A recent review of gout in the New England Journal by Robert Terkeltaub, MD is worth reading. Several points merit emphasis. Hyperuricemia is central to gout but does not inevitably cause disease. An acute gouty attack may be seen in the presence of normal uric acid levels. Classic symtomology is usually a painful monoarticular inflammation but polyarthritis and chronic arthritis can also occur. The prevalence among post-menopausal women in association with obesity, diuretic-treated hypertension, and renal insufficiency is rising. Initial symptomology in this sub-population include tophi in osteoarthritic small joints of the hand. NSAID's are considered first line therapy. Selective Cox-1I inhibitors are an alternative in patients with GI contraindications. Colchicine should not be used intravenously but is still useful by the oral route. Long term uric acid lowering therapy in gout is justified by the presence of tophi or frequent attacks of gouty arthritis. Allopurinol or other potent uricoursuric agents are available. Eighty percent of transplant recipients develop hyper-uricemia and gout develops in 10 percent of this population. Weight loss and alcohol restriction will also lower the uric acid. (N Engl JMed 2003;349:1647-55)

Colorectal cancer is the second leading cause of cancer related deaths in the United States. Most are believed to arise within adenomatous polyps which undergo transformation into cancer hence their removal is a way to prevent it. Several screening approaches are available ranging from fecal occult blood testing to more costly invasive procedures of flexible sigmoidoscopy, barium enema, and colonoscopy. These authors screened 1253 consecutively enrolled asymptomatic adults who underwent complete virtual and standard optical colonoscopy examinations on the same day. The sensitivity and specificity of virtual colonoscopy for the detection of adenomatous polyps 8mm or larger was more than 92%. The virtual colonoscopy test required the same bowel cleansing preparation as conventional colonoscopy but sedation was not required and the time required for the procedure was about 10-15 minutes. Adenoma's 10mm or greater in size were found in 3.9% of the patients. A total of 611 of the 1233 patients screened had no polyps. Two polyps, one in the cecum and one in the ascending colon were malignant both of which would have failed detection by standard flexible sigmoidoscopy. Patients reported more discomfort with virtual colonoscopy than with standard optical colonoscopy; although because of its convenience, they indicated they would choose this procedure for their next screening test. The major disadvantage, of virtual colonoscopy, is that the patients who have polyps detected need to then undergo a standard colonoscopy for their removal. In conclusion, the results of this study were impressive and it seems as though this procedure will be another way to get more people screened for colon cancer. (N Engl J Med 2003;349:2191-2200)

John J. Mohr, M.D.