Observer variation in detecting the radiologic features associated with bronchiolitis

Chest radiographs are commonly obtained to assess children for bronchiolitis, both to corroborate the diagnosis and to exclude other diagnostic possibilities. Their utility in this setting has not previously been examined. Using a blinded, randomized study design, we examined the interobserver and intraobserver variation in the detection of the radiologic features of bronchiolitis from the chest radiograph using "weighted kappa" statistics. This observer variation was compared with that found by other authors for other diagnoses. We also determined the reported presence of these radiologic features in radiographs from patients with bronchiolitis as compared with normal controls. Our study showed acceptable interobserver (kappa = 0.40-0.66) and intraobserver agreement (kappa = 0.50-0.78) on the radiologic features of bronchiolitis relative to other diagnoses. We demonstrated a higher reported presence of these accepted radiologic features in patients with bronchiolitis as compared to controls. Although kappa statistics are widely used in studies of observer variation, "weighted kappa" has received little attention in the radiologic literature. This statistical analysis allows observers to equivocate on the presence or absence of a feature and therefore allows the format of observer variation studies to simulate more closely the normal clinical setting.     

Digitized impressions: myth and daily reality

The digitizing of impressions, or models made from them, opens, in the same way that digitized 3D X-rays did, new horizons for practitioners in the management for their offices, in their interactions with patients, and in their shared work with dental laboratories. Mastery of digitized models improves the efficiency and reinforces the quality of dental treatment through the new perspectives digital analyses provide. Finally the maintenance of records is greatly simplified in far less space while still respecting all pertinent legal requirements, thus assuring total suitability for all current regulations.     

Impact of second opinion pathology in the definitive management of patients with bladder carcinoma

BACKGROUND: The accurate diagnosis, staging, and grading of bladder neoplasms depend heavily on the interpretation of biopsies and transurethral resection (TUR) specimens. Although many centers require review of outside pathologic material before definitive treatment such as radical cystectomy, the authors are unaware of data supporting the utility of this approach in urothelial (transitional cell) carcinoma. The authors therefore examined the clinical and cost impact of pathologic review on patients referred to an academic urology department for treatment of bladder neoplasia. METHODS: The pathologic material from 97 patients referred to an academic center for evaluation of urothelial carcinoma of the bladder from July 1996 to July 1999 was reviewed. This material was received from 30 community hospitals and 4 academic centers. The 97 patients had undergone 131 (mean, 1.35; range, 1-10) biopsies or TUR procedures before referral. Surgical pathologists at the authors' institution reviewed all outside patient material, and discordant cases were rereviewed by one of the authors (S.E.M), an experienced genitourinary pathologist. Follow-up chart review was performed in discordant cases to determine clinical and pathologic outcomes. RESULTS: Upon review at the authors' institution, 24 of 131 (18%) specimens with a referring diagnosis of urothelial carcinoma exhibited significant discrepancies with regard to the diagnosis, stage, grade, or tumor histologic type made at the outside institution. Four tumors (3%) were found to be nonurothelial neoplasms. Five specimens (4%) were judged inadequate for staging because they contained no muscularis propria. Three patients were upstaged, including two patients shown to have muscle invasive disease. Eight patients were downstaged, including two patients referred with purported muscle invasive disease who were determined to have only superficial disease on pathology review. Two patients initially thought to have carcinoma in situ (tumor in situ [Tis]) showed no evidence of Tis on pathology review. One patient with purported muscle invasive disease was shown to have only metaplasia, and one patient had a highly significant change in tumor grade. As a result of the pathology review, five radical cystectomies were avoided, whereas five repeat TUR procedures were recommended for inadequate staging. One patient shown to have muscle invasion on pathology review proceeded directly to cystectomy, avoiding a planned repeat TUR. A cystectomy also was recommended to a second patient who was shown to have invasive disease by the pathology review. Pathology review of 131 specimens resulted in net savings of $86,176 or $658 per TUR reviewed. CONCLUSIONS: The review of bladder pathologic materials before definitive therapy can impact clinical decisions significantly and can reduce overall expenditures for the management of this cohort of bladder carcinoma patients.     

Anatomical distribution of vertebral fractures: comparison of pediatric and adult spines

Summary

We compared the distribution of vertebral fractures in adults and children and found that fractures occurred in different locations in the two age groups. This likely relates to the different shape of the immature spine.

Introduction

We hypothesized that the anatomical distribution of vertebral fractures (VF) would be different in children compared to adults.

Methods

We compared the distribution of VF defined using the Genant semi-quantitative method (GSQ method) in adults (N?=?221; 545 fractures) and in children early in the course of glucocorticoid therapy (N?=?44; 94 fractures).

Results

The average age in the adult cohort was 62.9?years (standard deviation (SD), 13.4?years), 26% was male, the mean lumbar spine Z-score was ?1.0 (SD, 1.5), and the corresponding T-score was ?2.4 (SD, 1.4). The pediatric cohort median age was 7.7?years (range, 2.1–16.6?years), the mean lumbar spine Z-score was ?1.7 (SD, 1.5), 52% was male, and disease categories were acute lymphoblastic leukemia (66%), rheumatological conditions (21%), and nephrotic syndrome (14%). The VF distribution was biphasic in both populations, but the peaks differed in location. In adults, the peaks were at T7/T8 and at T12/L1. In children, the focus was higher in the thoracic spine, at T6/T7, and lower in the lumbar spine, at L1/L2. When children were assessed in two age-defined sub-groups, a biphasic VF distribution was seen in both, but the upward shift of the thoracic focus to T6 was observed only in the older group, with the highest rates of fracture present between ages 7 and 10?years.

Conclusions

These results suggest that the anatomical distribution of VF differs between children and adults, perhaps relating to the different shape of the immature spine, notably the changing ratio of kyphosis to lordosis.     

The musculoskeletal manifestations of cystic fibrosis

Twenty-seven patients with CF and joint complaints were reviewed. Twelve patients had arthritis, 11 had HPO, and four had symptoms of mechanical neck and back pain. We have confirmed the association of CF with an episodic form of arthritis. For the first time, we have reported that a subgroup of these patients later develop persistent synovitis with progressive asymmetric, erosive disease. The etiology of CF arthritis is unclear, but may relate to chronic infection and immune complex mechanisms. CF arthritis can be contrasted with CF induced HPO, which is associated with worse lung disease, a male predominance, and an older mean age of onset of symptoms. Mechanical neck and back pain may relate to an associated scoliosis or kyphosis in CF.     

Hypomorphic PCNA mutation underlies a human DNA repair disorder

Numerous human disorders, including Cockayne syndrome, UV-sensitive syndrome, xeroderma pigmentosum, and trichothiodystrophy, result from the mutation of genes encoding molecules important for nucleotide excision repair. Here, we describe a syndrome in which the cardinal clinical features include short stature, hearing loss, premature aging, telangiectasia, neurodegeneration, and photosensitivity, resulting from a homozygous missense (p.Ser228Ile) sequence alteration of the proliferating cell nuclear antigen (PCNA). PCNA is a highly conserved sliding clamp protein essential for DNA replication and repair. Due to this fundamental role, mutations in PCNA that profoundly impair protein function would be incompatible with life. Interestingly, while the p.Ser228Ile alteration appeared to have no effect on protein levels or DNA replication, patient cells exhibited marked abnormalities in response to UV irradiation, displaying substantial reductions in both UV survival and RNA synthesis recovery. The p.Ser228Ile change also profoundly altered PCNA’s interaction with Flap endonuclease 1 and DNA Ligase 1, DNA metabolism enzymes. Together, our findings detail a mutation of PCNA in humans associated with a neurodegenerative phenotype, displaying clinical and molecular features common to other DNA repair disorders, which we showed to be attributable to a hypomorphic amino acid alteration.     

Metastatic basal cell carcinoma: a review of the literature and report of two cases

A total of 95 cases of metastasizing basal cell carcinomas have been recorded in the literature with 20 of these metastatic to bone. Two additional cases of metastasizing basal cell carcinoma with osseous metastases are presented, with a review of the literature.     

Fungal microabscesses in immuno-suppressed patients--CT appearances

Disseminated fungal infections in leukemic patients treated with cytotoxic drugs are an increasing problem. Confirmation of such infection either by clinical or laboratory examination can be extremely difficult. The findings in four such patients, using computed tomography, are described here. The presence of small non-enhancing lesions in the liver, spleen, or kidney in such patients is strongly suggestive of deep-seated fungal infections.