Rare bone infections “excluding the spine”

Bone infections are usually due to haematogenous spread from distant infected organs. Spread of local sepsis or contamination of open wounds are less frequent routes of infection. The commonest cause of osteomyelitis is Staphylococcus aureus. The term rare bone infections refers to diseases where only a few percent affect bone or diseases which are essentially rare; these include bacteria, fungi, parasites and non-specific conditions. Common examples are tuberculosis, salmonellosis, brucellosis, hydatidosis, madura, actinomycosis, aspergillosis and American fungal infections. Certain bone infections have become exceedingly rare, particularly atypical mycobacteria, viral embryopathies and spirochaetes. Rare bone infections are encountered in many parts of the world commonly in the tropics and in the U. S. Immunocompromise and ease of travel can lead to increased incidence. A high index of clinical suspicion is necessary for diagnosis. Specific laboratory diagnosis is not always possible. Radiographs, computed tomography, isotope studies and magnetic resonance are useful but may not make the diagnosis. Aspiration or biopsy is necessary. Rare bone infections may simulate non-infective bone lesions. Received: 14 February 1998; Revision received: 3 August 1998; Accepted: 7 October 1998     

Osteomyelitis: a review of currently used imaging techniques

Conventional radiographs remain the initial imaging modality involved in the diagnosis of osteomyelitis. Bone scintigraphy and its specific agents did not only eliminate the problems of inherent low sensitivity of conventional radiographs, but also increased the specificity to higher degrees. Spiral CT, on the other hand, has solved several diagnostic problems, such as osteomyelitis of the sterno-clavicular junction and hidden areas in the pelvic bones. Magnetic resonance imaging with its multiplanar capability, greater anatomic details and excellent soft tissue bone marrow contrast resolution has a significant role in surgical planning and limb preservation. Ultrasound and US-guided aspiration has recently been involved in the diagnosis and management of osteomyelitis with several advantages particularly in children. Our goal in this review is to outline the ability of various imaging techniques by comparing their strengths and weaknesses in the diagnosis of osteomyelitis. Finally, we suggest various imaging algorithms for specific clinical scenarios. Spondylitis and septic arthritis are not discussed in this review. Received: 18 May 1998; Revision received: 6 July 1998; Accepted: 28 August 1998     

Malignant Tourette syndrome.

The aim of this work was to draw attention to potentially life-threatening symptoms associated with Tourette syndrome (TS) and to explore their relationship to TS comorbidities. Medical records of all patients with TS evaluated at our Movement Disorders Clinic between July 2003 and July 2006 were reviewed. Data on patients with malignant TS, defined as >or=2 emergency room (ER) visits or >or=1 hospitalizations for TS symptoms or its associated behavioral comorbidities, were entered into a dataset and analyzed. Five illustrative cases are described. Of 333 TS patients evaluated during the 3-year period, 17 (5.1%) met the criteria for malignant TS. Hospital admission or ER visits were for tic-related injuries, self-injurious behavior (SIB), uncontrollable violence and temper, and suicidal ideation/attempts. Compared with patients with nonmalignant TS, those with malignant TS were significantly more likely to have a personal history of obsessive compulsive behavior/disorder (OCB/OCD), complex phonic tics, coprolalia, copropraxia, SIB, mood disorder, suicidal ideation, and poor response to medications. Although TS is rarely a disabling disorder, about 5% of patients referred to a specialty clinic have life-threatening symptoms. Malignant TS is associated with greater severity of motor symptoms and the presence of >or=2 behavioral comorbidities. OCD/OCB in particular may play a central role in malignant TS; obsessive compulsive qualities were associated with life-threatening tics, SIB, and suicidal ideation. Malignant TS is more refractory to medical treatment than nonmalignant TS.     

Estimated burden of blood lead levels 5 microg/dl in 1999-2002 and declines from 1988 to 1994

In light of recent data suggesting adverse health effects at blood lead levels (PbB) <10 μg/dl, lowering the current definition of elevated blood lead (10 μg/dl) has been recommended. To ascertain the population level impact of such a change, we calculated the prevalence of PbB 5 μg/dl in 1–21-year-old population in the United States. Furthermore, we characterized changes in PbB between 1988–1994 and 1999–2002.We analyzed data from the National Health and Nutrition Examination Survey (NHANES) III (n=10,755) and NHANES 1999–2002 (n=8013).In 1999–2002, about 91.7% of study children had detectable levels of lead in the blood. Among them, 7.3%, 2.8%, and 1.0% children and adolescents aged 1–5, 6–11, and 12–21 years, respectively, had PbB between 5 and 9.9 μg/dl. This number translates to approximately 2.4 million individuals. Between 1988–1994 and 1999–2002, the geometric mean PbB declined from 2.88 to 1.94 μg/dl in children 1–5 years, 1.80 to 1.36 μg/dl in children 6–11 years, and 1.24–1.02 μg/dl in children and adolescents 12–21 years of age. Also, the prevalence of PbB 5 μg/dl declined from 25.7% to 8.8%, 12.8% to 3.0%, and 7.5% to 1.2% in these age groups, respectively.A substantial proportion of children may be at risk for adverse health effects from lead exposure below 10 μg/dl and a large number of children will be classified as having elevated PbB if 5 μg/dl is considered the threshold. Significant public health resources will have to be mobilized for intervention, screening, and case management of these children.     

Exploring the relationship between essential tremor and Parkinson's disease

Although essential tremor (ET) and Parkinson's disease (PD) are considered distinct disorders, there is overlap in some clinical features. In some PD patients, a long-standing postural tremor in the hands may precede the onset of parkinsonian features by several years or decades. Furthermore, large families with both ET and PD phenotypes have been described and autopsy studies have demonstrated Lewy body pathology in brains of ET patients. Functional neuroimaging suggests that some ET patients have dopaminergic deficit. We examine here the evidence for and against an association between ET and PD, and critically review data supporting the notion that a subset of ET patients is predisposed to developing PD.     

Mold and endotoxin levels in the aftermath of Hurricane Katrina: a pilot project of homes in New Orleans undergoing renovation

BACKGROUND: After Hurricane Katrina, many New Orleans homes remained flooded for weeks, promoting heavy microbial growth. OBJECTIVES: A small demonstration project was conducted November 2005-January 2006 aiming to recommend safe remediation techniques and safe levels of worker protection, and to characterize airborne mold and endotoxin throughout cleanup. METHODS: Three houses with floodwater lines between 0.3 and 2 m underwent intervention, including disposal of damaged furnishings and drywall, cleaning surfaces, drying remaining structure, and treatment with a biostatic agent. We measured indoor and outdoor bioaerosols before, during, and after intervention. Samples were analyzed for fungi [culture, spore analysis, polymerase chain reaction (PCR)] and endotoxin. In one house, realtime particle counts were also assessed, and respirator-efficiency testing was performed to establish workplace protection factors (WPF). RESULTS: At baseline, culturable mold ranged from 22,000 to 515,000 colony-forming units/m3, spore counts ranged from 82,000 to 630,000 spores/m3, and endotoxin ranged from 17 to 139 endotoxin units/m3. Culture, spore analysis, and PCR indicated that Penicillium, Aspergillus, and Paecilomyces predominated. After intervention, levels of mold and endotoxin were generally lower (sometimes, orders of magnitude). The average WPF against fungal spores for elastomeric respirators was higher than for the N95 respirators. CONCLUSIONS: During baseline and intervention, mold and endotoxin levels were similar to those found in agricultural environments. We strongly recommend that those entering, cleaning, and repairing flood-damaged homes wear respirators at least as protective as elastomeric respirators. Recommendations based on this demonstration will benefit those involved in the current cleanup activities and will inform efforts to respond to future disasters.     

MR,CT, and ultrasonography of splanchnic venous thrombosis

Nine patients with splanchnic venous thrombosis are presented and the value of noninvasive imaging in their initial diagnosis and subsequent follow-up is emphasized. Angiography, traditionally the definitive investigation in such cases, can be reserved for preoperative assessment in those patients considered candidates for surgery. The age of venous thrombi can be estimated by computed tomography (CT) and magnetic resonance imaging (MRI) which aids selection of therapy, and in those anticoagulated, prediction of prognosis.     

Patients' perspectives on the short- and long-term outcomes following surgery for benign parotid neoplasms

Surgery for benign parotid gland salivary neoplasms is associated with sequelae: scar and divot defect and complications, facial nerve paresis/paralysis and Frey's syndrome. These potential sequelae and complications are discussed with all patients prior to operation. We contacted 212 patients who had undergone surgery for benign parotid disease during 1988-1997, by postal questionnaire. We enquired about their perception and recollection of the information they had received pre-operatively and to document and comment upon what problems they had experienced in the early and late post-operative period. The usable return rate was 75.5 per cent (173/212). Most patients (90 per cent) were satisfied with the information they had received pre-operatively. The complication and/or sequelae rates for facial nerve palsy (temporary 26.3 per cent, permanent 1.9 per cent), Frey's syndrome (12.5 per cent) and sensory deficit about the cheek and ear (30.6 per cent), are comparable to other published studies.     

Use of flexibility tests in the manufacturing process of 60 degrees Björk-Shiley convexo-concave valves and the risk of outlet strut fracture

OBJECTIVES: Outlet strut fracture remains a concern for 30,000 patients living with a Bj?rk-Shiley convexo-concave heart valve (Shiley, Inc, Irvine, Calif, a subsidiary of Pfizer, Inc). Previous studies (Netherlands and United Kingdom) investigating valve manufacturing aspects identified multiple performance of the hook deflection test as a risk factor for 60 degrees valves. The present study validated this finding using new data with a greater number of valves implanted worldwide. Risks of outlet strut fracture associated with other manufacturing aspects were also investigated. METHODS: A matched case-control study design was used including 416 outlet strut fracture cases and 803 controls. RESULTS: Analyses similar to that of the Dutch and United Kingdom studies produced odds ratios of 3.4 (95% confidence interval [CI]: 1.1-10.3) and 2.8 (95% CI: 1.1-7.3), respectively, for multiple hook deflection tests. Load deflection test, which replaced the hook deflection test, showed a statistically significant association with outlet strut fracture: odds ratio of 5.0 (95% CI: 2.1-11.8) and 6.2 (95% CI: 2.2-18.0) for single and multiple load deflection tests, respectively. An analysis where hook deflection tests were separated from load deflection tests showed significantly elevated odds ratios with performance of any type of flexibility test, and the highest odds ratio was observed with a combined performance of load and hook deflection tests. CONCLUSIONS: Multiple hook deflection tests can now be considered for inclusion in the risk model used for guidelines on explant surgery to improve prediction of outlet strut fracture and provide patient reassurance. Load deflection tests and combined performance of hook and load deflection tests were found to be significant risk factors. No outlet strut fractures were reported for valves manufactured after March 1984 when the load deflection test was still in place. Examining manufacturing documents for these valves may identify new risk factors that could be responsible for the outlet strut fractures risk that remains unexplained to date.