Clinical course of pain in acute osteoporotic vertebral compression fractures.

PURPOSE: The authors prospectively determined the natural course of pain in patients with conservatively treated acute osteoporotic vertebral compression fractures (VCF). In addition, the type of conservative therapy that these patients received was assessed. MATERIALS AND METHODS: Patients older than 50 years, referred for spine radiography for acute back pain, were asked to complete a baseline clinical questionnaire. Patients with an acute VCF were followed up at 6 and 23 months with a questionnaire that included a Visual Analog Score (VAS) and type of pain medication and other conservative treatment. Significant pain relief was defined as a decrease in VAS of 50% or more. RESULTS: Forty-nine patients (mean age, 78 years; range, 51-95) with acute VCF were followed up for almost 2 years. Significant pain relief was noted in 22 of 35 patients (63%) at 6 months and in 25 of 36 (69%) at 23 months. In patients with persisting pain at 23 months (mean VAS 6.4), some decrease in VAS was apparent at 6 months but not in the 6-23 months interval. No predictors for significant pain relief could be identified. Patients with significant pain relief used less pain medication and had less physical therapy. CONCLUSIONS: In most patients with an acute VCF, pain decreases significantly with conservative therapy, predominantly in the first 6 months. However, almost 2 years after an acute VCF, a third of patients still had severe pain necessitating pain medication and physical therapy in the majority. No predictors for transition from acute to chronic pain could be identified.

VERTOS II: percutaneous vertebroplasty versus conservative therapy in patients with painful osteoporotic vertebral compression fractures; rationale, objectives and design of a multicenter randomized controlled trial.

BACKGROUND: The standard care in patients with a painful osteoporotic vertebral compression fracture (VCF) is conservative therapy. Percutaneous vertebroplasty (PV), a minimally invasive technique, is gaining popularity as a new treatment option. Many prospective and retrospective studies have reported on the effectiveness and safety of PV, but no large randomized controlled trial (RCT) has been published. OBJECTIVE: To estimate cost-effectiveness of PV compared to conservative therapy in terms of: pain reduction, quality of life, complications, secondary fractures and mortality. MATERIALS AND METHODS: The VERTOS II study is designed as a prospective, multicenter RCT. Patients with a painful VCF with bone edema on MR imaging, local back pain for 6 weeks or less, osteopenia and aged 50 years or older, after obtaining informed consent are included and randomized for PV or conservative therapy. In total 200 patients will be enrolled. Follow-up is at regular intervals during a 1-year period with standard questionnaires, addressing: clinical symptoms, pain medication, Visual Analogue Scale (VAS) score, quality of life and cost-effectiveness. Secondary fractures, necessary additional therapies and complications are recorded. CONCLUSION: The VERTOS II study is the first methodologically sound RCT designed to assess the cost-effectiveness of PV compared to conservative therapy in patients with an acute osteoporotic VCF. TRIAL REGISTRATION: http://www.clinicaltrials.gov, NCT00232466.

Ulnar neuropathy at the elbow: follow-up and prognostic factors determining outcome.

OBJECTIVE: To determine the outcome in patients with ulnar neuropathy at the elbow (UNE) treated surgically or conservatively, and the prognostic value of clinical, sonographic, and electrophysiologic features. METHODS: After a median follow-up of 14 months, 69 of 84 patients initially included in a prospective blinded study on the diagnostic value of sonography in UNE were re-evaluated. The patients underwent renewed systematic clinical and sonographic examination. Patients were scored as having a poor (stable or progressive symptoms) or favorable (complete remission of symptoms or improvement) outcome. RESULTS: Of the 74 initially affected arms, 12 (16%) had a complete remission, 21 (28%) improved, 25 (34%) remained stable, and 16 (22%) had progression. Surgically treated patients (28 arms) had a more favorable outcome than those treated conservatively (p = 0.03). After surgery, the mean ulnar nerve diameter decreased from 3.2 to 2.9 mm (p = 0.03), while this was not seen after conservative treatment. Multiple logistic regression analysis showed that more outspoken nerve enlargement found during sonography at the time of the diagnosis was associated with a poor outcome (OR: 2.9, p = 0.009). Furthermore, the presence of a motor conduction block (OR: 0.2, p = 0.03) and motor velocity slowing across the elbow (OR: 0.1, p = 0.01) were associated with a favorable outcome. CONCLUSION: More pronounced ulnar nerve thickening at the time of the diagnosis is associated with poor outcome at follow-up, especially in conservatively treated cases, while electrodiagnostic signs of demyelination on testing indicate favorable outcome.

Diagnostic value of high-resolution sonography in ulnar neuropathy at the elbow.

OBJECTIVE: To determine the diagnostic value of high-resolution sonography in ulnar neuropathy at the elbow (UNE). METHODS: Sonographic ulnar nerve diameter measurement was compared at three levels around the medial epicondyle with a criterion standard including clinical and electrophysiologic characteristics in a cohort of 123 patients presenting with clinical signs of UNE. UNE or probable UNE was diagnosed in 84 patients and a different condition in 39 patient controls. Reference values were obtained in 56 healthy volunteers. RESULTS: One hundred thirty-six affected arms were studied in 123 patients (UNE in 82, probable UNE in 9, and a different condition in 45 affected arms). Patients with UNE had a larger ulnar nerve diameter than patient controls (p < 0.0001). The sensitivity of sonography was 80%, specificity 91%, positive likelihood ratio 9, and negative likelihood ratio 0.2. The highest diagnostic yield was found in patients in whom electrodiagnostic studies showed signs of ulnar neuropathy but could not localize the lesion (17/20 cases, 86%) and in patients who had motor conduction velocity slowing across the elbow without conduction block (32/37 cases, 86%). CONCLUSIONS: High-resolution sonography is an accurate and easily applied test for the diagnosis of UNE. The authors recommend its use in addition to electrodiagnostic studies because it improves the reliability of the diagnosis of UNE.

[Embolization as treatment for postpartum hemorrhage]. / Embolisatie als behandeling bij bloedingen post partum.

A 33-year-old woman suffered from an early postpartum bleeding (15 hours after delivery) and a 29-year-old patient from a late one (nine days postpartum). Both women were treated with conservative methods including curettage and surgical evacuation of the haematoma in one case. However, blood loss didn't stop. Instead of hysterectomy it was decided to embolize the appropriate cervicouterine branch of the A. uterina in these young women, which appeared to be effective. In case of non-effective treatment of postpartum bleeding, hysterectomy is not the only remaining therapy. Gynaecologists and radiologists together may consider embolization therapy. This has proved to be a minimally invasive and successful treatment. Unlike hysterectomy, the uterus will be preserved, making an additional pregnancy possible.

Chronic obstructive pulmonary disease and abdominal aortic aneurysms.

In a prospective study during the period January-May 1992, 362 consecutive out-patients above 65 years of age, attending the pulmonary department for chronic obstructive airways disease (COPD), were ultrasonographically screened for an aneurysm of the abdominal aorta (AAA). Data from pulmonary function tests together with history of cardiac disease, diabetes mellitus, hypertension, hypercholesterolaemia, peripheral arterial obstructive disease, smoking and corticosteroid medication were collected. 30/282 men and 6/80 women with COPD had an AAA > or = 30 mm in diameter, which equals a prevalence of 9.9% (95% confidence limits: 6.8-13.0%). COPD patients with severe emphysema, having a decreased forced expiratory volume/vital capacity ratio (FEV/VC) of < 55%, have a significantly higher prevalence of aortic dilatation or AAA compared to COPD patients with mild or moderate decreased FEV/VC (chi-squared test: p < 0.05, alpha = 0.05). In the group of patients with AAA, significantly more smokers were seen compared to the group with normal and dilated aortas (chi-squared test: p < 0.05).

Effects of disodium cromoglycate and beclomethasone dipropionate on the asthmatic response to allergen challenge I. Immediate response (IAR).

This study deals with comparative investigation of the protective effects of disodium cromoglycate (DSCG, Lomudal, Intal) and beclomethasone dipropionate aerosol (BDA, Aldecin, Becotide, Beclovent) on 103 immediate asthmatic responses (IARs) to allergen challenge recorded in 103 patients with an allergic bronchial asthma. Disodium cromoglycate demonstrated highly significant protective effects on the IAR in patients investigated (P less than .01). The protective effects of BDA on the IAR were found to be non-significant (P greater than .01). It is suggested that DSCG should be the first choice in controlling allergic bronchial asthma when the immediate asthmatic response to allergen plays the predominant role.