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In chronically ill patients, mobility develops more unfavorably in persons with low socio-economic status (SES) than in their better-off counterparts. Using longitudinal data from the Dutch GLOBE study (a study of health and living conditions in Eindhoven and its surroundings), the present study examines whether psychosocial factors can explain socio-economic differences in mobility decline, independent of disease severity, co-morbidity, and health-related behavior in a chronically ill population. Data were from 1384 men and woman, aged 15-74 years, suffering from at least one of the four chronic diseases: asthma/COPD, heart disease, diabetes mellitus, and low back pain. Three indicators of SES were used: education, occupational class, and income. Change in physical mobility between 1991 and 1997 was measured with the Nottingham Health Profile (NHP). Psychosocial factors were measured extensively and included life events, long-term difficulties, coping styles, social support, and personality characteristics. Low occupational level and low income predicted an increased risk of mobility decline in comparison to people with a higher occupational level and income, even after controlling for sociodemographics, disease severity, co-morbidity, and health-related behavior. Additional adjustment for psychosocial factors hardly reduced the SES-related odds ratios of mobility decline. We conclude that psychosocial factors (and also health-related behaviors, disease severity and co-morbidity) cannot explain socio-economic differences in mobility decline in a chronically ill population. Our findings will not give us new tools for prevention and intervention strategies in order to reduce physical disability and particularly the SES differences therein.
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PMID:The role of psychosocial factors in explaining socio-economic differences in mobility decline in a chronically ill population: results from the GLOBE study. 1584 67

A 77-year-old man with diabetes mellitus presented with a 2-month history of lumbago radiating to the right lower limb as well as high fever spikes. Physical examination revealed a distended abdomen with right lower quadrant tenderness. A computed tomographic scan of the abdomen revealed a large right retroperitoneal cavity containing an air-fluid level that was consistent with a gas-producing abscess. The patient began receiving intravenous antibiotics, but fever and abdominal pain persisted and a large, fluctuating, tender swelling appeared on the medial aspect of his right thigh and right calf. The patient underwent surgical exploration: a right lateral abdominal incision was performed, and the pus collection in retroperitoneal space was completely evacuated. We also made 3 separate incisions on the medial aspect of the right thigh and 1 incision on the upper calf, resulting in the drainage of pus. The patient made a slow but steady recovery.
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PMID:Primary retroperitoneal abscess extending to the calf. 1636 48

In this study we assessed the evidence of some specific, "ad hoc", medical indications for city bus, tram and subway professional drivers. As known, professional drivers have very little chances of modifying shift organization and many chronic degenerative diseases (low back pain, diabetes type 2, cardiovascular diseases, ecc.) are difficult to manage according to job planning. In our study we observed a positive association between introduction of specific shift, in particular when shift is divided in two-piece, on morning "turno spezzato 1(0)/1(0)" or one on morning and the second part on afternoon "turno binato 1(0)/2(0)". Evidence of the real impact on professional drivers health conditions has been found from analysis of sickness leave during two, or in same case, one year before and after such medical indications intoduction. In our occupational drivers cohort a positive association, evidence based on real rates of two years sick absence before and after medical indications, was found between improvement of health general conditions and reduction of sickness leave rates correlated.
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PMID:[Assessment of the efficacy of limitations and indications issued by the occupational physician regarding the health of the staff working in public transportation vehicles]. 1680 54

In addition to chronic hepatitis, many individuals infected with hepatitis C virus (HCV) suffer from fatigue, which may compromise their health-related quality of life (HRQL). To assess systematically health-related quality of life (HRQL) in patients with chronic hepatitis C and to determine if any clinical, biochemical, virologic, demographic, and histologic features are associated with HRQL status. In this cross-sectional observational study, one hundred thirty patients with chronic HCV infection (HCV RNA positive by PCR) and 61 healthy controls were enrolled from a tertiary care teaching medical center. All patients and controls completed one generic HRQL questionnaire (MOS SF-36) and one liver-disease specific instrument (Chronic Liver Disease Questionnaire, CLDQ). Ninety-five HCV patients and all the controls also completed a fatigue questionnaire (Chronic Fatigue Screener, CFS) and had immunologic markers determined (Cryoglobulin, Soluble IL-2 receptors, Rheumatoid Factor). We compared the HRQL of HCV-infected patients to the controls and, using data from other studies, to the general population, patients with diabetes, and patients with chronic low back pain. Patients with chronic HCV had greater HRQL impairment than healthy controls and those with type II diabetes. Fatigue was the most important symptom with negative impact on HRQL. Sixty-one percent of HCV-infected patients reported fatigue-related loss of activity. Additionally, other factors associated with HRQL were gender and histologic cirrhosis. Chronic HCV infection has a profound negative impact on patients' HRQL. Disabling fatigue is the most important factor that contributes to loss of well-being in this relatively young group of patients.
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PMID:Fatigue and health-related quality of life (HRQL) in chronic hepatitis C virus infection. 1740 28

The role of diabetes mellitus (DM) in the etiopathogenesis of spontaneous intracerebral hemorrhage (SICH) is controversial. The aim was to assess the role of DM in our SICH patients. In a hospital-based cross-section study, the occurrence of DM prior to a hemorrhagic stroke was observed in 80 SICH patients (44 males, aged 36-87 years, mean 67.1 +/- 11.9 years; 36 females, aged 56-86 years, mean 71.1 +/- 8.3 years), and in a control group (CG) of 80 age- and sex-matched patients with low back pain. All patients were treated at the Departments of Neurology and Neurosurgery, University Hospital, Olomouc, Czech Republic. Two-sample t test and Pearson's homogeneity chi(2) test were applied when assessing statistical significance. DM was found in 37.5% of SICH patients versus 22.5% of CG subjects (P < 0.05). DM occurs significantly more frequently in SICH patients in the Olomouc region of the Czech Republic when compared to the general population.
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PMID:Occurrence of diabetes mellitus in spontaneous intracerebral hemorrhage. 1778 82

An 83-year-old woman was admitted to hospital with complaints of fever, abdominal pain and other complaints suggesting urosepsis. Additional analyses did not reveal the cause of her complaints. After cessation of antibiotic therapy, there was a spontaneous decrease in the infection parameters and she was subsequently discharged. Two and a half months later she was presented in our hospital with low back pain with radiating to the legs. MRI showed signs ofa spondylodiscitis at the level of LIII-LIV existing for some time. Finally, a gram-positive streptococcus infection was found and she was treated with antibiotics for 13 weeks. 6 months later she was free of symptoms. A 57-year-old man was admitted to the intensive care with a double-sided olecranon bursitis and sepsis. An endocarditis caused by Staphylococcus aureus was thought to be the cause of the sepsis and the patient was treated with surgical intervention and antibiotics. Because of persistent sepsis, different CT-scans were performed, and after one and a half months an extensive spondylodiscitis with abscess formation was diagnosed and subsequently treated surgically. A delay in diagnosing spondylodiscitis is the rule rather the exception. The diagnosis should be considered in any patient with localised back pain, especially when accompanied by fever, high ESR, and the presence of risk factors such as high age, diabetes mellitus, immunosuppression, and/or rheumatoid arthritis.
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PMID:[Spondylodiscitis as cause of unexplained fever]. 1839

Salmonella tiphymurium infection frequently causes gastroenteritis but some cases have a predilection for damaged blood vessels, especially those affected by atherosclerosis. The abdominal aorta is the most frequent location. Salmonella aortitis with mycotic aneurysm formation is a rare but serious condition, due to the high risk of rupture. We report the clinical case of a 61 year old man with a history of diabetes and hypertension, who was previously admitted with Salmonella gastroenteritis for which he had been treated with proper antibiotics. He was readmitted with fever, nausea and low back pain. Salmonella thyphimurium was isolated in blood cultures. The investigation revealed a pseudoaneurysm formation on the abdominal aorta. He was submitted to surgical vascular grafting with aneurysm resection and antibiotic therapy before and after surgery, with excellent clinical outcome. Bacteremia due to Salmonella Typhymurium must always raise the suspicion of focalization, especially a vascular infection. Particular attention should be given to predisposing factors, such as pre-existent atherosclerosis and age. The advised treatment of mycotic aneurysm due to a Salmonella agent must be a combined medical and surgical therapy.
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PMID:[Salmonella typhimurium aortitis]. 1816 78

A cross-sectional, retrospective medical and pharmaceutical claims data analysis was conducted to determine if Healthcare Effectiveness Data and Information Set (HEDIS) measures related to care for chronic conditions differed between enrollees in a traditional comprehensive major medical plan (CMM) and a consumer-directed health plan (CDHP). Eleven HEDIS measures for 2006 were compared for CMM and CDHP enrollees in a health plan. Measures included care for persons with diabetes, asthma, depression, cardiovascular disease, and low back pain, and for persons taking persistent medications for specific conditions. In the CMM population, 1,238,949 members were eligible to be included; 131,763 members in the CDHP population were eligible. Statistical significance testing was performed. As measured by HEDIS, CDHP enrollees received higher quality of care than did CMM enrollees in areas related to low back pain, and eye exams and nephropathy screening for persons with diabetes. No significant differences were found between CDHP enrollees and CMM enrollees for measures describing medication management for persons with depression and asthma, annual monitoring for persons taking persistent medications, cholesterol management for persons with cardiovascular disease, or HbA1c testing and low-density lipoprotein screening for persons with diabetes. Enrollees in CDHPs who have chronic conditions received care at levels of quality equal to or better than CMM enrollees. The potential for increased financial responsibility in the CDHP plan did not appear to deter those enrollees from pursuing necessary care. Future research should control for the demographic factors thought to influence both selection into a plan design and quality of care.
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PMID:Comparing quality of care between a consumer-directed health plan and a traditional plan: an analysis of HEDIS measures related to management of chronic diseases. 1932 Jun 5

A 49-year-old female with diabetes and chronic low back pain was treated with computed tomography-guided injections after years of unsuccessful pain management. Magnetic resonance imaging (MRI) demonstrated degenerative changes of the lumbar spine with disk herniation, facet joint degeneration, and instability of the presacral segment. Following epidural steroid injection, local infection and sepsis occurred and, finally, tetraparesis developed. A cervical epidural abscess was demonstrated on follow-up MRI and evacuation was performed. The patient survived severely handicapped. Legal proceedings were initiated against the radiologists. They were accused of causing damage to the patient. The plaint was defeated with special reference to the report and expertise of the neuroradiologic evidence.
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PMID:[Cervical epidural abscess following lumbar epidural steroid injections]. 1970 79

Opioid analgesics have an established role in the management of postoperative pain and cancer pain, and are gaining acceptance for the management of moderate to severe chronic noncancer pain, most notably chronic low back pain and osteoarthritis, that does not respond to other interventions. Many patients with chronic pain have co-morbid medical conditions that may complicate opioid therapy. Selecting the appropriate opioid requires knowledge of how individual opioids differ with respect to metabolism and interaction with concurrent medications, as well as the reasons why specific medical conditions may influence their efficacy and tolerability. Polypharmacy is a common complicating condition in the elderly and in patients with psychiatric illness, cancer, cardiovascular disease, diabetes mellitus or other chronic illnesses. Polypharmacy, though often necessary for patients with multiple medical conditions, also multiplies the risk of drug interactions. Pharmacokinetic drug interactions can increase or reduce exposure to the opioid or concurrent medications, reducing efficacy and/or tolerability and increasing toxicity. Pharmacodynamic interactions can enhance the depressive effects of opioids, compromising safety. Patients with impaired renal or hepatic function may have difficulty clearing or metabolizing opioids and concurrent medications, leading to increased risk of adverse events. Patients with cardiovascular, cerebrovascular or respiratory disease (including smokers of >/=2 packs/day with no other diagnosis) may be more susceptible to respiratory depression, bradycardia and hypotension with any opioid, and a few specific opioids pose additional risks. Patients with cerebrovascular disease, dementia, brain injury or psychiatric illness are more susceptible to opioid effects on the CNS, which can include euphoria, cognitive impairment and sedation. Appropriate opioid selection may mitigate these effects. Even in older patients, addiction, abuse and misdirection of prescribed opioids are of concern. Higher risk exists for patients with psychiatric illness, history of substance abuse, and identifiable substance abuse risk factors. Screening for abuse potential and vigilant patient monitoring should be routine. Opioids differ in their ability to produce euphoria, based on opioid receptor agonism, but substance abusers may be more influenced by availability, familiarity and cost factors. Consequently, opioid selection has limited influence on abuse potential but can facilitate ease of monitoring. This review provides an overview of opioid use in medically complicated patients and recommendations on how to optimize analgesia while avoiding adverse events and drug interactions in the clinical setting. Articles cited in this review were identified via a search of EMBASE and PubMed. Articles selected for inclusion discussed characteristics of specific opioids and general physiological aspects of opioid therapy in important patient populations.
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PMID:Implications of opioid analgesia for medically complicated patients. 2045 Feb 39


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