Comparative Analysis of Spontaneous Infectious Spondylitis : Pyogenic versus Tuberculous

OBJECTIVE: Spondylitis is often chemotherapy resistant and requires long-term treatment. Without adequate chemotherapy, the outcome can be fatal or result in severe neurologic damage. Therefore, differentiating the etiology of spondylitis is very important, particularly in spontaneous cases. As the prevalence of tuberculosis in Korea has decreased in recent years, updated clinical research about spondylitis is warranted.METHODS: From April 2010 to March 2016, data from spondylitis patients were collected retrospectively. In total, 69 patients (51 with pyogenic spondylitis and 18 with tuberculous spondylitis) were included. Clinical data, laboratory findings including erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) level, measurements of Cobb angles at the initial and final follow-up, and radiologic features on magnetic resonance imaging (MRI) scans were evaluated. To test differences between the pyogenic and tuberculous groups, numerical data were compared using the student’s t-test and Mann-Whitney U test, and categorical data were compared using the chi-square test and Fisher’s exact test.RESULTS: The patients’ mean age was 60.0 years. Male sex was slightly predominant (56.5%). There was no difference in mean age and sex between the two groups. The pyogenic group had a relatively higher proportion of immunocompromised patients. The peak CRP value was higher in the pyogenic group than in the tuberculous group (14.08 mg/dL and 8.50 mg/dL, respectively, p=0.009), whereas the ESR was not significantly different between the groups (81.5 mm/h and 75.6 mm/h, respectively, p=0.442). Radiologically, the presence of disc space sparing and vertebral body collapse differed between the groups. In the tuberculous group, the disc was more commonly preserved on contrast-enhanced MRI (50% and 23.5%, respectively, p=0.044), and vertebral body collapse was more common (66.6% and 15.7%, respectively, p < 0.001). The mean length of hospitalization was longer in the pyogenic group (56.5 days and 41.2 days, respectively, p=0.001). Four mortality cases were observed only in the pyogenic group. The most commonly isolated microorganism in the pyogenic group was Staphylococcus aureus (S. aureus) (methicillin susceptible S. aureus and methicillin resistant S. aureus [MRSA] in 8 and 4 cases, respectively).CONCLUSION: The clinical and radiological manifestations of spontaneous spondylitis differ based on the causative organism. Pyogenic spondylitis patients tend to have a higher CRP level and a more severe clinical course, whereas tuberculous spondylitis patients present with destruction of the vertebral body with disc sparing more frequently. The presence of MRSA is increasing in community-acquired spondylitis cases.

Comparative Analysis of Spontaneous Infectious Spondylitis : Pyogenic versus Tuberculous

OBJECTIVE: Spondylitis is often chemotherapy resistant and requires long-term treatment. Without adequate chemotherapy, the outcome can be fatal or result in severe neurologic damage. Therefore, differentiating the etiology of spondylitis is very important, particularly in spontaneous cases. As the prevalence of tuberculosis in Korea has decreased in recent years, updated clinical research about spondylitis is warranted. METHODS: From April 2010 to March 2016, data from spondylitis patients were collected retrospectively. In total, 69 patients (51 with pyogenic spondylitis and 18 with tuberculous spondylitis) were included. Clinical data, laboratory findings including erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) level, measurements of Cobb angles at the initial and final follow-up, and radiologic features on magnetic resonance imaging (MRI) scans were evaluated. To test differences between the pyogenic and tuberculous groups, numerical data were compared using the student’s t-test and Mann-Whitney U test, and categorical data were compared using the chi-square test and Fisher’s exact test. RESULTS: The patients’ mean age was 60.0 years. Male sex was slightly predominant (56.5%). There was no difference in mean age and sex between the two groups. The pyogenic group had a relatively higher proportion of immunocompromised patients. The peak CRP value was higher in the pyogenic group than in the tuberculous group (14.08 mg/dL and 8.50 mg/dL, respectively, p=0.009), whereas the ESR was not significantly different between the groups (81.5 mm/h and 75.6 mm/h, respectively, p=0.442). Radiologically, the presence of disc space sparing and vertebral body collapse differed between the groups. In the tuberculous group, the disc was more commonly preserved on contrast-enhanced MRI (50% and 23.5%, respectively, p=0.044), and vertebral body collapse was more common (66.6% and 15.7%, respectively, p < 0.001). The mean length of hospitalization was longer in the pyogenic group (56.5 days and 41.2 days, respectively, p=0.001). Four mortality cases were observed only in the pyogenic group. The most commonly isolated microorganism in the pyogenic group was Staphylococcus aureus (S. aureus) (methicillin susceptible S. aureus and methicillin resistant S. aureus [MRSA] in 8 and 4 cases, respectively). CONCLUSION: The clinical and radiological manifestations of spontaneous spondylitis differ based on the causative organism. Pyogenic spondylitis patients tend to have a higher CRP level and a more severe clinical course, whereas tuberculous spondylitis patients present with destruction of the vertebral body with disc sparing more frequently. The presence of MRSA is increasing in community-acquired spondylitis cases.

Clinical Results of Odontoid Fractures according to a Modified, Treatment-Oriented Classification

OBJECTIVE: Odontoid fracture is common in cervical injury, representing about 20% of total cervical fractures. Classic odontoid fracture classification focused on anatomy of fracture site has no treatment recommendation and a modified treatment-oriented classification of odontoid fracture was suggested in 2005. We reviewed our odontoid fracture patients to assess the feasibility and efficacy of Grauer's classification. METHODS: Between October 2000 and September 2015, we collected data from patients who came to our institute for odontoid fracture. Demographic data of patients was reviewed, and neck visual analog scale (VAS) score and fusion rate were assessed by reviewing electronic medical records retrospectively. RESULTS: Sixty-nine patients out of a total of eighty two odontoid fracture patients were reviewed according to Grauer's classification. Neck VAS of all subtypes in odontoid fracture classification were decreased at last follow-up (p=0.001). Overall fusion rate was 88.4% at last follow-up. Concordance rate between Grauer's recommendation and our treatment was 69.9%, especially in type II with the concordance higher than 80%. Complication was minimal representing 7.2%, only in types I and III. CONCLUSION: In this study, there were statistically significant improvement in all subtypes in terms of neck VAS at the last follow up, especially in types II and III. Grauer's classification appears to be meaningful to decide treatment plan for odontoid fractures, especially type II odontoid fracture.

Demineralized Bone Matrix (DBM) as a Bone Void Filler in Lumbar Interbody Fusion: A Prospective Pilot Study of Simultaneous DBM and Autologous Bone Grafts

OBJECTIVE: Solid bone fusion is an essential process in spinal stabilization surgery. Recently, as several minimally invasive spinal surgeries have developed, a need of artificial bone substitutes such as demineralized bone matrix (DBM), has arisen. We investigated the in vivo bone growth rate of DBM as a bone void filler compared to a local autologous bone grafts. METHODS: From April 2014 to August 2015, 20 patients with a one or two-level spinal stenosis were included. A posterior lumbar interbody fusion using two cages and pedicle screw fixation was performed for every patient, and each cage was packed with autologous local bone and DBM. Clinical outcomes were assessed using the Numeric Rating Scale (NRS) of leg pain and back pain and the Korean Oswestry Disability Index (K-ODI). Clinical outcome parameters and range of motion (ROM) of the operated level were collected preoperatively and at 3 months, 6 months, and 1 year postoperatively. Computed tomography was performed 1 year after fusion surgery and bone growth of the autologous bone grafts and DBM were analyzed by ImageJ software. RESULTS: Eighteen patients completed 1 year of follow-up, including 10 men and 8 women, and the mean age was 56.4 (32–71). The operated level ranged from L3/4 to L5/S1. Eleven patients had single level and 7 patients had two-level repairs. The mean back pain NRS improved from 4.61 to 2.78 (p=0.003) and the leg pain NRS improved from 6.89 to 2.39 (p<0.001). The mean K-ODI score also improved from 27.33 to 13.83 (p<0.001). The ROM decreased below 2.0 degrees at the 3-month assessment, and remained less than 2 degrees through the 1 year postoperative assessment. Every local autologous bone graft and DBM packed cage showed bone bridge formation. On the quantitative analysis of bone growth, the autologous bone grafts showed significantly higher bone growth compared to DBM on both coronal and sagittal images (p<0.001 and p=0.028, respectively). Osteoporotic patients showed less bone growth on sagittal images. CONCLUSION: Though DBM alone can induce favorable bone bridging in lumbar interbody fusion, it is still inferior to autologous bone grafts. Therefore, DBM is recommended as a bone graft extender rather than bone void filler, particularly in patients with osteoporosis.

Factors Affecting Quality of Life and Family Burden among the Families of Patients with Schizophrenia / 대한정신분열병학회지

OBJECTIVES: Study aimed to identify factors that may affect family burden and quality of life (QOL) of primary caregivers in schizophrenia family. METHODS: Among outpatients with schizophrenia undergoing treatment at the psychiatric department of a university hospital, 72 patients and their primary caregivers were investigated. Sociodemographic and clinical data were collected and analyzed. RESULTS: As a result of multiple regression of primary caregivers’ family burden (R²=0.284), primary caregiver’s income (p=0.001) and patient’s delusional symptoms (p=0.001) significantly explained the total family burden of primary caregivers. In multiple regression on QOL (R²=0.515), primary caregiver’s income (p=0.033) and education level (p=0.006), patient’s sex (p=0.006), treatment duration (p<0.001), degree of disorganized speech (p=0.008), negative drug attitudes (p=0.026) and the attitude of overcoming stigma against mental patients (p=0.029) all significantly explained the average QOL score. CONCLUSION: Various factors determining primary caregiver’s QOL, including Clinical symptoms such as patient’s disorganized speech and clinically correctable factors such as negative drug attitude and insight into disease. Therefore, provision of education regarding drug and disease for patients and caregivers will be helpful to effectively reduce burden and improve the QOL of primary caregivers.

Unusual Presentation of Cerebral Cavernous Malformation

Cerebral cavernous malformations (CMs) are vascular malformations of the central nervous system, which can be detected in the absence of any clinical symptoms. Nodules and cysts with mixed signal intensity and a peripheral hemosiderin rim are considered brain magnetic resonance imaging (MRI) findings typical of CMs. A 48-year-old man was admitted to our hospital because of abnormal MRI findings without significant neurological symptoms. A cyst with an internal fluid-fluid level was found in the left basal ganglia on the initial brain MRI. We decided to observe the natural course of the asymptomatic lesion with serial MRI follow-up. On MRI at the 5-month follow-up, the cystic mass was enlarged and showed findings consistent with those of cystic CM. Surgical resection was performed and the pathological diagnosis was CM. Our experience suggests that the initial presentation of a CM can be a pure cyst and neurosurgeons should consider the likelihood of CMs in cases of cystic cerebral lesions with intracystic hemorrhage.

Is Routine Repeated Head CT Necessary for All Pediatric Traumatic Brain Injury?

OBJECTIVE: Repeated computed tomography (CT) follow up for traumatic brain injury (TBI) patients is often performed. But there is debate the indication for repeated CT scans, especially in pediatric patients. Purpose of our study is to find risk factors of progression on repeated CT and delayed surgical intervention based on the repeated head CT. METHODS: Between March, 2007 and December, 2013, 269 pediatric patients (age 0-18 years) had admitted to our hospital for head trauma. Patients were classified into 8 subgroups according to mechanisms of injury. Types, amount of hemorrhage and amount changes on repeated CT were analyzed as well as initial Glasgow Coma Scale (GCS) scores. RESULTS: Within our cohort of 269 patients, 174 patients received repeat CT. There were progression in the amount of hemorrhage in 48 (27.6%) patients. Among various hemorrhage types, epidural hemorrhage (EDH) more than 10 cc measured in initial CT was found to be at risk of delayed surgical intervention significantly after routine repeated CT with or without neurological deterioration than other types of hemorrhage. Based on initial GCS, severe head trauma group (GCS 3-8) was at risk of delayed surgical intervention after routine repeated CT without change of clinical neurologic status. CONCLUSION: We suggest that the patients with EDH more than 10 cc or GCS below 9 should receive repeated head CT even though absence of significant clinical deterioration.

The Use of the Korean Version of Short Form Geriatric Depression Scale (SGDS-K)in the Community Dwelling Elderly in Korea

OBJECTIVES: The purpose of this study was to evaluate whether the diagnostic validity of the Korean version of short form (15 item version) Geriatric Depression Scale (SGDS-K) was maintained well in the community dwelling elderly. METHODS: In a face-to-face household survey conducted in Korea, 2,004 subjects aged more than 65 were interviewed by trained interviewers. 63 subjects diagnosed as dementia were excluded. The Mini Mental State Examination (MMSE) and SGDS-K were administered. Major depressive disorder (MDD) and minor depressive disorder (MnDD) were diagnosed with the diagnostic section of depressive disorder of the Korean version of the Composite International Diagnostic Interview (K-CIDI) according to DSM-IV diagnostic criteria. The sensitivity, the specificity and optimal cut-off point estimation and receiver operating characteristics (ROC) curve analysis were performed to investigate the diagnostic validity of the SGDS-K to screen MDD and MnDD. The diagnostic validity tests were also compared between two groups (with cognitive impairment and without cognitive impairment) divided by the MMSE scores. RESULTS: We suggest a score of 8 (sensitivity 0.9365, specificity 0.7603) as optimal cut-off score of SGDS-K for screening MDD and a score of 6 (sensitivity 0.7898, specificity 0.6586) as optimal cut-off score for screening both MDD and MnDD. The area under curve (AUC) was 0.900 for screening MDD and 0.797 for both MDD and MnDD. In the community dwelling elderly suffering from cognitive impairment, the sensitivity and specificity were 0.9500, 0.6870 with a cut off score of 8 for screening MDD and 0.8409, 0.5691 with a cut off score of 6 for screening both MDD and MnDD. The AUC was 0.893 for MDD and 0.767 for both MDD and MnDD. CONCLUSION: The SGDS-K was useful in screening MDD, both MDD and MnDD in the community dwelling elderly and also useful in the elderly suffering from cognitive impairment.

Factors Affecting Treatment Discontinuation and Treatment Outcome in Patients with Schizophrenia in Korea: 10-Year Follow-Up Study

OBJECTIVE: There have been few long-term studies that have assessed factors influencing treatment discontinuation and long-term outcome of schizophrenia in Korea. The present study aimed to evaluate factors affecting treatment discontinuation and treatment outcome, after 10 years, in patients with schizophrenia. METHODS: Among hospitalized patients between 1997 and 1999, 191 patients were given continuous follow-up service. We examined the clinical characteristics and outcome of patients who remained in treatment. Regression analyses were used to find any clinical factors affecting treatment discontinuation. RESULTS: One hundred thirty-three patients (71.12%) discontinued the treatment. The treatment retention group contained more female patients, paranoid-type patients, patients who had shown self-harming behavior, patients receiving clozapine, and patients with good medication compliance. The recovery rate was 25%. However, 42.3% did not have gainful employment. Further, most patients couldn't live independently. CONCLUSION: The results show the importance of gender, patient behavior, medication, and medication compliance in predicting treatment discontinuation in patients with schizophrenia.

Comparative Analysis of Involuntary Admission and Voluntary Admission in Schizophrenia: A 3-Year Follow Up / 신경정신의학

OBJECTIVES : The purpose of this study was to investigate differences between involuntarily and voluntarily hospitalized patients with schizophrenia. METHODS : Patients who were hospitalized between 2001 and 2005 with a diagnosis of DSM-IV schizophrenia were included. The subjects were grouped by whether their admission was voluntary or involuntary. The data were collected through inpatient medical records. The two groups were compared regarding demographic variables and clinical features, and we examined the number of rehospitalizations, duration of follow-up, follow-up retention rate and second admission pattern for a period of 3 years after discharge. RESULTS : 181 subjects were classified as according to their admission into the involuntary group, and 69 subjects as the voluntary group. There were more female patients, more past admissions and longer duration of illness in the involuntary group. The patients in the involuntary group had more problematic behaviors with their chief complaint being delusions. The follow-up retention rate was lower (44.8% vs. 59.4%) and the rate of the second involuntary admission was higher in the involuntary group. CONCLUSION : Involuntary hospitalization may be an important predictor for treatment maintenance in patients with schizophrenia.

Comparative Analysis of Involuntary Admission and Voluntary Admission in Schizophrenia: A 3-Year Follow Up / 신경정신의학

OBJECTIVES : The purpose of this study was to investigate differences between involuntarily and voluntarily hospitalized patients with schizophrenia. METHODS : Patients who were hospitalized between 2001 and 2005 with a diagnosis of DSM-IV schizophrenia were included. The subjects were grouped by whether their admission was voluntary or involuntary. The data were collected through inpatient medical records. The two groups were compared regarding demographic variables and clinical features, and we examined the number of rehospitalizations, duration of follow-up, follow-up retention rate and second admission pattern for a period of 3 years after discharge. RESULTS : 181 subjects were classified as according to their admission into the involuntary group, and 69 subjects as the voluntary group. There were more female patients, more past admissions and longer duration of illness in the involuntary group. The patients in the involuntary group had more problematic behaviors with their chief complaint being delusions. The follow-up retention rate was lower (44.8% vs. 59.4%) and the rate of the second involuntary admission was higher in the involuntary group. CONCLUSION : Involuntary hospitalization may be an important predictor for treatment maintenance in patients with schizophrenia.

Pericarditis with Pericardial Effusion and Bilateral Pleural Effusion Associated with Clozapine Treatment in an Adolescent Boy / 대한정신약물학회지

The clozapine has been associated with serious side-effects, such as agranulocytosis and seizure. Less attention has been given to clozapine's adverse cardiac complications, including myocarditis, pericarditis and cardiomyopathy despite a high mortality rate. Here we describe a case of an adolescent male patient who developed pericarditis with pericardial effusion and bilateral pleural effusion 17 days after being started on clozapine therapy, whose symptoms improved after discontinuation of clozapine. We also reviewed literatures of clozapine-related cardiac complications. We hope clinicians to be vigilant for clozapine-related cardiac complications against the many benefits of clozapine for patients with schizophrenia.

Pericarditis with Pericardial Effusion and Bilateral Pleural Effusion Associated with Clozapine Treatment in an Adolescent Boy / 대한정신약물학회지

The clozapine has been associated with serious side-effects, such as agranulocytosis and seizure. Less attention has been given to clozapine's adverse cardiac complications, including myocarditis, pericarditis and cardiomyopathy despite a high mortality rate. Here we describe a case of an adolescent male patient who developed pericarditis with pericardial effusion and bilateral pleural effusion 17 days after being started on clozapine therapy, whose symptoms improved after discontinuation of clozapine. We also reviewed literatures of clozapine-related cardiac complications. We hope clinicians to be vigilant for clozapine-related cardiac complications against the many benefits of clozapine for patients with schizophrenia.