Diagnosing,planning and evaluating osteochondral ankle defects with imaging modalities

This current concepts review outlines the role of different imaging modalities in the diagnosis, preoperative planning, and follow-up of osteochondral ankle defects. An osteochondral ankle defect involves the articular cartilage and subchondral bone (usually of the talus) and is mostly caused by an ankle supination trauma. Conventional radiographs are useful as an initial imaging tool in the diagnostic process, but have only moderate sensitivity for the detection of osteochondral defects. Computed tomography (CT) and magnetic resonance imaging (MRI) are more accurate imaging modalities. Recently, ultrasonography and single photon emission CT have been described for the evaluation of osteochondral talar defects. CT is the most valuable modality for assessing the exact location and size of bony lesions. Cartilage and subchondral bone damage can be visualized using MRI, but the defect size tends to be overestimated due to bone edema. CT with the ankle in full plantar flexion has been shown a reliable tool for preoperative planning of the surgical approach. Postoperative imaging is useful for objective assessment of repair tissue or degenerative changes of the ankle joint. Plain radiography, CT and MRI have been used in outcome studies, and different scoring systems are available.     

Variation in serum C-reactive protein across the clinical spectrum of meningococcal disease

In a multicentre prospective study, 124 cases of meningococcal disease were classified into the clinical categories, meningitis alone (n = 15), meningitis and septicaemia (n= 79) and septicaemia alone (n = 30). A further 60 children referred with other illnesses served as controls. Serial measurements of serum C-reactive protein (admission, day 1, day 2, days 5–7) were compared. Children with septicaemia had significantly lower C-reactive protein levels on admission than those with meningitis alone or meningitis and septicaemia which were unexplained by differences in the duration of the presenting illness or severity of the disease. Within each clinical category of meningococcal disease, significant changes in C-reactive protein concentration occurred during the course of the disease. Four control children had other types of septic meningitis: admission C-reactive protein concentrations did not differ from those with meningitis or meningitis and septicaemia, but were significantly higher than those with septicaemia alone. The other 56 patients had a significantly lower admission C-reactive protein concentration compared with all cases of meningococcal disease. For the diagnosis of meningococcal disease, admission C-reactive protein levels of ≥ 40 mg/l had a sensitivity of 79%, specificity of 80% and positive predictive value of 87%. For the prognostic prediction of death in meningococcal disease (or meningococcal disease with shock) CRP < 100 mg/l on admission had a sensitivity of 69% (69%), specificity of 50% (56%) and positive predictive value of 18% (53%). In children with suspected meningococcal disease, serum C-reactive protein, measured on admission, has diagnostic value but not prognostic value. The C-reactive protein concentration on admission varies with the clinical category of meningococcal disease and the day of illness.     

Salvage definitive chemo‐radiotherapy for locally recurrent oesophageal carcinoma after primary surgery: Retrospective review

To determine the overall survival and gastrointestinal toxicity for patients treated with salvage definitive chemo‐radiotherapy after primary surgery for locoregional relapse of oesophageal carcinoma. A retrospective review of 525 patients who had a resection for oesophageal or oesophagogastric carcinoma at Princess Alexandra Hospital identified 14 patients treated with salvage definitive radiotherapy or chemo‐radiotherapy, following localized recurrence of their disease. We analysed the patient and treatment characteristics to determine the median overall survival as the primary end point. Gastrointestinal toxicity was examined to determine if increased toxicity occurred when the stomach was irradiated within the intrathoracic radiotherapy field. The median overall survival for patients treated with curative intent using salvage definitive chemo‐radiotherapy was 16 months and the 2‐year overall survival is 21%. One patient is in clinical remission more than 5 years after therapy. Age <60 years old and nodal recurrence were favourable prognostic factors. Treatment compliance was 93% with only one patient unable to complete the intended schedule. Fourteen per cent of patients experienced grade 3 or 4 gastrointestinal toxicity. Salvage definitive chemo‐radiotherapy should be considered for good performance status patients with oesophageal carcinoma who have a locoregional relapse after primary surgery. The schedule is tolerable with low toxicity and an acceptable median survival.     

Association between cigarette smoking and colorectal cancer in the Women's Health Initiative

The evidence linking cigarette smoking to the risk of colorectal cancer is inconsistent. We investigated the associations between active and passive smoking and colorectal cancer among 146,877 Women's Health Initiative participants. Women reported detailed smoking histories at enrollment. Hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated for the association between smoking and overall and site-specific risk of colorectal cancer. Invasive colorectal cancer was diagnosed in 1242 women over an average of 7.8 years (range = 0.003-11.2 years) of follow-up. In adjusted analyses, statistically significant positive associations were observed between most measures of cigarette smoking and risk of invasive colorectal cancer. Site-specific analyses indicated that current smokers had a statistically significantly increased risk of rectal cancer (HR = 1.95, 95% CI = 1.10 to 3.47) but not colon cancer (HR = 1.03, 95% CI = 0.77 to 1.38), compared with never smokers. Passive smoke exposure was not associated with colorectal cancer in adjusted analyses. Thus, active exposure to cigarette smoking appears to be a risk factor for rectal cancer.     

Body mass index and mortality from ischaemic heart disease in a lean population: 10 year prospective study of 220,000 adult men

BACKGROUND: Increased body mass index (BMI) is known to be related to ischaemic heart disease (IHD) in populations where many are overweight (BMI>or=25 kg/m2) or obese (BMI>or=30). Substantial uncertainty remains, however, about the relationship between BMI and IHD in populations with lower BMI levels. METHODS: We examined the data from a population-based, prospective cohort study of 222,000 Chinese men aged 40-79. Relative and absolute risks of death from IHD by baseline BMI were calculated, standardized for age, smoking, and other potential confounding factors. RESULTS: The mean baseline BMI was 21.7 kg/m2, and 1942 IHD deaths were recorded during 10 years of follow-up (6.5% of all such deaths). Among men without prior vascular diseases at baseline, there was a J-shaped association between BMI and IHD mortality. Above 20 kg/m2 there was a positive association of BMI with risk, with each 2 kg/m2 higher in usual BMI associated with 12% (95% CI 6-19%, 2P=0.0001) higher IHD mortality. Below this BMI range, however, the association appeared to be reversed, with risk ratios of 1.00, 1.09, and 1.15, respectively, for men with BMI 20-21.9, 18-19.9, and <18 kg/m2. The excess IHD risk observed at low BMI levels persisted after restricting analysis to never smokers or excluding the first 3 years of follow-up, and became about twice as great after allowing for blood pressure. CONCLUSIONS: Lower BMI is associated with lower IHD risk among people in the so-called normal range of BMI values (20-25 kg/m2), but below that range the association may well be reversed.