Duloxetine

By K. Topork. Great Lakes Maritime Academy.

Availability and knowledge of pharmacology and therapeutics are important factors in suicide within the medical profession buy duloxetine 60 mg with mastercard. Extra stresses on female doctors include lack of senior female role models order duloxetine on line amex, conflicts between career and family buy duloxetine 30 mg online, prejudice and attitudes of male colleagues buy duloxetine australia, and loneliness. Accident and emergency departments carry certain stresses for juniors: intense workload, diagnostic uncertainty, unsociable hours, and fatigue. Some are afraid to seek advice in case this might have adverse career implications. The only difference between the two groups was that alcohol abuse was more common among business students than among medical students. About 6% of students reported suicidal thinking in the last month and such thinking was more likely in the presence of stressful life events and absence of social support. In the first postgraduate year, one-quarter to one-third of interns suffer from clinical depression, but this figure tends to decline with the passage of time. Long hours, lack of sleep, poor diet, poor social supports, large bank loans, feelings of inadequacy, and separation from home may be important factors here, as are the abuse of alcohol, and the use of drugs for physical illness or for recreation. Creed(1993) reckoned that doctors’ spouses have a standardised mortality ratio of 275! Junior doctors, especially if female or foreign, often perceive that they are subject to bullying. Doctors should not be made to feel stigmatised if they seek help, and treatment should not be unduly modified because of their professional status. Doctors have to overcome stigma, misguided professional loyalty, a tradition of self-treatment, and fear of jeopardising career and job prospects if they are to step forward for help. Doctors should not hope that drug dependent colleagues will somehow snap out of it, making this a excuse for inactivity. Doctors who give the impression of rushing an interview are more likely to be the objects of litigation or complaints about care. To err is human and occasions of error should be tackled as learning opportunities,( Firth- Cozens(2003) although the litigiousness of society may militate against this in practice. Doctors and responsible others should utilise strategies that reduce the level of stress to which they are exposed (see box). Things doctors might do to reduce personal stress (after Iversen ea, 2009) Doctor-initiated Find and use mentors Take care of self (exercise etc) Reflect on ones emotions/reactions Challenge your own unhelpful beliefs Spend time with non-work related others (e. In the urban West, women with chronic severe psychiatric illness may be more likely to live with their families, while men live in hostels. According to Paykel (1991), much of the excess occurs in married women aged 25 to 45 years with children. Explanations might include expression of distress (depression in women, alcohol abuse in men), biology (hormones), and social (carer status, young children: see Kennedy & Hickey, 2005) factors. Romans ea (1993) conducted a follow up of New Zealand women in the community and found that onset of non-psychotic psychiatric disorder was associated with being separated or divorced, coming from a large family, having poor social networks, living alone, having few social role responsibilities such as a paid job or motherhood, being in poor physical health, and being financially insecure. Those women who were less likely to have their disorder remit were middle-aged, financially poor, and had poor social relationships at initial assessment. Psychosocial factors may be less important in determining outcome in severely depressed women. Started 1985 by patients’ relatives and mental health professionals to help tackle depression in Ireland. Expert Consensus Pocket Guide to the Pharmacotherapy of Depressive Disorders in Older Patients. In: Results of Community Studies in Prediction and Treatment of Recurrent Depression. Association of mu-opioid receptor variants and response to citalopram treatment in major depressive disorder. Guidelines for the Management of Depression and Anxiety Disorders in Primary Care. The convergence of pharmacotherapy and psychotherapy in maintenance treatment of bipolar disorder. The Sixth Report of Confidential Enquiries into Maternal Deaths in the United Kingdom. As part of the ageing process, people discard the youthful fantasies of immortality with varying degrees of success. Definitions Bereavement refers to the situation of having lost a significant other though death. Mental illness in a close relative may evoke complex emotional reactions, including grief, hate, sorrow and fear of developing the same disorder. Caplan, of crisis theory fame, elaborated on such primary prevention measures as the use of domestic pets to offset loneliness. Milner(1966) described a man with amnesia following bilateral temporal lobectomy that mourned afresh every time he learned that his uncle had died! The support offered by a spouse may have a protective role for physical health during parental bereavement. Lack of social support, mental illness, conflict or excessive dependency, and alcoholism, may increase mortality after loss of a close other. It is difficult to distinguish the effects of social isolation and low social support on the heart from that exercised by bereavement, since men return to the 1553 Modern scientific interest in bereavement dates to Erich Lindemann and the Coconut Grove fire in Boston, Massachusetts during World War Two. Lindemann influenced a generation of Boston investigators, including Gerald Caplan, Robert Weiss, and Colin Murray Parkes, Parkes bringing this work in England. Useful sources of practical information and contact numbers in Ireland are O’Connor ea (undated) and the Irish Medical Directory. Lymphocytic response seems to be diminished in early bereavement, in major depression and in other forms of stress, (Rogers & Reich, 1988) but enhanced immune response has been reported in those people anticipating grief. The dying may displace their hostility onto the doctor and the aged may displace it onto the young who misspend their youth. Depression is common after the loss of a spouse, especially for young widows and widowers with a history of depression. A balance must be struck between ones own needs and those of our charges, we must acknowledge fallibility and accept help as needed. We too often see death as something to be avoided, postponed or resisted at the expense of a humanistic approach to the dying. Distinguishing grief from depression* Grief Depression Intense symptoms for at least 1-2 months** Longer duration Usually no suicidal ideation*** Such ideas are common Visions or voice of deceased transient only**** May have sustained depressive delusions Pangs interspersed with normal feelings Continuous, pervasive depressed mood May blame deceased Blames self Improves with time No change or worsening *If in doubt, treat for depression – antidepressants do not retard the grieving process. See Kendler ea (2008) who doesn’t see the value of distinguishing these two phenomena. With regard to stillbirth, it is important to know when to promote grieving and when not to blow the event up out of proportion in the mind of the bereaved. It is suggested that women experiencing a stillbirth be nursed on a gynaecology ward instead of a postnatal ward after delivery. Anticipatory guidance involves covering such topics as how to explain the loss to others, giving away clothes and toys, meeting friends with young babies, and anything else that may help the woman to cope when she goes home. Fathers may be almost as anxious antenatally as the mother when there is a history of previous stillbirth. It has been suggested that induction of delivery should be considered as soon as feasible after diagnosis of death in utero. In the ‘replacement child syndrome’(Cain & Cain, 1964) a child is specifically conceived to replace a dead sibling, or an existing sibling may be forced into taking this role. The mother may have experienced unusually high numbers of family losses in her own childhood. The home may have a funereal atmosphere with a palpable obsession with links to the deceased. Men may be more secretive about infertility than are women and men may experience difficulty performing sexually according to prescribed schedules. Occasional cases of infertility are associated with non- consummation or anorexia nervosa. She may harbour guilt over past sexual acts and regret over past induced abortion or she may blame herself for delaying attempts to conceive for career reasons. Some cases who do conceive may paradoxically become depressed, possibly as a let down after years of fantasising about how wonderful ordinary parenting would be. Clomiphene, used to induce ovulation, may be associated with depression, anxiety, and poor sleep. Assisted reproduction is associated with a small increase in low birth weight and congenital defects, although the great majority of such babies are normal.

Conclusion: Tarlov cyst was frst described pain was better mildly with these treatments but not completely by Tarlov in 1938 discount duloxetine 40 mg on line. They may be a rare cause purchase generic duloxetine line, but should be considered in the teal region trigger points generic 60mg duloxetine fast delivery. After six session of dry needling buy duloxetine 40mg mastercard,the pa- differential diagnosis of radiculopathy. Fractures and de- 1Kangwon National University Hospital, Rehabilitation Medicine, velopmental abnormalities should be kept in mind in the differ- Chuncheon-Si, Republic of Korea ential diagnosis. We presented two cases diagnosed with limbus Introduction/Background: To investigate the association between vertebrae. Material and Methods: 523 Korean farm- His pain was increasing while long term of sitting and standing. There was no abnormal activity and patho- Low back pain was defned moderate or more severe pain intensity logical refex in the deep tendon refexes. His pain was decreasingwith resting and there was no disc height change noticed in either disc level of the L4/5 or L5-S1. Conclusion: This meta-analysis demonstrates a strong generative changes and lumbar lordosis is not clear. The following morphometric parameters were measured in plain radiograph for lumbar lordosis: lumbar lor- F. Young age group showed tendency with with a common goal of reducing pain and muscle spasm. They underwent 12 sessions cross-sectional relationships were observed among disc degenera- of Pilates within 6 weeks for one to two hours per session. The tion, lordosis and ages suggesting that disc degeneration could be Pilates regimen includes foating arms, arm lift, pelvic tilt, pelvic associated with aging and decreased lumbar lordosis. Cho1 mechanical low back pain can signifcantly reduce the pain scale 1 and improve disability index. It is proved Medicine- Ankara- Turkey, Department of Physical Medicine and Rehabilitation, Ankara, Turkey, 5Güven Hospital, Department of that physiotherapeutic scoliosis-specifc exercises improve physical 6 function but there are few evidences on their effects on the perceived Physical Medicine and Rehabilitation, Ankara, Turkey, Ankara quality of life. Oswestry question- adolescents with idiopathic scoliosis, independently from severity. In the comparison of two groups, acterized by wedge shaped vertebral bodies, irregularities of the ver- signifcant differences were determined in all parameters in fa- tebral endplates, narrowed disk spaces, thoracic hyperkyphosis and vour of group-1 at fourth week. Evcik4,5 shaped vertebral bodies and vertebral end plate irregularities as well 1Ufuk University Faculty of Medicine, Department of Physical as grade 3–4 sacroiliitis bilaterally. Sacroiliitis was confrmed by 2 Medicine and Rehabilitation, Ankara, Turkey, Ankara Univer- magnetic resonance imaging. Results: Indomethacin, 25 mg, orally sity Faculty of Medicine, Department of Anatomy, Ankara, Turkey, three times daily and physical therapy including posture exercises 3 was started. Conclusion: Despite FizyoCare Medical Center, The Clinic of Physical Therapy and Rehabilitation, Ankara, Turkey, 4Güven Hospital, Department of the coexistence of Ankylosing spondylitis and Scheuermann’s dis- 5 ease is a rare condition, it should be considered in the diagnosis. Outcomes were assessed at the beginning, week 3 and after 1Research Center of Medical Assessment and Rehabilitation - three months. Results: Seventy-fve patients com- cal estimation of neurologic status, manual testing of muscles, pleted the three months follow-up evaluations. It is established, that katadolon shows not only analgesic and neu- 3 4 roprotective, but also myorelaxing action on muscles of pelvic gir- Evcik , 1 dle and feet in patients with acute and chronic pain syndrom. Material Medicine, Istanbul, Turkey and Methods: A total of 123 patients were randomly divided into four groups. The aim of this study to asses the comorbid psychiatric received hot pack therapy. The fndings of this preliminary study can offer of the injection with pain level and disability. Results: One hun- favorable insight that can be applied to future studies concerning dred and ten patients (F=58, M=52) were included in this research. There wasn’t any signifcant difference between anxiety tients has yet to be investigated. The sion: In this preliminary study we found that information forms can Biering-Sorensen test were used to assess under three condition:no be benefcial for patients with comorbid anxiety about the function- taping(T0); immediately after taping (T1); 24 hours after taping with ality. The current comorbid conditions of patients with depression the tapes remaining in situ (T2). Results: Patients’ mean score of the and anxiety is not an obstacle for responding to treatment. Patients’ Biering-So- 1Erciyes University School of Medicine, Department of Physical rensen test recorded of T0 was 58. There was the signifcant difference not 2 only between T0 and T1 but also between T0 and T2 (p<0. Con- Turkey, Marmara University School of Medicine, Department of clusion: Lumbar disc degeneration patients experienced statistically Physical Medicine and Rehabilitation-Section of Pain Medicine, signifcant improvements in pain, disability and back muscle endur- Istanbul, Turkey ance after taping. The data were compared between 1Holy Cross Hospital, Interventional Spine & Pain Medicine, Fort patients with or without history of surgery. It Introduction/Background: Widespread dependency on subjective was found that 33 patients (14. Thus, we propose to broaden the utility of factors for assessment of treatment response and surgery. Discussion: Discitis is a serious and rare condition which can cause signifcant neurologi- 365 cal injury. Saraceni history of discitis who have sudden unexplained back pain—even in 1Sapienza University of Rome, Medicina Fisica e Della Riabili- the absence of the usual physical or laboratory signs of infection. By ment of back pain intensity, back trouble severity and spine profle Friedman analysis, there were both groups experienced signifcant with p<0. Case Description: A 67 year old female was admitted to the is the result of a mechanical and/or refex spinal dysfunction. Results: It is about a 28 years old woman, with no medical histo- requirement of pain medications. However, after the frst week, she ry, who consulted for dysesthesia and spontaneous parietal mechani- suddenly began experiencing increasing back pain. She did not ap- cal pain next to the outer edge of the left knee radiating to the upper pear acutely ill, and her vitals and labs were unremarkable. Physical examination revealed that the left knee was next couple days, her pain progressed despite aggressive medication not infammatory or painful, and its mobility was normal. Introduction/Background: In the process of treating scoliosis X-ray is one of the objective methods of assessing the progress of therapy. Material and Methods: We evalu- 1 2 3 4 ated a group of 70 children diagnosed with idiopathic scoliosis in N. The children remained in 1Moscow Research and Practice Center of Medical Rehabilitation the two monthly turnusach apart semester. During the stay twice and Sports Medicin, Rehabilitation, Moscow, Russia, 2Federal State a day participated in therapy by the Fed. Analysis and evaluation Budget Institution “Russian Scientifc Center of Medical Rehabili- of X-ray were performed before treatment and at the end of the tation and Balneology”, Department of Physiotherapy Exercises, half-year stage. With images were evaluated Cobb angle, vertebral Москва, Russia, Federal State Budget Institution “Russian Scientifc3 rotation by raimondii test Risser, type of scoliosis by King-Moe. Center of Medical Rehabilitation and Balneology”, Department of Results: The results have been developed in the form of tables and Physiotherapy Exercises, Moscow, Russia, 4Moscow Scientifc Cen- charts, broken down by the scoliosis to 20°, 30°, 40° and above 40°. The results presented in the study are the evaluation of the effectiveness of the method the Fed. Yang study included 87 patients aged 23 to 59 years with radiculopathy First Affliated Hospital of Sun Yat-sen University, Department of who underwent decompression surgery on the lumbosacral spine Rehabilitation Medicine, Guangzhou, China in period from 3 months to 3 years. All patients were randomly Objective: To explore the characteristics of the fractional amplitude been divided into 3 groups of 29 people in each. Results: We detected a decrease in the se- Methods: Twelve healthy subjects (male: 7, female: 5; age: 23. Studies showed trunk muscles atrophy alent disease, which is associated with high costs to the society,and (multifdus, transversus abdominis, paraspinal and psoas) contributed it is still relatively diffcult to treat and to maintain treatment effect. These approaches have good biomechanical function, Material and Methods: Medical record data by convenience sampling are widely available and have a modest cost. Therefore, a randomised controlled the patient in positions of challenge against gravity through 360°rota- trial is required to compare the effectiveness of these treatments in tion and 0° to 60° inclination control, muscle contraction recorded by patients with lumber disc herniation. Results were recorded as degrees hundred and forty patients was randomly assigned to a four-week of the maximum inclination angle.

There may be less suicidal ideation and early morning worsening of mood than in non-seasonal mood disorder patients buy duloxetine 30 mg overnight delivery. The depression may improve by travelling toward the Equator and worsen with proximity to the Poles order generic duloxetine on-line. Early guidelines for winter depression suggested that eyes should be exposed to full visible light duloxetine 60 mg fast delivery. The light should be sufficiently intense and the treatment sufficiently prolonged (e cheap duloxetine 60 mg. Treatment is given daily throughout the seasonal period of risk (early autumn to early spring). Portable bright light visors may reduce the need to sit in front of a light for long periods. The eyes may become slightly irritated or reddened initially but this is generally transient. Because rapid tryptophan depletion reverses gains from bright light therapy, serotonergic mechanisms may be involved in its therapeutic action. Negative air ion generation, used at home, is currently being studied for winter depression. Failure of exogenous dexamethasone to suppress endogenous cortisol was reported to be of value in differentiating endogenous or biological depression from other types of depression. Plasma cortisol levels fall in the second half of the day in healthy people but were noticed to remain high in some depressives. Increased plasma cortisol concentrations may be simply a non-specific symptom of psychosis or of acute distress. Depressed patients do not become cushingoid despite evidence for increased glucocorticoid levels. Finally, it should be noted that dexamethasone itself may have some antidepressant properties! Pregnancy One should never assume that a woman is sexually inactive because she has a mental disorder, and whilst unplanned pregnancy is very common in the community it is especially frequent likely if the woman is mentally ill. Depression during pregnancy is not uncommon (about 10% during any trimester), contrary to popular belief (Kitamura ea, 1993; Dietz ea, 2007), although not all research agrees. There may be an association between early gestational depression and psychosocial factors, such as first or unwanted pregnancy, poor marital relationship, unsatisfactory living conditions, less maternal care in own childhood, and having remarried. Parry ea (2008) found that night-time plasma melatonin levels, especially during the morning hours, were relatively low in depressed pregnant women but relatively increased in depressed postpartum women; also, the timing of melatonin production was advanced in pregnant women with a personal or family history of depression. Suicide (and deliberate self-harm) is rare during pregnancy,(Appelby & Turnbull, 1995) although it may have been more common in the past, although teenage and single mothers may represent high-risk groups. Panic disorder may be exacerbated during the puerperium, and Cohen ea (1994) suggest that this possibility may be heightened by not treating panic disorder during pregnancy. The postpartum/maternity blues/reactivity affects over 50% of mothers on days 3-5 postpartum and is generally resolved by day 10. There are transient labile emotions (heightened responsiveness to good and bad stimuli), tearfulness, mild hypochondriasis, irritability, and anxiety. Aetiology (unclear) Primigravida History of third trimester depression or premenstrual dysphoria Psychological, e. Particularly severe cases should prompt a search for another psychiatric disorder. Vigod ea (2010) conducted a systematic review and reported that mothers of preterm infants are at increased risk of depression compared with mothers of term infants in the immediate postpartum period; risk continued throughout the first postpartum year for mothers of very low birth weight infants. High scores on the Edinburgh Postnatal Depression Scale at 6 weeks are associated with single marital status, unemployment, unplanned pregnancy, public patient status, and bottle-feeding. Management involves a package of counselling, psychotherapy, family work, chemotherapy (e. There is evidence from Canada (Dennis ea, 2009) of a prophylactic effect of telephone-delivered support delivered by people with a self-reported history of and recovery from 1403 postnatal depression for women at risk of postnatal depression. The risk of recurrence in another puerperium is at least 20%, higher (40%) if there is a history of episodes of affective illness unrelated to childbirth. Symptoms, which usually commence within two weeks of delivery, include guilt, despair, psychomotor retardation or agitation, perplexity, lability of affect and disorientation. Mixed affective state may carry a higher suicide risk than postnatal psychotic depression. The requirement for mother and baby unit beds has been estimated at 8/million total population. Treatment strategies 1408 Treatment options include supportive psychotherapy , cognitive-behaviour or interpersonal therapy 1409 (when available), cognitive remediation therapy , marital therapy (especially if there is accompanying marital distress) environmental manipulation (e. Today, infanticide, especially in the first days after the birth, may indicate social reasons (the unwanted and disguised pregnancy) rather than psychiatric disorder. Miklowitz (2008) looked at 18 trials of individual and group psychoeducation, systematic care, family therapy, and interpersonal or cognitive behavioural therapy as adjuncts in bipolar patients and found that they improved symptoms and function over 2 years; emphasis on medication compliance and recognition of early mood changes had stronger effects on mania, whereas emphasis on cognitive and interpersonal coping strategies had stronger effects on depression. Except for the mildest cases (where ‘watchful waiting’ may be appropriate) the earlier treatment is instituted the better. Immediate response to antidepressant therapy may constitute a placebo effect; such cases are prone to early relapse. Many people imagine antidepressants to be non-efficacious or addictive, and many have magical expectations of counselling. Apart from giving medication, it is important to address any persistent dysphoria, low self-esteem, or confounding psychosocial issues. Arguably, physical exercise, such as running, may alleviate less severe forms of depression and anxiety (Greist ea, 1979; Mather ea, 2002), but is this due to exercise, lack of inactivity, or a third unknown factor? Four different psychotherapeutic strategies for depression are summarised in the box. Couple therapy may help in cases where relapse appears to be precipitated by having a critical partner. According to Keck,(2004) psychoeducation may be better at preventing manic than depressive relapses in bipolar disorder, with the opposite effect for family-focused therapy. Therapist must understand past, defences, ego distortions, superego defects, and provide role model and permit catharsis. Clarify maladaptive relationships and learn new ones via communication/social skills training. Interpersonal psychotherapy is an alternative to medication in the depressed breast- feeding mother. Use partner as objective reporter/couples therapy if relationship disturbed/thoughts sustained by relationship. Can be used with any other suitable 1411 No better than sham treatment according to Mogg ea. The results of their meta-analysis suggested that while psychotherapy had significant effects such effects are much smaller than was previously understood. Cipriani ea (2009) compared the efficacy and acceptability of twelve ‘new-generation’ antidepressants in a meta-analysis: mirtazapine, escitalopram, venlafaxine and sertraline were more efficacious than duloxetine, fluoxetine, fluvoxamine, paroxetine, and, the least efficacious, reboxetine. The authors suggest starting with sertraline (Lustral, Seretral) when treating moderate/severe major depression in adults because it had the best balance between efficacy, acceptability, and cost. Uher ea (2009) found that escitalopram improves observed mood and cognitive symptoms more than does nortriptyline whereas the opposite applies to neurovegetative symptoms. Past personal response to a particular antidepressant or a family history of such a response is a good argument for using it again during the index episode. The old idea of reducing a therapeutic dose to a maintenance or prophylactic one after symptoms remit was mistaken: the patient should be kept on the dose that worked for at least 6 months. It is the author’s practice to aim at 2 years treatment, followed by a slow taper if history and symptoms/function suggest it is safe to do so. Not everyone who needs long term antidepressant treatment gets it or receives it for long enough. Geddes ea (2003) conducted a systematic review of 31 randomised trials of continuation antidepressant drug therapy and found that whilst treatment effects seemed to last over 3 years, most trials were only a year in duration; average relapse rate on drug therapy was 18%, 41% on placebo; and 18% of active drug treatment cases stopped the drug, 15% on placebo. The authors wondered if treatment effects would have been superior with better adherence. Williams ea (2009) conducted a meta- analysis of long-term antidepressant drug therapy and found relapse rates of 23% and 51% for active drug and placebo respectively, and time on treatment significantly influenced the relapse rate. The neurotic-endogenous and other aetiological distinctions or the presence of life stresses or ‘understandability’ of depression are no longer regarded as important in defining the presence of disorder and the need for antidepressant drug treatment.

In patients with pelvic symptoms buy generic duloxetine from india, one or more of the following additional views are useful: —A second image taken immediately after voiding order duloxetine on line amex. Normal and abnormal bone scintigraphy It is essential to be thoroughly familiar with normal bone findings in order to accurately recognize pathology order duloxetine 60 mg line. Physiologically cost of duloxetine, there tends to be a distinct accumulation of tracer in the cranial vault, facial bones around the nasal cavity, shoulders, manubriosternal junction, sternoclavicular joints, spine, sacroiliac joints, pelvis and hips. It is well known that tracer accumulates intensely in the physes of growing bones. Scintigraphic abnormalities of bones and joints are presented as either increased or decreased uptakes, often described as ‘hot areas’ and ‘cold areas’ respectively. Among a range of parameters that may distort scan findings, the tilting of the body to either side is probably the most critical. Since photon energy diminishes rapidly according to the inverse distance square law, even a slight difference between the target–detector distances results in significant image distortion and asymmetry. Thus, bone structures closest to the detector may appear unusually hot, leading to an erroneous interpretation. Bone scintigraphic abnormalities can be recognized in three essential ways: morphology, tracer uptake pattern and vascularity. Morphological alterations are expressed in terms of size, shape and position, and radionuclide uptake pattern and vascularity as increased, unaltered or decreased. Lesions that tend to display cold areas include acute avascular necrosis, lytic metastasis and multiple myeloma. Clinical applications Scintigraphy is useful for the following diseases and conditions: (1) Acute infective diseases of bone; (2) Tuberculosis of bone; (3) Non-infective inflammations of bone; (4) Indium-111 and 99mTc labelled leucocytes and 67Ga scans in bone infections; (5) Transient synovitis of the hip; (6) Acute pyogenic arthritis; (7) Osteoarthritis; (8) Rheumatoid arthritis; (9) Ankylosing spondylitis; (10) Reiter’s syndrome; (11) Reflex sympathetic dystrophy syndrome; (12) Avascular necrosis of bone; (13) Osteochondroses; (14) Traumatic and sports injuries of bone; (15) Periarticular rheumatism syndromes; (16) Muscular and musculotendinous rheumatism syndromes; (17) Metabolic diseases of bone; (18) Benign and primary malignant bone tumours; (19) Metastatic bone tumours; (20) Tumorous conditions of bone. Acute osteomyelitis typically involves metaphysis of the long bones where the end-arteries are distributed, providing favourable conditions for bacterial embolization. Osteitis, which commonly occurs in association with osteomyelitis, is the infection of compact bone. Cortical abscesses are a special form of acute pyogenic infection in which the infective focus is within the cortex. Pinhole scintigraphy can distinguish these conditions by specifically locating the anatomic pathological site and assessing the tracer uptake pattern of the individual diseases. Infection is either blood borne or the direct result of a traumatic wound or surgery. Infective spondylitis, both acute and chronic, produces the characteristic ‘sandwich’ sign on magnified scintigraphs. This sign consists of intense tracer uptake in two apposing end-plates with narrowed disc space. Pathologically, bone tuberculosis is characterized by destruction with relatively mild reactive bone formation. A special form of tuberculosis, which involves the finger in infants, is known as spina ventosa. Planar bone scan findings are usually not specific, but pinhole scinti- graphy reveals findings of diagnostic value. The diseased bone shows a localized area of increased tracer uptake, occasionally with associated photopenic area(s). In the spine, as in acute infective spondylitis, tuberculosis involves two or more neighbouring vertebrae and intervertebral discs. Extended tracer uptake can be seen deep in the vertebral bodies, confirming that the chronic granulo- matous process spreads from the end-plate into the vertebral body. Each of these diseases manifests characteristic signs on pinhole images that are comparable to radiographic signs. Granulocytes avidly accumulate in acute infective foci while lymphocytes accumulate primarily in chronic foci. Gallium-67 scans are non-specific, accumulating in both inflammatory and neoplastic lesions. In contrast, pinhole scintigraphy precisely localizes tracer uptake to the synovia, which cover the femoral head and acetabular fossa. Such uptake is due to an increase in blood flow through the anastomotic vascular channels in the inflamed synovium. The tracer uptake may be prominent in the active stage but rapidly returns to normal with rest and conservative treatment. It is to be noted that in the early stage with large synovial effusion, tracer uptake may become reduced due to ischaemia of the femoral head created by capsular distension. However, bone scintigraphy reveals an increased blood flow and blood pool in septic joints, and intense tracer uptake in the subchondral bone on static images in the early stages. The intensity of subchondral tracer uptake in acute pyogenic arthritis has been described as roughly paral- lelling the intensity of infection. Dual head pinhole scintigraphy produces a pair of either the anterior and posterior, or the medial and lateral, images, permitting a three dimensional analysis of the disease. Histologically, it is characterized by the derangement and eventual destruction of the cartilage and subchondral bone without obvious inflammation. Bone scintigraphs may show discrete unifocal or multifocal tracer uptake in subchondral bones, and can be spotty, patchy or segmental in type. Whole body bone scans are the only way to portray symmetric polyarthritis panoramically; spot views can depict characteristic changes in both large and small joints in great detail. Pinhole scintigraphy is useful in delineating many scintigraphic signs of rheumatoid arthritis. Nuclear angiography provides information on lesional vascularity and on the activity of the pathological process. Ankylosing spondylitis is a non- specific inflammatory disease of the sacroiliac joints and the spine. The disease primarily involves the synovial components of the sacroiliac joints and the cartilaginous discovertebral junctions as well as the apophyseal, costovertebral and neurocentral joints of the vertebrae. Planar bone scintigraphy reveals symmetric intense tracer uptake in the sacroiliac joints and/or spine. Pinhole scintigraphy can portray the characteristic ribbon-like tracer uptake in the synovial joints of the spine, producing a ‘bamboo spine’ appearance. In the late stage, tracer uptake becomes reduced, reflecting a quiescent metabolic state. The disease mechanism is still obscure, but an interaction between several different infective organisms and a specific genetic background is currently being given serious consideration. Pathologically, the main alterations are present in the enthesis, which is the site of insertion of a tendon, ligament or articular capsule into the bone, creating characteristic inflammatory enthesopathy. Conspicuous involvement of entheses in this syndrome sharply contrasts with the dominant involvement of the synovium in rheumatoid arthritis. The whole body scan can panoramically reveal characteristic asymmetrical pauciarticular involvement of the spine and appen- dicular bones and joints. Pinhole scintigraphy often detects characteristic enthesopathy in the pre-radiographic stage, especially in the heel and knee. In addition, pinhole scintigraphy can show specific signs of Reiter’s syndrome, namely the ‘knuckle bone’ sign of the sausage digit, the ‘teardrop’ sign of paravertebral enthesopathy and the ‘whisker’ sign of periarticular hyperostosis. It is a rheumatic disorder of clinical importance and academic interest, often related to previous trauma. The pathogenesis has not yet been clarified, although the theory of the internuncial pool is widely accepted. The identification of the ‘sympathetic vasoactive intestinal peptide-containing nerve fibres’ at the cortical bone and the bone–periosteal junction has provided a biochemical basis for the theory. Three phase scintigraphy is useful, revealing increased blood flow and blood pooling, which denotes hyperperfusion. Involvement of periarticular structures of one or more joints of a limb is characteristic. The common causes include trauma, embolism, thrombosis, elevated bone marrow pressure, irradiation and vasculitis. Scintigraphically, avascular necrosis presents as a hot area on the planar image, especially in small bones. However, when magnified using pinhole scintigraphy, a photopenic area can be detected within the hot area.

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