Antithrombotic medication in cancer-associated thrombocytopenia: Current evidence and knowledge gaps.

In cancer patients, antithrombotic medications (i.e. anticoagulation or antiplatelet therapy) are frequently prescribed for prior or new indications such as venous thromboembolism or stoke prevention in atrial fibrillation. Balancing the risks of bleeding and thrombosis during periods of thrombocytopenia represents a significant challenge. Management is informed mainly by expert opinion and several recent retrospective studies on venous thromboembolism. The main management options include no change, temporarily withholding antithrombotic therapy, reducing dose, changing the regimen, and increasing the platelet transfusion threshold. Important recent advances in knowledge include the prognostic importance and apparent safety of aspirin in acute myocardial infarction and thrombocytopenia and data suggesting a low risk of recurrent venous thromboembolism in autologous stem cell transplantation patients who had anticoagulation withheld. This paper will review the literature on antithrombotic medication in thrombocytopenic patients with cancer. The significant knowledge gaps will be summarized and considerations for practice and research will be provided.

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.

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.