diet and Dia$et&. Composition: Glyburide 5 mg. Indications: Uncom. licated diabetes mellitus of the stable, mild, non. etot ic, maturity-onset type not controlled by diet alone, in patients who have failed to respond to or cannot be maintained on other suifonylureas. Contraindicatlons: Severely brittle and juvenile diabetes, severe ketosis, acidosis, coma, thyrotoxicosis, frank jaundice and liver disease, severe renal impairment, severe infections, trauma, surge., pregnancy and complications peculiar to diabetes. .recautlons: Careful selection of patients Is important. It is imperative that there be rigid adherence to diet, careful adjustment of dosage, instruction of the patient on hypoglycemic reactions and their control and regular follow-up examinations. Administer with or immediately after a meal; lunchtime for patients eating a light breakfast. Periodic liver function tests, peripheral blood counts and ophthalmic examinations are advisable. The possibility of hypoglycemia should be considered when certain long-act ing su Iphonamides, tuberculostatics, phenylbutazone, monoamine oxidase Inhibitors, coumarin derivatives, salicylates, probenecid or propranolol are administered simultaneously. Use sedatives cautiously in patients receiving oral hypoglycemic agents since their action may be prolonged. The effects of oral hypoglycemic agents on the vascular changes and other long-term sequelae of diabetes are not known; patients receiving such drugs must be very closely observed for both short-and long-term complications. Intolerance to alcohol rarely occurs. Administer oral hypoglycemic agents with caution to patients with Addison's disease. Adverse reactIons: Allergic skin reactions including photosensitivity, pruritus, headache, tinnitus, fatigue, malaise, weakness, dizziness have been reported in a small number of patients. Hypoglycemic reactions are infrequently observed. Thrombocy topenia is uncommon. Overdosage: Symptoms: Manifestations of hypoglycemia include sweating, flushing or pallor, numbness, chilliness, hunger, trembling, headache, dizziness, increased pulse rate, palpitations, increase In blood pressure, apprehensiveness and syncope in the mild cases. In the more severe cases, coma appears. Treatment: Administer dextrose or glucagon and dextrose. Dosage and admInIstratIon: Total daily dosage ranges between 2.5 and 20 mg. 1. Newlydiagnosed diabetics: Initial dosage is 5 mg daily (2.5 mg in patients over 60 years of age) for 5 to 7 days. Adjust dosage by increments of 2.5 mg according to response. The maximum daily dose of DIAI3 A is 20 mg. Most cases can be controlled by 5-10 mg daily given as a single dose during or Immediately after breakfast. 2. Chan9eover from other oral hypoglycemic agents: Discontinue previous oral medication and start DIAIJETA 5 mg daily (2.5 mg in patients over 60 years of age). Determine maintenance dosage as in newly-diagnosed diabetics. 3. Changeover from insulin. Less than 20 units daily-discontinue insulin and start on DIA.ETA 5 m. dally (2.5 mg in patients over 60 years o age). Adjust dosage according to response. Between 20-40 units of insulin dali yreduce insulin by 30-50% and start DIAI3ETA 2.5 mg daily. Further reduce insulin and increase DIAPETA dosage according to response. 4. Combined treatment with biguanides. If adequate control becomes impossible with diet and maximum doses of DIA.ETA (20 mg daily), control may be restored by combining with a biguanide. Maintain D IA.ETA dosage and add 50mg of phenformln. 5. Combined treatment with insulin. Patients with (relative) insulin resistance can occasionally be more smoothly controlled by adding DIAI3ETA. Supply: White, oblong, scored 5 mg tablets Code (LDI) In boxes of 30 and 300. Product Monograph on request. References: 1. O'Sullivan, D.J. and Cashman, W.F.: Brit. Med. J., 2:572, 1970. 2 Mueller, R. et al: Horm. Metab. Res. 1(suppl.):88, 1969. 3. Kraii, LP., Sinha, S. and Goldstein, H.H., Aust. & N.Z. J. Med., 46(suppi.):57, 1971. 4. Moses, A.M., Howanitz, J. and Miller, M.: Ann. Intern. Med., 78:541, 1973. 5. Luntz, G.R.WN.: Postgrad. Med. J., 46(suppi)84: 1970. 6. Schoeffling, K.: Aust. & N.Z. J. Med., 1(suppl.):47, 1971.

Hoechst

Pharmaceutical Division. Canadian Hoechst Ltd

Montreal

136117096E

The significance of low back pain in older adults J.C. FERNBACH,* MD; F. LANGER,t MD, FRCS[C]; A.E. GROSS4 MD, FRCS[C]

A retrospective study of the practice of an orthopedic surgeon at a university teaching hospital was done to evaluate the significance of low back pain in older adults. All 259 patients in a 3-year period 50 years of age and over whose presenting complaint was low back pain or sciatica or both were identified and classified by final diagnosis. A comparison group of 259 patients under 50 years with the same complaint was similarly identified and classified. Systemic disease, particularly cancer, was much more prevalent in the older group. It was demonstrated that a simple screening routine consisting of measuring the erythrocyte sedimentation rate and serum concentrations of alkaline phosphatase and calcium would identify all cases of unsuspected malignant disease - that is, at least one of the values would be abnormal in every case. Une etude r6trospective de Ia pratique d'un chirurgien-orthopediste attach6 a un centre hospitalier universitaire a 6t6 entreprise afin d'evaluer Ia signification de Ia douleur lombaire basse chez les adultes ig6s. Les 259 patients ig6s de 50 ans ou plus se plaignant de Ia douleur lombaire basse ou de Ia sciatique ou les deux, vus sur une periode de 3 ans, ont 6te identifies et classifies selon leur diagnostic final. Un groupe comparatif form6 de 259 patients Ages de moms de 50 ans se plaignant des mAmes malaises a et6 identifi6 et classifie de Ia mAine faqon. Les affections gAnerales, particulierement los cancers, etaient beaucoup plus frequentes chez les patients plus ig6s. II a et6 demontr6 qu'une simple s6rie de tests de depistage consistant a mesurer le taux de sedimentation des erythrocytes et les concentrations s6riques en phosphatase alcaline et en calcium permettrait d'identifier tous los cas insoup.onnes de maladies malignes, en ce sens qu'au moms une des valeurs obtenues dans chaque cas serait anormale. From the department of surgery, division of orthopedics, Mount Sinai Hospital, Toronto *Intern, Wellesley Hospital, Toronto iStaff orthopedic surgeon, Mount Sinai Hospital .Surgeon-in-chief, Mount Sinai Hospital Reprint requests to. Dr. J.C. Fernbach, 309 Beresford Ave., Toronto, Ont. M6S 3B4

898 CMA JOURNAL/NOVEMBER 6, 1976/VOL. 115

Low back pain and sciatica,* either alone or together, are frequent presenting complaints. Their etiologic and prognostic significance are often not as obvious as their role as a source of immediate misery and interference in a patient's daily activities; it is for this reason that the not uncommon and generally benign practice of empiric treatment can become a serious disservice to certain patients. In this paper we examine the causes of LBP in older adults and the possible importance of LBP as a marker for neoplasia and other systemic disease. There may be an important difference between the appropriate investigative protocol for this age group and a younger population, and it is hoped that a quantitative description of the reasons for LBP, resulting from our retrospective survey, will help to resolve this question. Classification Macnab1 advocated a practical tripartite classification of LBP: viscerogenic, psychogenic and spondylogenic. Viscerogenic LBP is usually not hard to diagnose and its treatment is clear. Either the disorder is in a nonmusculoskeletal organ of the chest, abdomen or pelvis and no pain is referred to the legs, or there is extraspinal involvement of the sciatic nerve by a pelvic or retroperitoneal mass. Psychogenic LBP is partially or wholly a conversion symptom. Alone, it is always a diagnosis of exclusion (although functional augmentation of pre-existing organically based LBP is common). Spondylogenic LBP, arising from the axial skeleton and its contiguous supporting structures, can be subclassified by cause as follows: 1. Trauma: fractures, fracture-dislocations, soft-tissue injuries. 2. Structural defects: spondylolysis, spondylolisthesis, scoliosis, facet abnormalities, spinal stenosis. 3. Lumbar disc disease: acute herniation, chronic degeneration. 4. Infection: pyogenic, granulomatous. 5. Neoplasm: benign, malignant primary or secondary. *Hereafter low back pain, sciatica and a combination will be collectively designated "LBP".

Table I-Final diagnosis of patients with low back pain Final diagnosis of lowbackpain Viscerogenic Psychogenic Spondylogenic Traumatic Structural defects Lumbar disc disease Infection Neoplasm Benign Malignant Primary Secondary Inflammation Seropositive Seronegative Metabolic (including osteoporosis) Miscellaneous Total

No. of patients, by age (yr) . 50 3 4

< 50 25

18 28 174 1

85 34 100 1

-

2

4 13

1

1 -

4

11 2

1 6

259

259

Table Il-Proportions of patients 50 or older with low back pain due to malignant disease having abnormal laboratory results

Malignant disease Primary Secondary

Proportions with abnormal values of: Serum alkaline Serum ESR phosphatase calcium 3/4 3/4 2/4 12/12 5/11 4/9

73 mm/h; serum calcium, 12.8 mg/dl; and serum uric acid, 23 mg/dl. (Serum alkaline phosphatase was not studied.) Radiologic investigation showed multiple collapsed dorsal and lumbar vertebrae (Fig. 1), widespread bony metastatic deposits and several pathologic rib fractures. Bone marrow smear was characteristic of multiple myeloma, which was shown to be type IgG(K). Case 2 A 63-year-old woman was admitted to hospital with a 3-month history of LBP radiating down to the right heel. She did not recall any injury to her back. Over the preceding 2 to 3 months she had become anorectic and had lost 4.5 kg. There were no other symptoms and past history was noncontributory. Physical examination revealed only neuromusculoskeletal signs. Las.gue's sign was evident, with straight-leg raising at 700 on the right side producing pain. The right ankle jerk was absent. The power of the plantar flexors of the right ankle was 4/5. Sensory examination of the lower limbs was equivocally normal and rectal sphincter tone was normal. Laboratory investigation showed normal hemogram, urinalysis results and values of serum electrolytes, calcium, uric acid and alkaline phosphatase. The ESR was 85 mm/h. Lumbar myelogram showed nerve root compression at L5,Sl, L4,5 and L3,4 (Fig. 2) and spinal stenosis at L3,4. Radiographs of the lumbar spine showed pronounced degenerative changes at the same levels. Routine admission chest radiograph revealed a mass in the left hilum (Fig. 3); tomography showed it to be in the superior segment of the left lower lobe, and its appearance was judged compatible with that of neoplasia. A bone scan demonstrated increased uptake in the left sacroiliac region and the right parietal area of the skull (Fig. 4); the appearance of these

lesions suggested secondary malignant disease. Parietal bone biopsy revealed metastatic adenocarcinoma. Palliative laminectomy was done at L4,5 and L5,Sl with central decompression from [4 to S2. and complete bilateral decompression of Si and 52. Metastatic carcinoma was found enveloping Si on the right side.

4

FIG. 4-Case 2 increased uptake of radiotracer in right panetal area, typical of metastatic invasion Discussion

FIG 2 Case 2: nerve root compression at L5,S1, L4,5 and L3,4 and degenerative disc changes evident on myelogrnm.

In this study the prevalence of systemic disease in the older group was. found to be more than double that in the younger. More significantly, 7% of the older group had either primary or secondary malignant disease and there were no such cases in the younger group. Hence LBP in older adults can be portentous and its cause must be fully determined. Measurement of the ESR and serum alkaline phosphatase and calcium concentrations has been shown to be a sensitive and reliable laboratory screening procedure. In no case of cancer were all three values normal. These tests are not expensive; the three together cost 24 laboratory medicine units, or $9.84 by the 1976 Ontario Medical Association fee schedule. It is probable that this screening procedure is not only good individual practice but also cost-effective in wide-scale application. There were no cases of prostatic carcinoma in this series of patients and we cannot cite data to justify the routine assay of serum acid phosphatase in cases of LBP in elderly men. However, this cancer has a propensity for spread to the vertebral column and is most common in this age group. The cost of the test is 15 units ($6.15); its costeffectiveness as a screening procedure will have to be assessed in light of the frequency of presentation of this cancer as isolated LBP. This question has not been studied and the consistency of the rule that bone pain is a late symptom remains open to question. Reference

FIG 1-Case 1: multIple collapsed verte bral bodies, a result of malignant unfiltradon and demineralization.

FIG. 3-Case 2: mass in left hilum, proven to he adeaocarcinoma.

900 CMA JOURNAL/NOVEMBER 6, 1976/VOL. 115

1. MACNAB I: Low back pain. The hyperextension syndrome. Can Med Assoc J 73: 448, 1955

The significance of low back pain in older adults.

diet and Dia$et&. Composition: Glyburide 5 mg. Indications: Uncom. licated diabetes mellitus of the stable, mild, non. etot ic, maturity-onset type no...
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