A comparative study of the risk of malignancy index and the ovarian crescent sign for the diagnosis of invasive ovarian cancer

OBJECTIVE

To compare the value of the risk of malignancy index (RMI) and the ovarian crescent sign (OCS) in the diagnosis of ovarian malignancy.

METHODS

This was a prospective observational study of women with ultrasonographic diagnosis of an ovarian cyst. The RMI was calculated in all cases using a previously published formula (RMI = U (ultrasound score) x M (menopausal status) x serum CA125 (kU/L)). A value > 200 was considered to be diagnostic of ovarian cancer. The OCS was defined as a rim of visible healthy ovarian tissue in the ipsilateral ovary. Its absence was taken as being diagnostic of invasive cancer.

RESULTS

A total of 106 consecutive women were included in the study, of whom 92 (86.8%) had a benign ovarian tumor, five (4.7%) had borderline lesions and nine (8.5%) had an invasive ovarian cancer. The absence of an OCS diagnosed invasive ovarian cancer with a sensitivity of 100% (95% CI, 70-100%), specificity of 93% (95% CI, 86-96%), positive predictive value (PPV) of 56%, negative predictive value (NPV) of 100% and positive likelihood ratio (LR+) of 13.86 (95% CI, 6.79-28.29). This compared favorably with a sensitivity of 89% (95% CI, 57-98%), specificity of 92% (95% CI, 85-96%), PPV of 50%, NPV of 99% and LR+ of 10.78 (95% CI, 5.34-21.77), which were achieved using RMI > 200 (P < 0.01).

CONCLUSIONS

The RMI and the OCS are useful tests for discriminating between invasive and non-invasive ovarian tumors. The application of these tests in a sequential manner might improve the overall accuracy of ovarian cancer diagnosis.

Predictors of Mortality in End-Stage Renal Disease Patients with Mitral Annulus Calcification

OBJECTIVE

Mitral annulus calcification (MAC) is an independent predictor of cardiovascular mortality in the general population. The purpose of the current historical cohort study is to assess risk factors for long-term mortality in end-stage renal disease (ESRD) patients with MAC (n = 30; age, 62 +/- 2 yr), as compared to ESRD patients without MAC (n = 30; age, 63 +/- 2 yr). Additional analysis compared ESRD patients with MAC to non-ESRD patients with MAC (n = 32; age, 66 +/- 2 yr).

METHODS

The groups included age-matched male patients followed at a single center. Long-term survival was assessed by Kaplan-Meier analysis. Regular and stepwise Cox proportional hazards models were used to determine risk factors for mortality.

RESULTS

There was a similarly high prevalence of cardiovascular complications, including hypertension, coronary artery disease, left ventricular hypertrophy, atrial fibrillation, and congestive heart failure, in all three groups. Median survival time was significantly longer in non-ESRD patients (90 months), compared with the ESRD with MAC (45 months) and ESRD without MAC (45 months) patients (log-rank test; P < 0.001). With stepwise Cox proportional hazards model, including ESRD patients with MAC and ESRD patients without MAC, increased calcium x phosphate product, decreased serum creatinine concentration, and the presence of coronary artery disease and lower extremity amputations were independent predictors of mortality for patients with ESRD. With stepwise Cox proportional hazards model, including ESRD patients with MAC and non-ESRD patients with MAC, the presence of ESRD, atrial fibrillation, diabetes, aortic valve calcification, coronary artery disease, and tricuspid regurgitation were independent predictors of mortality.

CONCLUSION

The mortality rate was high in ESRD patients, approximately 15% per year. After accounting for baseline cardiovascular disease and traditional risk factors, the presence of MAC did not confer additional risk for mortality.

The effects of hyaluronic acid on articular chondrocytes

The purpose of this study was to examine the effects of hyaluronic acid supplementation on chondrocyte metabolism in vitro. The clinical benefits of intra-articular hyaluronic acid injections are thought to occur through improved joint lubrication. Recent findings have shown that exogenous hyaluronic acid is incorporated into articular cartilage where it may have a direct biological effect on chondrocytes through CD44 receptors.Bovine articular chondrocytes were isolated and seeded into alginate constructs. These were cultured in medium containing hyaluronic acid at varying concentrations. Samples were assayed for biochemical and histological changes. There was a dose-dependent response to the exposure of hyaluronic acid to bovine articular chondrocytes in vitro. Low concentrations of hyaluronic acid (0.1 mg/mL and 1 mg/mL) significantly increase DNA, sulphated glycosaminoglycan and hydroxyproline synthesis. Immunohistology confirmed the maintenance of cell phenotype with increased matrix deposition of chondroitin-6-sulphate and collagen type II. These findings confirm a stimulatory effect of hyaluronic acid on chondrocyte metabolism.

The false profile arthrogram in developmental dysplasia of the hip

Arthrography is useful in the evaluation and treatment of developmental dysplasia of the hip. The authors describe the additional diagnostic value obtained from a "false profile" arthrogram. The "false profile" arthrogram allows assessment of anterior acetabulum cover, femoral neck anteversion and hip joint subluxation (instability), which may not be apparent on other views. (Hip International 2005; 15: 177-81).

Iliofemoral distraction and hip reconstruction for the sequelae of a septic dislocated hip with chronic femoral osteomyelitis

We describe a technique of ‘cross-hip distraction’ to reduce a dislocated hip with subsequent reconstruction of the joint for septic arthritis with extensive femoral osteomyelitis. A 27-year-old woman presented with a dislocated, collapsed femoral head and chronic osteomyelitis of the femur. Examination revealed a leg-length discrepancy of 7 cm and an irritable hip. A staged technique was used with primary clearance of osteomyelitis and secondary reconstruction of the hip. A cross-hip monolateral external fixator was used to establish normal anatomy followed by an arthroplasty. A good functional outcome was achieved. The use of cross-hip distraction avoids soft-tissue and nerve damage and achieved improved abductor function before arthroplasty.

Mechanisms and pattern of facial lacerations in the Accident Department

The purpose of this study was to determine patterns of facial laceration seen in the Accident and Emergency Department and identify how they are related to the mechanism of injury. A retrospective analysis of facial lacerations of an adult presenting to Accident and Emergency department was made over a 6-month period. There were 197 consecutive facial lacerations. The mean age of patients was 46 years. There were 137 male and 60 female patients. The aetiology of lacerations was falls (48%), assaults (11%), hit by an object by accident (21%) and hit stationary object by accident (15%). Mechanism of injury was found to be related to common patterns of laceration. Lacerations affecting the forehead mainly occurred in falls and those affecting the peri-orbital and peri-oral areas in assault. Lacerations were mainly linear, with a mean length of 2.4 cm, and about 75% were precipitated by blunt injury. Identification of common patterns of injury corresponding to a certain mechanism may allow assessment of the difficult or non-compliant patient. Understanding mechanisms of injury will allow safety planners to design safer domestic and workplace environments.

Ulnar tunnel syndrome due to anatomical variant of the ulnar artery

We report a case of ulnar tunnel syndrome due to an anatomical variant branch of the ulnar artery. Anatomical variants can cause compression not visible on imaging and need to be considered for successful surgical decompression.

Multiple schwannomas of the median nerve: a case report and literature review

We report a case of multiple schwannomas of the median nerve. Multiple schwannomas can be difficult to diagnose on clinical grounds and can be mistakenly diagnosed as carpal tunnel syndrome or ganglia as in our case. Nerve conduction studies helped locate non-visible tumours. Magnetic resonance imaging (MRI) is useful in the preoperative planning of these tumours. The appearances on scanning however can be sometimes confused for ganglia as in this case. Intraneural dissection of the schwannomas was carried out and the pathology is described.

Regional audit: perioperative management of MRSA orthopaedic patients in the Oxford region

AIM

Methicillin resistant staphylococcus aureus (MRSA) colonisation or infection is of particular importance in patients undergoing operations involving implantable materials, such as in orthopaedic surgery. An audit of the perioperative management of orthopaedic patients in the Oxford region was carried out to assess the level of clinician awareness and the uniformity of current guidelines between hospitals.

METHODS

A postal questionnaire was designed for asking information on various aspects of perioperative management of MRSA patients and was sent to each hospital.

RESULTS

Responses were obtained from nine of 10 hospitals in the region. The average response rate for each hospital was 75%, and the overall individual response rate was 67.5% (27/40). Seventy-eight per cent of respondents knew that there was a pre-admission screening policy. Fifteen per cent were unaware of any MRSA policy. Forty-four per cent indicated that teicoplanin was used for prophylaxis in implant surgery whilst 44% used vancomycin. Eighteen per cent believed that cefuroxime was used for prophylaxis. Forty-eight per cent of hospitals had an MRSA-free zone for orthopaedic patients.

CONCLUSION

This study indicates a lack of uniformity in the perioperative management of MRSA-positive patients in the region and a lack of awareness of both MRSA guidelines and their implementation. Uniformity of MRSA guidelines is necessary to allow better clinician awareness and compliance, especially in surgical trainees who are travelling between different training hospitals in the region. Implementation of such a policy with re-audit of subsequent awareness and compliance is proposed.

Snowdome, skiers and boarders: accident and emergency experience

A prospective case series was compiled of all people presenting to the accident and emergency department with an injury caused by snowboarding or skiing, during the first year of opening of the Milton Keynes snowdome. The aim was to analyse the types of injuries associated with recreational snowboarding and to compare these with the injuries seen in skiing. Of the snowboarders, 23 (86%) were males, and the mean age was 24 years. Of the skiers, 13 (81%) were males, and the mean age was 34 years. Forty-three injuries required orthopaedic review, and 12 were admitted for further management. Significant differences were noted between the patterns of injuries in snowboarding and skiing. The snowboarders had a higher incidence of upper limb injuries (96 vs. 62%) and a lower incidence of lower limb injuries (4 vs. 38%) compared to the skiers. This study demonstrates that the opening of a leisure facility has a significant impact on the local accident and emergency department. Snowboarding is associated with a unique pattern of injuries, the knowledge of which should influence education and accident prevention.

The value of detection of normal ovarian tissue (the 'ovarian crescent sign') in the differential diagnosis of adnexal masses

OBJECTIVE

The aim of the study was to evaluate whether the presence of normal ovarian tissue adjacent to an adnexal tumor (the 'ovarian crescent sign') could assist in the preoperative differential diagnosis of adnexal lesions.

METHODS

This was a prospective observational study including 100 women with a preoperative diagnosis of an adnexal mass. Demographic and biochemical data were collected and all women underwent a detailed transvaginal ultrasound scan. Tumor volume, morphological characteristics and Doppler features were recorded in each case. In addition, the tissue adjacent to the cyst was systematically examined for the presence of normal ovarian tissue. All the findings were compared to the final histological diagnosis.

RESULTS

Sixty-seven (67%) of the cysts removed were benign, nine (9%) were borderline and 24 (24%) women had invasive malignant lesions. Normal ovarian tissue was seen in 58/76 (76%) women with non-invasive lesions, and in one woman (4%) with an invasive malignancy. In the absence of normal ovarian tissue, ovarian cancer was diagnosed with a sensitivity of 96% and specificity of 76%.

CONCLUSION

The presence of normal ovarian tissue adjacent to an ovarian cyst is a useful morphological feature that may be used to help exclude an invasive ovarian malignancy in women with adnexal masses detected on ultrasound scan.

The impact of implementing the Ottawa ankle rules on ankle radiography requests in A&E

This audit was set up to quantify the effect of implementing the Ottawa ankle rules in a district general hospital that relies on both medical and nursing radiography requests. Data were collected prospectively on 207 patients who presented with an acute ankle injury between August 2001 and February 2002. The department's activity was recorded before and after a period of teaching on the Ottawa ankle rules. Before teaching, 71% of patients with an acute ankle injury were sent for radiography; teaching reduced this figure to 56% (p < 0.05). Auditing the activity of our department enabled us to observe a significant decrease in the number of patients sent for ankle radiography following acute ankle injury. This correlates well with research in other settings. The difficulties of rationalising radiology investigations are discussed.

Malignant ascites: new concepts in pathophysiology, diagnosis, and management

Malignant ascites is a manifestation of advanced malignant disease that is associated with significant morbidity. Mainstays of treatment include diuretics and recurrent large volume paracentesis. Although lymphatic obstruction has been considered the major pathophysiologic mechanism behind its formation, recent evidence suggests that immune modulators, vascular permeability factors, and metalloproteinases are contributing significantly to the process. These new observations offer the opportunity for development of new, more targeted therapies for the treatment of malignant ascites. This article uses a clinical case to highlight the problem, then reviews these new concepts in the pathophysiology of malignant ascites formation. The diagnosis and management of this challenging medical problem are subsequently discussed, with emphasis on how these new pathophysiologic insights are being applied to the development of novel therapies that may soon change how we manage this troubling clinical condition.

Insertion of Temporary Dialysis Catheters with the Aid of Real-time Ultrasound

Central venous catheters are widely used for both temporary and long-term angioaccess for hemodialysis. Insertion of these catheters is commonly performed using anatomic landmarks to guide vessel cannulation. Using traditional landmark-techniques, internal jugular venous catheter insertion is successful 82-88% of the time, with successful first-attempt cannulation of only 35-38%. Variations in anatomic relationships between the vein and surrounding structures may contribute to difficulty in venous cannulation using these traditional techniques. Real-time ultrasound guidance permits direct visualization of the target vein during catheter placement and is associated with increased successful cannulation (78-83% on first pass; 97-100% overall), a decreased number of attempts and a decreased complication rate. For this reason, we believe that real-time ultrasound-guided catheter insertion is superior to the traditional anatomic-landmark techniques and is emerging as the new standard of care.