: With 10.1% of offspring having consanguineous parents, the adjusted OR for major birth defect was 1.41 (1.12-1.74). Offspring of marriages between uncles-nieces, first cousins and more distant relatives showed adjusted ORs of 2.36 (0.98-5.68), 1.59 (1.22-2.07) and 1.20 (0.89-1.59) respectively. For descendents of grandfathers born in the same country, but not known to be related, the OR was 1.05 (0.91-1.21); these showed increased risk associated with ancestries in Western Asia (1.27, 1.04-1.55, p < 0.02) or Europe (1.13, 0.79-1.80). CONCLUSIONS: A strong association of consanguinity with poverty and low education points to the need to avoid exposure to environmental hazards in these families.

Gestational diabetes and the risk of breast cancer among women in the Jerusalem Perinatal Study.

Gestational diabetes is becoming increasingly common; it is important to determine how it relates to future risk of disease. We investigated the relation of gestational diabetes to breast cancer in 37,926 women who had one or more live births in 1964-1976 for whom information had been collected on complications of pregnancy. In this cohort there were 1,626 cases of breast cancer reported to the Israel Cancer Registry before January 1, 2005 and 410 cases of gestational diabetes recorded from birth records. There were 29 cases of breast cancer among women diagnosed with gestational diabetes. Using Cox proportional hazards models to control for age and birth order at the first observed birth and other characteristics, we found that the incidence of breast cancer was increased among women diagnosed with gestational diabetes (relative rate = 1.5, 95% confidence interval 1.0-2.1). This effect was seen only among women 50 years and older (relative rate 1.7, 95% confidence interval 1.1-2.5) but not among women <50 (relative rate = 1.0, 95% confidence interval 0.5-2.1). The findings suggest that gestational diabetes may be an important early marker of breast cancer risk among post-menopausal women, but these results need to be confirmed in future studies.

Gestational diabetes as a risk factor for pancreatic cancer: a prospective cohort study.

BACKGROUND: Diabetes is known to be associated with cancer of the pancreas, though there is some debate as to whether it is a cause or a consequence of the disease. We investigated the incidence of pancreatic cancer in a cohort of 37926 Israeli women followed for 28-40 years for whom information on diabetes had been collected at the time they gave birth, in 1964-1976, in Jerusalem. There were 54 cases of pancreatic cancer ascertained from the Israel Cancer Registry during follow-up. METHODS: We used Cox proportional hazards models to adjust for age at baseline and explore effects of other risk factors, including ethnic groups, preeclampsia, birth order and birth weight of offspring. RESULTS: We observed no cases of pancreatic cancer in the women with insulin dependent diabetes; however, there were five cases in the women with gestational diabetes. The interval between the record of diabetes in pregnancy and the diagnosis of pancreatic cancer ranged from 14-35 years. Women with a history of gestational diabetes showed a relative risk of pancreatic cancer of 7.1 (95% confidence interval, 2.8-18.0). CONCLUSION: We conclude that gestational diabetes is strongly related to the risk of cancer of the pancreas in women in this population, and that gestational diabetes can precede cancer diagnosis by many years.

Late fetal death in offspring and subsequent incidence of prostate cancer in fathers: the Jerusalem Perinatal Study cohort.

BACKGROUND: Little is known of the causes of prostate cancer and few previous studies have investigated men's reproductive histories in relation to this disease. We sought to determine whether risk of prostate cancer was altered in men who had fathered stillborn offspring. METHODS: We studied the incidence of prostate cancer (N = 252) in a cohort of 15,268 fathers followed for 28-41 years from the birth of a live offspring, whose wives participated in one of two separate surveys of outcomes of previous births. Proportional hazards models were used to estimate relative risks (RR) associated with previous stillbirths, controlling for changes in incidence over time, social and occupational factors. RESULTS: The 543 men with one or more stillborn offspring experienced an increased risk of prostate cancer (adjusted RR = 1.87, 95% confidence interval = 1.17-3.00, P = 0.0095), compared to men without stillbirths. With one reported stillbirth, the RR was 1.68 (0.99-2.84); with two or more, the RR was 3.29 (1.22-8.88). Results were consistent in men whose wives were interviewed in 1965-1968 and 1974-1976. In 100 fathers with no male offspring and at least one stillbirth the RR was 4.04 (1.87-8.71, P = 0.0004). CONCLUSIONS: These findings should be considered hypothesis-generating and require confirmation in other studies. They suggest that stillbirth and prostate cancer may have shared environmental causes; alternatively, genetic susceptibility to prostate cancer might increase the risk of a stillbirth in offspring.

Paternal age and spontaneous abortion.

OBJECTIVE: To evaluate the influence of paternal age upon spontaneous abortion. METHODS: This case-control study of 13,865 women draws on data from women's antenatal or postpartum interviews in the Jerusalem Perinatal Study, a population-based cohort derived from 92,408 births in 1964-1976. Case women (n=1,506) reported spontaneous abortion in the pregnancy preceding the interview; they were compared with women reporting live births in their previous pregnancy (n=12,359). Logistic regression was used to adjust for maternal age, maternal diabetes, maternal smoking, history of spontaneous abortions before the index pregnancy, parity at interview, and interval between the index pregnancy and the interview. RESULTS: The adjusted odds ratio for spontaneous abortion was 0.59 (95% confidence interval 0.45-0.76, P< .0001) for pregnancies conceived from fathers aged younger than 25 years compared with those from fathers aged 25-29 years. For fathers age 40 years or older the odds ratio for spontaneous abortion was 1.6 (95% confidence interval 1.2-2.0, P=.0003) when compared with the same reference group. CONCLUSION: Increasing paternal age is significantly associated with spontaneous abortion, independent of maternal age and multiple other factors.

Risk factors for pre-eclampsia in nulliparous and parous women: the Jerusalem perinatal study.

Pre-eclampsia has been described as a 'disease of first pregnancies' and many believe that its occurrence in a later pregnancy signals a fundamentally different entity. We sought to compare risk factors in first and subsequent pregnancies. We studied 1319 cases of pre-eclampsia recorded in a historical cohort of 82,436 deliveries in Jerusalem in 1964-76. Logistic regression was used to control for covariates. The adjusted odds ratio (OR) for pre-eclampsia in first births was 2.58 (95% confidence interval[CI] 2.23, 2.97), compared with all later birth order groups, between which there were no detectable differences in risk. Other risk factors included increasing maternal age, diabetes (OR 5.64, 95% CI 4.33, 7.35), multiple gestations (OR 3.38, 95% CI 2.54, 4.49), fetal haemolytic disease (OR 2.24, 95% CI 1.43, 3.50) and lower maternal education. The risk of pre-eclampsia was not associated with the mother's employment outside the home and did not differ between immigrants vs. Israeli-born mothers or between groups of women whose fathers had been born in Western Asia, North Africa or Europe. Effects of each risk factor were similar within first and subsequent births. These results lend no support to the hypothesis that there is a fundamental difference between pre-eclampsia in a first pregnancy compared with that occurring in a later pregnancy; conclusions may be moderated, however, by the knowledge that the incidence of pre-eclampsia was low in this historical cohort.

Central nervous system involvement in indolent lymphomas.

BACKGROUND: Central nervous system (CNS) involvement, a well-recognized complication of aggressive non-Hodgkin's lymphomas (NHL), has rarely been reported in indolent lymphomas. Large series have reported this complication in 3% of indolent NHLs, generally following histological transformation. PATIENTS AND METHODS: We retrospectively reviewed the disease characteristics and clinical course in seven patients (six females, one male) with indolent B-cell lymphomas who developed CNS involvement during various stages of their illness. RESULTS: The median ages at diagnosis of systemic and CNS lymphoma were 60 and 63 years, respectively. Histologies were: small lymphocytic lymphoma (two), follicular lymphoma grade I (two), follicular lymphoma grade II (two) and unclear low-grade histology (one). There were diverse neurological symptoms. Two patients had parenchymal involvement, three had leptomeningial involvement and two had both. Systemic lymphoma was found in all patients, all but one having bone marrow involvement. Four patients had a transformation to high-grade histology. Six patients were treated with systemic and intra-cerebrospinal fluid chemotherapy, and two received radiotherapy as well. Five patients achieved CNS response. Survival was 1-9 years for treated patients (median 2 years). Three patients died of CNS disease. CONCLUSIONS: CNS involvement is a rare and unexpected complication of indolent NHL, which should be considered in the differential diagnosis of patients presenting with new neurological signs. This condition is treatable and some patients have a long clinical course.

Paula method of circular muscle exercises for urinary stress incontinence--a clinical trial.

The aim of this study was to determine the efficacy of the Paula method of circular muscle training in the management of stress incontinence (SI). The theory behind this method states that activity of distant sphincters affects other muscles. In a pilot study, 59 women, mainly hospital employees, were randomly assigned to participate in exercises according to the Paula method or pelvic floor training. Efficacy was measured by reports of incontinence, quality of life (I-QOL), pad test, and pelvic floor muscle strength (assessed by perineometer and digital examination). Both the Paula exercises and pelvic floor training produced significant changes in urinary leakage compared to baseline as measured by the pad test [mean decrease of 5.4 g (p=0.002) and 9.5 g (p=0.003), respectively]. Women randomized to the Paula method reported improvement in I-QOL scores. The Paula method was found to be efficacious for SI in a population of Israeli women. Larger community-based studies will be required to confirm these results and enable evaluation of between-group differences.

Use of tranquilizers and sleeping pills among cancer patients is associated with a poorer quality of life.

PURPOSE: To evaluate the association between sleeping pill/tranquilizer (SP/T) use and quality of life (QOL) among cancer patients. PATIENTS AND METHODS: Oncology patients (n = 909) in three Israeli hospitals were interviewed in clinics, day centers and in-patient departments regarding SP/T use in the previous week. Crude and adjusted QOL scores, measured using the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire-C30 (EORTC QLQ-C30), were compared in users vs. non-users. RESULTS: Sleeping pill/tranquilizer use was self-reported by 234 (25.7%) participants, but rarely documented in medical charts. Factors associated with SP/T use were female gender (adjusted Odds ratio, OR: 1.79; 95% Confidence interval, CI: 1.22-2.62, age (OR: 4.6; 95% CI: 1.66-12.53 for age 70+), place of birth (OR: 1.97; 95% CI: 1.19-3.26 for Eastern Europe compared with Israel), concomitant use of painkillers (OR: 2.88; 95% CI: 1.97-4.20) and presence of cardiovascular disease (OR: 2.41; 95% CI: 1.48-3.91). Controlling these factors as well as disease status, users had a poorer QOL on all functional scales (p < 0.001) as well as global QOL. Furthermore, users reported increased severity of symptoms, especially fatigue, insomnia, pain, dyspnea and constipation (p < 0.01), compared to non-users. CONCLUSIONS: Use of SP/T, reported by one fourth of cancer patients, was associated with substantially poorer QOL and increased severity of symptoms. Causal inference is not possible given the cross-sectional design. Periodic inquiry regarding use of these medications in the Oncology Clinic is recommended since it may identify patients with poor QOL and unmet needs.

Birthweight and relationship with infant, child and adult mortality in the Jerusalem perinatal study.

There is growing evidence that several chronic adult diseases, such as coronary heart disease and stroke, can result from events occurring in fetal life. The aim of this study was to examine the relation between birthweight and all-cause mortality in young adults. We studied total mortality in a population-based cohort of 80 936 offspring born in Jerusalem in 1964-76. During an average follow-up of 28.8 years 2 324 984 person-years were contributed and 2092 deaths occurred. Overall, in both genders, the univariable and the multivariable Cox-proportional hazard models indicated a strong negative relationship between birthweight and total mortality, mostly because of infant deaths. At ages 1-14 birthweight seemed unrelated to all-cause mortality. In males aged 15+, birthweight was again a significant predictor of death (Hazard ratio (HR) = 0.88, 95% confidence interval (CI) [0.78, 0.99], for 1 standard deviation (SD) increase in birthweight). The analysis by categories suggested a general decreasing of the risk of mortality with increasing birthweight (HRs = 1.0, 1.02, 0.85, 0.77, 0.57 for those belonging to birthweight groups of < 2500 g, 2500-2999 g, 3000-3499 g, 3500-3999 g and > or = 4000 g, respectively). In females aged 15+ there was a J-shaped relation between birthweight and mortality but these associations were not statistically significant. These findings add to a growing body of evidence that events during intrauterine life have remote consequences for adult health and underline the need to consider gender differences.

Probabilistic reasoning and clinical decision-making: do doctors overestimate diagnostic probabilities?

BACKGROUND: The "threshold approach" is based on a physician's assessment of the likelihood of a disease expressed as a probability. The use of Bayes' theorem to calculate disease probability in patients with and without a particular characteristic, may be hampered by the presence of subadditivity (i.e. the sum of probabilities concerning a single case scenario exceeding 100%). AIM: To assess the presence of subadditivity in physicians' estimations of probabilities and the degree of concordance among doctors in their probability assessments. DESIGN: Prospective questionnaire. METHODS: Residents and trained physicians in Family Medicine, Internal Medicine and Cardiology (n = 84) were asked to estimate the probability of each component of the differential diagnosis in a case scenario describing a patient with chest pain. RESULTS: Subadditivity was exhibited in 65% of the participants. The total sum of probabilities given by each participant ranged from 44% to 290% (mean 137%). There was wide variability in the assignment of probabilities for each diagnostic possibility (SD 16-21%). DISCUSSION: The finding of substantial subadditivity, coupled with the marked discordance in probability estimates, questions the applicability of the threshold approach. Physicians need guidance, explicit tools and formal training in probability estimation to optimize the use of this approach in clinical practice.

Clinical utility of computed tomography-guided core needle biopsy in the diagnostic re-evaluation of patients with lymphoproliferative disorders and suspected disease progression.

BACKGROUND: Histological transformation is a common clinical event in patients with lymphoproliferative diseases, often requiring a modification in therapy. Minimally invasive biopsy techniques have been used for initial diagnosis of these disorders but their role has not been systematically evaluated in disease progression. The purpose of this study was to evaluate the yield of computed tomography (CT)-guided core needle biopsy in patients with lymphoproliferative disorders and suspected disease progression. PATIENTS AND METHODS: We performed a retrospective analysis of the records of patients with known lymphoproliferative disorders who underwent CT-guided core needle biopsy during the course of their disease, between 1990 and 2002. RESULTS: A total of 130 patients with lymphoproliferative disorders (91 patients with non-Hodgkin's lymphoma, 21 with Hodgkin's disease, 10 with chronic lymphocytic leukemia, six with combined malignancies and two with Castleman's disease) underwent CT-guided core needle biopsy 4.7 +/- 5.1 (standard deviation) (range 0-40) years after initial diagnosis. The procedure was diagnostic in 98 cases (75.4%). In 22 patients (17%) a subsequent open biopsy was performed, and in 10 (7.6%) the final diagnosis remained unconfirmed. Histological transformation was found in 20 cases (15.4%), of which 19 were suspected clinically. A new diagnosis (malignant and non-malignant) was apparent in 18 cases (13.9%) and relapsed or ongoing evidence of the original disease was found in 82 (63%). CONCLUSIONS: CT-guided core needle biopsy is a reliable procedure in patients with suspected histological transformation of lymphoproliferative disorders, and should be used as the initial tool for pathological re-evaluation.

Chest radiographs in the emergency department: is the radiologist really necessary?

BACKGROUND: The chest radiograph is considered one of the most complex imaging modalities to interpret. Several studies have evaluated radiograph interpretation in the emergency department, and considerable disagreement among clinical physicians and expert radiologists has been observed in the reading of chest films. The interpretation of chest radiographs by emergency department physicians was compared with senior radiologists in discharged patients, and misinterpretations assessed in relation to the physician's level of training. METHODS: Radiological descriptions of 509 chest radiographs of 507 patients, aged 16-98 years who were discharged from the emergency department, were prospectively reviewed. Missed findings were recorded with regard to the physician's level of training and experience. The effects of misinterpretations on discharge recommendations were also investigated. Statistical assessment was conducted using the chi(2) test. Interobserver agreement was also tested by the kappa coefficient. RESULTS: The sensitivity for detecting different abnormalities in the radiographs ranged from 20% to 64.9% and specificity from 94.9% to 98.7%. Despite the low sensitivities found, there were relatively few clinical implications of the "missed" findings since they were either of a minor nature or appropriate follow up was prescribed. The overall interobserver reliability, assessed by the kappa coefficient, was 0.40 (95% confidence interval 0.35 to 0.46). These findings did not change significantly by emergency department physician's level of training. CONCLUSIONS: Emergency department physicians frequently miss specific radiographic abnormalities and there is considerable discrepancy between their interpretations and those of trained radiologists. These findings highlight the importance of routine evaluation of chest radiographs by a well trained radiologist and emphasise the need for improving interpretive skills among emergency department physicians.