Treatment of Interspinous Pain With Extracorporeal Shockwave Therapy: A Case Report

ABSTRACT

The interspinous region is an atypical source of low back pain, and it can often be difficult to identify. There are many structural components in the interspinous region that can contribute to interspinous pain, including the interspinous ligament, which plays a role in providing stabilization to the spine. Successful treatments of interspinous pain have not been well characterized in the literature. This case presents the first documentation of the use of extracorporeal shockwave therapy as a noninvasive treatment for refractory interspinous-related low back pain. Extracorporeal shockwave therapy has previously been shown to facilitate regeneration and tissue healing in tendons and ligaments but has not previously been used to treat interspinous pain. A 24-yr-old former collegiate softball player presented with 5 mos of low back pain; the interspinous ligament was clinically suspected as a pain generator, and this was confirmed via an ultrasound-guided injection. She underwent a course of physical therapy that improved function but did not improve pain, and nonsteroidal anti-inflammatory drugs only provided minimal and temporary relief. Three consecutive extracorporeal shockwave therapy treatment sessions provided 90% improvement in pain and function, and she was able to return to exercise and recreational sports. At more than 6 mos after extracorporeal shockwave therapy treatment, she reported no recurrences or functional limitations.

Upper Body Injuries in Golfers

PURPOSE OF REVIEW

Golf is a sport that can be played by an athlete of any age, which enhances its popularity. Each golfer's swing is unique, and there is no "right" way to swing the golf club; however, the professional golfer often has more of a consistent swing as opposed to an amateur golfer. A collaborative, team approach involving the golfer with a swing coach, physical therapist, and physician often can be informative on how to prevent golf injury, but also how to treat golf injury if it occurs.

RECENT FINDINGS

As a rotational sport, the golfer needs to be trained and treated with respect for how the body works as a linkage system or kinetic chain. A warm-up is recommended for every golfer before practicing or playing, and this warm-up should account for every segment of the linkage system. Though it has been thought of as a relatively safe sport, injuries can be seen with golfers of any age or skill level, and upper body injuries involving the cervical and thoracic spine, shoulder, elbow, and wrist are common. A narrative review is provided here of the epidemiology of golf injury and common injuries involving each of these upper body regions. In addition, treatment and injury prevention recommendations are discussed.

The Spine Physical Examination Using Telemedicine: Strategies and Best Practices

STUDY DESIGN

Technical note.

OBJECTIVES

To provide spine surgeons new to telemedicine with a structured physical examination technique based on manual motor testing principles.

METHODS

Expert experience describing a series of specific maneuvers for upper and lower extremity strength testing that can be performed using a telemedicine platform. In addition, we offer instruction on "setting up" for these visits and highlight special tests that can be used to diagnose specific cervical and lumbar spine conditions.

RESULTS

From our experiences in conducting telemedicine visits, we provide a means of testing and scoring upper and lower extremity strength for interpretation of weakness in the context of traditional manual motor testing. Also, we acknowledge the limitations of a remote examination and discuss maneuvers that cannot be performed remotely.

CONCLUSIONS

COVID-19 has drastically altered the delivery of care for patients with spine-related complaints. The need for social distancing has led to the widespread adoption of telemedicine. This technical note provides an urgently needed framework for the standardization of the remote physical exam. Validation of the exam as a diagnostic tool will be a crucial next step in studying the impact of telemedicine.

Is There a Relationship Between Body Mass Index and Fluoroscopy Time During Cervical Interlaminar Epidural Steroid Injections?

Background

The challenge of obtaining medical imaging in individuals with higher body mass index (BMI) is described, but there is minimal data regarding the relationship between BMI and fluoroscopy time during cervical interlaminar epidural steroid injection (CIESI).

Objective

To determine the relationship between BMI and fluoroscopy time during CIESI.

Methods

Retrospective cohort study of patients who underwent fluoroscopically guided CIESI between January 2014 and February 2015 at an academic pain medicine center. Fluoroscopy time data were collected. Comparisons based on analysis of variance were made between patients with normal (<25.0 kg/m 2 ), overweight (25.0-29.9 kg/m 2 ), and obese (≥30.0 kg/m 2 ) BMI.

Results

Of 399 procedure encounters, 366 had documented BMI and fluoroscopy time data and were included for analysis. Mean age (± SD) in this cohort was 53 ± 13 years, including 189 females (52%) and 205 first-time injections. Mean fluoroscopy time for all injections was 18 ± 10 seconds. Separated by categorical BMI class, the mean fluoroscopy time was 18 ± 9 seconds for normal weight patients, 17 ± 10 seconds for overweight patients, and 20 ± 11 seconds for obese patients, respectively. Post hoc analysis showed that fluoroscopy time was significantly longer only in obese compared with overweight patients ( P  = 0.02). Trainee involvement and first-time vs repeat injection did not significantly alter fluoroscopy time ( P  = 0.17 and P  = 0.12, respectively).

Conclusions

The findings of this study indicate that BMI does not appear to have a clinically significant impact on fluoroscopy time during cervical interlaminar epidural steroid injection procedures. Future study is needed to directly quantify radiation exposure in patients and practitioners, as well as the associated health risk.

The Relationship Between Body Mass Index and Fluoroscopy Time During Intraarticular Hip Injection: A Multicenter Cohort Study

BACKGROUND

Higher body mass index (BMI) is associated with difficulty in obtaining imaging studies. While there is a small body of literature regarding the relationship between fluoroscopy time and BMI during injections for pain management, this has not been studied for intraarticular (IA) hip injections. Further, in academic training centers, trainee involvement may affect this relationship.

OBJECTIVE

To determine the relationship between BMI and fluoroscopy time during IA hip injections, both with and without involvement of a trainee.

STUDY DESIGN

Multicenter retrospective cohort study.

SETTING

Three academic, outpatient musculoskeletal and pain medicine centers.

METHODS

Patients who underwent fluoroscopically guided IA hip injections with encounter data regarding fluoroscopy time during the procedure and BMI were included. Mean and standard deviation fluoroscopy time were recorded. Comparisons were made between BMI categories of normal (18.5 - 24.9 kg/m2), overweight (25.0 - 29.9 kg/m2), and obese (greater than or equal to30.0 kg/m2). Statistical significance was set at P = 0.01 due to multiple comparisons.

RESULTS

A total of 559 IA hip injections are represented in this cohort. Patients had a mean age of 58 (standard deviation [SD] 14) years and 63% were women. There was no significant difference in fluoroscopy time when comparing BMI categories (P = 0.02). However, when trainees were not involved in the injection, fluoroscopy times were significantly shorter with decreasing BMI category, with normal weight patients requiring the shortest fluoroscopy times (P = 0.01).

LIMITATIONS

This study evaluated total fluoroscopy time, not radiation dose exposure per injection, which provides more direct and precise information with regard to provider and patient radiation exposure and overall safety. Future study of the impact of BMI on radiation dose during fluoroscopically guided IA hip injections is needed.

CONCLUSIONS

Fluoroscopy times during IA hip injections increase with higher BMI categories in a statistically significant manner when performed by experienced clinicians but this relationship is not observed when injections are performed with a trainee in a teaching institution. This finding appears to be related to longer fluoroscopy time required to complete an IA hip injection in patients with lower BMI when a trainee is involved.

KEY WORDS

Hip, injections, obesity, overweight, body mass index, fluoroscopy, radiation, pain.

The Kinetic Chain Revisited: New Concepts on Throwing Mechanics and Injury

The overhead throwing motion is a complex activity that is achieved through activation of the kinetic chain. The kinetic chain refers to the linkage of multiple segments of the body that allows for transfer of forces and motion. The lower extremities and core provide a base of support, generating energy that is transferred eventually through the throwing arm and hand, resulting in release of the ball. The kinetic chain requires optimal anatomy, physiology, and mechanics and is involved in all 6 phases of overhead throwing: windup, stride, arm cocking, acceleration, deceleration, and follow-through. Breaks or deficits in the kinetic chain can lead to injury or decreased performance. Through an understanding of the mechanics and pathomechanics seen in each phase of throwing, the clinician can better evaluate and screen for potential kinetic chain deficits in the overhead throwing athlete. The purpose of this article is to review the biomechanics of the overhead throwing motion, the role of the kinetic chain in throwing, and the clinical evaluation and management of abnormal throwing mechanics and related injuries.

The Impact of Body Mass Index on Fluoroscopy Time During Lumbar Epidural Steroid Injection; A Multicenter Cohort Study

Objective

This study aimed to assess the relationship between BMI and fluoroscopy time during lumbar epidural steroid injections (LESIs) performed for lumbosacral radicular pain.

Design

Multicenter retrospective cohort study.

Setting

Three academic, outpatient pain treatment centers.

Subjects

Patients who underwent fluoroscopically guided LESI.

Methods

Mean and standard deviation (SD) fluoroscopy time were compared between patients with normal (18.5-24.9 kg/m2), overweight (25.0-29.9 kg/m2), and obese (≥30.0 kg/m2) BMI. Statistical significance was set at P=0.01 due to multiple comparisons.

Results

A total of 2,930 procedure encounters were included, consisting of 598 interlaminar LESIs and 2,332 transforaminal LESIs. Fluoroscopy time was significantly longer in the obese patients compared to normal and overweight patients during interlaminar LESI (P < 0.01). Fluoroscopy time was significantly longer with each increasing BMI category in during transforaminal LESI (P < 0.01). These relationships remained when a trainee was involved (P < 0.01; P<0.01), during repeat injections (P < 0.01; P < 0.01), and during bilateral transforaminal LESIs (P < 0.01). While longer fluoroscopy times were required in high BMI categories during L5-S1 transforaminal LESI (P < 0.01), there was no relationship between fluoroscopy time and BMI during L4-L5 and S1 transforaminal LESI (P = 0.02; P = 0.13). Fluoroscopy time during interlaminar LESI compared to transforaminal LESI was significantly lower within all BMI categories (all P<0.01).

Conclusions

The findings of this study indicate that fluoroscopy time is increased during interlaminar LESIs and during L5-S1 transforaminal LESIs in patients who are obese. These relationships are not affected by injection number, performance of bilateral injections, or trainee involvement. Further study is needed to determine if this increase in fluoroscopy time is indicative of a clinically significant associated increase in radiation dose.

Local, national, and service component cost variations in the management of low back pain: Considerations for the clinician

In the past two decades, the cost associated with managing low back pain has increased significantly. Improved consciousness of how clinicians utilize resources when managing low back pain is necessary in the current economic climate. The goal of this review is to examine the component costs associated with managing low back pain and provide practical solutions for reducing healthcare costs. This is accomplished by utilizing examples from a major metropolitan area with several major academic institutions and private health care centers. It is clear that there is considerable local and national variation in the component costs of managing low back pain, including physician visits, imaging studies, medications, and therapy services. By being well informed about these variations in one's environment, clinicians and patients alike can make strides towards reducing the financial impact of low back pain. Investigation of the cost discrepancies for services within one's community of practice is important. Improved public access to both cost and outcomes data is needed.

Is Hip Abduction Strength Asymmetry Present in Female Runners in the Early Stages of Patellofemoral Pain Syndrome?

BACKGROUND

The current literature indicates that hip abduction weakness in female patients is associated with ipsilateral patellofemoral pain syndrome (PFPS) as part of the weaker hip abductor complex. Thus, it has been suggested that clinicians should consider screening female athletes for hip strength asymmetry to identify those at risk of developing PFPS to prevent the condition. However, no study to date has demonstrated that hip strength asymmetry exists in the early stages of PFPS.

PURPOSE

To determine whether hip abduction strength asymmetry exists in female runners with early unilateral PFPS, defined as symptoms of PFPS not significant enough to cause patients to seek medical attention or prevent them from running at least 10 miles per week.

STUDY DESIGN

Controlled laboratory study.

METHODS

This study consisted of 21 female runners (mean age, 30.5 years; range, 18-45 years) with early unilateral PFPS, who had not yet sought medical care and who were able to run at least 10 miles per week, and 36 healthy controls comparably balanced for age, height, weight, and weekly running mileage (mean, 18.5 mi/wk). Study volunteers were recruited using flyers and from various local running events in the metropolitan area. Bilateral hip abduction strength in both a neutral and extended hip position was measured using a handheld dynamometer in each participant by an examiner blinded to group assignment.

RESULTS

Patients with early unilateral PFPS demonstrated no significant side-to-side difference in hip abduction strength, according to the Hip Strength Asymmetry Index, in both a neutral (mean, 83.5 ± 10.2; P = .2272) and extended hip position (mean, 96.3 ± 21.9; P = .6671) compared with controls (mean, 87.0 ± 8.3 [P = .2272] and 96.6 ± 16.2 [P = .6671], respectively). Hip abduction strength of the affected limb in patients with early unilateral PFPS (mean, 9.9 ± 2.2; P = .0305) was significantly stronger than that of the weaker limb of control participants (mean, 8.9 ± 1.4; P = .0305) when testing strength in a neutral hip position; however, no significant difference was found when testing the hip in an extended position (mean, 7.0 ± 1.4 [P = .1406] and 6.6 ± 1.5 [P =.1406], respectively).

CONCLUSION

The study data show that early stages of unilateral PFPS in female runners is not associated with hip abduction strength asymmetry and that hip abduction strength tested in neutral is significantly greater in the affected limb in the early stages of PFPS compared with the unaffected limb. However, when tested in extension, no difference exists. Further studies investigating the early stages of PFPS are warranted.

CLINICAL RELEVANCE

Unlike patients with PFPS seeking medical care, early PFPS does not appear to be significantly associated with hip abduction strength asymmetry.

Recommendations for palliative and bereavement care in the NICU: a family-centered integrative approach

Technological advances have increased our ability to detect a life-threatening, life-limiting or lethal problem early in pregnancy, leaving parents months to anticipate a death or a prematurely born infant. Babies can also be born with unanticipated problems that could lead to death. In either scenario, perinatal palliative care should be offered as a strategy for family support. Since the preponderance of professional training focuses on saving lives, many health professionals are uncomfortable with palliative care. This article's purpose is to define best practices for the provision of family-centered perinatal and neonatal palliative care and provision of support to bereaved families experiencing anticipated and unanticipated life-limiting conditions or death of their infant. An overview of core concepts and values is presented, followed by intervention strategies to promote an integrated family-centered approach to palliative and bereavement care. The concluding section presents evidence-based recommendations.

Does Electrodiagnostic Confirmation of Radiculopathy Predict Pain Reduction after Transforaminal Epidural Steroid Injection? A Multicenter Study

OBJECTIVE

Minimal definitive literature identifies patients with radicular pain who would benefit most from epidural steroid injection (ESI). This study investigated if electromyographic (EMG) confirmation of radiculopathy with active or chronic denervation predicts a positive treatment outcome following ESI.

DESIGN

Longitudinal cohort study of adults who underwent EMG and subsequent transforaminal ESI within 6 months. The proportion of individuals who experienced >50% pain relief and mean change in daily morphine equivalents (DME) were calculated.

RESULTS

170 individuals with respective mean (Standard Deviation) age and duration of symptoms of 55 (15) years and 36 (56) months were included. Mean time to <30 day and >30 day follow-up post-injection were 18 (6) and 99 (130) days, respectively. At >30 day follow-up, a larger proportion of EMG-confirmed individuals (37.7%) reported >50% pain reduction compared to EMG-negative individuals (17.8%) (p=0.03). This was significant for lumbosacral (40% vs. 15%, p=0.01) but not cervical symptoms (p>0.05). Mean decrease in DME at long-term follow-up in EMG-confirmed compared to EMG-negative individuals trended toward significance (-4 vs. -1, p=0.11). There was no significant relationship between myotomal spontaneous activity and pain or opioid use.

CONCLUSIONS

Needle EMG predicts long-term pain reduction from transforaminal ESI in patients with lumbosacral radiculopathy, regardless of the presence of active denervation.

Lower-Limb Muscle-Activation Patterns During Off-Axis Elliptical Compared With Conventional Gluteal-Muscle-Strengthening Exercises

CONTEXT

Gluteal-muscle strength has been identified as an important component of injury prevention and rehabilitation in several common knee injuries. However, many conventionally prescribed gluteal-strengthening exercises are not performed during dynamic weight-bearing activities, which is when most injuries occur.

OBJECTIVES

To compare lower-limb muscle-activation patterns between conventional gluteal-strengthening exercises and off-axis elliptical exercises with motorized foot-plate perturbations designed to activate gluteal muscles during dynamic exercise.

EVIDENCE ACQUISITION

Twelve healthy volunteers (26.1 ± 4.7 y) participated in the study. They performed 3 conventional exercises (single-leg squat, forward lunge, and clamshell) and 3 elliptical exercises (regular, while resisting an adduction force, and while resisting an internal-rotation torque). Gluteus medius (GMed) and maximus (GMax), quadriceps, hamstrings, and gastrocnemius muscle activations during each exercise were recorded using surface electromyography (EMG) and normalized to maximal voluntary isometric contraction (MVIC).

EVIDENCE SYNTHESIS

Normalized GMed EMG was the highest during the adduction-resistance elliptical exercise (22.4% ± 14.8% MVIC), significantly greater than forward lunge (8.2% ± 3.8% MVIC) and regular elliptical (6.4% ± 2.5% MVIC) and similar to clamshell (19.1% ± 8.8% MVIC) and single-leg squat (18.4% ± 7.9% MVIC). Normalized GMax EMG during adduction-resistance (11.1% ± 7.6% MVIC) and internal-rotation-resistance elliptical (7.4% ± 3.8% MVIC) was significantly greater than regular elliptical (4.4% ± 2.4% MVIC) and was similar to conventional exercises. The single-leg squat required more muscle activation from the quadriceps and gastrocnemius than the elliptical exercises.

CONCLUSIONS

Off-axis elliptical exercise while resisting an adduction force or internal-rotation torque activates gluteal muscles dynamically while avoiding excessive quadriceps activation during a functional weight-bearing activity compared with conventional gluteal-strengthening exercises.

Current concepts for shoulder training in the overhead athlete

Nontraumatic shoulder pain in the adult overhead athlete is a common problem. The exact biomechanical adaptations that predispose the overhead athlete to injury can be multifactorial in nature, including range of motion deficits, muscular imbalances, and scapular dyskinesis. It is imperative that the rehabilitation professional not only correctly identify and treat the direct cause of the pain, but also initiate a rehabilitation program aimed at improvement of the underlying biomechanical deficits that predispose the overhead athlete to shoulder injury. This only can be accomplished through a better understanding of the most common biomechanical deficits that the overhead athlete develops and how to treat them. This article focuses primarily upon shoulder training in the adult baseball pitcher as a classic example of an overhead athlete.

Biomechanical effects of sitting with adjustable ischial and lumbar support on occupational low back pain: evaluation of sitting load and back muscle activity

Background

Compared to standing posture, sitting decreases lumbar lordosis, increases low back muscle activity, disc pressure, and pressure on the ischium, which are associated with occupational LBP. A sitting device that reduces spinal load and low back muscle activities may help increase sitting comfort and reduce LBP risk. The objective of this study is to investigate the biomechanical effect of sitting with a reduced ischial support and an enhanced lumbar support (Off-Loading) on load, interface pressure and muscle activities.

Methods

A laboratory test in low back pain (LBP) and asymptomatic subjects was designed to test the biomechanical effect of using the Off-Loading sitting posture. The load and interface pressure on seat and the backrest, and back muscle activities associated with usual and this Off-Loading posture were recorded and compared between the two postures.

Results

Compared with Normal (sitting upright with full support of the seat and flat backrest) posture, sitting in Off-Loading posture significantly shifted the center of the force and the peak pressure on the seat anteriorly towards the thighs. It also significantly decreased the contact area on the seat and increased that on the backrest. It decreased the lumbar muscle activities significantly. These effects are similar in individuals with and without LBP.

Conclusion

Sitting with reduced ischial support and enhanced lumbar support resulted in reduced sitting load on the lumbar spine and reduced the lumbar muscular activity, which may potentially reduce sitting-related LBP.

Mid-vastus vs medial para-patellar approach in total knee replacement--time to discharge

BACKGROUND

It has been shown before that when compared with the medial para-patellar approach, the mid-vastus approach for TKR results in less post-operative pain for patients and more rapid recovery of straight leg raise. As far as we are aware the post-operative length of stay of the two groups of patients has not been compared. We postulated that the reduced pain and more rapid recovery of straight leg raise would translate into an earlier, safe, discharge home for the mid-vastus patients compared with those who underwent a traditional medial para-patellar approach.

METHODS

Twenty patients operated on by each of five established knee arthroplasty surgeons were evaluated prospectively with regard to their pre and post-operative range of movement, time to achieve straight leg raise post-operatively and length of post-operative hospital stay. Only one of the surgeons performed the mid-vastus approach, and the measurements were recorded by physiotherapists who were blinded as to the approach used on each patient.

RESULTS

The results were analysed using a standard statistical software package, and although the mean length of stay was lower for the mid-vastus patients, the difference did not reach a level of significance (p = 0.13). The time taken to achieve straight leg raise post-operatively was significantly less in the mid-vastus group (p<0.001).

CONCLUSION

Although this study confirms previous findings that the mid-vastus approach reduces the time taken for patients to achieve straight leg raise, when compared with the medial para-patellar approach, on its own it does not translate into a significantly shorter length of hospital stay. In order to reduce the length of post-operative hospital stay with an accelerated rehabilitation program for TKR, a multi-disciplinary approach is required. Patient expectations, GP support, physiotherapists and nursing staff all have a role to play and the mid-vastus approach, in permitting earlier straight leg raising, significantly contributes to this.

Clinical/otologic score before and during treatment of acute otitis media

OBJECTIVES

To determine clinical characteristics of AOM at presentation and during therapy according to specific etiologies.

PATIENTS AND METHODS

1003 patients studied during 1996-2001 in antibiotic efficacy studies underwent tympanocentesis and middle ear fluid culture at enrollment and on Day 4-6 (in initially culture-positive patients only). We used a clinical/otologic (CO) score for evaluating severity of fever, irritability and tympanic membrane redness and bulging (0-3 each parameter, maximal score=12).

RESULTS

Seven hundred sixty-three patients had positive cultures with 392 (39%) Haemophilus influenzae, 198 (20%) Streptococcus pneumoniae and 173 (17%) mixed H. influenzae and S. pneumoniae infection. Mean CO score was higher in culture-positive versus culture-negative patients (8.21+/-2.17 vs. 7.73+/-2.32, p=0.003) regardless of isolated organism. A marked improvement in CO score was observed on Day 4-6 in all patients: 1.83+/-2.18 in children initially culture-positive and 0.9+/-1.67 in those initially culture-negative (p<0.001). The improvement was greater in patients with eradication versus those with bacteriological failure (CO score 1.52+/-1.82 vs. 2.77+/-2.85, p<0.001).

CONCLUSIONS

CO score before treatment, after bacterial eradication or in bacteriologic failures are similar in bacterial AOM and are not predictive of the etiology of the disease.

Outcome of a national Israeli cohort of pediatric systemic lupus erythematosus

The aim of this study was to describe the clinical manifestations and outcomes of a national cohort of childhood systemic lupus erythematosus (cSLE). All cases of cSLE registered in the Israeli national registry of children with rheumatic diseases between 1987-2003 were examined for disease activity and damage by the SLE disease activity index (SLEDAI) and SLE collaborating clinics/American College of Rheumatology (SLICC/ACR) damage index. Demographic, clinical, laboratory and treatment factors were analysed for their effect on the outcome. One-hundred and two patients were identified, 81% females, with a mean age at diagnosis of 13.3 +/- 2.6 years. The mean SLEDAI score was 17.2 +/- 9.0 (range 2-60). Fifty four patients were followed for at least five years. The mean SLEDAI decreased to 7.6 +/- 6.3 (0-29) and the mean SLICC/ACR damage index was 0.7 +/- 1.6 (0-8). Five patients developed chronic renal failure. No patients died. No factors were found to be significantly associated with the outcome except the initial SLEDAI score. The five-year outcome of our national cSLE cohort was good; with relatively low activity and minimal damage in most patients. The initial SLEDAI predicted the development of late damage.

The role of core stability in athletic function

The importance of function of the central core of the body for stabilisation and force generation in all sports activities is being increasingly recognised. 'Core stability' is seen as being pivotal for efficient biomechanical function to maximise force generation and minimise joint loads in all types of activities ranging from running to throwing. However, there is less clarity about what exactly constitutes 'the core', either anatomically or physiologically, and physical evaluation of core function is also variable. 'Core stability' is defined as the ability to control the position and motion of the trunk over the pelvis to allow optimum production, transfer and control of force and motion to the terminal segment in integrated athletic activities. Core muscle activity is best understood as the pre-programmed integration of local, single-joint muscles and multi-joint muscles to provide stability and produce motion. This results in proximal stability for distal mobility, a proximal to distal patterning of generation of force, and the creation of interactive moments that move and protect distal joints. Evaluation of the core should be dynamic, and include evaluation of the specific functions (trunk control over the planted leg) and directions of motions (three-planar activity). Rehabilitation should include the restoring of the core itself, but also include the core as the base for extremity function.

Aerobic fitness in women with chronic discogenic nonradicular low back pain

OBJECTIVE

The purpose of this study was to determine if aerobic fitness varies between women with and without chronic discogenic non-radicular low back pain.

DESIGN

Prospective cross-sectional descriptive study.

RESULTS

: Analysis of variance revealed that maximal oxygen consumption was lower (P = 0.05) in women with low back pain compared with the control group. In addition, there was a significant reduction (P = 0.05) in reported exercise training duration and frequency but no change in exercise intensity (P = 0.1) in the study group after the onset of low back pain. The low back pain group had minimal disability (19%) based on the Oswestry Disability Questionnaire.

CONCLUSIONS

Women with chronic discogenic non-radicular low back pain have lower maximal oxygen consumption than age-matched controls. However, this study group continued to exercise safely at the same exercise training intensity as before their low back pain and had minimal disability and above-average aerobic fitness.

Comprehensive functional evaluation of the injured runner

In most cases, a detailed history provides the information that is necessary for the clinician to diagnose the injured runner correctly; however, to treat the injury and guide a successful rehabilitation program, the physical examination must go beyond the standard regional musculoskeletal examination. The victims (tissue injury) and the culprits (biomechanical deficits) must be identified to facilitate treatment (Table 3). Gait and other dynamic assessments help to reveal underlying deficits in function that may have contributed to injury. In short, the entire functional kinetic chain must be considered and weak links identified.

The effect of long-distance bicycling on ulnar and median nerves: an electrophysiologic evaluation of cyclist palsy

BACKGROUND

Distal ulnar neuropathies have been identified in cyclists because of prolonged grip pressures on handlebars. The so-called cyclist palsy has been postulated to be an entrapment neuropathy of the ulnar nerve in the Guyon canal of the wrist. Previous studies utilizing nerve conduction studies have typically been either case reports or small case series.

HYPOTHESIS

Electrophysiologic changes will be present in the ulnar and median nerves after a long-distance multiday cycling event.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

A total of 28 adult hands from 14 subjects underwent median and ulnar motor and sensory nerve conductions, which were performed on both hands before and after a 6-day, 420-mile bike tour. A ride questionnaire was also administered after the ride, evaluating the experience level of the cyclist, equipment issues, hand position, and symptoms during the ride.

RESULTS

Distal motor latencies of the deep branch of the ulnar nerve to the first dorsal interosseous were significantly prolonged after the long-distance cycling event. The median motor and sensory studies as well as the ulnar sensory and motor studies of the abductor digiti minimi did not change significantly. Electrophysiologic and symptomatic worsening of carpal tunnel syndrome was observed in 3 hands, with the onset of carpal tunnel syndrome in 1 hand after the ride.

CONCLUSION

Long-distance cycling may promote physiologic changes in the deep branch of the ulnar nerve and exacerbate symptoms of carpal tunnel syndrome.

Influenza virus vaccination of patients with SLE: effects on generation of autoantibodies

The sera of 24 women with SLE who received influenza vaccine were tested by ELISA for anti-DNA, anticardiolipin, anti-Sm, anti-Sm/RNP, anti-Ro and anti-La. Blood samples were withdrawn at the time of vaccination and 6 and 12 weeks after vaccination. The mean age at enrolment into the study was 46.1 years. The mean disease duration was 9.1 years. SLEDAI scores were 6.6 at vaccination, 4.9 at 6 weeks and 5.1 at week 12. The vaccine was not associated with the generation of anti-DNA. At time of vaccination a single patient had anti-Sm, four patients had anti-Sm/RNP antibodies, none of the patients had anti-La antibody and six had anti-Ro antibodies. Six weeks after vaccination four, eight, nine and three patients had autoantibodies reacting with Sm, Sm/RNP, Ro and La, respectively. Twelve weeks after vaccination none of the patients had anti-Sm, three had anti-Sm/RNP, five had anti-Ro and two had anti-La antibodies. Following vaccination six and three patients developed IgG and IgM anticardiolipin antibodies, respectively. In summary, although the influenza virus vaccine is clinically safe for patients with SLE it may trigger the generation of autoantibodies. This effect is usually short term and has no clinical significance.

Assessment of quality of life of parents of children with juvenile chronic arthritis

The aim of the study was to assess the quality of life (QOL) and the psychological status of parents of children with juvenile chronic arthritis (JCA). The QOL, anxiety and depression of the parents of 28 children with JCA were evaluated and compared to those of the parents of 28 healthy children. Mothers of JCA children and mothers of healthy children reported similar QOL. The reported anxiety and depression levels were similar for mothers and fathers in both groups. The parents of children with pauciarticular-type JCA reported lower QOL and higher levels of anxiety and depression than the parents of children with other types, namely polyarticular and systemic JCA. These findings may be explained by the fact that the pauciarticular patients had shorter disease duration and were less frequently seen in the outpatient clinic. The QOL of mothers of children with JCA was found to be slightly impaired in the group of children with pauciarticular JCA. Future larger studies are needed to confirm these results, as the number of subjects in the three groups was rather low.

Leukocyte count in the synovial fluid of children with culture-proven brucellar arthritis

Brucellosis is an important cause of paediatric septic arthritis in endemic areas. Because the Gram stain is frequently negative and culture results are unavailable at the time of the patient's admission, the diagnosis of brucellar arthritis is usually entertained on the bases of epidemiological considerations and cytological examination of the synovial fluid aspirate. The aim of this study was to assess the sensitivity of a synovial fluid leukocyte count >50 000 WBC/mm(3) for detecting culture-proven brucellar arthritis in children. The medical records of all children with brucellar arthritis diagnosed since 1994 in a hospital serving an endemic area for brucellosis in southern Israel were reviewed. Nine patients (six males and three females), aged 3-14 years, were identified. A single joint was affected in all patients. The median leukocyte count in the synovial fluid was 9500 WBC/mm(3) (range 300-61 500 WBC/mm(3)), and in eight of the nine patients it was less than 50 000 WBC/mm(3). Brucella melitensis was recovered from the synovial fluid culture in all patients. The diagnosis of brucellar septic arthritis cannot be excluded on the basis of a low leukocyte count in the joint aspirate. A high index of suspicion and use of modern culture techniques are recommended to improve the diagnosis of brucellar arthritis.

Neuroendocrine mechanisms in fibromyalgia-chronic fatigue

Fibromyalgia and chronic fatigue syndrome are poorly understood disorders that share similar demographic and clinical characteristics. Because of the clinical similarities between both disorders it was suggested that they share a common pathophysiological mechanism, namely, central nervous system dysfunction. This chapter presents data demonstrating neurohormonal abnormalities, abnormal pain processing and autonomic nervous system dysfunction in fibromyalgia and chronic fatigue syndrome. The possible contribution of the central nervous system dysfunction to the development and symptomatology of these conditions is discussed. The chapter concludes by reviewing the effect of current treatments and emerging therapeutic modalities in fibromyalgia and chronic fatigue syndrome.

Appropriateness of pediatric admissions to a tertiary care facility in Israel

BACKGROUND

Appropriateness of hospital admission has both clinical and economic relevance, especially in light of the growing pressure for increased efficiency of health services utilization. In Israel, the number of referrals and use of the emergency room continue to rise along with an increase in hospital admissions and the number of inappropriate admissions. Using evaluation protocols, such as the Pediatric Appropriateness Evaluation Protocol, international studies have shown that 10-30% of hospital admissions are medically unnecessary. Inappropriate hospitalizations have an economic impact as well as medical and psychological effects on the child and the family.

OBJECTIVES

To assess the extent and characteristics of inappropriate pediatric admissions to a tertiary care facility in Israel.

METHODS

We conducted a prospective study using chart review of pediatric admissions to Soroka University Medical Center on 18 randomly selected days in 1993, and evaluated the appropriateness of admissions using the PAEP.

RESULTS

Of the 221 pediatric admissions 18% were evaluated as inappropriate. The main reason for such an evaluation was that the problem could have been managed on an ambulatory basis. Inappropriate admissions were associated with hospitals stays of 2 or less days, children older than 1 year of age, Jewish children, and self-referrals to the pediatric emergency room.

CONCLUSIONS

The assessment and identification of characteristics of inappropriate hospital admissions can serve as indicators of problems in healthcare management and as a basis for improving quality of care and developing appropriate medical decision-making processes.

The Hebrew version of the Childhood Health Assessment Questionnaire (CHAQ) and the Child Health Questionnaire (CHQ)

We report herein the results of the cross-cultural adaptation and validation into the Hebrew language of the parent's version of two health related quality of life instruments. The Childhood Health Assessment Questionnaire (CHAQ) is a disease specific health instrument that measures functional ability in daily living activities in children with juvenile idiopathic arthritis (JIA). The Child Health Questionnaire (CHQ) is a generic health instrument designed to capture the physical and psychosocial well-being of children independently from the underlying disease. The Hebrew CHAQ-CHQ were fully developed with 3 forward and 3 backward translations. A total of 144 subjects were enrolled: 80 patients with JIA (12% systemic onset, 34% polyarticular onset, 23% extended oligoarticular subtype, and 31% persistent oligoarticular subtype) and 64 healthy children. The CHAQ clinically discriminated between healthy subjects and JIA patients, with the systemic, polyarticular and extended oligoarticular subtypes having a higher degree of disability, pain, and a lower overall well-being when compared to their healthy peers. Also the CHQ clinically discriminated between healthy subjects and JIA patients, with the JIA patients having a lower physical and psychosocial well-being when compared to their healthy peers. In conclusion the Hebrew version of the CHAQ-CHQ is a reliable, and valid tool for the functional, physical and psychosocial assessment of children with JIA.

Bacteriologic and clinical efficacy of trimethoprim-sulfamethoxazole for treatment of acute otitis media

BACKGROUND

Trimethoprim-sulfamethoxazole (T/S) has often been used as first and second line of treatment for acute otitis media (AOM). Because of the increasing resistance of Streptococcus pneumoniae and Haemophilus influenzae to T/S, we undertook the present study to investigate the bacteriologic and clinical efficacy of this drug in AOM.

METHODS

Fifty-four culture-positive evaluable patients ages 3 to 32 months with AOM were treated with T/S 4/20 mg/kg in two divided daily doses for 10 days. Middle ear fluid (MEF) was cultured at enrollment (Day 1) and on Days 4 and 5 after initiation of treatment. Additional MEF cultures were obtained if clinical relapse occurred. Clinical failure was determined when the symptoms and signs of AOM did not improve or recurred during therapy. Bacteriologic failure was defined by positive culture on Days 4 and 5, or negative on Days 4 and 5 but positive again before the end of treatment. Patients were followed until Day 28 +/- 2.

RESULTS

A total of 67 organisms were isolated from MEF specimens of the 54 study patients: S. pneumoniae, 24; H. influenzae, 40; and Streptococcus pyogenes, 3. Fifteen (63%) of 24 S. pneumoniae were nonsusceptible to T/S (trimethoprim MIC, >0.5 microg/ml), of which 10 (67%) were highly resistant to T/S (trimethoprim MIC, > or = 4.0 microg/ml). Twelve (30%) of 40 H. influenzae and all 3 S. pyogenes isolates were nonsusceptible to T/S (MIC > or = 4.0 microg/ml). Bacteriologic eradication occurred in 9 of 9 (100%) and 27 of 27 (100%) T/S-susceptible S. pneumoniae and H. influenzae, respectively, vs. 4 of 15 (27%) and 6 of 12 (50%) T/S-nonsusceptible S. pneumoniae and H. influenzae, respectively (P < 0.001). The 3 patients with S. pyogenes failed bacteriologically. Nine new organisms, not initially isolated, emerged during treatment, 7 of which (77%) were resistant to T/S. Altogether bacteriologic failure (organisms not eradicated plus newly emerged) occurred in 29 (53%) of 54 patients. Clinical failures occurred in 8 (15%) of 54 patients, and in 7 of these 8 cases the clinical failures occurred in those with bacteriologic failures. Ten patients relapsed clinically after completion of treatment and in 8 of them tympanocentesis for MEF culture was performed. Six of these 8 cultures were positive, and the initial pathogen was isolated in 4 of 6 (67%).

CONCLUSIONS

A high bacteriologic failure rate as well as a considerable clinical failure rate occurred among patients with AOM treated with T/S. We believe that T/S is no longer an appropriate empiric choice for the treatment of AOM in regions where high T/S resistance among respiratory pathogens is reported.

CLINHAQ scale--validation of a Hebrew version in patients with fibromyalgia. Clinical Health Assessment Questionnaire

Assessment of health status in patients with rheumatic disease, including fibromyalgia (FM), using structured questionnaires has become an important approach to evaluate treatment and outcome. The objectives of this study were to validate a translated version of the Clinical Health Assessment Questionnaire (CLINHAQ) to be used by Hebrew-speaking populations, and specifically to evaluate its usefulness in fibromyalgia syndrome (FM). The CLINHAQ was translated into Hebrew and administered to 90 women with FM along with the Hebrew versions of the Fibromyalgia Impact Questionnaire (FIQ) and the Quality of Life (QOL) Scale. The CLINHAQ includes scales of functional disability, helplessness, anxiety and depression, as well as assessment of current health status and satisfaction with this. All subjects were asked about the presence and severity (assessed by visual analogue scale) of current FM symptoms (pain, fatigue, anxiety etc.); a count of 18 tender points was conducted by thumb palpation, and tenderness thresholds were measured by dolorimetry. Test-retest reliability was assessed by Pearson correlation coefficients, and internal consistency was evaluated with Cronbach's alpha coefficient of reliability. Construct validity was tested by correlating the CLINHAQ items with measures of symptom severity, count of tender point, tenderness thresholds, physical functioning measured by FIQ, and with a score of QOL. Test-retest reliability coefficients ranged from 0.82 to 0.99, and Cronbach's alpha coefficients from 0.725 to 0.929. Significant moderate to high correlations were obtained between most subscales of CLINHAQ and measures of physical functioning, quality of life and severity of FM symptoms. In conclusion, the CLINHAQ is a reliable and valid instrument for measuring health status and physical functioning in Israeli women with FM.

Use of BACTEC 9240 blood culture system for detection of Brucella melitensis in synovial fluid

Synovial fluid specimens aspirated from patients with arthritis were inoculated into an aerobic Peds Plus blood culture bottle and monitored by the BACTEC 9240 instrument for 4 weeks. A total of 1,072 synovial fluid cultures were processed, and 15 (0.14%) were positive for Brucella melitensis. A single culture, harboring 1.3 CFU of viable organisms per ml, was missed by the instrument. All 14 positive BACTEC cultures were detected within 3 to 7 days.

Near fatal acute colchicine intoxication in a child. A case report

An 8-year-old child with familial Mediterranean fever exhibited signs of colchicine intoxication while receiving prophylactic doses of the drug. She developed gastrointestinal, central nervous system, cardiovascular and haematological disturbances. Over 2 months she had been drinking high doses of natural grapefruit juice which, combined with long-term colchicine therapy and a viral upper respiratory tract infection, increased her susceptibility to the drug.

CONCLUSION

To the best of our knowledge, this is the first time colchicine intoxication in this age group has been described in the English literature.

Oral ciprofloxacin vs. intramuscular ceftriaxone as empiric treatment of acute invasive diarrhea in children

BACKGROUND

Acute invasive diarrhea is a potentially serious condition in children. Because of the increasing resistance of enteric pathogens to commonly used oral antibiotics, intramuscular ceftriaxone has become the routine drug in the treatment of acute invasive diarrhea requiring an emergency visit in southern Israel. The inconvenience of this parenteral regimen created an increased need for oral pediatric formulations for the treatment of invasive diarrhea.

OBJECTIVES

To evaluate the efficacy and safety of a suspension formulation of ciprofloxacin in the treatment of acute invasive diarrhea in infants and children.

PATIENTS AND METHODS

From July 1996 through December 1997, 201 evaluable children ages 6 months to 10 years (35% <1 year; 70% <3 years) presenting with acute invasive diarrhea at the Pediatric Emergency Room were randomized to receive either ciprofloxacin suspension (10 mg/kg twice a day + im placebo; n = 95) or im ceftriaxone (50 mg/kg/day + placebo suspension; n = 106) for 3 days in a double blind manner. Stool cultures for Shigella, Salmonella, Campylobacter spp. and diarrheagenic Escherichia coli were obtained on Days 1, 3, 4 to 5 and 21 +/- 5. Clinical response and safety were assessed on Days 1, 2, 3, 4 to 5 and 21 +/- 5.

RESULTS

We isolated 127 pathogens from 121 (60%) patients: 73 (57%) Shigella; 23 (18%) Salmonella; 18 (14%) E. coli; and 13 (10%) Campylobacter. Overall bacteriologic eradication on Day 4 to 5 was 99% for Shigella, 77% for Salmonella and 77% for Campylobacter, with no difference between the 2 groups. Clinical cure or improvement was observed in 100 and 99% of the ciprofloxacin and ceftriaxone groups, respectively. Serum ciprofloxacin values determined on Day 3 of the treatment were higher in the majority of patients than were the MIC50 and MIC90 values for the Shigella and Salmonella spp. isolated. Possible drug-related adverse events occurred in 13 patients [ciprofloxacin, 8 (8%); ceftriaxone, 5 (4.7%)] and were mild and transient. Joint examination was normal during and after completion of therapy in all patients.

CONCLUSION

Oral ciprofloxacin was as safe and effective as intramuscular ceftriaxone for the empiric treatment of acute invasive diarrhea in ambulatory pediatric patients requiring an emergency room visit.

Bacteriologic and clinical efficacy of one day vs. three day intramuscular ceftriaxone for treatment of nonresponsive acute otitis media in children

BACKGROUND

One dose of intramuscular ceftriaxone has been recently licensed in the United States for the treatment of acute otitis media. However, data regarding the bacteriologic and clinical efficacy of this regimen in the treatment of nonresponsive acute otitis media are incomplete.

OBJECTIVES

To determine the bacteriologic and clinical efficacy of a 1-day 50-mg/kg vs. a 3-day 50-mg/kg/day intramuscular ceftriaxone regimen in the treatment of nonresponsive acute otitis media in children.

PATIENTS AND METHODS

In an open, prospective study 109 patients ages 3 to 36 months with culture-proved, nonresponsive acute otitis media were randomized to receive 1 (n = 49) or 3 (n = 60) 50-mg/kg/day intramuscular ceftriaxone doses, respectively. Middle ear fluid was aspirated for culture by tympanocentesis on the day of enrollment (Day 1); a second tympanocentesis with middle ear fluid culture was performed on Days 4 to 5. Additional middle ear fluid cultures were obtained if clinical relapse occurred after completion of therapy. Bacteriologic failure was defined by positive cultures on Days 4 to 5. Patients were followed until Day 28 after completion of therapy. Susceptibility of the middle ear pathogens was measured by E-test.

RESULTS

Organisms recovered (n = 133) were Streptococcus pneumoniae (30 and 35 isolates for the 1-day and 3-day treatment group, respectively), Haemophilus influenzae (26 and 38, respectively) and Moraxella catarrhalis (n = 4). Of the 30 S. pneumoniae isolated from the 1-day group, 27 (90%) and 6 (20%) were nonsusceptible to penicillin and ceftriaxone, respectively; 9 of 27 (33%) were fully resistant to penicillin. Thirty-four (97%) and 6 (17%) of the 35 S. pneumoniae isolated from the 3-day group were nonsusceptible to penicillin and ceftriaxone, respectively; 16 of 34 (47%) were fully resistant to penicillin. Bacterial eradication of all H. influenzae and penicillin-susceptible S. pneumoniae was achieved in both treatment groups. Bacterial eradication of 14 of 27 (52%) and 33 of 34 (97%) penicillin-nonsusceptible S. pneumoniae was achieved in the 1-day and 3-day group, respectively. Seven (50%) of the 14 patients from the 2 groups who did not achieve bacterial eradication did not improve clinically on Days 4 to 5 and required additional ceftriaxone treatment.

CONCLUSION

The 3-day intramuscular ceftriaxone regimen was significantly superior to the 1-day intramuscular ceftriaxone regimen in the treatment of nonresponsive acute otitis media caused by penicillin-resistant S. pneumoniae.

Outcome of "out of hospital" cardiopulmonary arrest in children admitted to the emergency room

BACKGROUND

The outcome of cardiopulmonary arrest in children is poor, with many survivors suffering from severe neurological defects. There are few data on the survival rate following cardiopulmonary arrest in children who arrived at the emergency room without a palpable pulse.

OBJECTIVE

To determine the survival rate and epidemiology of cardiopulmonary arrest in children who arrived without a palpable pulse at a pediatric ER in southern Israel.

METHODS

We retrospectively reviewed the medical records of all patients with cardiopulmonary arrest who arrived at the ER of the Soroka University Medical Center during the period January 1995 to June 1997.

RESULTS

The study group included 35 patients. Resuscitation efforts were attempted on 20, but the remaining 15 showed signs of death and were not resuscitated. None of the patients survived, although one patient survived the resuscitation but succumbed a few hours later. The statistics show that more cardiopulmonary arrests occurred among Bedouins than among Jews (32 vs. 3, P < 0.0001).

CONCLUSIONS

The probability of survival from cardiopulmonary arrest in children who arrive at the emergency room without palpable pulse is extremely low. Bedouin children have a much higher risk of suffering from out-of-hospital cardiopulmonary arrest than Jewish children.

Familial Mediterranean fever in two Bedouin families: mutation analysis and disease severity

Familial Mediterranean fever (FMF) is an autosomal recessive disease prevalent among non-Ashkenazi Jews, Armenians, Arabs, and Turks. The Bedouin are nomad Arab tribes residing in desert margins of the Middle East and Arabia. FMF is quite rare in Bedouins, and here we report on two Bedouin families from southern Israel suffering from this disorder. The MEFV mutations found in the Bedouin patients M694I, V726A, and E148Q are consistent with their Arab origin. The disease severity score showed a mild to moderate severity disease in six patients. The Bedouins, leading a unique nomadic life, may prove instrumental in unraveling the role of environmental factors in the course and severity of FMF.

Pediatric emergency room response to community pediatricians' expectations

BACKGROUND

In Israel the pediatric emergency room functions as an urgent primary care clinic in addition to dealing with life-threatening situations. Due to health insurance stipulations, most patients come to the PER with a referral from the community clinic. The relationship between the referring physician's expectations and the subsequent management of the referred patient in the PER is not well defined.

OBJECTIVES

To evaluate the relationship between the expectations of the primary care physician and the management of referred patients in the PER, assess the type of information provided by the referring physician, and examine the effect of additional information obtained from the referring physician on patient management in the PER.

METHODS

We reviewed the records of patients presenting at the PER with referrals from primary care physicians as well as additional information obtained by telephone interviews with the referring physicians.

RESULTS

The expectations of the referring physicians were not fully documented in the referral form. The PER responded to the patient as if the PER was the initial contact. There was no significant difference in the response of PER physicians with or without additional information from the referring physicians.

CONCLUSIONS

The PER acts as an independent unit with no obligation to satisfy the expectations of the referring physicians. The relationship between the PER and the referring physicians needs to be clarified. Guidelines and structured PER referral forms should be implemented in all primary care clinics to improve patient management and communication between health providers.

Predictive value of pneumococcal nasopharyngeal cultures for the assessment of nonresponsive acute otitis media in children

BACKGROUND

Nonresponsive acute otitis media (NR-AOM) is reported in > 10% of children with AOM treated with antibiotics. Drug-resistant Streptococcus pneumoniae is currently considered the leading cause of antibiotic failures in AOM. Nasopharyngeal colonization with S. pneumoniae was found to increase significantly during episodes of AOM.

OBJECTIVES

To investigate the nasopharyngeal colonization with S. pneumoniae during NR-AOM and compare it with that found in AOM not recently treated with antibiotics (NT-AOM); to assess the predictive value of nasopharyngeal pneumococcal cultures results for the bacteriologic assessment of NR-AOM.

MATERIALS AND METHODS

Patients age 3 to 48 months with NT-AOM and NR-AOM were prospectively studied. Simultaneous nasopharyngeal cultures for S. pneumoniae and middle ear fluid cultures were obtained at enrollment. Antibiotic susceptibility testing was performed in all S. pneumoniae isolates. Penicillin and ceftriaxone MICs for S. pneumoniae were determined by E-test. The sensitivity, specificity and positive and negative predictive values of positive or negative nasopharyngeal cultures for the presence of S. pneumoniae in middle ear fluid were calculated.

RESULTS

We studied 362 and 217 children with NT-AOM and NR-AOM, respectively. Of the children with NT-AOM and NR-AOM, 95 and 97%, respectively, were younger than 2 years of age. S. pneumoniae was isolated in the nasopharynx of 66 and 58% of children with NT-AOM and NR-AOM, respectively. Penicillin-nonsusceptible S. pneumoniae was isolated more frequently from the nasopharynx of patients with NR-AOM than from those with NT-AOM (84% vs. 47%; P < 0.01). Antibiotic susceptibility patterns were similar for S. pneumoniae isolates recovered from the nasopharynx and those from the middle ear fluid in both NT-AOM and NR-AOM. A positive nasopharyngeal culture had only little predictive value for the presence of S. pneumoniae in middle ear fluid (41 and 51% for NT-AOM and NR-AOM, respectively). However, the negative predictive value of nasopharyngeal cultures for recovery of S. pneumoniae in NR-AOM was high and significantly higher in NR-AOM than in NT-AOM (91% vs. 78%, respectively; P = 0.009). The negative predictive value of nasopharyngeal cultures for recovery of antibiotic-resistant S. pneumoniae was 95 and 93% in NT-AOM and NR-AOM, respectively. Conclusions. A significantly higher nasopharyngeal colonization rate with antibiotic-resistant S. pneumoniae was found in patients with NR-AOM than in those with NT-AOM. Negative nasopharyngeal culture for antibiotic-resistant S. pneumoniae practically rules out its presence in middle ear fluid.

Living with a child with familial Mediterranean fever: does it affect the quality of life of the parents?

OBJECTIVE

The aim of the present study was to assess the quality of life (QOL) and the psychological status of parents of children with familial Mediterranean fever (FMF).

METHODS

The QOL, anxiety and depression of the parents of 35 children with FMF were evaluated and compared to the parents of 23 healthy children.

RESULTS

Mothers of FMF children had lower QOL scores than mothers of healthy children: 5.5 +/- 1.1 versus 6.0 +/- 0.6 (p = 0.048). They also expressed higher levels of anxiety and depression. Within each group, mothers were more anxious and depressed than fathers. Parents with several FMF children were not significantly different from parents with only one FMF child.

CONCLUSION

The QOL and psychological well being of parents with FMF children were found to be slightly impaired, especially that of the mothers.