Tramadol/acetaminophen combination as add-on therapy in the treatment of patients with ankylosing spondylitis.

This study aimed to determine the safety and efficacy of tramadol 37.5 mg/acetaminophen 325 mg combination tablets (Ultracet®) in patients with ankylosing spondylitis (AS). This was a 12-week, randomized, double-blind, placebo-controlled study. Sixty patients with active AS according to the Modified New York Criteria were enrolled. Active disease was defined by Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) for more than 3 at randomization. Subjects were randomized equally into two groups: the treatment group received aceclofenac plus Ultracet® one tablet twice a day, and the control group received aceclofenac plus placebo for 12 weeks. The primary endpoint was a difference of Assessment in Ankylosing Spondylitis (ASAS20) response criteria between two groups at week 12. At week 12, ASAS20 was achieved by 53.3 % of the aceclofenac plus Ultracet group and 31 % of the aceclofenac alone group (p = 0.047). For the pain visual analogue scale at week 12, there was a reduction of 45.6 % in aceclofenac plus Ultracet group and 25.7 % in the aceclofenac alone group (p = 0.087). There was no statistically significant difference between two groups in BASDAI, Bath Ankylosing Spondylitis Functional Index, Bath Ankylosing Spondylitis Global Index, Physician Global Assessment, spinal mobility, ESR, hs-CRP, and Ankylosing Spondylitis Quality of Life Questionnaire. A slight increase in total adverse events was noted with dizziness (7.5 vs 1.5 %), vertigo (4.5 vs 1.5 %), and nausea/vomiting (6 vs 0 %) in the Ultracet arm compared to placebo. The tramadol 37.5 mg/acetaminophen 325 mg combination tablet (Ultracet®) might has additional effect to nonsteroidal anti-inflammatory drugs in the treatment of patients with ankylosing spondylitis. It showed marginal benefit in pain and disease activity. However, a slight increase in minor adverse events was noted.

Dislodged upper thoracic cage in the gastrointestinal tract: a case report and literature reviews.

STUDY DESIGN: A rare case of esophageal perforation secondary to a dislodged upper thoracic cage found by the gastrointestinal endoscope is presented. OBJECTIVE: To report an extremely rare complication of upper thoracic vertebral tuberculosis treated with corpectomy and interbody cage surgery and suggest the cause, mechanism, and outcome of the complication of esophageal perforation. SUMMARY OF BACKGROUND DATA: Tuberculotic spondylitis often affects the anterior column of the spine and surgery is indicated in the presence of an epidural abscess, neurologic deficits secondary to compression of the spinal cord, bone destruction with instability, or failure of antituberculous therapy. Surgical treatment requires radical debridement followed by anterior stabilization. A controversy exists regarding the use of the instrumentation in the tuberculous spine. METHODS: Retrospective case study and literature review. RESULTS: Because of the concomitant medical problems and little deterioration of the neurologic function, our patient is managed uneventfully with conservative treatment. CONCLUSION: To the authors' knowledge, this is an extremely rare reported complication of upper thoracic cage surgery for vertebral tuberculosis. This case demonstrates that the cage migration in the tuberculous spondylitis might have a rather benign clinical course and structural bone grafting or interbody cage insertion without supplemental instrument fixation seems to be inadequate.

Painful scoliosis secondary to osteoid osteoma of the lumbar spine in adolescents.

Painful scoliosis is a well-recognized presentation of spinal osteoid osteoma, especially in adolescents, and is thought to be caused by pain-provoked muscle spasm on the side of the lesion. The diagnosis, however, is often initially missed, and prolonged duration of symptoms and rigid spinal curve may result. In this report, we present two cases of adolescent patients with painful scoliosis, subsequently diagnosed with spinal osteoid osteomas. Complete surgical excision resulted in dramatic symptomatic resolution after surgery and improved spinal curve at 1-year follow-up in both cases.

Femoral head avascular necrosis after interlocking nail of a femoral shaft fracture in a male adult: a case report.

Reamed interlocking nail through the piriformis fossa remains the golden standard for treatment of femoral shaft fracture. Fracture healing rates are 95-99%, and infection rates less than 1% (Clawson et al. in J Bone Joint Surg (Am) 53:681-692, 1971; Winquist et al. in J Bone Joint Surg (Am) 66:529-539, 1984; Brumback et al. in J Bone Joint Surg (Am) 70:1453-1462, 1988). Previous reports recognize avascular necrosis of the femoral head as a complication of antegrade interlocking nail in the adolescent (Beaty et al. in J Pediatr Orthop 14:178-183, 1994; Mileski et al. in J Bone Joint Surg (Am) 76:1706-1708, 1994; O'Malley et al. in J Pediatr Orthop 15:21-23, 1995; Buckaloo et al. in J Southern Orthop Assoc 6(2):97-100, 1997). This report describes a male adult who developed avascular necrosis of the femoral head after an open antegrade interlocking nail of a proximal third femoral shaft fracture. To our knowledge, there is no similar report in the English medical literature.

Iliac vessel injury by a cement spacer: report of a case.

The use of antibiotic-impregnated acrylic cement as a bone spacer between the intervals of revision hip arthroplasty for infection has been widely practiced. Vascular injuries caused by the migration of a cement spacer with subsequent erosion of the vessel wall have never been reported. A 67-year-old woman presented with tense swelling over her left lower extremity and hemarthroses of the left hip after implantation of a cement spacer for infected hip arthroplasty. Complete external compression of the external iliac vein and laceration of the iliac artery by the spacer were found. The symptoms were resolved after surgical debridement, removal of the spacer and femoral stem, and repair of the vessel. Cautious placement of a cement spacer in the acetabular fossa accompanied with poor bone stock must be emphasized.

Simultaneous bilateral anterior fracture dislocation of the shoulder with neurovascular injury: report of a case.

This paper reports an unusual case of orthopedic trauma in a 29-year-old man who experienced concomitant bilateral anterior shoulder fracture dislocation with associated brachial plexus and axillary artery injury. We also highlight the mechanism underlying this rare workplace injury related to use of a forklift.

Evaluation of internal consistency and re-test reliability of Bath ankylosing spondylitis indices in a large cohort of adult and juvenile spondylitis patients in Taiwan.

The Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), Bath Ankylosing Spondylitis Functional Index (BASFI), and Bath Ankylosing Spondylitis Global Score (BAS-G) have been recommended for evaluating function and disability in patients with ankylosing spondylitis (AS). The aim of this study was to develop a Chinese version of the BASDAI, BASFI, and BAS-G and assess their reliability and validity. The Chinese version was obtained after a translation and back-translation process. A total of 447 patients with adult and juvenile AS were assessed using these three instruments. Reliability was tested by internal consistency and test-retest reliability. Internal consistency of the instrument was given as Cronbach's alpha. Test-retest reliability was assessed by intraclass correlation coefficient. To assess the sensitivity to change, 153 patients were included in an 8-week follow-up study. In our analysis, the reliability of these three instruments-the BASDAI, BASFI, and BAS-G-for a 24-h test-retest showed acceptable intraclass correlation coefficients (0.92-0.94). Our Chinese versions of the BASDAI, BASFI, and BAS-G also showed 0.87, 0.94, and 0.90, respectively, with Cronbach's alpha coefficient, indicating good reliability. For sensitivity to change in 8-week follow-up, all three instruments showed 5.0 to 5.4% changes. Our Chinese versions of the BASDAI, BASFI, and BAS-G showed adequate reliability, validity, and responsiveness to clinical change. Thus, disease activity and functional status in Chinese-speaking patients with AS may be adequately evaluated with these versions of the original instruments.

Tumoral calcinosis of the shoulder.

Tumoral calcinosis is a rare clinical and histopathologic syndrome that causes the formation of calcium salt crystal deposits in periarticular soft tissue. This soft tissue calcification typically behaves as a large-sized tumor. However, the mechanism is unknown for the massive periarticular calcification caused by tumoral calcinosis. In addition, tumor calcinosis occurs infrequently in patients who have been on long-term hemodialysis and have end-stage renal disease (ESRD). This report describes a 40-year-old male uremia patient on long-term hemodialysis. This patient developed a huge tumor mass and pain over the left shoulder and was diagnosed with tumoral calcinosis. Although common treatments include management of metabolic levels such as calcium and phosphate, in some cases, surgical intervention may be needed. In this patient case, complete surgical excision was done successfully with an excellent outcome at the 2-year follow-up.

Effects of hyperbaric oxygen therapy on circulating interleukin-8, nitric oxide, and insulin-like growth factors in patients with type 2 diabetes mellitus.

BACKGROUND: The potential benefits of hyperbaric oxygen therapy (HBOT) have been reported in diabetic patients with foot ulcers. However, the roles of HBOT on wound healing-associated growth factors and inflammatory mediators are not completely understood in diabetes mellitus (DM). OBJECTIVES: The aim of this study was to investigate the effects of HBOT on circulating cytokines, NO, and insulin-like growth factors (IGF) in patients with type 2 DM. DESIGN AND METHODS: Serum samples were collected from patients with type 2 DM (n=31) and healthy subjects (n=29) before (baseline) and after the first and third exposure. RESULTS: Before HBOT, body mass index (BMI) and serum HbA1c were significantly greater, whereas serum IGF-I was significantly lower in diabetic patients compared to healthy subjects (one-way ANOVA, p<0.05). After adjusting for age, gender, and BMI, serum insulin, growth hormone (GH), IGF-II, IGF-binding protein (IGFBP)-1, IGFBP-3, leptin, interleukin (IL)-8, and NO were not significantly altered by HBOT in diabetic patients and healthy subjects (repeated-measures ANOVA). Change in serum insulin (baseline to the third exposure) was a positive predictor of changes in leptin and NO in healthy subjects and diabetic patients, respectively. CONCLUSIONS: Our results suggest that short-term HBOT may not alter the circulating insulin, IGF, leptin, IL-8, and NO levels. In addition, healthy subjects and diabetic patients showed differential responses to HBOT in the relationships of leptin, insulin, and NO. Further studies are needed to clarify the mechanism of HBOT-improved wound healing in diabetic patients with foot ulcers.

Plasma homocysteine status in patients with ankylosing spondylitis.

Homocysteine (Hcy), a sulfur-containing amino acid, is eliminated through B vitamins-dependent pathways. Hyperhomocysteinemia has been found to be an independent risk factor for atherosclerotic cardiovascular, cerebrovascular, and peripheral vascular diseases. Recently, psoriasis, lupus, and rheumatoid arthritis were reported to be associated with hyperhomocysteinemia. This study was aimed to evaluate the changes of plasma Hcy level before and after sulfasalazine and MTX therapy in patients with ankylosing spondylitis (AS). One hundred and two patients with AS and ten normal controls were enrolled in the cross-sectional case-control study. Fasting plasma Hcy levels were determined by ELISA kits (IMX, Abbott). Hcy levels were compared to their Bath AS disease activity index (BASDAI) and the usage of sulfasalazine and/or MTX. Active disease was defined by BASDAI as more than 3 in a 10-cm scale with ESR >20 mm/h. For those patients with plasma Hcy >or=15 micromol/l, a perspective trial of daily supplement of vitamin B-12 0.5 mg, B-6 50 mg, and folic acid 5 mg for 2 weeks were also tested for the efficacy. Plasma Hcy level increased significantly in AS patients under sulfasalazine (10.4+/-3.8 micromol/l, p<0.05), MTX (11.9+/-4.7, p<0.05) and sulfasalazine/MTX combination treatment (11.2+/-2.6, p<0.05) compared with normal controls (8.6+/-1.2 micromol/l) and AS patients without DMARD(9.4+/- 2.6 micromol/l). No correlation between disease activity and plasma Hcy level was found. Daily supplement of vitamin B-12 0.5 mg, B-6 50 mg, and folic acid 5 mg can lower Hcy level in 2 weeks (32.3+/-24.0 vs 15.6+/-11.1 micromol/l, p=0.007). Plasma homocysteine level did significantly increase in AS patients under sulfasalazine or MTX treatment. B-vitamins should be considered as a routine supplementation for patients who underwent sulfasalazine and/or MTX treatment. Further longitudinal studies are required to confirm the conclusions.