Percutaneous treatment of radial neck fractures in adult patients.

INTRODUCTION: Radial neck fractures in adults are rare, but outcomes are often poor. Closed reduction and internal fixation (CRIF) technique has been advocated for the treatment of minimally displaced fractures in children, with a few reports on adult subjects. The aim of the present paper is to investigate mid-term results of a CRIF technique in adults with retrograde intramedullary K-wires in Mason's type II and III fractures. The proposed technique yields to good anatomical reduction of displaced neck fractures, faster rehabilitation, and easier hardware removal after fracture consolidation. MATERIAL AND METHODS: A consecutive series of 17 patients were treated with closed reduction and intramedullary osteosynthesis, and outcomes were retrospectively evaluated. Elbow X-ray (XR) and CT scan were obtained preoperatively. Objective assessment before surgery and at an average 36-month follow-up included active and passive elbow range of motion (ROM). Functional evaluation was carried out through the collection of the Mayo Elbow Performance Score (MEPS), the Disabilities of the Arm, Shoulder, and Hand (DASH) score, and Elbow Self-Assessment Score (ESAS). XR at last follow-up was evaluated. RESULTS: The cohort included 10 males and seven females, with a mean age of 32 years. Patients returned for a follow-up evaluation at a mean of 36 months (range 6-43 m) form the surgery. The DASH score revealed good to excellent outcomes with a mean of 6.32 ± 10.24 points at last follow-up. The ESAS was 98.35 ± 1.89, indicating a non-restricted elbow function. Acceptable radiographic healing was achieved in all patients. CONCLUSIONS: The advocated technique is promising for obtaining good reduction and stabilization, and good to excellent satisfaction for patients. Given the challenging technique, the learning curve could be long and initial results unsatisfactory. More research with larger cohorts and improved study design could be carried out, comparing the technique with the current choice of treatment (ORIF, radial head resection).

An artificial intelligence-driven scoring system to measure histological disease activity in ulcerative colitis.

BACKGROUND AND AIMS: Assessment and scoring of histological images in Ulcerative colitis (UC) is prone to inter- and intra-observer variability. This study aimed to investigate whether an artificial intelligence (AI) system developed using image processing and machine learning algorithms could measure histological disease activity based on the Nancy index. METHODS: A total of 200 histological images of patients with UC were used in this study. A novel AI algorithm was developed using state-of-the-art image processing and machine learning algorithms based on deep learning and feature extraction. The cell regions of each image, followed by the Nancy index, were manually annotated and measured independently by four histopathologists. Manual and AI-automated measurements of the Nancy index score were conducted and assessed using the intraclass correlation coefficient (ICC). RESULTS: The 200-image dataset was divided into two groups (80% was used for training and 20% for testing). Intraclass correlation coefficient statistical analyses were performed to evaluate the AI tool and used as a reference to calculate the accuracy. The average ICC among the histopathologists was 89.3 and the average ICC between histopathologists and the AI tool was 87.2. The AI tool was found to be highly correlated with histopathologists. CONCLUSIONS: The high correlation of performance of the AI method suggests promising potential for inflammatory bowel disease clinical applications. A standardized automated histological AI-driven scoring system can potentially be used in daily inflammatory bowel disease practice to reduce training needs and resource use, eliminate the subjectivity of the pathologists, and assess disease severity for treatment decisions.

Neglected synovial osteochondromatosis of the elbow: a rare case.

BACKGROUND: Synovial osteochondromatosis is a benign metaplastic proliferative disorder of the synovium characterised by the formation of multiple cartilaginous nodules in the synovium, many of which detach and become loose bodies. The disease is characteristically monoarticular, most commonly involving the knee. A site in the elbow was first reported in 1918 by Henderson, but any joint may be involved. Very few cases of synovial osteochondromatosis of the elbow have been reported in the literature. The presenting symptoms are usually diffuse discomfort in the affected joint and decreased range of motion with an accompanying gritty or locking sensation. The treatment of choice is excision of the synovium and removal of the loose bodies. CASE PRESENTATION: We report a rare neglected case covering a 32-year period of a locally aggressive synovial osteochondromatosis of the elbow in a 47-year-old man. Clinical examination revealed a significant increase in size of the left elbow compared to the contralateral one. The simple radiographs and the computed tomography showed multiple rounded, calcified bodies widespread throughout the elbow joint. At surgery we removed and counted a total of 312 loose bodies, varying in size from a few millimeters to 3 cm. The evaluation at 6 months postoperatively showed marked reduction in the volume of the elbow, improvement of extension and flexion and an increase of the Mayo elbow performance score from 50 points before surgery to 80 points at 6 months postoperative. CONCLUSION: Synovial osteochondromatosis is an uncommon condition characterized by the formation of multiple nodules of hyaline cartilage within the sub-synovial connective tissue. The differential diagnosis includes chronic articular infection, osteoarthritis, pigmented villonodular synovitis, mono-articular inflammatory arthritis and periarticular neoplasms like synovial sarcoma. The treatment of choice is excision of the synovium and removal of the loose bodies. The prognosis is good, but recurrences may occur if the removal is incomplete.

Tocilizumab in patients with active rheumatoid arthritis and inadequate responses to DMARDs and/or TNF inhibitors: a large, open-label study close to clinical practice.

OBJECTIVE: To evaluate the safety and efficacy of tocilizumab in clinical practice in patients with rheumatoid arthritis (RA) with inadequate responses (IR) to disease-modifying antirheumatic drugs (DMARDs) or both DMARDs and tumour necrosis factor α inhibitors (TNFis). METHODS: Patients-categorised as TNFi-naive, TNFi-previous (washout) or TNFi-recent (no washout) -received open-label tocilizumab (8 mg/kg) every 4 weeks ± DMARDs for 24 weeks. Adverse events (AEs) and treatment discontinuations were monitored. Efficacy end points included American College of Rheumatology (ACR) responses, 28-joint disease activity score (DAS28) and European League Against Rheumatism responses. RESULTS: Overall, 1681 (976 TNF-naive, 298 TNFi-previous and 407 TNFi-recent) patients were treated; 5.1% discontinued treatment because of AEs. The AE rate was numerically higher in TNFi-recent (652.6/100 patient-years (PY)) and TNFi-previous (653.6/100PY) than in TNFi-naive (551.1/100PY) patients. Serious AE rates were 18.0/100PY, 28.0/100PY and 18.6/100PY; serious infection rates were 6.0/100PY, 6.8/100PY and 4.2/100PY, respectively. At week 4, 36.5% of patients achieved ACR20 response and 14.9% DAS28 remission (<2.6); at week 24, 66.9%, 46.6%, 26.4% and 56.8% achieved ACR20/ACR50/ACR70 responses and DAS28 remission, respectively. Overall, 61.6% (TNFi-naive), 48.5% (TNFi-previous) and 50.4% (TNFi-recent) patients achieved DAS28 remission. CONCLUSIONS: In patients with RA who were DMARD-IR/TNFi-IR, tocilizumab ± DMARDs provided rapid and sustained efficacy without unexpected safety concerns.

Minimally invasive fixation in tibial plateau fractures using an pre-operative and intra-operative real size 3D printing.

The purpose of our study was to compare the outcome after minimally invasive reconstruction and internal fixation with and without the use of pre- and intra-operative real size 3D printing for patients with displaced tibial plateau fractures (TPFs). We prospectively followed up 40 consecutive adult patients with closed TPF who underwent surgical treatment of reconstruction of the tibial plateau with the use of minimally invasive fixation. Sixteen patients (group 1) were operated using a pre-operative and intra-operative real size 3D-model, while 24 patients (group 2) were operated without 3D-model printing, but using only pre-operative and intra-operative 3D Tc-scan images. The mean operating time was 148.2±15.9min for group 1 and 174.5±22.2min for group 2 (p=0.041). In addition, the mean intraoperative blood loss was less in group 1 (520mL) than in group 2 (546mL) (p=0.534). After discharge, all patients were followed up at 6 weeks, 12 weeks, 6 months, 1year and then every year post surgically and radiographic evaluation was carried out each time using clinical and radiological Rasmussen's score, with no significant differences between the two groups. Two patients (group 2) developed infection which resolved within 3 weeks after usage of antibiotics. Neither superficial nor deep infections were present in group 1. In all patients, no non-union occurred. No intraoperative, perioperative, or postoperative complications, such as loss of valgus correction, bone fractures, or metallic plate failures were detected at follow-up. In patients operated with the use of 3D-model printing, we found a significant reduction in surgical time. Moreover, the technique without a 3D-model increased the patient's and the surgeon's exposure to radiation.

Reliability and validity of the Italian version of the Chronic Pain Grade questionnaire in patients with musculoskeletal disorders.

The aim of this study is to analyse the psychometric properties of the Italian version of the Chronic Pain Grade (CPG) questionnaire within a population of chronic musculoskeletal pain patients. The CPG questionnaire was adapted following the translation and back-translation methodologies. There were 576 patients with chronic musculoskeletal pain. Internal consistency was checked by the Cronbach's alpha coefficient. Construct validity was analysed by performing principal component factor analysis and by comparing CPG dimensions and subscales with the SF-36 questionnaire. Discriminant validity was assessed by comparing the CPG and SF-36 dimensions in patients with and without other health conditions. Factor analysis yielded two factors which accounted for 76.4% of the variance of the questionnaire. Both subscales of the CPG showed satisfying to good internal consistency. Cronbach's alpha was 0.89 for the first factor 'Disability Score' (58.72% of the explained variance) and 0.81 for the second factor 'Characteristic Pain Intensity' (17.70% of the explained variance). Item-total correlations for the subscales were moderate up to high (from 0.500 to 0.771). In comparison with the SF-36, the expected correlations were found when comparing items measuring similar constructs, supporting the concepts of convergent construct validity. Discriminant validity, assessed by comparing the CPG dimensions in patients with and without other health conditions, showed that the CPG shows moderate association with the presence of co-morbidities. Furthermore, the CPG Disability Score was inversely correlated (p=0.01) to years of formal education. In conclusion, the Italian version of the CPG questionnaire has shown to be valid and reliable for evaluating the severity of chronic musculoskeletal pain, with metric properties in agreement with the original, widely used version.

Development and validation of the osteoporosis prescreening risk assessment (OPERA) tool to facilitate identification of women likely to have low bone density.

Osteoporosis and its consequent increase in fracture risk is a major health concern for postmenopausal women and older men and has the potential to reach epidemic proportions. The "gold standard" for osteoporosis diagnosis is bone densitometry. However, economic issues or availability of the technology may prevent the possibility of mass screening. The goal of this study was to develop and validate a clinical scoring index designed as a prescreening tool to help clinicians identify which women are at increased risk of osteoporosis [bone mineral density (BMD) T-score -2.5 or less] and should therefore undergo further testing with bone densitometry. Records were analyzed for 1522 postmenopausal females over 50 years of age who had undergone testing with dual-energy X-ray absorptiometry (DXA). Osteoporosis risk index scores were compared to bone density T-scores. Hologic QDR 4500 technology was used to measure BMD at the femoral neck and lumbar spine (L1-L4). Participants who had a previous diagnosis of osteoporosis or were taking bone-active medication were excluded. Receiver-operating characteristic (ROC) analysis was used to identify the specific cutpoint value that would identify women at increased risk of low BMD. A simple algorithm based on age, weight, history of previous low impact fracture, early menopause, and corticosteroid therapy was developed. Validation of this five-item osteoporosis prescreening risk assessment (OPERA) index showed that the tool, at the recommended threshold (or cutoff value) of two, had a sensitivity that ranged from 88.1 [95% confidence interval (CI) for the mean: 86.2-91.9%] at the femoral neck to 90% (95% CI for the mean: 86.1-93.1%) at the lumbar spine area. Corresponding specificity values were 60.6 (95% CI for the mean: 57.9-63.3%) and 64.2% (95% CI for the mean: 61.4-66.9%), respectively. The positive predictive value (PPV) ranged from 29 at the femoral neck to 39.2% at the lumbar spine, while the corresponding negative predictive values (NPVs) reached 96.5 and 96.2%, respectively. Based on this cutoff value, the area under the ROC curve was 0.866 (95% CI for the mean: 0.847-0.882) for the lumbar spine and 0.814 (95% CI for the mean: 0.793-0.833) for the femoral neck. We conclude that the OPERA is a free and effective method for identifying Italian postmenopausal women at increased risk of osteoporosis. Its use could facilitate the appropriate and more cost-effective use of bone densitometry in developing countries.

Minimal clinically important changes in chronic musculoskeletal pain intensity measured on a numerical rating scale.

OBJECTIVES: To determine the minimal clinically important difference (MCID) of changes in chronic musculoskeletal pain intensity that is most closely associated with improvement on the commonly used and validated measure of the patient's global impression of change (PGIC), and to estimate the dependency of the MCID on the baseline pain scores. METHODS: This was a prospective cohort study assessing patient's pain intensity by the numerical rating scale (NRS) at baseline and at the 3 month follow-up, and by a PGIC questionnaire. A one unit difference at the lowest end of the PGIC ("slightly better") was used to define MCID as it reflects the minimum and lowest degree of improvement that could be detected. In addition we also calculated the NRS changes best associated with "much better" (two units). In order to characterize the association between specific NRS change scores (raw or percent) and clinically important improvement, the sensitivity and specificity were calculated by the receiver operating characteristic (ROC) method. PGIC was used as an external criterion to distinguish between improved or non-improved patients. RESULTS: 825 patients with chronic musculoskeletal pain (233 with osteoarthritis of the knee, 86 with osteoarthritis of the hip, 133 with osteoarthritis of the hand, 290 with rheumatoid arthritis and 83 with ankylosing spondylitis) were followed up. A consistent relationship between the change in NRS and the PGIC was observed. On average, a reduction of one point or a reduction of 15.0% in the NRS represented a MCID for the patient. A NRS change score of -2.0 and a percent change score of -33.0% were best associated with the concept of "much better" improvement. For this reason these values can be considered as appropriate cut-off points for this measure. The clinically significant changes in pain are non-uniform along the entire NRS. Patients with a high baseline level of pain on the NRS (score of >7 cm), who experienced either a slight improvement or a higher level of response, had absolute raw and percent changes greater that did patients in the lower cohort (score of less than 4 cm). CONCLUSIONS: These results are consistent with the recently published findings generated by different methods and support the use of a "much better" improvement on the pain relief as a clinically important outcome. A further confirmation in other patient populations and different chronic pain syndromes will be needed.

Intraoperative ultrasound assistance for percutaneous repair of the acute Achilles tendon rupture.

Various methods have been used to treat the acute Achilles tendon rupture. Traditional open repair is associated with a higher rate of complications. Percutaneous methods avoid most of the disadvantages of open surgical treatment, but the degree of tendon regeneration cannot be ensured. The authors prospectively followed 40 patients with acute Achilles tendon rupture who underwent percutaneous repair with intraoperative ultrasound assistance an average of 13 months after the injury. No surgery-related complications, such as wounds or deep infections, sural nerve injury, or re-rupture, were detected at follow-up. This technique avoids injury to the sural nerve, minimizes wound complications, and provides a strong repair.

Women, men, and rheumatoid arthritis: analyses of disease activity, disease characteristics, and treatments in the QUEST-RA study.

INTRODUCTION: Gender as a predictor of outcomes of rheumatoid arthritis (RA) has evoked considerable interest over the decades. Historically, there is no consensus whether RA is worse in females or males. Recent reports suggest that females are less likely than males to achieve remission. Therefore, we aimed to study possible associations of gender and disease activity, disease characteristics, and treatments of RA in a large multinational cross-sectional cohort of patients with RA called Quantitative Standard Monitoring of Patients with RA (QUEST-RA). METHODS: The cohort includes clinical and questionnaire data from patients who were seen in usual care, including 6,004 patients at 70 sites in 25 countries as of April 2008. Gender differences were analyzed for American College of Rheumatology Core Data Set measures of disease activity, DAS28 (disease activity score using 28 joint counts), fatigue, the presence of rheumatoid factor, nodules and erosions, and the current use of prednisone, methotrexate, and biologic agents. RESULTS: Women had poorer scores than men in all Core Data Set measures. The mean values for females and males were swollen joint count-28 (SJC28) of 4.5 versus 3.8, tender joint count-28 of 6.9 versus 5.4, erythrocyte sedimentation rate of 30 versus 26, Health Assessment Questionnaire of 1.1 versus 0.8, visual analog scales for physician global estimate of 3.0 versus 2.5, pain of 4.3 versus 3.6, patient global status of 4.2 versus 3.7, DAS28 of 4.3 versus 3.8, and fatigue of 4.6 versus 3.7 (P < 0.001). However, effect sizes were small-medium and smallest (0.13) for SJC28. Among patients who had no or minimal disease activity (0 to 1) on SJC28, women had statistically significantly higher mean values compared with men in all other disease activity measures (P < 0.001) and met DAS28 remission less often than men. Rheumatoid factor was equally prevalent among genders. Men had nodules more often than women. Women had erosions more often than men, but the statistical significance was marginal. Similar proportions of females and males were taking different therapies. CONCLUSIONS: In this large multinational cohort, RA disease activity measures appear to be worse in women than in men. However, most of the gender differences in RA disease activity may originate from the measures of disease activity rather than from RA disease activity itself.

Health-related quality of life in older adults with symptomatic hip and knee osteoarthritis: a comparison with matched healthy controls.

BACKGROUND AND AIMS: Health-related quality of life (HRQOL) assessment is receiving increasing attention as an outcome measure in osteoarthritis (OA). The aims of this study were to compare HRQOL among older adults aged 55 to 78 years with hip and/or knee OA with those without OA, and to assess the influence of selected variables (sex, body mass index, radiographic OA severity, educational level, comorbidities) on HRQOL. METHODS: The generic Medical Outcome Study Short Form-36 item health status questionnaire (SF-36) was administered to a cohort of 264 OA patients (105 with hip OA alone, 108 with knee OA alone, and 51 with both hip and knee OA) and 112 healthy controls. RESULTS: Compared with the healthy controls, OA of the lower extremities has a detrimental effect on the eight-scale profile score, as well as on physical and mental summary measures of the SF-36. The most striking impact was seen in the physical measures "physical functioning", "physical role" and "pain" (p<0.0001). No statistically significant differences in SF-36 scores were found among the three groups of OA patients. The physical and mental summary scales of the SF-36 were closely correlated (p<0.0001). One hundred and forty-five patients (54.9%) reported at least one chronic coexisting disease. There was a significant inverse association with measures of comorbidity (number of comorbidities and comorbidity index score) and both physical and mental summary scores of the SF-36 questionnaire. In patients with OA of the knee alone (but not in hip OA alone or hip and knee OA), the SF-36 pain score was inversely correlated with years of formal education (p=0.016). In addition, the impact of hip and knee SF-36 dimensions was not influenced by the degree of radiographic severity. CONCLUSIONS: Older adults with OA of the lower extremities undergo a significant impact on multiple dimensions of HRQOL, compared with healthy controls. The use of a generic measure of HRQOL such as the SF-36, in studies of OA where comorbidity is common, should be useful in characterizing the global burden of this disease.

Radiographic assessment of osteoarthritis: analysis of disease progression.

Osteoarthritis (OA) is one of the most prevalent and disabling chronic conditions affecting older adults, and is a significant public health problem among adults of working age. The knee is the most frequently involved joint site associated with disability in OA. Diagnosis of OA is primarily based on history and physical examination, but radiographic findings, including asymmetric joint space narrowing (JSN), subchondral sclerosis, osteophyte formation, subluxation, and distribution patterns of osteoarthritic changes are all helpful when diagnosis is uncertain. Structural morphological changes on X-rays are also considered the primary outcome variables for assessing the progression of OA. The development of new methods for prevention and treatment of OA requires improved understanding of the factors that influence its progression. The ability to assess progression quantitatively is a necessary first step in understanding factors that influence the disease process. Depending on the joint studied, several indices are currently used for assessing radiological progression of OA, including individual radiographic features (e.g., marginal osteophytes), composite indices (e.g., Kellgren and Lawrence scoring systems), and quantitative measures (e.g., joint space width measurement). Unfortunately, the review of studies evaluating the longitudinal rate of JSN indicates that the yearly change may be very small and of doubtful clinical significance. This emphasizes the need for further refinement in the definition of radiographic outcomes in prospective clinical trials. This review focuses on the available scoring methods used for the sites most frequently involved in OA (hand, knee, hip) and their various advantages and disadvantages.