Spontaneous collapse of the tibial plateau: radiological staging.

OBJECTIVE: This paper proposes a radiological staging system for necrosis of the tibial plateau, similar to those already developed for the hip and the medial femoral condyle. DESIGN AND PATIENTS: We retrospectively studied the clinical case histories and radiographic findings of 14 patients (15 affected knees) with histologically proven osteonecrosis of the tibial plateau. RESULTS: Stage I was marked by normal radiograph, but increased uptake in bone scan and subchondral areas of abnormal marrow signal intensity in magnetic resonance imaging (MRI), as reported in other osteonecrosis sites. Stage II was characterised by cystic and sclerotic changes, and stage III fracture of the medial rim of the medial tibial plateau and tibial plateau collapse were present. Stage IV was marked by joint narrowing. These changes appeared earlier and were more pronounced when there was genu varum/valgum or involvement of the lateral tibial plateau. CONCLUSIONS: The radiological evolution of the disease appears to follow a four-stage course over a period of roughly one year from the onset of symptoms.

Progression of bone lesions in cured leprosy patients.

A group of 52 patients deemed to be cured of Hansen's disease were examined in order to determine the appearance or aggravation of bone lesions after cure. A study was made of X-rays performed both at the moment these patients were considered to be cured and a minimum of 2 years later. During the elapsing interval, new lesions had appeared in 8 patients, and existing lesions had worsened in 12 patients. Factors associated with the progression of lesions were: impaired sensitivity, physical activity and appearance of plantar ulcers. The authors feel that leprosy patients, even when considered to be bacteriologically cured, should undergo regular checkups. Factors which might aggravate bone lesions should be borne in mind.

Bone island and leprosy.

OBJECTIVE: To determine the incidence of bone islands in leprosy patients. DESIGN: X-rays of feet and hands of patients with Hansen's disease (leprosy) were reviewed retrospectively. A second group of related age- and sex-matched patients who did not have Hansen's disease was used for control purposes. Controls had undergone hand and foot X-rays during diagnosis of other pathologies. The patients with Hansen's disease were compared with the control groups, and were also analyzed as subgroups with different types of leprosy. The results were subjected to statistical analysis. PATIENTS: Ninety patients with Hansen's disease were randomly selected for this study. Patients who had had ulcers on hands or feet were excluded from the study. RESULTS AND CONCLUSIONS: Bone islands were demonstrated in 20 patients with Hansen's disease; no bone islands were observed in the controls. This was statistically significant (P < 0.01). Bone islands were only seen in patients with lepromatous leprosy and borderline types but were not demonstrated in patients with tuberculoid leprosy. There was also a statistically significant relationship for a disease duration of 15 years or more. The cause of this raised incidence of enostosis in leprosy patients is not clear, but there may be a genetic predisposition in patients with leprosy, or it may be a side effect of leprosy, especially the lepromatous form.

Comparison of the cervical cytology test using the PAPNET method and conventional microscopy.

From August 1994 to June 1995, laboratories in 28 Mexican states and the Federal District submitted a total of 10098 diagnosed Pap test slides to Mexico's National Institute of Epidemiologic Diagnosis and Reference (INDRE) for reexamination by conventional methods and also by the automated PAPNET system in Suffern, New York, U.S.A. The aim was to determine the degree of agreement obtained by these various methods. Most of the slides examined (at least 78%) yielded negative results or merely indicated an inflammatory process; 8% to 14% indicated mild or moderate cervical dysplasia; and 2% to 3% indicated conditions ranging from severe dysplasia to invasive cervical cancer. Comparison of the state laboratory and INDRE diagnoses yielded a Kappa correlation coefficient of 0.62, near the lower limit of agreement, the agreement being poorest in cases where it was necessary to distinguish between degrees of abnormality. Although state laboratory underestimation appeared lowest with respect to cases of atypia and of mild, moderate, and severe dysplasia (between 12% and 20%), these percentages are alarming because it is at these stages that the patient may be treated to prevent evolution to carcinoma. While the Kappa correlation coefficient was better (0.80) when the INDRE and PAPNET diagnoses were compared, PAPNET showed only limited ability to distinguish between various pathologic alterations, and the percentages of underestimates (false negatives) obtained with PAPNET were also high. Overall, the results indicate a need to improve the quality of cervical cytology diagnoses at state public health laboratories in Mexico through stepped-up training and supervision. They also indicate that the use of PAPNET involves greater difficulty than does manual microscopic examination of cervical smears, and that a way still needs to be found to detect and review the false negative results generated by PAPNET before approving use of this technology.

PIP: Comparison of cervical smear analyses conducted in Mexican laboratories through conventional microscopy with the results of quality control studies conducted by the National Institute of Epidemiologic Diagnosis and Reference (INDRE) using both conventional and automated (PAPNET) methods revealed an alarming lack of agreement. A total of 10,098 slides prepared by technicians working at state public health laboratories in 28 Mexican states and the federal district were reviewed. Most slides (about 78%) yielded negative results or an inflammatory process; 8-14% indicated mild or moderate cervical dysplasia, and 2-3% revealed severe dysplasia or cervical cancer. The Kappa correlation coefficient for agreement between positive and negative diagnoses made by the states and INDRE was 0.62, near the lower limit, while comparison of diagnoses made by INDRE and PAPNET produced a coefficient of 0.80, near the upper limit. Diagnostic agreement between state laboratories and INDRE was greatest (93%) with slides classified as normal or exhibiting inflammatory changes. Agreement rates were lowest when it was necessary to differentiate degrees of abnormality: unspecified carcinoma (13.3%), invasive carcinoma (51.4%), and moderate dysplasia (63.1%). PAPNET generated substantially more false-negative results than traditional microscopy performed either by INDRE or the states and underestimated the presence of human papillomavirus virus, Candida infection, and trichomoniasis. Inadequate fixing, staining, and mounting of the slides compromised PAPNET analysis. Overall, these findings indicate a need to improve the quality of cervical cytology diagnoses at state laboratories through increased training and supervision.