Chiropractic care and ochronotic arthropathy.

OBJECTIVE: To discuss the case of a patient with ochronotic arthropathy whose symptoms were treated with chiropractic care. An emphasis is placed on this condition's radiographic features. CLINICAL FEATURES: A 59-year-old woman with pain in her low back, right knee, and left ankle sought chiropractic evaluation. Black pigmentation was found in the sclera of both eyes, and homogentisic acid was present in the urine. Orthopedic evaluation revealed uncomplicated, nonspecific joint pain, and radiographs demonstrated characteristic spinal changes. INTERVENTION AND OUTCOME: The patient was treated with chiropractic manipulation, physiotherapy modalities, bracing, and exercises. This type of therapy was successful in reducing the symptoms and helped decrease the severity and frequency of acute exacerbations. CONCLUSION: Ochronotic arthropathY is a rare metabolic disorder that can be diagnosed from spinal radiographs. Chiropractic care is an appropriate tool for reducing its symptomatology.     

Patients' attitudes and beliefs about back pain and its management after physiotherapy for low back pain

Background and Purpose . Contemporary guidelines for the management of low back pain often consider patient involvement and responsibility an essential component; however, there has been little exploration of patients' opinions about back pain and its management. Method . A qualitative study of patients' perspectives of back pain in the UK; 34 semi‐structured interviews were conducted with participants who had recently received physiotherapy for back pain; interviews were transcribed and analysed using framework analysis. A topic guide was used to steer the interview and themes were extracted from the data. Results . Thirteen key themes were revealed; seven of these related to issues of satisfaction with physiotherapy and are described elsewhere. The six themes considered here dealt with the participants' experience of and attitudes to back pain and its management. Themes were: the impact of back pain on their life; perspectives about back pain; its management; their involvement in its management; what strategies they had for self‐management; and expectations about the episode of physiotherapy beforehand. Conclusions . In this group of participants with a history of back pain and physiotherapy treatment a common finding was a degree of acceptance of the back pain problem and the belief that patient involvement in management was essential. These findings would suggest that many patients with back pain may respond positively to the message of self‐management. However, acceptance of this message was not automatic, but generally occurred gradually in line with patients' experience of back pain and treatment. Copyright © 2007 John Wiley & Sons, Ltd.     

Patient characteristics and physicians' practice activities for patients with chronic low back pain: a practice-based study of primary care and chiropractic physicians

BACKGROUND: Chronic low back pain sufferers are among those who account for the greatest usage of health care resources. Primary care medical (MD) physicians and chiropractic (DC) physicians treat most of these patients. OBJECTIVES: To study patient characteristics and physician practice activities for patients with chronic low back pain treated by DC physicians and MD physicians. METHODS: A longitudinal, practice-based observational study was undertaken in 14 general practice and 51 DC community-based clinics. A total of 2945 consecutive patients with ambulatory low back pain of mechanical origin were enrolled; 835 patients were in the chronic subgroup. Patients were followed for 12 months. Data were obtained on all of the following: patient demographics, health status, and psychosocial characteristics; history, duration, and severity of low back pain and disability; physicians' practice activities; and low back complaint status at 1 year. RESULTS: Patients treated by MD physicians were younger and had lower incomes; their care was more often paid for by a third party; their baseline pain and disability were slightly greater. In addition, patients treated by MD physicians had one fourth as many visits as patients treated by DC physicians. Utilization of imaging procedures by enrolling physicians was equivalent for the two provider groups. Medications were prescribed for 80% of the patients enrolled by MD physicians; spinal manipulation was administered to 84% of patients enrolled by DC physicians. Physical modalities, self-care education, exercise, and postural advice characterized low back pain management in both provider groups. Patients' care-seeking was not exclusive to one provider type. Most patients experienced recurrences (patients treated by MD physicians, 59.3%; patients treated by DC physicians, 76.4%); 34.1% of patients treated by MD physicians and 12.7% of patients treated by DC physicians reported 12 months of continuous pain. Only 6.7% of patients treated by MD physicians and 10.9% of patients treated by DC physicians reported 1 resolved episode during the year. CONCLUSIONS: Differences in sociodemographics, present pain intensity, and functional disability may distinguish patients with chronic low back pain seeking care from primary care medical physicians from those seeking care from DC physicians. Although the primary treatment modality differs, the practice activities of MD physicians and DC physicians have much in common. Long-term evaluation suggests that chronic back pain is persistent and difficult to treat for both provider types.     

Retrograde hydrostatic irrigation enema-induced perforation of the sigmoid colon in a chronic renal failure patient before colonoscopy

We present a rare case of colon perforation caused by hydrostatic irrigation enema in a patient with chronic renal failure. A 76-year-old woman was admitted to our hospital because of an exacerbation of lumbar pain and increased difficulty in walking. She had a medical history of traumatic neck pain and chronic lower back pain, which had been treated with non-steroidal anti-inflammatory drugs (NSAIDs) for 8 years. On admission, the C-reactive protein level was 6.8 mg/dl, so we planned to do a colonoscopy to determine the cause of inflammation. The patient developed abdominal pain approximately 3.5 h after a pre-procedural enema was administered. An emergency operation was performed and a small perforation was found in the sigmoid colon. We conclude that the cause of the colon perforation was a combination of the use of a hydrostatic retrograde irrigation enema in a patient with chronic renal failure who had been treated with long-term NSAIDs.     

腹膜透析相关性腹膜炎的临床分析和护理对策

[目的]分析腹膜透析相关性腹膜炎发生的原因,为预防、治疗和护理提供一定依据。[方法]分析62例行腹膜透析病人的临床资料。[结果]62例病人中发生腹膜透析相关性腹膜炎11例次,其中7例次治愈,2例次行肾移植,2例改为血液透析,1例死亡。[结论]腹膜透析相关性腹膜炎的发生与病人的操作不当、隧道口和隧道感染、肠道和血源性感染有关;原发疾病为糖尿病者发生腹膜透析相关性腹膜炎风险增高;加强培训及长期严格有效的随访,加强导管隧道口护理、饮食护理有助于预防和减少腹膜炎的发生,提高腹膜透析病人的生活质量。     

Management of patients with chronic renal failure. Role of physical therapy

Chronic renal failure can lead to multiple medical and physical problems requiring physical therapy treatment. The purpose of this article is to provide an understanding of the medical treatment and the complications of chronic renal failure. Medically, patients with chronic renal failure are treated by hemodialysis, by peritoneal dialysis, or with a kidney transplant. The physical therapy management of the patient on dialysis and that of the patient with a kidney transplant differs as to the extent and aggressiveness of the program. Providing the proper physical therapy program for patients with chronic renal failure is often a challenge because of such complications as congestive heart failure and peripheral neuropathies. Physical therapy is a necessary part of the rehabilitation of the patient with chronic renal failure.     

Verbesserung der ambulanten Versorgung von Patienten mit chronischen Rückenschmerzen

BACKGROUND: Treatment for chronic low back pain in primary care has a poor-quality outcome. There is evidence that multimodal therapy is the most successful approach to its management. We tried to evaluate whether giving primary care physicians evidence-based recommendations on therapy of chronic back pain or directly implementing a multimodal program would improve the outcome of patients with low back pain treated in primary care. METHODS: In the first phase, physicians were asked to document the course of patients suffering from low back pain of at least 4 weeks' duration with no decrease in intensity, noting pain intensity before and after 6 months of conventional, nonsurgical treatments. In the present, second, phase of the study, recommendations issued by the Medicines Committee of the German Medical Profession and the U.S. Agency for Health Care Policy and Research for the management of back pain were presented to doctors in printed form and at conferences. In parallel with this, a multimodal program for the treatment of chronic low back pain (4 h/day for 20 days: medical training therapy, cognitive-behavioral therapy, physiotherapy, and patient education) was organized in a private health-oriented sports center in cooperation with three private physiotherapy practices, and a psychologist and a pain specialist from the outpatient pain clinic at the University Hospital in Erlangen. We examined how physicians changed the therapy and how effective it was, the latter as reflected in the mean sum value of the percent pre- to posttreatment changes in pain intensity, how much pain interfered with daily living, depressivity, and quality of life. Data after interventions were compared with baseline data from the first phase. RESULTS: Data relating to 36 patients following treatment by 14 primary care physicians who had been given information about therapy recommendations and to 51 patients who had participated in the multimodal therapy program were compared with baseline data recorded in 157 patients. Recommendations changed neither the therapy preferred by primary care physicians nor the quality of outcome of conventional treatment. In contrast, the multimodal program of therapy for chronic low back pain improved the outcome significantly more than conventional therapy (mean improvement in general outcome score 22 vs. 7%, respectively, compared with baseline data; P<0.001). CONCLUSIONS: Giving primary care physicians information on the therapy recommended for treatment of low back pain does not lead to any change in physicians' preferred therapy. Multimodal programs for treatment of chronic low back pain should be organized locally, with existing health care providers joining forces to improve the quality of outcome in chronic low back pain managed in primary care.     

Efficacy of spinal manipulative therapy for low back pain of less than three months' duration

OBJECTIVES: To review the efficacy of spinal manipulation for low back pain of less than 3 months duration.Data sources Randomized clinical trials on spinal manipulative therapy for low back pain were identified by searching EMBASE, CINAHL, MEDLINE, and the Physiotherapy Evidence Database (PEDro).Study selection Outcome measures of interest were pain, return to work, adverse events, disability, quality of life, and patient satisfaction with therapy.Data extraction Methodological assessment of the trials was performed using the PEDro scale. Trials were grouped according to the type of intervention, outcome measures, and follow-up time. Where there were multiple studies with sufficient homogeneity of interventions, subjects, and outcomes, the results were analyzed in a meta-analysis using a random effects model.Data synthesis Thirty-four papers (27 trials) met the inclusion criteria. Three small studies showed spinal manipulative therapy produces better outcomes than placebo therapy or no treatment for nonspecific low back pain of less than 3 months duration. The effects are, however, small. The findings of individual studies suggest that spinal manipulative therapy also seems to be more effective than massage and short wave therapy. It is not clear if spinal manipulative therapy is more effective than exercise, usual physiotherapy, or medical care in the first 4 weeks of treatment. CONCLUSIONS: Spinal manipulative therapy produces slightly better outcomes than placebo therapy, no treatment, massage, and short wave therapy for nonspecific low back pain of less than 3 months duration. Spinal manipulative therapy, exercise, usual physiotherapy, and medical care appear to produce similar outcomes in the first 4 weeks of treatment.     

利用mNGS成功诊治多形拟杆菌致难治性腹膜透析腹膜炎一例

腹膜透析相关性腹膜炎是腹膜透析患者常见的并发症之一,但是厌氧菌感染所导致的腹膜炎较少见。该文报道了一例44岁女性患者,维持性腹膜透析4年余,因腹痛腹泻、腹膜透析液浑浊并被诊断为腹膜透析相关性腹膜炎收入院。该例患者的多次腹膜透析液培养结果均呈阴性,经验性抗感染治疗后无效,考虑为难治性腹膜透析相关性腹膜炎,最终经基于宏基因...     

Continuous renal replacement therapy: the treatment of choice for acute renal failure

The health care issues facing society today are complex. Access to care, quality of life, relative value scales, diagnosis related groups, and cost containment demands have had an impact on the decision-making processes of health care professionals. The availability of alternative therapeutic treatment modalities adds additional considerations when prescribing medical therapy. This is especially true when a patient is diagnosed with renal failure. In the past, either peritoneal dialysis or hemodialysis have been the only therapies for supporting patients with acute renal failure. This article explores continuous renal replacement therapy for the management of acute renal failure: what it is, when and where it should be used, and the responsibilities of nephrology and critical care nurses and physicians.     

Infectious spondylitis

Infection of the spine is a rare but serious cause of back pain. Conventional radiographs remain the initial screening procedure. Typically two adjacent vertebral bodies and the intervening disk space are affected. Early in the course of the disease, radiographs may be normal or nondiagnostic. Magnetic resonance imaging or radionuclide bone scan will establish pathology centered in the vertebral body. Because of the ability to image soft tissues, magnetic resonance imaging is particularly helpful in detecting paravertebral and extradural abscesses. Four other conditions may mimic infectious spondylitis: degenerative disk disease associated with Modic type 1 changes, pseudoarthrosis in ankylosing spondylitis, dialysis spondyloarthropathy, and neuropathic spondyloarthropathy. Advanced imaging studies in combination with radiographs and clinical information are essential in determining the correct diagnosis.     

中药结肠透析治疗慢性肾功能衰竭的临床观察（附63例报告）

目的 :研究中药结肠透析治疗慢性肾功能衰竭 (chronicrenalfailure,CRF)的临床疗效。方法 :对慢性肾功能衰竭 6 3例进行中药结肠透析 ,疗程 8周 ,治疗前后抽血观察血肌酐、尿素氮等指标 ,并进行统计学处理。结果 :6 3例CRF患者行中药结肠透析后血肌酐及尿素氮比治疗前明显下降。结论 :中药结肠透析是治疗慢性肾衰竭的有效方法 ,对尿毒症早期疗效尤为显著     

Ultrasound‐guided Prolotherapy with Polydeoxyribonucleotide Sodium in Ischiofemoral Impingement Syndrome

Ischiofemoral impingement syndrome is an uncommon disorder defined by hip pain caused by the narrowing of the space between the ischial tuberosity and lesser trochanter with associated entrapment of the quadratus femoris muscle. We effectively treated two male patients using ultrasound‐guided prolotherapy with polydeoxyribonucleotide sodium mixed with local anesthetics. A 24‐year‐old male patient with no history of trauma or surgery complained of bilateral hip and groin pain; magnetic resonance imaging demonstrated slight narrowing of the bilateral ischiofemoral spaces with mild enhancement of the left quadratus femoris muscle. A 23‐year‐old male patient with a history of iliotibial band release and iliopsoas tendon release complained of left hip and groin pain; magnetic resonance imaging revealed swelling of the left quadratus femoris muscle. After the fifth treatment session of prolotherapy, the pain severity score using the visual analog scale was found to be minimal (0–1/10), and follow‐up magnetic resonance imaging revealed a slightly decreased enhancement of the quadratus femoris muscle compared with that on previous images. Prolotherapy with polydeoxyribonucleotide sodium was an efficacious treatment for two patients with ischiofemoral impingement syndrome who were not candidates for surgery.     

Daily remote peritoneal dialysis monitoring: an adjunct to enhance patient care

Peritoneal dialysis (PD) is the preferred dialysis modality in children, but it relies on the patient or caregiver to perform dialysis daily at home. We describe the utilization of a modem transmission system in 2 pediatric PD patients to improve communication with the dialysis team, monitor compliance via frequent remote data collection, and decrease dialysis-related complications. A home dialysis modem was provided for each patient and connected to the home telephone line by the dialysis nurse. PD treatment data were transmitted daily to the dialysis unit, records entered into the patient's electronic medical record, and reviewed by the patient's PD nurse and/or pediatric nephrologist and adjustments made accordingly. This resulted in improved medical outcomes specifically related to fluid balance and cardiovascular health, ultimately facilitating renal transplantation in each case. In summary, the use of the ProCard (Baxter Healthcare, Deerfield, Illinois, USA) has improved the ability to monitor home PD patients effectively. However, the additional use of the modem to transmit data on a more frequent basis can further enhance the care of chronic continuous cycling PD patients and should be considered in more challenging medical situations.     

基于“四主题理论”的慢性肾衰竭诊疗伦理问题分析——以慢性肾衰竭患者拒绝血液透析为例

对于慢性肾衰竭患者的治疗,肾内科医生需摆脱“千篇一律”的透析方案,考虑患者生命质量、特定情境因素,尊重患者偏好,并意识到患者参与在确定治疗目标和治疗决策中的重要性。本文以“慢性肾衰竭患者拒绝血液透析”为例,基于临床伦理学“四主题理论”模式,结合医学伦理学原则,剖析慢性肾衰竭患者肾脏替代治疗中面临的临床伦理学问题。医生在提供诊疗建议时既应结合患者偏好,又需保持最佳诊疗质量,最终实现以患者为中心、医患共同决策的诊疗模式。     

Segmental stabilizing exercises and low back pain. What is the evidence? A systematic review of randomized controlled trials

STUDY DESIGN: A systematic review of randomized controlled trials. OBJECTIVES: To evaluate the effectiveness of segmental stabilizing exercises for acute, subacute and chronic low back pain with regard to pain, recurrence of pain, disability and return to work. METHODS: MEDLINE, EMBASE, CINAHL, Cochrane Controlled Trials Register, PEDro and article reference lists were searched from 1988 onward. Randomized controlled trials with segmental stabilizing exercises for adult low back pain patients were included. Four comparisons were foreseen: (1) effectiveness of segmental stabilizing exercises versus treatment by general practitioner (GP); (2) effectiveness of segmental stabilizing exercises versus other physiotherapy treatment; (3) effectiveness of segmental stabilizing exercises combined with other physiotherapy treatment versus treatment by GP and (4) effectiveness of segmental stabilizing exercises combined with other physiotherapy treatment versus other physiotherapy treatment. RESULTS: Seven trials were included. For acute low back pain, segmental stabilizing exercises are equally effective in reducing short-term disability and pain and more effective in reducing long-term recurrence of low back pain than treatment by GP. For chronic low back pain, segmental stabilizing exercises are, in the short and long-term, more effective than GP treatment and may be as effective as other physiotherapy treatments in reducing disability and pain. There is limited evidence that segmental stabilizing exercises additional to other physiotherapy treatment are equally effective for pain and more effective concerning disability than other physiotherapy treatments alone. There is no evidence concerning subacute low back pain. CONCLUSION: For low back pain, segmental stabilizing exercises are more effective than treatment by GP but they are not more effective than other physiotherapy interventions.     

Pulmonary Cement Embolism after Kyphoplasty

Abstract: An 80‐year‐old female with a history of osteoporosis was evaluated for sudden onset axial low back pain with bilateral lower extremity weakness, hyperreflexia, pain, urinary retention, and decreased rectal tone. Computed tomography of the lumbar spine revealed L1 compression fracture, retropulsion of bone causing spinal canal compromise with associated severe central canal stenosis. Following cement kyphoplasty of L1 with polymethyl methacrylate, the patient developed tachycardia and dyspnea. Chest radiograph and computed tomographic pulmonary angiogram revealed a large collection of hyperdense material within the right lower lobe pulmonary artery, consistent with pulmonary cement emboli. Management and imaging are discussed.     

Chronic low back pain, depression, and attributional style

Twenty consecutive, chronic low back pain patients admitted to our pain treatment unit completed the Attributional Style Questionnaire (an instrument that detects a cognitive style that is correlated with, and that predicts, depression) and the Beck Depression Inventory. An age, sex, and education-matched group of normal subjects, a group of patients with asymptomatic essential hypertension, and a group of patients with end-stage renal disease receiving dialysis treatment served as controls. The majority of the chronic-pain and renal-dialysis patients had elevated depression scores, whereas none of the normal subjects or hypertensive patients were outside the nondepressed range. The Attributional Style scores of the pain and renal dialysis patients were significantly deviant from the normal control group, but no more so than those of the patients with hypertension. The results of this study suggest that individuals with a chronic medical condition, either symptomatic (chronic low back pain or renal disease) or asymptomatic (essential hypertension) in nature, develop an attributional style characteristic of depression. These data neither lend support nor refute the thesis that chronic pain syndromes are a variant of, or a masked, depression. Rather, this research implies that a more important question is what identifiable risk factors (for example, attributional style) predispose patients with chronic pain to develop a depressive illness.     

Evaluation of back pain in children and adolescents

Back pain is fairly prevalent in healthy children and adolescents. When children or adolescents seek medical care for back pain, it is highly likely that underlying pathology will be identified. Common causes of back pain include nonspecific pain or muscle strain, herniated disk, spondylolysis, scoliosis, and Scheuermann's kyphosis. Less common causes include tumor, infection, and sickle cell crisis. If nonspecific back pain is suspected, treatment may include home-based exercise, physical therapy, or nonsteroidal anti-inflammatory drugs. If the history and physical examination suggest underlying pathology, radiography, complete blood count, erythrocyte sedimentation rate, and a C-reactive protein measurement should be performed. Follow-up magnetic resonance imaging, computed tomography, or bone scanning may be needed depending on the suspected cause. It is generally accepted that the following factors warrant immediate evaluation: patient age younger than four years, persistent symptoms, self-imposed activity limitations, systemic symptoms, increasing discomfort, persistent night-time pain, and neurologic symptoms.     

A single-pass batch dialysis system: an ideal dialysis method for the patient in intensive care with acute renal failure

PURPOSE OF REVIEW: Conventional intermittent hemodialysis and continuous veno-venous hemofiltration are the opposite poles of current treatment modalities for patients with acute renal failure in the intensive care unit. Because both intermittent and continuous renal replacement techniques have several disadvantages, alternative treatment strategies have been developed. This review summarizes relevant information on these new hybrid techniques, and special attention is paid to the use of a single-pass batch dialysis system in the intensive care unit. RECENT FINDINGS: Prospective controlled studies have been published from several centers that use standard dialysis equipment for hybrid techniques, called sustained low-efficiency dialysis or slow extended dialysis. Their common therapeutic aim is to provide an easy-to-perform treatment with reduced solute clearances maintained for prolonged periods of time. These studies have documented that sustained low-efficiency dialysis offers (1) solute removal that is comparable with that obtained with intermittent hemodialysis and continuous veno-venous hemofiltration, even if high substitution fluid rates are used, (2) cardiovascular tolerability like that observed with continuous veno-venous hemofiltration, (3) significantly reduced heparin use in comparison with continuous veno-venous hemofiltration, (4) simple handling and high acceptance by the intensive care unit staff, (5) reduced treatment costs, and (6) the possibility of nocturnal treatments, allowing unrestricted patient access for daytime procedures. SUMMARY: Sustained low-efficiency dialysis is increasingly being used as renal replacement therapy in critically ill patients in the intensive care unit. It combines several advantages of both intermittent and continuous techniques. The procedural simplicity, particularly if single-pass batch dialysis is used, makes it an ideal treatment for patients with renal failure in the intensive care unit.