Sacral insufficiency fractures: an easily overlooked cause of back pain in elderly women

Sacral insufficiency fractures (SIF) that usually present as nonspecific pelvic or low back pain are often overlooked in the elderly. In a retrospective study conducted in a department of internal medicine, 16 patients with SIF were identified during a 6-year period. All patients were elderly women (mean age of 81 years) who presented with low back or pelvic pain. Radicular pain in the lower limb was common. Ten patients were bedridden. All 16 patients were osteopenic. Plain radiographs of the pelvis were nondiagnostic in 11 patients. Radionuclide bone scan showed a typical H-shaped pattern of increased uptake in 11 patients, and computed tomographic scan confirmed SIF (9/9 patients). With bed rest and analgesics, outcome was favorable in all patients. This study confirms the nonspecific presentation of SIF and the need to maintain a high index of clinical suspicion to make a prompt diagnosis and avoid unnecessary and sometimes invasive procedures.

Relevance of residue 116 of HLA-B27 in determining susceptibility to ankylosing spondylitis

Ankylosing spondylitis (AS) is an autoimmune disorder strongly associated with HLA-B27. A direct role of B27 molecules in the disease pathogenesis has been postulated, possibly by presenting to T cells an as-yet unidentified arthritogenic peptide that triggers the autoimmune response. There are nine HLA-B27 alleles differing from each other at one or more amino acid positions. It is important, for the identification of the arthritogenic peptide, to define which alleles, and therefore which polymorphic positions, predispose to the disease. Here, we report that HLA-B*2709 is not associated with AS, as it was not found in patients. HLA-B*2709 differs from the most frequent and disease-associated HLA-B*2705 allele for a single substitution (His vs. Asp) at position 116. Amino acid 116 is located at the bottom of the groove where the antigenic peptide sits, and it has been proven to influence the peptide-binding specificity of HLA class I molecules. The most likely interpretation of these data is that the differences in charge and size that accompany the His-to-Asp substitution exclude the acceptance of the arthritogenic peptide.

Cauda equina compression by epidural lipomatosis in obesity. Effectiveness of weight reduction

Epidural lipomatosis (EL) is characterized by abnormal accumulation of unencapsulated fat in the epidural space, and usually occurs as a complication of longterm steroid therapy. This condition, which may result in devastating neurologic complications, has also been reported without exogenous steroid intake. We describe a case of nonsteroid induced symptomatic EL associated with obesity, and emphasize the possibility of effective medical management of this entity with weight reduction instead of decompressive laminectomy whenever neurologic symptoms are mild and stable.

Tracheo-bronchial mucociliary clearance in patients with primary and secondary Sjögren's syndrome

We determined the tracheo-bronchial mucociliary clearance (MCC) in order to evaluate a possible impairment of this function in patients affected by Sjögren's syndrome (SS) with or without overt clinical symptoms of xerotrachea. The MCC was expressed as flow rate (mm/min) and studied in 22 non-smoking SS patients (10 pSS and 12 sSS) and in 8 control subjects by specifically adapted ventilation lung scintigraphy (VLS). The MCC in the control group was 5.9 +/- 1.1 mm/min. No values were produced for MCC in 16 SS patients (8 pSS and 8 sSS) in the time interval considered and were reduced in the remaining 6 SS patients (3.3 +/- 1.2 mm/min). In all nine cases with clinical evidence of xerotrachea no values for MCC were obtained. A significant correlation was found between the MCC values and the rate of stimulated salivary excretion determined by dynamic scialoscintigraphy in the same patients (p < 0.001). These preliminary data show that the majority of SS patients studied presented with MCC impairment, always found when clinical symptoms of xerotrachea were present.

Abnormalities of magnetic resonance imaging of the central nervous system in patients with systemic lupus erythematosus correlate with disease severity

Forty randomly selected patients with systemic lupus erythematosus (SLE) were studied by clinical and serologic parameters and magnetic resonance imaging (MRI). Abnormal MRI was found in 15/40 patients (37.5%): all 15 cases showed multiple widespread small-sized areas of increased signal in T2 in the white matter; in one of these patients MRI also displayed a large area with a reduced signal in T1 and an increased signal in T2 involving both the white and the gray matter. Among the 15 patients with abnormal MRI, only 7 had neuropsychiatric symptoms. The presence of MRI changes was highest in patients with organic type symptoms and was associated to the highest disease severity scores. A long-term follow up of asymptomatic patients would be useful to establish whether the application of MRI is appropriate for the assessment of CNS involvement in SLE.

[Continuous infusion of vancomycin during the neonatal period]

Twenty-five infants with suspected or confirmed coagulase negative staphylococcal infection were studied. Continuous administration of vancomycin was used because it is usual with infusions prepared daily for catheterized patients, and because continuous infusions are well tolerated and achieve better penetration in tissues and CSF. Vancomycin acts as a time-dependent antibiotic. The aim was to obtain a level of 20-25 mg/l. in serum. Fifteen newborns term 27-35 weeks (m = 30.3) aged 7-30 days (m = 16.1) received 10 to 45 mg/kg/day of vancomycin and were monitored for 2 to 12 days. The sample for assay was taken in a peripheral vein, and the results were the same during the infusion or 15 minutes after its end. The daily dose of vancomycin necessary varied from 25 to 40 mg/kg for newborns with serum creatinine < 70 mmol/l and 10 to 30 mg/kg with serum creatinine > or = 90 mmol/l. Except for a newborn with multiorgan failure, serum creatinine rapidly decreased. Four newborns term 38-40 weeks (m = 39.5) aged 2-12 days (m = 8.3) received 20 to 45 mg/kg/day of vancomycin and were monitored for 2 to 12 days. The daily dose necessary varied from 30 to 40 mg/kg/day with important individual variations, and 20 mg/kg/day in a newborn with a high level of creatinine. In 6 infants aged 2-22 months receiving 22-45 mg/kg/day of vancomycin, a mean daily dosage of 40-45 mg/kg was adequate, with important individual variations.(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of computer-based clinical decision support systems on clinician performance and patient outcome. A critical appraisal of research

OBJECTIVE

To review the evidence from controlled trials of the effects of computer-based clinical decision support systems (CDSSs) on clinician performance and patient outcomes.

DATA SOURCES

The literature in the MEDLARS, EMBASE, SCISEARCH, and INSPEC databases was searched from 1974 to the present. Conference proceedings and reference lists of relevant articles were reviewed. Evaluators of CDSSs were asked to identify additional studies.

STUDY SELECTION

793 citations were examined, and 28 controlled trials that met predefined criteria were reviewed in detail.

DATA EXTRACTION

Study quality was assessed, and data on setting, clinicians and patients, method of allocation, computer system, and outcomes were abstracted and verified using a structured form. Separate summaries were prepared for physician and patient outcomes. Within each of these categories, studies were classified further according to the primary purpose of the CDSS: drug dose determination, diagnosis, or quality assurance.

RESULTS

Three of 4 studies of computer-assisted dosing, 1 of 5 studies of computer-aided diagnosis, 4 of 6 studies of preventive care reminder systems, and 7 of 9 studies of computer-aided quality assurance for active medical care that assessed clinician performance showed improvements in clinician performance using a CDSS. Three of 10 studies that assessed patient outcomes reported significant improvements.

CONCLUSIONS

Strong evidence suggests that some CDSSs can improve physician performance. Additional well-designed studies are needed to assess their effects and cost-effectiveness, especially on patient outcomes.

Association of the HLA-A2, CW2, B27, S31, DR2 haplotype with ankylosing spondylitis. A possible role of non-B27 factors in the disease

With the aim of searching for HLA haplotypes and non-B27 allele frequency variations in Sardinian AS patients, HLA-A, B, Cw, DR, DQ and Bf, C4A and C4B typing and haplotype assignment was carried out in the families of 25 AS patients and in 44 healthy individuals, all B27 heterozygotes. In the AS patients a significant increase of the A2, Cw2, B27, DR2, DQ1 haplotype was found. This depends only partially on the linkage disequilibrium existing in the Sardinian population between B27 and the other alleles of this haplotype, and rather seems to be due to a primary association of Cw2 and DR2 alleles with AS. Preliminary data seem to show that this haplotype bears the S31 complotype and the DRB1*1601 allele both in the AS patients and in the healthy controls. The pathogenetic implications of these findings are discussed.

Nerve growth factor and mast cell distribution in the skin of patients with systemic sclerosis

Nerve growth factor (NGF), a well-characterized neurotrophic factor, induces an increase in the number of mast cells (MCs) in the peripheral tissues of developing rats, as well as histamine release in fully differentiated MCs. Since MCs increase in the dermis of patients with early systemic sclerosis (SSc), we examined the distribution of NGF in the skin of patients affected by SSc. Immunohistochemical studies showed that NGF distribution was more intense in the dermis of patients with SSc than in the skin of controls. A possible correlation between MCs and NGF in disease activity is hypothesized.

The Italian version of the Functional Disability Index of the Health Assessment Questionnaire. A reliable instrument for multicenter studies on rheumatoid arthritis

A working group of ten rheumatology institutes (UNIREUM) was formed in Italy to promote multicenter therapeutic studies on rheumatoid arthritis. The Functional Disability Index (FDI) of the Health Assessment Questionnaire (HAQ) was chosen as a measure of disability. This paper reports the results of a multicenter study to validate an Italian translation of the instrument and to assess its reliability and validity. Two questions were modified to achieve cross-cultural equivalence. Back-translation into English showed agreement with the American instrument. Reproducibility was high: the test-retest correlation coefficient was 0.989 and ranged from 0.81 to 0.99 for the centers taken separately. Validity was confirmed by a correlation coefficient of 0.95 between the patient self-attributed and the physician-attributed FDI scores. We conclude that our Italian version of the HAQ FDI is a reliable and valid self-administered instrument.

[Fracture of the sacrum caused by bone insufficiency in the elderly: apropos of 14 cases]

We report a series of 14 elderly patients with sacral insufficiency fractures of the sacrum. All patients presented with pain in low back, pelvis or lower limb which was often misleading. Bone scintigraphy was diagnostic in all the patients. Outcome was favourable in all the cases.

Circulating antibodies to DNA-related antigens in patients with autoimmune thyroid disorders

A high prevalence of antibodies to double-stranded DNA (AbDNAds) has been recently reported in serum of patients with autoimmune thyroid disorders, but the specificity of this finding has been questioned. For this reason, the prevalence of several antibodies to DNA-related nuclear antigens (AbDRENA) has been evaluated in sera of patients with autoimmune and non-autoimmune thyroid disease. The study group included: 46 Graves' disease patients, 28 Hashimoto's thyroiditis patients, 25 patients with toxic nodular goitre and 11 with non-toxic nodular goitre. Twenty-eight Graves' patients were retested during methimazole (MMI) therapy, and 5 after radioiodine administration. Twenty-two patients with systemic lupus erythematosus and 28 normal subjects served as positive and negative controls, respectively. AbDRENA included: AbDNAds by RIA or immunofluorescence (IF); antibodies to single-stranded DNA (AbDNAss) and antibodies to histone (AbHist) by ELISA methods; antibodies to nuclear antigens (ANA) by immunofluorescence. RIA values were considered to be abnormal when 2 SD above the mean of normal controls. In our study 13% of Graves' patients were positive for AbDNAds by RIA: all of them had negative tests by IF; 11% were positive for AbDNAss, 2% for AbHist and 7% for ANA. A comparable prevalence of positive results for AbDNAds by RIA, with negative IF tests, was found in Hashimoto's thyroiditis patients. No significant changes of antibody levels were observed in Graves' patients during MMI treatment or after radioiodine administration. A positivity for AbDNAds or AbDNAss was found in 8% of patients with toxic nodular goitre, but in none of those with non-toxic goitre.(ABSTRACT TRUNCATED AT 250 WORDS)

Correlations among capillaroscopic abnormalities, digital flow and immunologic findings in patients with isolated Raynaud's phenomenon. Can laser Doppler flowmetry help identify a secondary Raynaud phenomenon?

Thirty subjects with a diagnosis of isolated Raynaud's phenomenon, according to anamnestic and objective criteria, were cross-evaluated by various methods: laser Doppler flowmetry (LDF) during a standardized cold and rewarming test, nailfold capillaroscopy, immunological and other laboratory parameters, to assess the diagnostic and prognostic significance of each method. Correlations were also assessed among disease duration, capillaroscopic pattern score, quantitative digital flow values and laboratory parameters. Nearly 30% of patients showed immunologic abnormalities (ANA positivity at variable titres, ENA, hypocomplementemia, immunocomplexes); 16% of patients had a pathologic capillaroscopic pattern, not well correlated with immunologic findings; a characteristic cold stop reaction of digital flow (partial or total) was detected in 86% of the subjects; in ANA+ pts., ANA titers were positively correlated with the intensity and length of stop reaction (Trec). A significant correlation between digital flow parameters and the capillaroscopic score was also found in each considered group. Our results outline the relevance of LDF, during a standardized thermic test, to evaluate apparently primary RP, because even if a definite scleroderma-like capillaroscopic pattern is absent, this flowmetric method may detect potentially secondary RP patients.