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PICTURE QUIZ
Rusty joints
A 47 year old white man presented to the outpatient clinic with progressive
pain and stiffness of hands and feet of five years’ duration. During this
time he once experienced swelling of the knuckles of his right hand that
resolved spontaneously within a week. Diclofenac 50 mg twice daily had
not been effective. A year ago ankle osteoarthritis had been diagnosed
arthroscopically. He did not smoke or drink alcohol. His father, who
had diabetes, also had painful joints. On examination, he was noted to
be tanned, with a body mass index of 27. He had subtle arthritis of the
second and third metacarpophalangeal joint of the left hand and third
metacarpophalangeal joint of the right hand, Heberden’s nodes of several
distal interphalangeal hand joints, and crepitus of ankle and knee joints
bilaterally. The liver was palpable 3 cm below the right costal margin.
Otherwise, physical examination was unremarkable. Laboratory tests and
radiographs (fig 1) were ordered.
1 What are the differential diagnoses for this patient’s joint problems?
2 What abnormalities can be seen on the radiograph?
3 What is the most likely clinical diagnosis?
4 How is this clinical diagnosis confirmed?
5 How can this condition be treated?
Submitted by Marieke van Onna, B Sweder van Asbeck, and Johannes W G Jacobs
Cite this as: BMJ 2011;343:d6197
Fig 1| Radiographof hands and wrists
STATISTICAL QUESTION
Random sampling versus random allocation
Researchers investigated the effects of providing people with evidence based information about
colorectal cancer and screening. A randomised controlled study design was used. The intervention
was a brochure that included personalised risk of colorectal cancer, available screening options with
possible benefits and harm, plus information on prevention of colorectal cancer. People also had
access to two optional interactive internet modules on risk and diagnostic tests. The control treatment
was the official information leaflet of the German colorectal cancer screening programme. Primary
outcome measures included “informed choice” based on knowledge and attitude, plus the planned
and actual uptake of screening.
Potential trial participants were people insured by a large German statutory health insurance scheme
who were aged 50-75 years and had no history of colorectal cancer. A total of 7946 people were
eligible. A random sample of about 4000 people was drawn and invited to participate in the trial. In
total, 1577 agreed and were randomly allocated to the intervention (n=785) or control (n=792).
The researchers reported that providing evidence based risk information on colorectal cancer and
screening improved knowledge and increased informed choices but had little effect on attitudes. The
intervention did not increase combined actual and planned uptake of screening.
Which of the following statements, if any, are true?
a) The objective of random sampling was to facilitate application of the trial results to the study
population
b) Random allocation of trial participants minimised allocation bias
c) Random sampling ensured treatment groups were of similar size
d) Random allocation of trial participants minimised confounding at baseline
e) Random allocation of trial participants facilitated application of the trial results to the study
population
Submitted by Philip Sedgwick
Cite this as: BMJ 2011;343:d7453
1116
CASE REPORT
Problems in pregnancy
A 19 year old woman attended antenatal
clinic at 16 weeks’ gestation (gravida 2, para
0+1). Routine urine dipstick testing identified
blood (+++) and protein (++). Similar findings
had been recorded three weeks earlier. She
described tiredness and occasional painless
minor haemoptysis. She had a history of
chlamydial infection and a spontaneous
miscarriage two years earlier. She occasionally
smoked marijuana but did not drink alcohol.
Her body mass index was 32.2. She had
no family history of note. Examination was
unremarkable except for bilateral renal angle
tenderness. Sequential urine specimens were
culture negative.
1 What is the differential diagnosis?
2 What else should be done for a pregnant
woman with haematoproteinuria?
3 What is the prognosis for this woman if her
condition is left untreated?
4 Is there any prospect of a successful
outcome to this pregnancy?
Submitted by Thomas Nicholson, Daniel Zehnder, Andrew
Short, and Alastair Ferraro
Cite this as: BMJ 2011;343:d7239
BMJ | 26 NOVEMBER 2011 | VOLUME 343