Craniocervical junction tuberculosis: a rare but dangerous disease

BACKGROUND

Mycobacterium tuberculosis of the cervical spine is a rare but dangerous manifestation of extra-pulmonary tuberculosis. The clinical picture ranges from early, nonspecific, insidious symptoms to severe neurological complications and death, attributed to craniocervical junction instability and cervicomedullary compression. The different lines of management include antituberculous medication with traction and external fixation or adjunctive surgery (debridement and stabilization) in patients with severe or persistent neurological complications and/or vertebral instability.

METHODS

We describe two patients with advanced craniocervical junction tuberculosis. The early clinical picture was nonspecific in Case 1 and obscured by psychiatric illness in Case 2. The detailed clinical and radiological findings, and the management, will be described. Involvement of the occipital condyles and foramen magnum, which has not been reported previously, will be demonstrated.

RESULTS

Both cases underwent transoral biopsy, aspiration, and debridement of retropharyngeal abscess (granuloma). Histological and tissue culture studies proved the abscesses were tuberculous and anti-tuberculous medications were started. Case 1 showed complete resolution of the clinical and radiological findings. Case 2 developed cardiorespiratory arrest while in a halo jacket. He was resuscitated but remained quadriplegic and semiconscious; he developed nosocomial gram negative pneumonia. He was referred back to his local hospital where he died 1 year later.

CONCLUSIONS

Tuberculosis is an infrequent but notable cause of cervicomedullary compression. It should be suspected in patients with infective spondylitis who are immunocompromised or reside in an area highly endemic for tuberculosis. Management strategies include antituberculosis medication, transoral biopsy and drainage of the abscess, traction and external fixation, posterior decompression, and internal fixation, according to the clinical and radiological findings.

Relation of cigarette smoking to non-Hodgkin's lymphoma among middle-aged men

Because of previous inconsistencies in the observed relation of cigarette smoking to non-Hodgkin's lymphoma, this association was investigated in the Selected Cancers Study, a population-based case-control study of 1,193 non-Hodgkin's lymphoma cases and 1,903 controls, conducted between 1984 and 1988. Study subjects were men, and the median age of non-Hodgkin's lymphoma cases was 50 years (range, 32-60 years). As compared with the risk among men who had never smoked cigarettes, the risk among ever smokers was not increased (odds ratio (OR) = 1.05, p approximately 0.50), but the risk was significantly elevated among men who reported smoking > or = 2 1/2 packs per day and among men who had smoked for 30-39 years (OR = 1.45 in each group, p < 0.05). The estimated odds ratio among the 350 heavy smokers (> or = 50 pack-years) was 1.41 (95% confidence interval 1.08-1.85) after controlling for educational achievement, various occupational and medical exposures, and other potential confounders. The observed associations, however, tended to vary by age, with the odds ratio among heavy smokers decreasing from 2.8 among 32- to 44-year-olds to 1.1 among men over 55 years of age. These age-related differences, which may account for some of the inconsistencies seen in previous studies of cigarette smoking and non-Hodgkin's lymphoma, should be considered in future investigations.

Measurement of aging anxiety in an elderly Australian population

The purpose of this investigation was to modify an existing aging anxiety scale to produce an instrument specifically designed to assess aging anxiety in an elderly population. Existing instruments fail to consistently orientate aging associated threats into the future, and this poses a significant problem for the measurement of aging anxiety in the elderly population. It is proposed that this factor has confounded reports of the relationship between aging anxiety and advancing age. An existing valid and reliable instrument, the Anxiety about Aging Scale was modified for use with elderly respondents and tested on 123 independent community dwelling elderly individuals. The results indicated the modified scale provides a valid assessment of aging anxiety in the elderly.

Ethnicity and variation in breast cancer incidence

A breast cancer case-control study in Atlanta and 5 counties of central New Jersey involving interviews with 960 white and 281 black cases younger than 54 years of age enabled assessment of reasons for the varying incidence rates among these 2 ethnic groups. Of interest was why rates of breast cancer are higher among older white women, a trend that is reversed among very young women (<40 years). Calculation of the prevalence of exposure to classic and speculative risk factors and associated relative risks enabled derivation of population attributable risks (PARs) for the various combinations of age and ethnic groups. A higher PAR was derived for older (40-54 years) white (62%) than black (54%) women, which appeared to account for the observed difference in incidence between the 2 ethnic groups. Most of the difference in PARs between older whites and blacks was accounted for by whites having fewer births, later ages at first birth and slightly higher risks associated with reproductive and menstrual factors. Consideration of only well-established breast cancer risk factors showed a PAR among older whites of 57%, an estimate comparable to those previously published. Slightly higher overall PARs were derived when analyses considered several speculative but modifiable risk factors, including years of use of oral contraceptives, body size and alcohol consumption. Many of the analyses among younger women (20-39 years) were limited by available numbers, but it appeared that very little disease occurrence in young black women was associated with the factors studied.

Learning contracts in higher professional training: a user's guide

If the doctor undergoing higher professional training is to make best use of the attachment to a training location, and that training location is to make the most efficient use of the contribution of the trainee, then a written framework such as a learning contract can meet the needs of both. The first stage is to list the learning needs of the individual trainee and to match them with the work experience offered by the training location. Next, the work programme for the coming six to 12 months should be formalised in a learning contract, spelling out the tasks to be performed and the expected training benefit. This is then reviewed at agreed intervals and a written appraisal made. At the end of the attachment the trainee, trainer and any outside accrediting or auditing body, has a written account of what was expected, what was achieved, and the performance of trainee and trainer.

Atypical course of carotid cavernous sinus fistula in a six-year-old child

A case of post-traumatic carotid cavernous sinus fistula complicated by coma-producing intraventricular tamponade in a 6-year-old boy is reported. Urgent surgical treatment included external ventricular draining, trapping and muscle embolization by the Jaeger-Hamby procedure. Follow-up cerebral angiography showed complete obliteration of the fistula. The child made an excellent recovery and now leads a normal life.

The Women's Health Trial Feasibility Study in Minority Populations: design and baseline descriptions

The Women's Health Trial: Feasibility Study in Minority Populations (WHT:FSMP), a randomized trial of 2208 women, was conducted to investigate three questions. First, can women from minority and low-socioeconomic-status populations be recruited in numbers sufficient to evaluate a dietary intervention designed to lower fat intake. Second, the efficacy of a low fat, increased fruit/vegetable/ grain product intervention for reducing fat consumption. Third, will participation in the intervention lower plasma cholesterol and estradiol levels relative to the controls. The baseline results showed that an adequate number of minority and low SES women could be recruited to test the study hypotheses. A diverse study population of postmenopausal women consuming a high fat diet was recruited: 28% of participants were Black, 16% were Hispanic, 11% had less than a high school level of education, and 15.5% had household incomes of < $15,000.

Matrix metalloproteinases degrade myelin basic protein

Matrix metalloproteinases (MMPs) are a group of enzymes responsible for the degradation of interstitial connective tissue and basement membrane. The coding sequences for five of the human MMPs, viz. interstitial collagenase, 72 kDa gelatinase, stromelysin-1, matrilysin and 92 kDa gelatinase, were cloned and expressed in Chinese hamster ovary cells, and the proteins purified. The enzymes were compared for their ability to digest myelin basic protein, the major extrinsic membrane protein of central nervous system myelin. The most active on this substrate was 72 kDa gelatinase, followed by stromelysin-1; interstitial collagenase, matrilysin and 92 kDa gelatinase were of comparable but lesser activity. Production of these enzymes by glia or infiltrating inflammatory cells could therefore contribute to demyelination in neuroinflammatory disease.

Prevalence of human immunodeficiency virus and associated risk behaviour in injection drug users in Toronto

During 1989-90, interviews were conducted with 582 current injection drug users in the City of Toronto, 535 of whom also provided blood and/or saliva for anonymous unlinked HIV antibody testing. The rate of seropositivity identified was 4.3% (95% CI 3-6). The subjects were predominantly male, with a mean age of 28.3. The commonest drug of choice was cocaine (70%). Forty-six percent of the subjects reported using someone else's needle in the preceding six months, 60% of these indicating that they always cleaned it first. Eighty-one percent of those interviewed had been in jail at some time since they began injecting; 25% of these had injected while in custody, and of these 61% had shared injection equipment. Eighty-two percent of the men and 85.4% of the women reported opposite sex partners in the previous six months. Only about 20% of men reported consistent condom use, while 22% of females reported condom use at least 75% of the time.

Recruitment and retention of subjects for a longitudinal cancer prevention study in an inner-city black community

Recruiting and retaining subjects for longitudinal prevention trials is challenging. The inherent difficulties are compounded when the trial is to take place in a low-income minority community, since prevention is a low priority among residents of such communities, and research is viewed with suspicion. We present our experiences in attempting to recruit and retain low-income black women living in inner-city Atlanta for a trial of an educational intervention to promote screening for cancer. The intervention was conducted in the home by trained lay health workers. We found that recruitment was more successful when we recruited directly from the community than when we recruited from the patient registry of a primary health care center. The attrition rate over an 18-month period was high. Among members of the intervention group, those retained in the study tended to be wealthier and better educated and were more likely to be married and employed than those who dropped out. It seems probable that women of lower socioeconomic status found our intervention to be intrusive or burdensome. Among the controls, socioeconomic factors did not discriminate between those who completed the study and those who did not; loss to follow-up in this group was associated only with younger age. In conducting research of this type in low-income minority communities, special attention must be given to issues of recruitment and retention if the validity of the study is to be preserved.

The spectrum of intracranial aneurysms in pediatrics

Intracranial aneurysms are rare in children, accounting for merely 0.5-4.6% of all aneurysms. Several characteristics distinguish them from aneurysms in adults: male predominance; higher incidence of unusual location, such as peripheral or posterior circulation; and a greater number of large and giant aneurysms. These unique features can be attributed to the higher incidence of traumatic, infectious, developmental, and congenital lesions. Subarachnoid hemorrhage is not the exclusive mode of presentation; neuro-compressive signs and symptoms are also frequently seen. The treatment of intracranial aneurysms in pediatrics is dictated by their unusual pathology and liability to rehemorrhage. Although direct clipping has been the standard surgical technique, certain obsolete or innovative procedures should also be considered, such as entrapment, proximal occlusion, and endovascular embolisation, or even, in some cases, the non-invasive treatment of "watch and wait" for a spontaneous thrombosis. Six representative cases from King Faisal Specialist Hospital and Research Centre are reviewed. They reflect the diversity of the problem and the multi-disciplinary approach to the treatment.

Glutaric aciduria yype 1: First reported cases in three Saudi patients

The clinical and biochemical findings in three patients with glutaric aciduri Type 1 (GAT1) are presented. They had a normal postnatal period of three to 14 months. They developed sudden and severe encephalopathy following an infection or trauma (patient 3) that gradually progressed to severe dystonia, choreathetosis, spastic quadriplegia and mental retardation. Neuroradiologic studies of the brain revealed while matter disease and frontotemporal lobe hypoplasia. The urine findings by gas chromatography/mass spectrometry (GC)/(MS) were characteristic of GAT1. Since GAT1 is an organic acidemia without intermittent acidotic attacks, but primarily manifests with progressive encephalopathy, it is important to recognize the potential of its existence among handicapped children in chronic care facilities. The good clinical response in two of the patients urges early diagnosis in subsequent newborn siblings of the families with the disease. The diagnosis of three patients in less than two years indicate the need for neonatal screening for the recognition of this disease, among other treatable metabolic diseases, in Saudi Arabia.

Myelopathy after intrathecal chemotherapy. A case report with unique magnetic resonance imaging changes

BACKGROUND

Paraplegia caused by intrathecal chemotherapy has no known pathognomonic features and is a diagnosis of exclusion.

METHODS

The authors reported the clinical and neuroimaging findings in one patient with this syndrome.

RESULTS

The patient had severe paraplegia with urinary retention and impaired pain and touch sensation below T-10 with sparing of proprioception and vibration sense. Magnetic resonance imaging (MRI) scan showed diminished intensity throughout the central cervical spinal cord. Post-gadopentetate dimeglumine enhancement was scattered throughout the cervical spinal cord and in two areas of the dorsal spinal cord. Axial views of the cervical spinal cord showed that this enhancement was limited to the lateral columns.

CONCLUSIONS

The MRI in myelopathy due to intrathecal chemotherapy may show a unique pattern of postgadopentetate dimeglumine enhancement limited to the lateral columns of the spinal cord. However, two recently encountered patients with the same syndrome did not show similar changes.

The prevalence and spectrum of brain abnormalities in congenital choanal atresia

Over the past few years there has been increasing awareness of the association of congenital choanal atresia (CCA) with other congenital defects, including brain abnormalities. We obtained CT scans of the brain in twenty-three consecutive patients with CCA (10 boys and 13 girls) to determine the prevalence and the scope of associated brain abnormalities. CCA was associated with known syndromes or different congenital abnormalities in 7 and 10 patients, respectively, and was an isolated finding in 6 patients. Six patients (26%) had brain abnormalities including alobar holoprosencephaly, absent corpus callosum, benign enlargement of the subarachnoid space of infancy, cerebral calcification, small right hemisphere, small ventricles and microcephaly. None of the brain abnormalities were suspected clinically. Brain abnormalities were more common in boys compared to girls (40% vs 15.4%, p = 0.18), in bilateral compared to unilateral CCA (31.3% vs 14%, p = 0.38), and in membranous compared to bony CCA (75% vs 15.7%, p = 0.02). Brain abnormalities associated with CCA may be more common than generally recognized and more so in certain subgroups of patients. Obtaining a CT scan of the brain should be considered in all patients with CCA.

Treatment of small cell lung cancer in the elderly

OBJECTIVE

Since both the incidence of lung cancer and the proportion of the population over age 65 are increasing rapidly in North America, we undertook a retrospective review of elderly patients with small cell lung cancer (SCLC) in an attempt to assess the effect of age on treatment decisions, response, survival, and toxicity.

DESIGN

Retrospective chart view.

SETTING

Oncology Unit of a university-affiliated teaching hospital.

PATIENTS

There were 123 patients age > 70 years treated from 1976-88. Chemotherapy consisted of either cyclophosphamide, doxorubicin, and vincristine, or etoposide and cisplatin.

RESULTS

There were 74 patients aged 70-74, 35 aged 75-80, and 14 aged 80 years or older. No significant differences existed between the groups in sex, stage, performance status, or presence of co-morbid disease. Median survivals for patients with limited and extensive disease were 11.9 and 5.2 months, respectively (P = < 0.0001), with no significant difference for patients in any age group (P = 0.4). For both limited and extensive disease, survival correlated strongly with the treatment received. Twenty-five patients received no treatment (median survival 1.1 months), 20 had radiation only (median 7.8 months), and 27 patients had < 3 cycles of chemotherapy (median 3.9 months). Median survival for the 50 patients who had 4-6 cycles was 10.7 months (limited disease 15.0 months, extensive disease 8.61 months). In the Cox Model, survival correlated strongly with stage of disease and chemotherapy treatment (P < 0.0001), but only marginally with performance status (P < 0.077). Of the 77 patients who had chemotherapy, less than 50% in all age groups completed six cycles. Only two patients completed chemotherapy without a single dose reduction, and 76.7% required more than two reductions.

CONCLUSIONS

Chemotherapy should not be withheld from elderly patients with SCLC on the basis of age. The survival of patients who receive chemotherapy is significantly longer than that of untreated patients even though frequent dose reductions for toxicity may be required. The survival benefit is due to treatment effect and is not due to a selection bias in the cohort of patients chosen for therapy.

Seroprevalence of and risk factors for HIV-1 infection in injection drug users in Montreal and Toronto: a collaborative study

OBJECTIVE

To determine the prevalence of antibodies to HIV-1 and risk factors for HIV-1 infection among injection drug users.

DESIGN

Questionnaire survey. A venous blood sample was taken for HIV-1 antibody testing.

SETTING

Montreal and Toronto.

PARTICIPANTS

A total of 810 subjects who had used injection drugs in the previous 6 months recruited mainly from treatment centres and from the street in Montreal (425 subjects) and from treatment centres in Toronto (385 subjects) between September 1988 and September 1990. The overall participation rate was 82%.

OUTCOME MEASURES

HIV-1 seropositivity, sociodemographic and behavioural risk factors for HIV-1 infection.

RESULTS

The overall seroprevalence rate of HIV-1 infection was 4.8% (95% confidence limits [CL] 3.5 and 6.5). In Montreal the rate was 8.2% (95% CL 6.0 and 11.2), and in Toronto 1.0% (95% CL 0.4 and 2.6) (p < 0.001). Seropositive subjects were significantly older (p = 0.041) and were more likely to have a history of imprisonment (p = 0.006) than seronegative subjects. In univariate analysis seropositivity was associated with the following behaviours: more frequent cocaine use (p < 0.001), injecting drugs in "shooting galleries" (p = 0.002), sharing equipment with a person known to be HIV-1 seropositive (p = 0.006), "booting" fresh blood (p = 0.004), homosexual or bisexual orientation (p = 0.006), engaging in prostitution (p < 0.001) and, for men, number of male sexual partners in the previous 6 months (p = 0.007). In multivariate analysis the determinants of HIV-1 seropositivity were Montreal as the city of recruitment (odds ratio [OR] 6.7, 95% CL 2.32 and 19.42), engaging in prostitution (OR 2.13, 95% CL 1.01 and 4.75), a history of imprisonment (OR 3.51, 95% CL 1.33 and 9.29) and sharing equipment with a person known to be HIV-1 seropositive (OR 4.43, 95% CL 1.43 and 13.74).

CONCLUSIONS

Our findings show that HIV-1 is circulating among injection drug users in Montreal and Toronto and that both drug use and sexual behaviours are implicated in the transmission of infection in the populations studied. Adapted preventive programs should be developed to prevent further spread of HIV-1 infection in this population.

The development of airways obstruction in sarcoidosis among smokers and non-smokers

The prevalence of respiratory function abnormalities was studied in 32 patients with pulmonary sarcoidosis, 16 (50%) of whom were smokers. Airflow obstruction was found at presentation in one non-smoker and developed in four more during the course of follow-up. Similar airflow obstruction was present in six smoking patients and developed in four patients subsequently. Airways obstruction was a common physiological defect even in non-smokers, though smokers had more frequent airflow obstruction and developed a worse defect.

Evaluation of a brief telephone questionnaire to estimate fruit and vegetable consumption in diverse study populations

We evaluated the use of a six-item telephone questionnaire to estimate fruit and vegetable intakes in five diverse populations. Researchers administered the telephone questionnaire to persons who had previously undergone more extensive dietary assessment. The study population included 553 middle-aged and older adults in Beaver Dam, WI; 252 middle-aged and older women throughout Wisconsin; 150 parents of school children in Augusta, GA; 73 low-income, Hispanic mothers in Chicago, IL; and 51 older adults in Arizona. Spearman correlation coefficients between total fruit and vegetable intakes measured by the brief telephone survey and by more extensive food frequency questionnaires were 0.47 (Augusta), 0.48 (Arizona), 0.56 (Wisconsin), and 0.57 (Beaver Dam). Correlations between intakes measured by the brief telephone survey and by multiple diet records or recalls were 0.29 (Arizona), 0.46 (Chicago), and 0.54 (Beaver Dam). With the exception of Arizona, mean daily fruit and vegetable intakes measured by the telephone survey were similar to intakes estimated by multiple diet records or recalls and lower than those estimated by extensive food frequency questionnaires. Although caution may be needed in interpreting dietary reports from some ethnic subgroups, this brief telephone questionnaire may be useful for surveillance of fruit and vegetable intake in the United States.

Stapedial artery supplying sphenoid wing meningioma: case report

A 46-year-old woman presented complaining of resting tremor of the right arm and attacks of inappropriate crying and laughing. Computed tomography and magnetic resonance imaging of the head revealed a large left sphenoid wing meningioma. Preoperative cerebral angiography demonstrated a persistent stapedial artery, terminating as a middle meningeal artery which was the main blood supply to the tumour.

The accuracy of parental reports of their children's intake of fruits and vegetables: validation of a food frequency questionnaire with serum levels of carotenoids and vitamins C, A, and E

It has been recommended that U.S. children increase their dietary intake of fruits and vegetables. Measuring diets of children to support and evaluate nutritional interventions can be a difficult task, however. We administered to 97 parents of children age 6-10 years a food frequency questionnaire on their children's usual dietary intake over the previous 3 months. We then compared these reports by parents of their children's intakes of fruits and vegetables, and the derived estimates of intake of carotenoids and vitamins C, A, and E, with the children's serum levels of carotenoids and vitamins C, A, and E. The dietary reports of intakes of 35 fruits and vegetables showed Spearman rank-order correlations of 0.30 with serum carotenoids and 0.34 with serum vitamin C. Children in the highest quartile for intake of fruits and vegetables according to their parents' food frequency reports had 35% higher carotene levels and 31% higher vitamin C levels in their serum than did children in the lowest quartile for intake of fruits and vegetables. We conclude that parental reports of young children's diets using food frequency methods are accurate enough to be useful in nutritional screening and dietary surveillance of fruit and vegetable intake.

Assessing consumption of high-fat foods: the effect of grouping foods into single questions

Questionnaires on the frequency of consumption of foods are commonly used to measure dietary intake in epidemiologic research. To reduce the burden on respondents, questionnaires are often shortened by combining inquiries on similar foods into a single question. The effect of this practice on the reporting of dietary intake has never been investigated, however. To address this issue, we used two food frequency questionnaires in a telephone survey designed to rank adult residents of Alabama by their intake of dietary fat. One questionnaire included 29 questions about separate high-fat foods, whereas the other grouped these same foods into 14 questions. Compared with the 443 respondents interviewed using the 29-item separated-foods questionnaire, the 465 respondents responding to the 14-item grouped-foods questionnaire reported lower average intakes of the foods. In addition, a substantially higher percentage of respondents to the grouped-foods questionnaire reported never consuming the foods.

Renal cell cancer among paperboard printing workers

A physician's alert prompted us to investigate workers' cancer risk at a paperboard printing manufacturer. We conducted a retrospective cohort mortality study of all 2,050 persons who had worked at the facility for more than 1 day, calculated standardized incidence ratios (SIRs) for bladder and renal cell cancer, and conducted a nested case-control study for renal cell cancer. Standardized mortality ratios (SMRs) from all causes [SMR = 1.0, 95% confidence interval (CI) = 0.9-1.2] and all cancers (SMR = 0.6, 95% CI = 0.3-1.0) were not greater than expected. One bladder cancer and one renal cell cancer were included in the mortality analysis. Six incident renal cell cancers were observed, however, compared with less than two renal cell cancers expected (SIR = 3.7, 95% CI = 1.4-8.1). Based on a nested case-control analysis, the risk of renal cell cancer was associated with overall length of employment but was not limited to any single department or work process. Although pigments containing congeners of dichlorobenzidine and o-toluidine had been used at the plant, environmental sampling could not confirm any current exposure. Several limitations and a potential selection bias limit the inferences that can be drawn.

Congenital muscular dystrophy with abnormal radiographic myelin pattern

We report 11 children with a homogeneous clinical syndrome affecting both sexes, characterized by weakness at birth, slowly improving course, weakness of all muscle groups, arreflexia, elevated blood creatine kinase, normal nerve conduction velocity, dystrophic changes on muscle biopsy, and diffuse periventricular cortical white-matter abnormalities with sparing of corpus callosum, internal capsule, and brain stem. We compare them to 48 other previously reported similar cases and designate them as altered myelin radiographic pattern congenital muscular dystrophy (CMD), which is the same as occidental CMD. We compare them to the other presently accepted phenotypes: progressive Fukuyama CMD, Walker-Warburg or cerebral-ocular CMD, and Santavuori or muscle-eye-brain CMD. We suggest that the different phenotypes are alleles of the same gene, which regulates or expresses a structural protein required for muscle integrity, myelination, and formation of the cortex. Such phenotypic diversity has been established for mutations of Xp21 in X-linked muscular dystrophies.

Colonoscopically detected colorectal cancer missed on barium enema

The radiographs and clinical records of 26 patients with colorectal cancer missed on barium enema, and subsequently detected at colonoscopy, were reviewed to determine the cause of radiological error. Twenty (77%) of the patients were female. In 24 of 26 patients, anemia and/or rectal bleeding was a presenting feature. Fourteen of the 26 (54%) missed cancers were in the sigmoid colon, 10 (38%) in the ascending colon or hepatic flexure, and two (8%) in the rectum. Tumor size ranged from 20-100 mm. Fifteen were polyps, and 11 annular cancers. Fourteen (54%) were Dukes C or D tumors. Twenty-eight barium enemas in 23 patients were available for review: 86% were double-contrast studies. In 18 (76%), the cancer could be seen in retrospect and, in over half, the tumor was obvious. The dominant perceptive error was due to missing the lesion in the barium pool. Other major errors were missing the lesion en face or in overlapping loops. As most cancers were missed because of observer perceptive error, by both experienced and inexperienced radiologists, the authors recommend double reporting of all barium enemas.