Improving the Treatment of Colorectal Cancer: The Role of EUS

The two most important factors for determining the risk of local failure and overall prognosis in colorectal carcinoma are nodal status and the depth of tumor penetration into or through the bowel wall. These features have traditionally been determined pathologically because the clinical-staging accuracy of other imaging modalities such as computed tomography (CT) has not proven sufficiently predictive of surgical staging. However, endorectal or endoscopic ultrasonography (EUS) can be used to preoperatively evaluate nodal involvement with an accuracy of up to 86% (median: 80%) and depth of tumor penetration through the bowel wall with an accuracy of up to 97% (median: 85%) for effective clinical staging. This high staging accuracy is useful in managing colorectal cancer. Through clinical evaluation of the initial stage of colorectal cancer with EUS, a patient's risk of disease recurrence can best be determined and patients stratified for the most appropriate treatment. EUS can be used to select patients with lesions that can be treated with local excision or sphincter-sparing surgery, often combined with radiation therapy, in situations otherwise requiring an abdominoperineal resection. EUS can also be used to preoperatively identify patients with locally advanced or unresectable disease. Chemoradiation can then be given preoperatively, when it appears to be better tolerated and more effective than postoperative treatment. Unresectable tumors can often be downstaged sufficiently to allow their excision. In resectable disease, EUS can also identify patients at high risk for recurrence who would benefit from adjuvant chemoirradiation. EUS for precise staging or for earlier diagnosis of recurrence will further improve the clinical outcome of patients with colorectal tumors as significant advances both in surgical techniques and in combined chemotherapy/ radiotherapy continue to be made and applied selectively in a stage-dependent manner.     

Rectal injury caused by a personal watercraft accident

PURPOSE: An original case of rectal injury after a personal watercraft accident is reported. Principles of rectal trauma management are discussed. METHODS: We present a case of a rectal injury after a fall from a personal watercraft. Rigid sigmoidoscopy and a water-soluble contrast enema documented a posterior rectal tear. The patient was managed by diversion, drainage, and administration of antibiotics. RESULTS: The patient's rectal tear healed without complication. CONCLUSION: To our knowledge, this is the first reported case of an injury to the rectum as a result of a personal watercraft accident. A high suspicion of rectal injury must be maintained in victims who have fallen from the back of a personal watercraft. Treatment of a rectal injury should follow the basic principles of drainage, diversion, and administration of antibiotics, but variations in traditional management may be appropriate. Finally, preventative methods including wearing protective clothing, and possible modification to the watercraft to reduce risk of injury should be considered.     

Risk factors for a first-incident radiographic vertebral fracture in women > or = 65 years of age: the study of osteoporotic fractures.

Vertebral fractures in older women signal an increased risk of additional osteoporotic fractures. To identify risk factors for first vertebral fractures, we studied 5822 women > or =65 years of age who had no fracture on baseline radiographs of the spine. Several modifiable risk factors increased an older woman's risk of developing a first vertebral fracture, and women with multiple risk factors and low BMD had the highest risk. Risk factors and low BMD should be useful to help focus efforts to prevent these fractures. INTRODUCTION: Vertebral fractures are a common cause of back pain and disability and signal an increased risk of additional osteoporotic fractures in older women. Little is known about the risk factors for the first occurrence of a vertebral fracture. MATERIALS AND METHODS: To identify risk factors for a first vertebral fracture, we studied 5822 women > or =65 years of age from the Study of Osteoporotic Fractures who had no fracture on baseline radiographs of the spine. We measured potential risk factors and BMD of the wrist and calcaneus at baseline and BMD of the spine and hip halfway through follow-up. Fractures were assessed by standard methods from spine radiographs obtained at baseline and follow-up an average of 3.7 years later. RESULTS AND CONCLUSIONS: In multivariable analyses, older age, previous nonspine fracture, low BMD at all sites, a low body mass index (BMI), current smoking, low milk consumption during pregnancy, low levels of daily physical activity, having a fall, and regular use of aluminum-containing antacids independently increased the risk of a first vertebral fracture. Women using estrogen and those who engaged in recreational physical activity had a decreased risk. The effects of low BMI, smoking, use of estrogen and antacids, and previous fracture were partially mediated by BMD. Women in the lower third of wrist BMD with five or more risk factors had a 12-fold greater risk than women in the highest third of BMD who had zero to three risk factors. The 27% of women at highest risk suffered 60% of the incident fractures. In conclusion, several modifiable risk factors and BMD independently increase an older woman's risk of developing a first vertebral fracture. The combination of risk factors and BMD should be useful for focusing efforts to prevent vertebral fractures.     

Femoral neck trabecular microstructure in ovariectomized ewes treated with calcitonin: MRI microscopic evaluation.

Ovariectomy induces deterioration of the trabecular structure in the femoral neck of ewes, as depicted by MR microscopic imaging. This structural deterioration is prevented by salmon calcitonin treatment. INTRODUCTION: This study evaluated the trabecular (Tb) microarchitecture of an ovariectomy (OVX)-induced osteoporotic model in ewes and determined the effects of salmon calcitonin (sCT), an osteoclast inhibitor, on the Tb structure. This is the first report of OVX-induced changes in the Tb structure in the femoral neck in the ewes and effect of sCT on the microarchitecture. MATERIALS AND METHODS: Ewes (5-8 years old, n = 28) were equally allocated into sham (Sham), OVX injected with vehicle, or OVX injected with sCT at 50 or 100 IU, three injections per week. They were killed 6 months after OVX. The femoral neck was examined with an MR imager at 9.4 T in axial, coronal, and sagittal planes. An internal calibration procedure as a means of standardizing image analysis was used to adjust the segmentation threshold. Data from all three planes were averaged. RESULTS AND CONCLUSIONS: Compared with Sham, OVX induced significant changes (p < 0.0125) in the MRI-derived femoral neck Tb structure: Tb bone volume fraction (BV/TV), -18%; Tb number, -20%; Tb separation, +23%; number of free ends, +28%; number of nodes, -39%; number of Tb branches, -23%; mean length of Tb branches, -19%. Compared with OVX, treatment of sCT at 100 IU significantly improved all the Tb structural parameters to the Sham level (p < 0.0001 approximately p = 0.0281), whereas 50 IU significantly increased the Tb number and the mean length of the Tb branches. BV/TV explained 74% of the variation of compressive stress of the trabecular cylinder cores of the femoral neck. Combining all structural parameters in a multivariate regression analysis significantly improved the explanation to 84%, and adding BMD further improved the predictive ability of the model to 92%. We conclude that OVX induces deterioration of the MRI-derived Tb microstructure in the femoral neck of ewes. sCT treatment prevents OVX-induced changes. The femoral neck microarchitecture significantly correlates with its biomechanical properties. Combining microstructural parameters with BMD further improves the prediction of bone biomechanical properties. The effects of sCT on OVX ewes may help explain reduced fracture risk in postmenopausal osteoporotic women treated with sCT.     

Preliminary in vitro evaluation of an adjunctive therapy for extremity wound infection reduction: Rapidly resorbing local antibiotic delivery

Despite the continuing advances in treatment of open fractures and musculoskeletal wounds, infection remains a serious complication. Current treatments to prevent infection utilize surgical debridement and irrigation, and high doses of systemic antimicrobial therapy. The aim of this work was to evaluate, in vitro, the potential of a fast‐resorbing calcium sulfate pellet loaded with an antibiotic. The pellet could be used as an adjunctive therapy at the time of debridement and irrigation to reduce bacterial wound contamination. Small pellets containing a binder and calcium sulfate were engineered to resorb rapidly (within 24 h) and deliver high local doses of antibiotic (amikacin, gentamicin, or vancomycin) to the wound site while minimizing systemic effects. Results from dissolution, elution, and biological activity tests against P. aeruginosa and S. aureus were used to compare the performance of antibiotic‐loaded, rapidly resorbing calcium sulfate pellets to antibiotic‐loaded crushed conventional calcium sulfate pellets. Antibiotic‐loaded rapidly resorbing pellets dissolved in vitro in deionized water in 12–16 h and released therapeutic antibiotic levels in phosphate buffered saline that were above the minimal inhibitory concentration for P. aeruginosa and S. aureus, completely inhibiting the growth of these bacteria for the life of the pellet. Crushed conventional calcium sulfate pellets dissolved over 4–6 days, but the eluates only contained sufficient antibiotic to inhibit growth for the first 4 h. These data indicate that fast‐resorbing pellets can release antibiotics rapidly and at therapeutic levels. Adjunctive therapy with fast‐acting pellets is promising and warrants further in vivo studies. © 2008 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 27: 903–908, 2009     

The role of lecithin cholesterol acyltransferase and organic substances from coal in the etiology of Balkan endemic nephropathy: a new hypothesis.

Balkan endemic nephropathy (BEN) occurs in Serbia, Bulgaria, Romania, Bosnia and Herzegovina, and Croatia. BEN has been characterized as a chronic, slowly progressive renal disease of unknown etiology. In this study, we examined the influence of soluble organic compounds in drinking water leached from Pliocene lignite from BEN-endemic areas on plasma lecithin-cholesterol acyltransferase (LCAT) activity. We found that changes for all samples were the most prominent for the dilution category containing 90% plasma and 10% of diluting media. Water samples from BEN villages from Serbia and Romania showed higher LCAT inhibiting activity (p=0.02) and (p=0.003), respectively, compared to deionised water and non-endemic water. A secondary LCAT deficiency could result from this inhibitory effect of the organic compounds found in endemic water supplies and provide an ethiopathogenic basis for the development of BEN in the susceptible population.