[Chronic low back pain: multispecialty assessment of 100 patients]. / Dolor lumbar crónico. Valoración multidisciplinaria de 100 pacientes.

OBJECTIVES: Chronic lower-back pain (CLP) is a common pathology and has a high social and economic impact, especially in primary care where its treatment is changing at present. The results of the multi-disciplinary assessment of 100 patients with chronic lower-back pain are given. DESIGN: Cross-sectional, observational and prospective study. SETTING: Out-patient clinics of the rheumatology service of a tertiary-level hospital (referral from base districts where there is no primary care rheumatologist). PATIENTS: 100 consecutive patients seen for back pain lasting for more than 6 months were analysed. INTERVENTIONS: There was no therapeutic intervention. MEASUREMENTS AND MAIN RESULTS: The personal, work, clinical, examination, x-ray, functional and psychological features of 100 patients with CLP were analysed. There were 38 men and 62 women, with average age of 45 +/- 10 years and low social, cultural and job levels. Pain had lasted 82 +/- 7 months and 52% had had time off work. Mean intensity of pain was 6.5 +/- 2.3 (scale of zero to 10). There was vertebral restriction in 16%, and conduct expressing pain on examination in 47%. The x-ray showed disorder in 51%. Functional incapacity was nil or light in 46% and severe in 16%. 74.5% of the patients were depressed; 57% had features of anxiety; and 44% were anxious at the time of the interview. CONCLUSIONS: Patients with CLP are middle-aged, with long-standing pain and frequent time off work. Pain intensity is high, but vertebral restriction, disorders on x-rays and functional incapacity are scant. However, anxiety and depression levels are high. This could suggest a change in how we treat CLP towards a multi-disciplinary approach and psycho-affective, social and labour assessment, both at the time of assessment and in later treatment of patients.

Dolor lumbar crónico. valoración multidisciplinaria de 100 pacientes / Chronic lower-back pain. multi-disciplinary assessment of 100 patients

Objetivo. El dolor lumbar crónico (DLC) es una patología frecuente y de elevado impacto socioeconómico, especialmente en asistencia primaria, cuyo abordaje en la actualidad está variando. Se ofrecen los resultados de la valoración multidisciplinaria de 100 pacientes con lumbalgia crónica. Diseño. Estudio transversal, observacional y prospectivo. Emplazamiento. Consultas externas del servicio de reumatología de un hospital de tercer nivel (referencia del área básica correspondiente donde no existía reumatólogo en atención primaria). Pacientes. Se analizaron 100 pacientes consecutivos que consultaron por dolor lumbar de más de 6 meses de duración. Intervenciones. Estudio observacional sin ninguna intervención terapéutica. Mediciones y resultados principales. Se analizaron las características demográficas, laborales, clínicas, exploratorias, radiológicas, funcionales y psicológicas de 100 pacientes con DLC. Se incluyeron 38 varones y 62 mujeres, edad 45 ñ 10 años, bajo nivel sociocultural y laboral, duración del dolor 82 ñ 7 meses y baja laboral en un 52 por ciento. La intensidad media del dolor fue de 6,5 ñ 2,3 (0-10), hubo limitación vertebral en un 16 por ciento y conductas de dolor a la exploración en el 47 por ciento. La radiología se hallaba alterada en el 51 por ciento de los pacientes. La incapacidad funcional fue nula o leve en un 46 por ciento y severa en el 16 por ciento. Un 74,5 por ciento de los pacientes estaba deprimido, el 57 por ciento tenía un rasgo ansioso y estaba ansioso en el momento de la entrevista un 44 por ciento. Conclusiones. El paciente con DLC es un sujeto de mediana edad, con dolor de larga evolución y baja laboral frecuente. La intensidad del dolor es alta, pero la limitación vertebral, alteraciones radiológicas e incapacidad funcional son escasas. Sin embargo, los niveles de ansiedad y depresión son elevados. Ello podría sugerirnos un cambio en el enfoque del DLC, incidiendo en el abordaje multidisciplinario y el estudio psicoafectivo, social y laboral, tanto en la valoración como en el tratamiento posterior de los pacientes (AU)

D-lactic acid in synovial fluid. A rapid diagnostic test for bacterial synovitis.

OBJECTIVE: To analyze the usefulness of D-lactic acid levels in synovial fluid (SF) as a rapid test to support the early diagnosis of bacterial arthritis (BA). METHODS: A simple modification of the enzyme method used for measuring L-lactic acid was used to analyze levels of D-lactic acid in SF from 20 cases of BA. Results were compared with those from 99 noninfectious arthritis, which included 90 inflammatory SF samples. Total white blood cell count (WBC), percentage of polymorphonuclears (% PMN) and gram stains were also determined. RESULTS: D-lactic acid levels were significantly higher in BA than in noninfectious arthritis. Using a cutoff value of 0.05 mM, 85% of the SF samples from BA had a positive test for D-lactic acid compared with 4% of the control group. The overall sensitivity of the assay was 85% with a specificity of 96%, showing a positive predictive value for BA of 81% and a negative predictive value of 97%. CONCLUSION: The data presented suggest that D-lactic acid is an accurate, easy test that can be carried out in any laboratory, to support the early diagnosis of BA.

Sacral stress fracture after liver transplantation.

Sacral insufficiency fractures have been related to osteoporosis and steroid therapy, however only one case has been reported following liver transplantation. We describe three patients who developed insufficiency fractures of the sacrum following liver transplantation, these fractures could be overlooked or confused with inflammatory processes involving the sacrum.

Prevalence of articular chondrocalcinosis in elderly subjects in a rural area of Catalonia.

OBJECTIVES: To undertake an epidemiological survey of the prevalence of radiological chondrocalcinosis in the elderly population of Osona, a rural area of Catalonia, north east Spain. METHODS: Knee and wrist radiographs were performed on 261 subjects (141 women, 120 men) aged at least 60 years, who attended a series of 35 general practitioners for various medical problems. RESULTS: Twenty seven subjects had articular chondrocalcinosis, which represents a crude prevalence of 10%. Articular chondrocalcinosis was more often observed in women than in men (14 v 6%). Articular chondrocalcinosis increases in occurrence with age, rising from 7% in subjects aged 60-69 years to 43% in subjects older than 80 years. A similar occurrence of articular chondrocalcinosis was noted in the indigenous population, in which several cases of familial chondrocalcinosis have previously been reported, and in subjects born in other areas of Spain. All but one subject with articular chondrocalcinosis had chondrocalcinosis of the knee. The occurrence of rheumatic disorders did not differ significantly between subjects with articular chondrocalcinosis and those without. CONCLUSIONS: Articular chondrocalcinosis is an age related disorder, which could partly explain the discrepancies in its prevalence reported in previous studies. In most subjects with articular chondrocalcinosis recruited from an unselected population the clinical manifestations are probably mild or even absent.

Determination of D-lactate concentration for rapid diagnosis of bacterial infections of body fluids.

The value of determining D-lactate concentrations in body fluids for the rapid diagnosis of bacterial infections was investigated. A total of 336 body fluid samples were analyzed: 208 ascitic fluids, 57 synovial fluids, 40 cerebrospinal fluids and 32 pleural fluids. Using a cut-off value of 0.05 mM, the overall sensitivity was 0.96 and the specificity was 0.88. Therefore, the measurement of D-lactate concentration in body fluids offers a rapid (2-hour) and useful method of differentiating between infectious and non-infectious body fluid diseases.

Septic arthritis in heroin addicts.

Over a 6-year period (1982 to 1988), 36 episodes of septic arthritis were diagnosed in 35 heroin addicts from Barcelona, Spain. Thirty (86%) were men and five (14%) were women, with a mean age of 24 years (range, 14 to 39). Twenty-nine episodes (80%) were monoarticular and seven (20%) were oligoarticular. The sacroiliac (16 cases), sternoclavicular (8), hip (5), and shoulder (4) joints were most frequently infected. Staphylococcus aureus and Pseudomonas aeruginosa were the etiological agents in 75% and 11% of episodes, respectively. Response to antibiotic treatment was good in 32 cases (90%), eight patients needed surgical drainage, and none died. We conclude that septic arthritis in heroin addicts localizes predominantly in axial joints. In our geographic area, infection with S aureus is more frequent than with gram-negative rods such as P aeruginosa or Serratia marcescens, which are most frequently found in reports from the United States.

Factors influencing the development of metabolic bone disease in primary biliary cirrhosis.

The prevalence, type, and factors that may influence the development of bone disease in primary biliary cirrhosis, have been investigated in 20 consecutive patients, who, in addition to liver function tests and mineral and vitamin D metabolism studies, were submitted to a transiliac bone biopsy after tetracycline double-labeling for quantitative histomorphometric examination. Intestinal calcium absorption was also assessed in 16 patients. Seven patients (35%) had reduced bone volume and were considered osteoporotic. Three also had bone mineralization impairment, but did not have criteria for osteomalacia. Bone formation was depressed in 15 patients, and bone resorption was low or normal in 19 cases. Eroded surfaces were reduced in all osteoporotic patients. Duration of primary biliary cirrhosis was significantly longer in patients with osteoporosis (6.3 +/- 0.6 yr) than in those without osteoporosis (2.6 +/- 0.6, p = 0.004). Moreover, osteoporosis was more prevalent in postmenopausal women, and in those who had intestinal calcium malabsorption, which was present in 80% of osteoporotic patients but in only 18% of nonosteoporotic patients (p = 0.03). Osteoporosis and mineralization bone impairment were unrelated to the severity of cholestasis. 25-Hydroxyvitamin D was significantly lower in those patients with intestinal calcium malabsorption. The results of this study indicate that osteodystrophy in primary biliary cirrhosis is characterized mainly by "low-turnover" osteoporosis, which is related to the duration of the liver disease, postmenopausal condition, and calcium malabsorption.

[Chondrocostal and chondrosternal tuberculosis in 2 heroin addicts infected with the human immunodeficiency virus]. / Tuberculosis condrocostal y condroesternal en dos heroinómanos infectados por el virus de la inmunodeficiencia humana.

We report two cases of osteoarticular tuberculosis in heroin addict patients infected with human immunodeficiency virus. Both patients presented an inflammatory tumor in the anterior chest wall, with subacute onset; one patient had chondrosternal involvement and the other had chondrocostal involvement with a retrosternal pus collection. Diagnosis was established by needle aspiration of the tumor that gave raise to caseum. Ziehl-Neelsen stain was positive and Löwenstein-Jensen culture yielded Mycobacterium tuberculosis in both cases. The course was good after surgical debridement and tuberculous treatment for 6 months. We review the features of osteoarticular tuberculosis in drug addicts and patients infected with human immunodeficiency virus that in our environment mainly affects this population group. As in our geographical area, an increased incidence of both infections does exist and owing to the high prevalence of extrapulmonary and disseminated tuberculosis in those patients, it is expected that in a future time, the number of cases of tuberculosis will increase. Therefore, physicians must entertain a high degree of suspicion with the purpose of establishing an early diagnosis of these atypic presenting forms.

[Hereditary articular chondrocalcinosis in the Osona region (Barcelona): presentation of 3 families]. / Condrocalcinosis articular hereditaria en la comarca de Osona (Barcelona): presentación de tres familias.

The familial study of three patients from the Osona region (Barcelona) with early onset (fourth decade) of articular chondrocalcinosis (CCA) disclosed the occurrence of CCA in other members of the three families. The clinical and radiological features were heterogeneous, with polyarticular forms with marked clinical expression in one family, oligoarticular forms with few symptoms in another, and both types in the third family. These first reports of familial CCA in Catalonia can be added to those found in other parts of Spain, and they support the idea that familial cases of CCA are not exceptional if adequately investigated.

Immunoglobulin A in the skin of patients with ankylosing spondylitis.

Cutaneous immunofluorescence studies were carried out in 21 patients with ankylosing spondylitis (AS) and the results compared with those for 18 healthy subjects. The most prominent finding was the presence of IgA in dermal vessels of patients with AS (71% compared with 17% of the control group). IgG and IgM cutaneous deposits were also observed in patients with AS, but these results did not differ from those of the control group. A renal biopsy was performed in three of the patients presenting with unexplained microscopic haematuria. One of them had an IgA nephropathy, but no correlation was found between kidney and skin deposits of IgA. These findings suggest that IgA cutaneous deposits in AS are not a marker of IgA nephropathy but stress the role of immunoglobulin A in the pathogenesis of this disease.

Costochondral involvement in systemic candidiasis in heroin addicts: clinical, scintigraphic, and histologic features in 26 patients.

We studied the clinical, scintigraphic, and histopathologic characteristics of 26 intravenous drug abusers with costochondral involvement secondary to systemic infection with Candida albicans. The clinical findings were of a mass appearing in the anterior region of the thorax. In general, signs of inflammation were absent. Histopathologic study of this costochondral mass in 12 patients showed perichondritis in 100% and myositis in 87%, with secondary involvement of cartilage in 43% and of bone in 75%. Results of bone scintigrams using 99mTc-methylene diphosphonate were positive in only 7 of 15 patients (47%), with a correlation between positive uptake and osteitis. Gallium scintigraphy findings were positive in 9 of 10 patients (90%). The greater sensitivity of 67Ga was probably because the invariably present pericartilaginous inflammatory mass was not always accompanied by secondary cartilage and bone involvement.