Nihal Ozaras

Bone loss in the contralateral asymptomatic hand in patients with complex regional pain syndrome type 1

Regional osteoporosis was seen radiographically in clinically affected areas in patients with complex regional pain syndrome type 1 (CRPS1). The aim of the this study was to investigate whether bone loss developed in the contralateral hand in patients with unilateral CRPS1 of the hand. Thirty-two patients with CRPS1 of the hand were included in this study. Bone mineral density was measured in the left proximal femur and both ultradistal radiuses, using dual-energy X-ray absorptiometry. The subjects were classified as grades 1 to 3 according to the T-score of both ultradistal radiuses (densitometric grades): grade 1, both radiuses were normal; grade 2, bone loss was determined only in the affected radius; and grade 3, there was bone loss in both radiuses. Twenty (62.5%) patients had bone loss in the affected hand; 11 patients (34.4%) had bone loss only on the affected side and 9 patients (28.1%) had bone loss on both sides. The mean duration of the period between the diagnosis of the injury and the measurement of bone density was 1.9 ± 0.6 months in patients with grade 1, 3.1 ± 1.0 months in patients with grade 2, and 5.5 ± 2.2 months in patients with grade 3. The Spearman test showed a significant correlation between the period of injury and the densitometric grade (R = 0.774; P = 0.0001). In conclusion, the current study of patients with CRPS1, showed that the bone loss in the asymptomatic contralateral hand developed at a later stage than that in the affected hand. This bone loss was less frequent and of a lower degree in the asymptomatic contralateral hand than in the affected hand. The bone loss in the asymptomatic contralateral hand could be explained by the loss of sympathetic tone in CRPS1 and contralateral sympathetic innervation.

Bone mineral density in women with sarcoidosis.

Sarcoidosis is a multisystem granulomatous disease of unknown etiology. Almost any organs of the body, but mostly the lungs, are involved. Bone mineral density (BMD) can be affected directly or indirectly in chronic granulomatous systemic diseases such as sarcoidosis. The aim of our study was to evaluate BMD in premenopausal and postmenopausal sarcoidosis patients with or without prednisone treatment and to compare their BMD values with those of a control group having the same menopausal status. Thirty-five premenopausal women (18 untreated, 8 treated, and 9 controls) and 21 postmenopausal women (5 untreated, 5 treated, and 11 controls) were included in the study. All of the patients had a histologically proven diagnosis and were being followed-up at the Sarcoidosis Outpatient Clinic of our unit. BMD of the lumbar (L) spine and femoral neck was measured by dual-energy absorptiometry (DEXA). The subgroups of premenopausals and postmenopausals were compared separately. Comparison among the groups was performed by using analysis of variance. Age, duration of the disease, and body mass index were comparable in treated, untreated, and control subgroups of the pre- and postmenopausal groups, and the subgroups of postmenopausals had comparable durations since menopause. For premenopausals, BMD values at L1–4 were not significantly different among the subgroups (0.920 ± 0.08 g/cm2, 0.801 ± 0.09 g/cm2, and 0.910 ± 0.05 g/cm2, for untreated, treated, and controls, respectively). However, the BMD value at the femoral neck in treated patients (0.921 ± 0.1 g/cm2) was significantly lower than the values in untreated patients (1.080 ± 0.2 g/cm2; P ≪ 0.01) and in controls (1.028 ± 0.17 g/cm2; P ≪ 0.05). For postmenopausals, the BMD value at L1–4 in controls (1.019 ± 0.07 g/cm2) was significantly higher than the values in untreated patients (0.783 ± 0.01 g/cm2) and in treated patients (0.751 ± 0.08 g/cm2; P ≪ 0.001 for both). The BMD value at the femoral neck in controls (0.890 ± 0.1 g/cm2) was higher than the values in untreated patients (0.745 ± 0.08 g/cm2) and treated patients (0.747 ± 0.1 g/cm2), but the difference was not statistically significant (P = 0.06). We concluded that sarcoidosis patients, especially postmenopausal patients with corticosteroid treatment, may have an increased risk of bone mineral loss. Large-scale studies are warranted in order to delineate the exact roles of the disease itself, menopausal status, and corticosteroid treatment in this bone mineral loss.

Carbamazepine-induced hypogammaglobulinemia

Carbamazepine is used to control seizures. Its common side effects are sleep disorders, anorexia, nausea, vomiting, polydipsia, irritability, ataxia, and diplopia. Involvement of the immune system is rare, and few cases of decreased immunoglobulin levels have been reported. We describe a patient with low immunoglobulin levels due to carbamazepine use who presented with recurrent urinary tract infection. Intravenous immunoglobulin was administered, and immunoglobulin levels increased to safer levels after discontinuation of carbamazepine. Previous reports describe severe infection after carbamazepine-induced hypogammaglobulinemia. Therefore, in patients using antiepileptics, particularly carbamazepine, serum immunoglobulin levels should be checked in those with recurrent infections.

Ciprofloxacin and Achilles' tendon rupture: a causal relationship.

Fluoroquinolones are commonly used antimicrobials with favorable pharmacokinetic properties and a broad spectrum of activity. These drugs are very well tolerated. Tendinous involvement is a rare complication of fluoroquinolone use [1]. We describe a case of spontaneous rupture of the Achilles tendon associated with ciprofloxacin use on one side, and the development of the same complication on the other side 1 year later following another use of the same drug. A 32-year-old male surgeon presented with a severe pain in his right Achilles tendon region while walking. He recalled no specific injury. He had used ciprofloxacin (500 mg tablets twice daily, 10 days) for typhoid fever 1 month ago. The right Achilles tendon was tender to mild palpation. The clinical suspicion of Achilles tendon rupture was confirmed by MRI. He was treated surgically with an uneventful outcome. One year later he suddenly fell down with severe pain in his left foot while walking. He had again used ciprofloxacin (500 mg tablets twice daily, 10 days) for urinary tract infection 1 month ago. An orthopedic surgeon diagnosed left Achilles tendon rupture, confirmed by MRI (Fig. 1). Surgical repair was again carried out uneventfully. After the first report of fluoroquinolone-induced tendinitis in 1983 [2], many others have reported it subsequently [3, 4, 5, 6, 7]. The tendinopathy appears within a few weeks of the use of the drug, although extremes (1 day to 5–6 months) have also been reported [5, 6]. The patients are usually elderly. The risk factors are renal failure, steroid use, and collagen vascular diseases [6, 7]. However, the mechanism of this complication and the reason why tendinopathy and rupture occur more frequently in the Achilles tendon are not precisely known. Fluoroquinolone use and repeated tendon ruptures in our patient, who did not have any risk factors, both suggested a clear causal relationship and emphasized the roles of individual factors. Because these antimicrobials are in common use, physicians should consider this side effect even in the absence of the risk factors.

The effect of flurbiprofen and tiaprofenic acid on serum cytokine levels of patients with osteoarthrosis

39 patients with active knee osteoarthrosis, chosen according to ACR criteria, were assigned to receive flurbiprofen (n 12, 2 2 100 mg), tiaprofenic acid (n 14, 2 2 300 mg) and placebo (n 13) in a 3-week, placebo-controlled study. All patients completed the study, and both medications were found to be effective: improvement occurred in the clinical signs. These drugs reduced the TNF- f levels. Flurbiprofen especially affected the IL-6 levels. Our findings indicate that NSAIDs may be effective in the etiopathogenesis of osteoarthrosis.

Affective temperament in stroke patients

Objective: The aims of this study were to determine the dominant affective temperament changes in stroke survivors and whether temperament affects the disability. Methods: A total of 63 stroke patients were included in this study. Temperament Evaluation of Memphis, Pisa, Paris and San Diego Autoquestionnaire was used to determine the dominant affective temperament (depressive, hyperthymic, cyclothymic, irritable or anxious). The disability level was measured with the Barthel index (BI). Results: Depressive temperament (17.5%) and anxious temperament (12.7%) were the most common dominant affective temperaments. The frequencies of irritable, cyclothymic and hyperthymic temperaments were 4.8, 3.2 and 0%, respectively. The mean BI score was 78.1 ± 18.3 in patients with depressive temperament and 67.4 ± 28.4 in patients without depressive temperament (p = 0.403). The mean BI score was 78.1 ± 15.3 in patients with anxious temperament and 68.0 ± 28.3 in patients without anxious temperament (p = 0.541). Multiple linear regression analysis indicated that BI score was not associated with affective temperament changes. Conclusion: The results of the current study suggest that depressive and anxious temperaments are the most common affective temperaments and that there appears to be no association between disability level and dominant affective temperament in stroke survivors.

Differential diagnosis of multiple vertebral compression: butterfly vertebrae

[Purpose] A butterfly vertebra is a rare congenital anomaly resulting from a symmetric fusion defect. Only a few cases of butterfly vertebra have been described. This anomaly may be isolated or associated with Pfeiffer, Jarcho-Levins, Crouzon, or Alagille syndrome. [Subject and Methods] We herein describe a 38-year-old man who presented with neck and low back pain and was found to have butterfly vertebrae at the T9 and L3 levels. He also had Behçet’s disease and psoriasis. [Results] The patient’s symptoms improved with analgesics and physiotherapy. [Conclusion] To our knowledge, butterfly vertebrae at two levels have never been reported. Butterfly vertebrae may be confused with vertebral fractures in lateral radiographs, and awareness of this anomaly is important for a correct diagnosis.

Upper Extremity Problems in Doner Kebab Masters

[Purpose] Doner kebab is a food specific to Turkey; it is a cone-shaped meat placed vertically on a high stand. The doner kebab chefs stand against the meat and cut it by using both of their upper extremities. This work style may lead to recurrent trauma and correspondingly the upper extremity problems. The aim of this study was to investigate the upper extremity disorders of doner chefs. [Subjects and Methods] Doner kebab chefs were selected as the study group, and volunteers who were not doner kebab chefs and didn’t exert intense effort with upper extremities their business lives were selected as the control group. A survey form was prepared to obtain data about the participants’ ages, working experience (years), daily work hours, work at a second job, diseases, drug usage, and any musculoskeletal (lasting at least 1 week) complaint in last 6 months. [Results] A total of 164 individuals participated in the study, 82 doner chefs and 82 volunteers. In 20.6% of the study group and 15.6% of the control group, an upper extremity musculoskeletal system disorder was detected. Lateral epicondylitis was more frequently statistically significant in the work group. [Conclusion] Hand pain and lateral epicondylitis are more frequent in doner chefs than in other forms of business.

Functional limitations due to foot involvement in spondyloarthritis.

[Purpose] Spondyloarthritis is a major inflammatory disease followed-up in the rheumatology clinics, foot involvement in spodyloarthritis is common. The functional states of patients with spondyloarthritis are usually evaluated globally. The aim of this study was to assess the foot involvement-related functional limitations in patients with spondyloarthritis. [Subjects and Methods] Patients with ankylosing spondylitis and psoriatic arthritis with foot pain more than 4 weeks who underwent anteroposterior and lateral feet radiography were enrolled into the study. A “clinical findings score” was calculated by assigning 1 point for every finding of swelling, redness, and tenderness. C-reactive protein and erythrocyte sedimentation rate were used as serum markers for disease activity. Foot radiograms were evaluated using the spondyloarthropathy tarsal radiographic index and the foot-related functional state of patients was determined by the Turkish version of the Foot and Ankle Outcome Score. [Results] There were no relationships between Foot and Ankle Outcome Score subscales and clinical findings score, serum markers, or radiologic score. Pain and symptoms subscale scores were result positively correlated with activity of daily living, sport and recreation, and quality of life subscale scores. [Conclusion] Pain and symptoms are the main determinants of foot-related functional limitations in spondyloarthritis.

Coexistence of osteopoikilosis with seronegative spondyloarthritis and spinal stenosis.

[Purpose] Osteopoikilosis is a rare hereditary bone disease that is usually asymptomatic. It is generally diagnosed incidentally on plain radiography. The coexistence of osteopoikilosis with seronegative spondyloarthritis or spinal stenosis is rarely reported. Here, we report the case of a 27-year-old male patient with osteopoikilosis, seronegative spondyloarthritis, and spinal stenosis. [Subject] A 27-year-old male patient with buttock pain and back pain radiating to the legs. [Methods] A plain anteroposterior radiograph of the pelvis revealed numerous round and oval sclerotic bone areas of varying size. Investigation of the knee joints showed similar findings, and the patient was diagnosed with osteopoikilosis. Lumbar magnetic resonance images showed spinal stenosis and degenerative changes in his lumbar facet joints. Magnetic resonance images of the sacroiliac joints showed bilateral involvement with narrowing of both sacroiliac joints, nodular multiple sclerotic foci, and contrast enhancement in both joint spaces and periarticular areas. HLA B-27 test was negative. [Results] The patient was diagnosed with osteopoikilosis, seronegative spondyloarthritis, and spinal stenosis. Treatment included asemetasin twice daily and exercise therapy. [Conclusion] Symptomatic patients with osteopoikilosis should be investigated for other possible coexisting medical conditions; this will shorten the times to diagnosis and treatment.