A variety of methods of tophus assessment have been described for use in clinical trials of chronic gout. Physical measurement techniques (particularly the Vernier calliper method) and US measurement of tophus size appear to meet most aspects of the OMERACT filter.

Fentanyl is a potent opioid analgesic used in the treatment of pain. Transdermal fentanyl patches are now widely utilized as an acceptable and efficacious method of medication delivery. Unfortunately, the potential for their abuse is well recognized. Previous case reports have documented deaths after intravenous (IV) misuse of fentanyl which had been extracted from Duragesic (liquid reservoir type) patches. We present a case of IV fentanyl abuse after the extraction from a Mylan (matrix type) patch. This method of abuse has not previously been described in the literature.

Background: Surveillance colonoscopy has been shown to be an effective tool for prevention of colorectal cancer (CRC) in high-risk populations, if adhered to.Aim: To discover the sequelae of late surveillance in a cohort of patient's overdue for colonoscopy. Methods:We conducted a retrospective cohort study on all patients from the Bay of Plenty District Health Board region, New Zealand, placed on the colonoscopy surveillance waitlist from 2006 onwards who had their procedure completed between 1 November 2016 and 31 January 2018. Patients with overdue surveillance, defined as done later than 90 days after the recommended due date, were compared with patients who were done either early or on time.Results: A total of 786 patients was recorded as overdue for surveillance colonoscopy and 386 were completed early or on time. The median time overdue was 22 months. Three (0.4%) cases of CRC were found in overdue patients compared with four (1%) cases for those done on time (adjusted P = 0.24). There were 86 (11%) advanced adenomas (AA) in patients overdue compared with 27 (7%) in those not overdue (odds ratio (OR) 1.6; 95% confidence interval (CI) 1.0-2.5; P = 0.04). Surveillance of 180 high-risk post-polypectomy patients identified 2 CRC and 8/43 AA in those overdue compared with no CRC and 9/137 AA (18.6% vs 6.6%; OR 1.79; 95% CI 1.07-2.0; unadjusted P = 0.03) in those done on time. Conclusion:While overdue surveillance is not predictive of increased CRC, it is associated with an increase in expected number of AA, particularly in patients having surveillance for previous high-risk polypectomy.Abbreviations: AA, advanced adenoma; CI, confidence Interval; CRC, colorectal cancer; FHx, family history; HNPCC, herediatry non-polyposis colorectal cancer (in this paper, HNPCC refers to patients who fulfilled the Amsterdam criteria, although a proportion also had confirmed germline mutation in one of the DNA mismatch repair genes (Lynch syndrome

A 62-year-old woman with progressive shortness of breath and a 40-pack-year smoking history was referred for pulmonary evaluation after a radiograph of the chest showed nodularity along the left hemidiaphragm (Panel A, arrows), raising the possibility of cancer. The radiograph was otherwise unremarkable except for hyperinflation suggestive of emphysema and mild thoracic scoliosis. Her medical history was notable for a gunshot wound to the thoracoabdominal region 28 years earlier, which had resulted in injury to the liver, left hemidiaphragm, and spleen, requiring a laparotomy and splenectomy. Computed tomography revealed several small, basilar, pleural nodules on the left side (Panel B, arrows) as well as a diaphragmatic defect and nodules in the splenic bed, with findings of prior splenectomy. A technetium-99m-labeled scan with heat-damaged red cells confirmed the diagnosis of splenosis. This study showed remnants of splenic tissue above and below the left hemidiaphragm, including nodules in the left hemithorax that extended as high as the aortic arch (Fig. S1 in the Supplementary Appendix, available with the full text of this article at NEJM.org). Splenosis refers to heterotopic viable splenic tissue that is implanted because of spillage or intravascular migration of cells from splenic pulp. This condition usually follows splenic trauma with rupture, accidental damage to the spleen during surgery, or elective splenectomy. The degree of immunocompetence was uncertain, and we recommended that the patient be immunized against encapsulated bacteria. She began using an inhaler for chronic obstructive pulmonary disease, which was confirmed with the use of spirometry and explained her initial symptoms of progressive shortness of breath, and had a good response.

Background and Aim: Despite widespread recommendations and use of intravenous corticosteroids (IVCS) for the treatment of acute flares of ulcerative colitis and Crohn's disease, limited evidence exists comparing outcomes of the two most common regimens, intravenous methylprednisolone (IVMP) and intravenous hydrocortisone (IVHC). IVHC has stronger mineralocorticoid effects compared with IVMP and may cause higher rates of hypokalemia. We aimed to determine differences in clinical outcomes including requirement for inpatient rescue therapy, bowel resection, and rates of hypokalemia. Methods: We conducted a multicenter cohort study of all adult patients admitted with an acute flare of inflammatory bowel disease (IBD) to the three tertiary hospitals in Auckland, New Zealand, where the protocol at each institution is either IVMP 60 mg daily or IVHC 100 mg four times daily. All patients requiring IVCS between 20 June 2016 and 30 June 2018 were included. The IVCS protocol was then changed at one hospital, where further data were collected for a further 12 months from 30 January 2019 until 30 December 2019. Results: There were 359 patients, including 129 (35.9%) patients receiving IVMP and 230 (64.1%) patients receiving IVHC. IVMP treatment was associated with a greater requirement for rescue therapy than IVHC (36.4% vs 19.6%, P = 0.001; odds ratio [OR] = 2.79; 95% confidence interval [CI], 1.64-4.75, P < 0.001), but also reduced rates of hypokalemia (55.8% vs 67.0%, P = 0.04; OR = 0.49; 95% CI, 0.30-0.81, P = 0.005). There was no difference between treatment groups for the median length of admission (5 days, interquartile range [IQR] 3-8), median duration of IVCS treatment (3 days, IQR 2-5), or bowel resection within 30 days of admission (12.4% vs 11.7%; OR = 1.04). Conclusion:For the treatment of an acute flare of IBD, treatment with IVMP results in significantly more requirement for inpatient rescue biologic or cyclosporin. In addition, it causes statistically significant less hypokalemia than IVHC, although in practice differences are negligible.