Time Of Workup Research Articles

Modern CT diagnosis of acute thoracic and abdominal trauma

To evaluate a modified algorithm in the diagnostic management of polytraumatized patients by using whole body multislice CT (MSCT) as primary diagnostic tool. Between June 1999 and October 2000 532 polytraumatized patients were referred to the emergency department. 336 polytraumatized patients were primarily evaluated using whole body MSCT according to the "Innsbruck Emergency Algorithm." MSCT is performed immediately after cardiovascular stabilization of the patient. During the initial stabilization period free intraabdominal fluid is excluded or demonstrated by abdominal ultrasound. Time-consuming conventional radiographs are omitted with exception of an optimal chest X-ray. In patients with suspected or obvious arterial injuries or fractures the multislice-CT-dataset is used to perform 2D and 3D reconstructions in order to optimize visualization of additional skeletal and vascular injuries. By means of whole body MSCT it was possible to detect all injuries. The diagnostic advantage of whole body MSCT as compared to conventional X-ray was analyzed in 111 consecutive polytraumatized patients with an injury severity score (ISS) of 34.77. The early use of MSCT shortened the time for diagnostic work-up substantially (approximately 50%). Whole body multislice-CT used as primary diagnostic tool in the management of polytraumatized patients allows for a fast, accurate and comprehensive diagnostic work-up.

Peripheral Paraneoplastic Neuropathy, an Uncommon Clinical Onset of Sigmoid Cancer. Case Report and Review of the Literature

A case of a 76-year-old man presenting with weakness of the lower legs and bilateral steppage gait is described. Neurological examination revealed a sensorimotor neuropathy with axonopathy and myelinic aspects. At the time of the diagnostic workup an episode of rectal bleeding occurred. Colonoscopy demonstrated an exophytic cancer of the sigmoid colon at 40 cm from the anal verge. At surgery the tumor adhered to the ileum, so a left hemicolectomy and ileo-ileal resection were performed. Tumor stage was Dukes' B, Jass III, Astler-Coller B2, T3N0M0. The patient underwent postoperative chemotherapy and was followed for the past three years. At present he is free of disease and the neuropathy has completely regressed without any dedicated therapy. As reported in the literature the appearance of a paraneoplastic neurological syndrome (PNS) may be the first sign of a malignancy that is occult at the time of clinical presentation. The most widely supported theory about its etiology is that of an autoimmune origin. The paraneoplastic neurological syndrome is considered to be at a point of intersection between tumor immunology, autoimmune neurological disease, and basic neurobiology. Previous experience has resulted in a pathogenic model and in a definition of a group of autoantibodies related to the disease. Small cell lung cancer (SCLC) is the neoplasm most frequently associated with PNS; other malignancies include lymphomas and various hematological malignancies. Some authors reported also that the percentage of patients with a high titer of neuronal autoantibodies is small and several of the autoantibodies are present at low levels without any accompanying clinical manifestation. In a clinical retrospective study of the Mayo Clinic Group 115,081 patients were examined over the period 1984-1993 and only 58 patients (0.05%) could be defined as being affected by a paraneoplastic neurological syndrome. Only five of these patients had colon tumors. The number of patients is so small and so widely scattered among publications that no statistical analysis is possible. Probably the only possibility for early identification of such a syndrome is a high degree of suspicion. In fact, these patients are usually first admitted and studied in a neurological unit, and the diagnosis of a tumor-associated disease is a delayed event.

Liver transplantation in patients with previous portasystemic shunt

Liver transplantation in patients with previous portasystemic shunt

Initial Traumatic LP Adversely Affects Outcome in ALL

Hematology-Oncology| March 01 2001 Initial Traumatic LP Adversely Affects Outcome in ALL AAP Grand Rounds (2001) 5 (3): 24. https://doi.org/10.1542/gr.5-3-24 Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Peer Review Share Icon Share Twitter LinkedIn Tools Icon Tools Get Permissions Cite Icon Cite Search Site Citation Initial Traumatic LP Adversely Affects Outcome in ALL. AAP Grand Rounds March 2001; 5 (3): 24. https://doi.org/10.1542/gr.5-3-24 Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search toolbar search search input Search input auto suggest filter your search All PublicationsAll JournalsAAP Grand RoundsPediatricsHospital PediatricsPediatrics In ReviewNeoReviewsAAP NewsAll AAP Sites Search Advanced Search Topics: blast cells, cerebrospinal fluid, leukemia, lipopolysaccharides, traumatic lumbar puncture, treatment outcome, van der woude syndrome, acute lymphocytic leukemia, atypical, central nervous system dysfunction Source: Gajjar A, Harrison PL, Sandlund JT, et al. Traumatic lumbar puncture at diagnosis adversely affects outcome in childhood acute lymphoblastic leukemia. Blood. 2000;96: 3381–3384 This retrospective study was conducted to answer an important, controversial question: does a traumatic lumbar puncture (TLP) at the time of the initial diagnostic work-up and/or induction treatment have any effect on the treatment outcome in children with acute lymphoblastic leukemia (ALL)? The authors reviewed the cerebrospinal fluid (CSF) findings of lumbar punctures (LP) performed in 546 patients enrolled on two consecutive therapeutic trials at St. Jude Children’s Research Hospital, Memphis, Tennessee between 1984 to 1991. All patients underwent 2 LPs, usually within 24–48 hrs of each other at the time of initial diagnostic evaluation and at the beginning of the induction chemotherapy. A complete blood count and examination of a centrifuged and stained CSF cell pellet were performed in all patients. The patients were divided into 5 groups depending on their central nervous system (CNS) status: LP not traumatic with <10 red blood cells (RBCs) per μL in the CNS and no leukemic blast cells (n=336), LP not traumatic with <5 white blood cells (WBCs) per μL and containing leukemic blast cells (n=80), LP not traumatic with ≥5 WBCs per μL and containing leukemic blast cells (n=16), LP traumatic with ≥10 RBCs per μL and no leukemic blast cells (TLP−, n=54), and LP traumatic with leukemic blast cells (TLP+, n=60). There were 26 patients who had 2 consecutive TLPs with blast cells (TLP++). The 5-year event-free survival (EFS± 1 SE) for the 5 groups is shown in the tableT1: The EFS was similar between patients with an atraumatic LP and no blast cells and those who were TLP− (P=.85). The EFS of patients who were TLP+ was worse than that for those who had an atraumatic LP with no blast cells (P=.026) and comparable to those who had an atraumatic LP with <5 WBCs and leukemic blast cells (P=.59). The authors conclude that a TLP during initial diagnostic evaluation and treatment of ALL leads to contamination of the CSF with circulating leukemic blast cells and will adversely affect the treatment outcome of children with ALL. Furthermore, the EFS of patients with 2 TLPs with blast cells (TLP++) was comparable to that of patients with overt CNS disease (≥5 WBCs with blast cells). The definition of CNS leukemia is controversial when the CSF contains a small number of WBCs and blasts are seen on a stained cytospin preparation. Most physicians follow the recommendation of the Rome Leukemia Workshop,1 which characterizes patients who have >5 WBCs μL with identifiable blasts as having CNS involvement. The problem is positively identifying the few “atypical” looking cells as true blasts, thus justifying more intensive CNS directed therapy. This is true even if more specific tests such as determination of surface markers by staining or flow cytometry... You do not currently have access to this content.

Traumatic lumbar puncture at diagnosis adversely affects outcome in childhood acute lymphoblastic leukemia

AbstractThe effect of traumatic lumbar puncture at the time of initial diagnostic workup on treatment outcome in children with newly diagnosed acute lymphoblastic leukemia (ALL) was investigated. The findings of the first 2 lumbar punctures performed on 546 patients with newly diagnosed ALL treated on 2 consecutive front-line studies (1984-1991) at St Jude Children's Research Hospital were retrospectively reviewed. Lumbar punctures were performed at the time of diagnosis and again for the instillation of first intrathecal chemotherapy. The event-free survival (EFS) experience for patients with 1 cerebrospinal fluid (CSF) sample contaminated with blast cells was worse than that for patients with no contaminated CSF samples (P = .026); that of patients with 2 consecutive contaminated CSF samples was particularly poor (5-year EFS = 46 ± 9%). In a Cox multiple regression analysis, the strongest prognostic indicator was 2 consecutive contaminated CSF samples, with a hazard ratio of 2.39 (95% confidence interval, 1.36-4.20). These data indicate that contamination of CSF with circulating leukemic blast cells during diagnostic lumbar puncture can adversely affect the treatment outcome of children with ALL and is an indication to intensify intrathecal therapy.

Traumatic lumbar puncture at diagnosis adversely affects outcome in childhood acute lymphoblastic leukemia

The effect of traumatic lumbar puncture at the time of initial diagnostic workup on treatment outcome in children with newly diagnosed acute lymphoblastic leukemia (ALL) was investigated. The findings of the first 2 lumbar punctures performed on 546 patients with newly diagnosed ALL treated on 2 consecutive front-line studies (1984-1991) at St Jude Children's Research Hospital were retrospectively reviewed. Lumbar punctures were performed at the time of diagnosis and again for the instillation of first intrathecal chemotherapy. The event-free survival (EFS) experience for patients with 1 cerebrospinal fluid (CSF) sample contaminated with blast cells was worse than that for patients with no contaminated CSF samples (P = .026); that of patients with 2 consecutive contaminated CSF samples was particularly poor (5-year EFS = 46 ± 9%). In a Cox multiple regression analysis, the strongest prognostic indicator was 2 consecutive contaminated CSF samples, with a hazard ratio of 2.39 (95% confidence interval, 1.36-4.20). These data indicate that contamination of CSF with circulating leukemic blast cells during diagnostic lumbar puncture can adversely affect the treatment outcome of children with ALL and is an indication to intensify intrathecal therapy.

Premature infants respond to early-onset and late-onset sepsis with leukocyte activation

Objective: Leukocyte differentiation antigens are expressed on the cell membrane during activation. The purpose of this study was to evaluate leukocyte activation in premature neonates with sepsis. Paired blood samples from the same individual while sick and while convalescent were examined to quantify the expression of leukocyte antigens in these clinical states. Methods: Mononuclear blood cells from 21 premature infants (24 to 30 weeks’ gestation) were analyzed. The “sick” samples were drawn at the time of workup for sepsis; “convalescent” samples were drawn 20 days later. Samples were incubated with monoclonal antibodies to the lymphocyte antigens CD3, CD19, CD25, CD26, CD71, and CD69 and neutrophil antigens CD11b, CD11c, CD13, CD15, CD33, and CD66b. The cells were lysed, fixed, and analyzed by flow cytometry. Results: Twenty-one infants enrolled in the study had multiple sepsis evaluations and had more than one sample available for a paired observation. CD33, CD66b, and CD19 levels were significantly elevated in both the presumed sepsis and culture-proven sepsis groups when compared with the samples drawn from those same patients when healthy. Expression of CD33 and expression of CD66b were correlated, and in a multivariate analysis the elevation of antigen expression was predictive of sepsis. Conclusions: Leukocytes from preterm newborn infants respond to infection with an increased expression of CD19, CD33, and CD66b on their cell surfaces. (J Pediatr 2000;137:345-50)

Small bowel bleeding

Most patients with small bowel bleeding present with chronic, recurrent, transfusion-dependent, debilitating disease. Less commonly, an acute gastrointestinal bleeding episode with negative upper and lower endoscopic exams may be the initial presentation. Lesions responsible for small bowel bleeding, on the other hand, include arterio-venous malformations, tumors, and ulcers. The treatment options must therefore be directed to the specific cause of bleeding and its mode of presentation (acute versus chronic; intermittent). Treatment before a specific diagnosis has been reached includes blood transfusions as needed, and chronic iron supplementation. Once the diagnosis of arterio-venous malformations has been made, thermal endoscopic therapy (heater probe, bipolar electrocoagulation, argon plasma coagulation, or laser) with or without injection (epinephrine) is the mainstay treatment option. The same option is available for small bowel ulcers that show stigmata of recent bleeding, eg, a non-bleeding visible vessel or adherent clot, or are actively bleeding at the time of enteroscopy. For the patient with a small bowel tumor thought to be responsible for the bleeding, surgical excision or resection is the treatment of choice. The surgical option is also reserved for those patients with diffuse and multiple lesions, and those with lesions beyond the reach of the push enteroscope, which preclude endoscopic therapy. Invasive radiological methods via selective catheterization and vasopressin injection or embolization are reserved for patients with a demonstrable actively bleeding lesion found at the time of the diagnostic work-up, and those who may not be candidates for surgery. For those patients in whom endoscopic therapy or surgery is not amenable (ie, anatomical location, multiple lesions involving several segments of the small bowel), those who are not surgical candidates and those who have recurrent bleeding after repeat endoscopic or surgical therapies, medical therapy with continuous iron supplementation, avoidance of ulcerogenic drugs (eg, NSAIDs) and hormonal therapy (for those with arteriovenous malformations) should be considered.

Diagnostic Value of Voided Urine and Bladder Barbotage Cytology in Detecting Transitional Cell Carcinoma of the Urinary Tract

In this article we report on our experience with the use of urine cytology for the screening and diagnosis of transitional cell carcinoma (TCC) of the bladder and upper urinary tracts at our institution between January 1987 and December 1995. A total of 76 patients were included in the study. All patients had voided urine cytology studies read as positive or highly suspicious for malignancy and no prior history of TCC of the urinary tract. All these patients subsequently underwent cystoscopy, bladder/ureteral barbotage cytology, random bladder biopsies, and radiographic studies of the upper tracts. Of the 76 patients with positive urine cytology, 53 also had barbotage urine cytologies which were positive. Six of these patients were found to have cystoscopically evident TCC of the bladder, and 1 patient had upper tract TCC. Three other patients subsequently went on to develop TCC of the bladder at 52, 89 and 111 months of follow-up. An additional patient was diagnosed with upper tract TCC at 12 months of follow-up. Among the 23 patients with negative bladder/ureteral barbotage cytology, 3 patients, 2 at the time of initial cystoscopy, and one 15 months later, showed evidence of TCC. Median patient follow-up was 97 (range 35–132) months. Thus of 76 patients with initial positive voided urine cytology studies, only 9 proved to have TCC at initial work-up, while 5 other patients were diagnosed with TCC during a median follow-up of 97 months. The statistical diagnostic values of the bladder/ureteral barbotage urine cytology studies at the time of cystoscopic work-up were: sensitivity 77%; specificity 31%; positive predictive value 13%, and negative predictive value 91%. Our data suggest that in patients without a previous history of TCC, the diagnostic value of bladder barbotage urine cytology is insignificant, and therefore not cost effective to be included as part of the routine work-up of TCC. Moreover, in patients with initially positive voided urine cytology and negative work-up, if the cytology subsequently becomes negative, the likelihood of the development of TCC is low. However, if the initially positive cytology continues to remain positive, there is a much higher probability of TCC being detected in this population.

Computed tomographic angiography as a screening modality for blunt cervical arterial injuries: preliminary results.

The diagnosis of blunt cervical arterial injury (CAI) is made difficult by its infrequent occurrence and delayed presentation. Beginning in January of 1995, we used computed tomographic angiography (CTA) of the neck to screen for CAI. We hypothesized that CTA could be incorporated into the workup of patients sustaining blunt neck injury as a screening modality for CAI and that CTA would increase the early detection of CAI. Retrospective review of all CAI for the years January of 1988 to June of 1997 at a Level I trauma center. CAI diagnosed before introduction of CTA (pre-CTA; January of 1988 to December of 1994) were compared with those after (post-CTA; January of 1995 to June of 1997). The overall incidence of CAI for the entire time period was 0.11%. Motor vehicle crash (53%) was the most common mechanism, with focal neurologic deficit (23%) or seizures (17.6%) the most common presenting clinical symptoms. CTA added only a few additional minutes to the time required for the workup of patients sustaining blunt neck injury in whom CAI was suspected. The incidence of CAI increased from 0.06% pre-CTA to 0.19% post-CTA (p = 0.02; Fisher exact test). CTA was associated with a decrease in mean time to make the diagnosis of CAI (156 hours pre-CTA vs. 5.9 hours post-CTA). In addition, CTA was associated with a decrease in the incidence of permanent neurologic sequelae from CAI (50% pre-CTA vs. 0% post-CTA; p = 0.07; Fisher exact test). We conclude that CTA does not significantly increase the time of the diagnostic workup of the patient with injuries caused by blunt trauma. The introduction of CTA at our institution was associated with an increase in the detection rate of CAI. Earlier detection of CAI may allow for more timely therapeutic intervention and potentially prevent permanent neurologic sequelae.

The ‘Sentinel Node’ Concept: More Questions Raised than Answers Provided?

The ‘Sentinel Node’ Concept: More Questions Raised than Answers Provided?

Simple approach for analysis of plasma oxo-, hydroxy- and dicarboxylic acids.

Following deproteinization of plasma with organic solvents the supernatant was shaken with hexane and cation-exchange resin in an Eppendorf tube to remove fatty and amino acids and the medium was subjected to direct treatment with ethyl chloroformate under catalytic influence of pyridine. A subsequent extraction of the immediately formed ethyl esters with a drop of chloroform enabled us to subject the sample to gas chromatographic (GC) analysis. Since ketocarboxylic acids do not require a preliminary oximation the total time of sample workup and analysis takes only several minutes.

Breaking bad news: realistic versus unrealistic hopes

Hope is an essential aspect of the therapeutic relationship between cancer patients and their carers. Realistic hopes provide considerable support, whereas unrealistic hopes can be destructive by impairing the ability to make appropriate decisions about future plans, treatment, and issues of personal importance. Realistic hopes exist for cancer patients at all stages of their illness. Provision of realistic hope facilities the process of breaking bad news. In this article, the role of hope is explored. Appropriate hopes are identified from the time of pre-diagnostic work-up throughout the phase of definitive treatment and into the transition to palliative and supportive care. A practical approach is developed, which emphasises communication and listening skills, the importance of providing time and the benefits of intermediate goals that facilitate a gradual adjustment in hopes as the disease progresses.

Primary Malignant Lymphoma of the Uterine Cervix: Is Radiotherapy the Best Therapeutic Choice for Stage IE?

The present report describes a 27-year-old woman diagnosed with Ann Arbor stage IE primary malignant lymphoma of the cervix. Radiation therapy was instituted as conventionally advocated at this early stage of the disease. Despite adequate local tumor response, central nervous system metastasis occurred a few months later. She succumbed to her condition 7 months after initial diagnosis. As occult distant foci may not be amenable to detection by available imaging techniques at the time of initial work-up, combination chemotherapy alone or in conjunction with radiation therapy may be the most appropriate first line of therapy in patients with stage IE primary malignant lymphoma of the cervix.

Serum tumour necrosis factor in newborns at risk for infections

Tumour necrosis factor-alpha (TNF-alpha) is an important mediator in the pathogenesis of Gram-negative shock. In order to assess the role of TNF-alpha as a marker of the severity of infections in the neonates, serum TNF-alpha concentrations were determined at the time of septic work-up in 69 newborns (gestational age: 28-40 weeks). Nine patients had systemic infection (group A), four of them with signs of circulatory failure. Eleven patients had positive cultures of gastric aspiration or placental smears (group B) and 49 patients had completely negative septic work-up. Patients of group A had significantly more elevated serum TNF-alpha levels than patients of group B and C. Within group A, patients with circulatory failure had mean serum TNF-alpha concentration of 2165 +/- 817 pg/ml versus 27 +/- 8 pg/ml in newborns without shock. Serum TNF-alpha concentrations of more than 15 pg/ml detected systemic infections in eight out of nine patients. The specificity was 98% (1 elevated TNF-alpha concentration out of 60 non infected patients). These data indicate that premature neonates and term newborns are able to produce TNF-alpha when they are infected. Highly elevated TNF-alpha concentrations are found in severe systemic infections causing cardiovascular impairment.

Peripheral Neuropathy as an Early Marker of AL Amyloidosis

Fifty-one of 146 patients with primary amyloid deposits of light-chain origin (AL) examined between 1972 and 1986 were found to have peripheral neuropathy as part of their systemic amyloidosis. Peripheral neuropathy was the presenting symptom in 11 patients, and it was a later symptom or an incidental physical examination finding at the time of amyloid workup in 40 additional patients. The median duration of time from first symptom to the diagnosis of primary amyloidosis was longer in those whose first symptom was neuropathy (48 months vs 12 months). In addition, survival time after diagnosis for these patients was significantly longer (at least 35 months vs 16 months). Peripheral neuropathy is not an uncommon symptom of primary amyloidosis and may mark the onset of the disease process years before infiltration of vital structures of the heart, kidneys or gastrointestinal tract leads to failure and a subsequent downhill course. Appreciating amyloid disease at this early stage may widen the potential therapeutic window.

Is routine triple endoscopy cost-effective in head and neck cancer?

The multicentric occurrence of tumors of the upper aerodigestive tract has been well described, with an incidence ranging from 5 to 16 percent. Detection of a synchronous primary tumor at the time of initial work-up is crucial both for management and final outcome. However, there is a diversity of opinions regarding the extent of the work-up to search for a second primary tumor. Some investigators consider routine panendoscopy to be essential for every patient with a head and neck primary tumor. Routine esophagoscopy and bronchoscopy with bronchial washings in the absence of specific symptoms appear to have minimal benefit and high cost. In our study of 140 consecutive patients with primary squamous cell carcinoma of the head and neck seen over a period of 3 years, detailed history, thorough head and neck examination, routine chest radiograph, and barium swallow when indicated were sufficient to identify 18 patients (13 percent) with a second primary tumor in the upper aerodigestive tract. The synchronous tumors of eight patients were in the head and neck area, seven patients had carcinoma of the lung, and three patients had a second primary in the esophagus. Two patients had three synchronous primaries. Follow-up of these patients ranged from 1 to 4 years. Panendoscopy with cytologic washings was performed routinely. We questioned the cost-effectiveness of routine triscopy in every patient with head and neck cancer.

Distant metastases of nasopharyngeal carcinoma: a study of 256 male patients.

The records of 256 patients with nasopharyngeal carcinoma have been reviewed to determine the incidence and location of distant metastases. Sixty-three patients underwent autopsy. The incidence of distant metastases was 36% overall, and 51% in the autopsy patients. Bones, distant lymphnodes, liver, and lungs were the most common sites of distant metastases. Liver was the most common site in the autopsy patients. Compared to other major histological subtypes, undifferentiated carcinoma had the highest incidence of bone but lowest incidence of lung metastases. There was a strong correlation between advanced locoregional disease and distant metastases. Of those patients who developed distant metastases, 98% were discovered within 3 years or earlier. Thorough evaluation of the above organs/systems is indicated at the time of initial staging work-up and at follow-up, specifically for patients with advanced locoregional disease. A literature review of distant metastases in nasopharyngeal carcinoma is presented.

Prospective screening for multiple tumors of the upper aerodigestive tract: A simple routine procedure

Detection of a second primary at the time of initial work-up of patients with head and neck cancers has an important bearing on management planning. In a 12-month period, a series of 105 patients with an index head and neck primary (skin malignancies excluded) of the squamous cell type were subjected to the following screening procedure. Under topical anesthesia, with the patient in the sitting position, a small-size flexible bronchofiberscope (Olympus B3R) was introduced through the nose. As the scope was advanced, the nasal cavity, nasopharynx, oropharynx, hypopharynx, and larynx were examined. The tracheobronchial tree was also examined if the chest x-ray showed abnormal findings. The endoscope was then passed down to examine the esophagus, with oxygen insufflated via the biopsy channel at a rate of 1 liter per minute. The index primary sites included the tongue (20), alveolus (7), floor of mouth (2), palate (4), buccal mucosa (3), hypopharynx (17), and larynx (52). There was little patient discomfort and no complication. Nine patients (8.5%) were found to have simultaneous primary tumors including two patients with triple primaries and one with quadruple lesions. The additional tumors were in the following sites: esophagus (6), tonsil (2), floor of mouth (1), nasopharynx (1), bronchus (1), palate (1), and oropharynx (1). The treatment plans were changed in all nine patients with the discovery of multiple tumors. It is concluded that the panendoscopic screening in the manner described is simple, safe, and convenient and the information is contributory to treatment planning.

Distribution and natural history of stress fractures in U.S. Marine recruits.

In a prospective study of stress injuries of the lower extremities of U.S. Marine recruits, we derived a frequency distribution of stress fractures. The most frequently fractured bone was the tibia (73%), while the single most common site was the posterior calcaneal tuberosity (21%). The natural history of stress fractures by scintigraphy and radiography has been outlined, showing the evolutionary changes on either study as a universal progression independent of injury site or type of stress. An identical spectrum of changes should be present within any group undergoing intense new exercise. The frequency distribution of stress fractures should be a function of differing forms and intensities of exercise, therefore, our figures should not be applied to other groups. We used the presence of a scintigraphic abnormality at a symptomatic site as the criterion for diagnosis of stress fracture. Since the distribution of skeletal radiotracer uptake is directly dependent on local metabolic activity, it is expected that a focal alteration in bone metabolism will result in a scintigram approaching 100% sensitivity for the abnormality (9). In the proper clinical setting, the specificity should approximate this figure; however, a focal, nonstress-related bone abnormality which has not manifested any radiographic change, such as early osteomyelitis, could result in a false-positive examination. Specificity cannot, therefore, be accurately determined without an actual determination of the pathologic changes within the bone, necessarily involving biopsy. In summary, we believe that we have established bone scintigraphy as an early and accurate means for the detection of lower extremity stress fractures, even in the absence of radiographic findings (6). We feel that a focally abnormal scintigram, in the proper clinical setting, establishes the diagnosis of stress fracture, with radiography to be performed at the time of initial work-up only to rule out a non-stress injury (such as complete fracture, fibrous dysplasia, osteomyelitis, primary bone tumor).