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I retrospectively reviewed the records of 111 patients who had pyogenic vertebral osteomyelitis unrelated to an open procedure on the spine. The mean age at the time of the diagnosis was sixty years (range, eighteen to eighty-four years); sixty-one patients (55 per cent) were sixty years old or more. Forty-four patients (40 per cent) had an impaired immune system secondary to diabetes mellitus, the use of corticosteroids, chemotherapy for cancer, rheumatic or immunological disease, renal or hepatic failure, malnutrition, or myelodysplasia. Magnetic resonance imaging, critical for the determination of an early diagnosis, was performed for 103 patients (93 per cent). The infection in sixty-eight patients (61 per cent) was diagnosed within one month after the onset of symptoms. The most frequent infecting organism was Staphylococcus aureus (forty patients; 36 per cent). The infection in forty-one patients (37 per cent) was caused by organisms, such as Staphylococcus epidermidis, Propionibacterium acnes, and diphtheroid species, that are traditionally considered to be of low virulence. The urinary tract was the most frequent source of infection (confirmed in thirteen patients and suspected in twenty-one). The success of non-operative treatment was predicted by four independent variables: an age of less than sixty years, the immune status, infection with Staphylococcus aureus, and a decreasing erythrocyte sedimentation rate. Forty-two patients were managed with debridement and arthrodesis. Fourteen of these patients also had instrumentation of the spine, in the presence of infection, without compromise of the outcome. Eighteen patients died by the time of the latest follow-up evaluation at a mean of four years (range, two years and two months to six years and six months): seven who had been managed non-operatively died in the first month after the diagnosis was made, three died in the acute postoperative period, three died of late complications of paraplegia, and five died of unrelated causes. None of the eighty-nine patients who were seen at a minimum of two years postoperatively had had late recurrence of infection. Chronic, severe back pain was noted in only seven patients.
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PMID:Pyogenic vertebral osteomyelitis. 961 Oct 38

Despite modern medical advances, the morbidity and mortality rates associated with spinal epidural abscess remain significant, and the diagnosis is elusive. The incidence of spinal epidural abscess is approximately one to two cases per 10,000 among all patients admitted to hospitals. The symptoms of spinal epidural abscess are varied but include lower back pain, fever, local tenderness and neurological deficit especially in such high risk groups as patients with diabetes, intravenous drug abuse, chronic renal failure, alcoholism, liver disease and immunocompromization. Accumulation of data is difficult in that many physicians will never see a case during their careers. Herein, we present a case with lower back pain associated with both lower legs weakness. His abdomenon CT revealed retroperitonium and right perirenal abscess. External drainage as well as antibiotic treatment was done immediately. However, the lower legs weakness became severe and a lumbar spine MRI revealed T11-L4 epidural abscesses and L2-3 intervertebral space pus formation. Then, the patient was transfered to our Neurosurgical Ward for further treatment. His postoperative condition improved in both lower legs. This case report is to enhance the recognition and treatment of spinal epidural abscess, a rare affliction.
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PMID:Spinal epidural abscess--a case report. 926 Apr 67

Pyogenic infectious spondylitis (PIS) is an uncommon but serious inflammatory disorder of the discovertebral junction with frequent involvement of neural structures including the spinal cord. We report a series of 41 patients (age range 21-75 years, mean age 59 years) with primary PIS confirmed by signal abnormality of the intervertebral disk and adjacent vertebral bodies on magnetic resonance imaging. The prevailing clinical symptom was focal back pain aggravated by percussion in 90% of patients. Radicular signs or symptoms were present in 59% and spinal cord symptoms in 29% of patients, respectively. Evidence of inflammation consisted of an elevated sedimentation rate in 76%, leukocytosis in 61% and fever in 61% of individuals. Predisposing factors such as diabetes mellitus, previous nonspinal surgery and other sites of infection or inflammation were identified in 17 (41%) patients and 30 (73%) were older than 50 years. The lumbar spine was most often affected and PIS was associated with an epidural abscess in 15 (37%) patients. Increased alertness for PIS in the context of focal back pain with clinical or laboratory signs of inflammation is needed to speed up its detection.
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PMID:Pyogenic infectious spondylitis: clinical, laboratory and MRI features. 928 31

Depression is a common, life-disrupting, potentially lethal illness that can affect both sexes and all ages. Its peak onset is in the early adult years. It is more common than hypertension in primary care practice. Recent studies show that fewer than 1 in 20 depressed patients are correctly diagnosed and adequately treated. Depression periodically destroys the productivity of those with the condition, and depressed patients have a worse quality of life than patients with debilitating, chronic conditions such as arthritis, hypertension, diabetes mellitus and back pain. Suicide occurs in as many as 15% of patients with depression, especially those with recurrent episodes and hospitalisations, and may even occur in those with in subsyndromal depression. Suicide is one of the leading causes of death, and individuals who complete suicide have usually experienced mood disorders, mainly depression. Current data support a decreased frequency of suicidal ideation with all antidepressants, including selective serotonin (5-hydroxytryptamine; 5-HT) reuptake inhibitors (SSRIs). Modern pharmacotherapy is the cornerstone for effective treatment of depression. As they are well tolerated, even in the presence of comorbid medical illness, and easier to manage, SSRIs enhance compliance. A fully adequate antidepressant dosage is suitable for patients of all ages and can be used by non-psychiatrist physicians for the treatment of the acute episode, as well as the frequent recurrences that often require long term maintenance antidepressant medication. SSRIs have fewer drug interactions than older antidepressants, and even the SSRI inhibition of hepatic cytochrome P450 enzymes has proven only very infrequently to be of clinical importance. SSRIs also effectively treat anxious depression, dysthymia and atypical depression. Fluoxetine may provide more rapid onset of therapeutic effect because it can be started at closer to its usual full therapeutic dosage than other SSRIs or older antidepressants. SSRIs, in particular fluoxetine, are more suitable for use as long-term maintenance therapy in these chronic relapsing diseases. These factors and the high efficacy rate, increased safety in overdose, reduced incidence of adverse effects (mostly decreasing with time) and superiority in ease of maintaining patients in adequate treatment plans provides fluoxetine with an overall superior therapeutic profile.
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PMID:Risks and benefits of selective serotonin reuptake inhibitors in the treatment of depression. 946 88

A 67-year-old man with poorly controlled diabetes mellitus (DM) had acupuncture several times a month for chronic shoulder muscle stiffness. A few days after acupuncture in the posterior nuchal region, a low-grade fever and backache developed, and subacutely progressed. Finally he complained of gait disturbance, and then respiratory distress appeared. Magnetic resonance imaging (MRI) demonstrated high cervical epidural abscess with massive soft tissue inflammation and vertebral osteomyelitis. Conservative treatment with antibiotics was effective and it was well documented by following serial MRIs. This case suggested that needle acupuncture should be avoided for immunocompromised subjects such as patients with poorly controlled DM.
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PMID:Cervical spinal epidural abscess following acupuncture: successful treatment with antibiotics. 955 May 97

Infectious disease of the spine is infrequently seen in the rehabilitation setting. We examined retrospectively 26 patients with spinal infections admitted to the rehabilitation centre over a 6-year period to determine the demographic characteristics, clinical features and outcome after rehabilitation. Their ages ranged from 24 to 83 years (mean = 56.4); 65.4% were males. The infection was due to pyogenic bacteria in 14 patients (53.8%) and Mycobacterium tuberculosis in 12 (46.2%). Staphylococcus aureus was the causative agent in 69% of those with pyogenic infections. A history of diabetes mellitus was present in 35.7% of the pyogenic group but in only 8.3% of the tuberculous group. Localised back pain, fever and neurological deficits were the typical clinical manifestations. The most common site of infection was the thoracic region. Surgery was performed on 24 patients and all received prolonged courses of antibiotics. All but three patients completed the rehabilitation programme. The motor score for the lower limbs and the modified Barthel scores for activities of daily living (ADL) and mobility improved significantly (P < 0.05) for both pyogenic and tuberculous groups. The amounts of improvement achieved were not significantly different between the pyogenic and tuberculous groups except for ADL. Age, gender and the presence of diabetes mellitus did not appear to significantly affect the neurological or functional outcome in our study population. The majority of patients (87.5%) were discharged to their own homes.
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PMID:Infectious disease of the spine: outcome of rehabilitation. 967 Mar 88

We undertook this study to identify persons with high medical use to target them for health promotion and self-management interventions specific to their problems. We compared the reductions in cost and health risk of a health education program aimed at high-risk persons with a similar program addressed to all risk levels. We compared health risk and use in 2,586 high-risk persons with those of employee (N = 50,576) and senior (N = 39,076) groups and contrasted results in specific high-risk disease or behavior categories (modules)--arthritis, back pain, high blood pressure, diabetes mellitus, heart disease, smoking, and obesity--against each other, using validated self-report measures, over a 6-month period. Interventions were a standard generic health education program and a similar program directed at high risk individuals (Healthtrac). Health risk scores improved by 11% in the overall high-risk group compared with 9% in the employee group and 6% in the senior group. Physician use decreased by 0.8 visits per 6 months in the high-risk group compared with 0.05 and 0.15 visits, respectively, per 6 months in the employee and senior groups. Hospital stays decreased by 0.2 days per 6 months in the high-risk group compared with 0.05 days in the comparison groups. The duration of illness or confinement to home decreased by 0.9 days per 6 months in the high-risk group and 0.15 and 0.25, respectively, in the employee and senior groups. Using imputed costs of $130 per physician visit, $1,000 per hospital day, and $200 per sick day, previous year costs were $1,138 in direct costs for the high-risk groups compared with $352 and $995 in the employee and senior groups, respectively. At 6 months, direct costs were reduced by $304 in the high-risk group compared with $57 and $70 in the comparison groups. Total costs were reduced $484 in the high-risk groups compared with $87 in the employee group and $120 in the senior group. The return on investment was about 6:1 in the high-risk group compared with 4:1 in the comparison groups. Effective health education programs can result in larger changes in use and costs in high-risk persons than in unscreened persons, justifying more intensive educational interventions in high-risk groups.
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PMID:Reducing need and demand for medical services in high-risk persons. A health education approach. 979 79

This study examines whether there are differences between Mexican Americans and non-Hispanic whites in reported symptoms of acute myocardial infarction (AMI). The symptoms experienced by patients identified in a community-based surveillance program were examined to determine whether between-group differences existed by ethnicity, gender, and diabetic status. Data were available regarding the symptoms of 589 patients, between the ages of 25 and 74 years, who were hospitalized and diagnosed as either having definite or possible AMI in special care units at 1 of 7 hospitals in Corpus Christi, Texas. The most frequently reported symptoms were chest pain (83.2%), chest pressure or discomfort (67.6%), sweating (64.2%), fatigue (62.6%), dyspnea (60.3%), and arm or jaw pain (58.2%). After adjusting for age, diabetes mellitus, and gender, and relative to non-Hispanic whites, Mexican Americans were more likely to report chest pain, upper back pain, and palpitations, and less likely to report arm or jaw pain. Likewise, relative to men, women were more likely to report fatigue, dyspnea, dizziness, upper back pain, palpitations, and cough, and were less likely to report chest pain. Significant differences were also observed when older patients' symptoms were compared with younger patients' symptoms.
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PMID:Comparison of reported symptoms of acute myocardial infarction in Mexican Americans versus non-Hispanic whites (the Corpus Christi Heart Project). 985 14

Penetrating aortic ulcers (PAU) result from progressive erosion of atheromatose plaques perforating the internal elastic lamina. PAU is considered both a predisposing condition and differential diagnosis of classic aortic dissection; 93 cases of PAU are documented in the world literature, 60% of which are male over 60 years old. Systemic hypertension was prevalent in 85%, history of smoking in 72%, hyperlipoproteinemia in 35%, and diabetes mellitus in 31%. In 61%, PAU was associated with coronary artery disease, in 53% with abdominal or thoracic aortic aneurysm, in 31% with chronic renal insufficiency, in 17% with peripheral artery disease, and in 12% with a history of cerebrovascular accidents. In 73%, PAU was associated with formation of medial hematoma and in 16% with a thick, calcified intimal flap of less than 10 cm extent. Angiography, computed tomography, magnetic resonance imaging and transesophageal echocardiography were used in 66, 64, 23 and 14%, respectively, for diagnosing PAU; sensitivities for demonstrating PAU were 83, 65, 86 and 61%, respectively. Chest or back pain was found in 76% and an acute onset of symptoms in 68%. Signs of mediastinal widening were found in 59%, neurologic signs comprising hoarseness, syncope or coma in 8%, pulse differentials caused by embolism in 4%, aortic regurgitation in 7%, and mediastinal hematoma, pleural- or pericardial effusion in 42, 27 and 10%, respectively. PAU of the ascending aorta or aortic arch (type A) leads to dissection and rupture in 57%, compared to 12% and 5%, respectively, in the descending aorta (type B); 57% of medically managed type A PAU patients died within 30 d of hospital admission compared to only 14% of type B PAU with 20 cases of uncomplicated long-term outcome without surgery. Thus, similar to the Stanford classification for aortic dissection, type A PAU should primarily be considered for surgical management, whereas type B PAU without signs of instability may be managed medically.
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PMID:[Ulcer of the thoracic aorta: diagnosis, therapy and prognosis]. 1002 64

Spinal epidural abscess (SEA) is a rare disease with an unknown incidence rate. This paper will illustrate that early diagnosis and rehabilitation may result in improved outcomes for patients with neck or back pain presenting with neurological deficits. Three cases of SEA in individuals without the commonly acknowledged risk factors of intravenous drug abuse (IVDA), invasive procedures, or immunosuppression were seen at our institution during a 10-month period between October 1995 and July 1996. The patients presented with neck or thoracic back pain and progressive neurological deficits without a febrile illness. Predisposing factors were thought to be urinary tract infection with underlying untreated diabetes mellitus in the first case, a history of recurrent skin infection in the second, and alcoholism without a definite source of infection in the third. Leukocytosis, elevated sedimentation rate, and confirmatory findings reported on magnetic resonance imaging (MRI) led to the diagnosis of SEA in all three cases. Immediate surgical drainage and decompression followed by proper antibiotic treatment and early aggressive rehabilitation led to good functional outcomes. All the individuals became independent in activities of daily living, wheelchair mobility, and bowel and bladder management. Two eventually became ambulatory.
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PMID:Myelopathy secondary to spinal epidural abscess: case reports and a review. 1009 48


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