MR Imaging of Adverse Local Tissue Reactions around Rejuvenate Modular Dual-Taper Stems.

PURPOSE: To describe the magnetic resonance (MR) imaging characteristics associated with adverse local tissue reactions and tissue damage around hip arthroplasties in which the recalled Rejuvenate modular dual-taper stem was used. MATERIALS AND METHODS: The institutional review board of the Hospital for Special Surgery approved the study. All study patients provided informed consent. MR imaging studies were retrospectively reviewed in a cohort of 58 patients with 66 hip arthroplasties with Rejuvenate stems who had presented for imaging evaluation because of recall of the implant. Multiple regression analysis was used to examine MR imaging features, biomechanical factors, and metal ion levels as predictors of aseptic lymphocytic vasculitis-associated lesion (ALVAL) score at histologic assessment while adjusting for age and sex for 54 revised hips. RESULTS: Revision surgery was performed in 54 hips on the basis of clinical or imaging findings (24% of hips were completely asymptomatic). The median ALVAL score among the revised hips was 9 (range, 1-10). Imaging characteristics observed with high frequency in patients with ALVAL included synovitis, mixed- or solid-type synovitis, synovial thickening, and capsular dehiscence. CONCLUSION: MR imaging provides an effective noninvasive method for assessing the presence and severity of adverse local tissue reaction, as well as the degree of pre-existing tissue damage, thereby facilitating early and accurate identification of candidates for revision surgery.

The use of parenteral nutrition in patients with inflammatory bowel disease: A detailed guide on the indications, risks, and benefits.

Malnutrition is estimated to affect roughly 30%-80% of patients with inflammatory bowel disease (IBD). In those patients who cannot tolerate sufficient oral nutrition or there is no possibility for placing an enteral nutrition tube, parenteral nutrition offers a lifesaving alternative. However, this is not without risk. For patients with IBD, understanding the indications, contraindications, and complications associated with parenteral nutrition is crucial. In this review, we will discuss the indications and contraindications for parenteral nutrition in patients with IBD, the common complications associated with intravenous nutrition, the use of parenteral nutrition in special populations, such as in pediatric and perioperative patients, and the impact of parenteral nutrition on IBD-related outcomes.

Magnetic resonance imaging of the wrist: bone and cartilage injury.

Magnetic resonance imaging (MRI) is particularly useful for imaging the wrist due to its superior soft tissue contrast and ability to detect subtle bone marrow changes and occult fractures. A high field (1.5T or greater) strength, dedicated wrist coil, and high in-plane and through-plane resolution must be utilized to successfully visualize the relatively thin cartilage of the wrist. MRI can be used to detect occult carpal bone fractures, identify complications following scaphoid fractures, and assess for avascular necrosis in the setting in Kienböck's and Preiser's disease. MRI is useful to identify secondary soft tissue and chondral pathology in impaction/impingement syndromes. The use of an intermediate-echo time fast spin echo sequence allows for accurate assessment of articular cartilage, allowing evaluation of chondral wear in the setting of primary osteoarthritis and posttraumatic degenerative arthrosis. MRI is the most sensitive imaging modality for the detection of early inflammatory arthropathies and can detect synovitis, bone marrow edema, and early erosions in the setting of negative radiographs.

Identification and Evaluation of Mobile Applications for Self-Management of Diet and Lifestyle for Patients with Inflammatory Bowel Disease.

Background: Mobile health applications (apps) providing diet and lifestyle self-management programs to patients with inflammatory bowel disease (IBD) are emerging. The objective of this study was to evaluate current apps available in the US and Canada based on app quality, perceived impact on diet and mental health and comprehensiveness to support self-management. Methods: The Apple iOS and Google Play app stores were searched for terms related to IBD. Apps were included if they targeted diet and lifestyle behaviours for patients living with IBD and were available to the general public. Apps were excluded if they were not specific to IBD, not available in English, did not target diet or lifestyle therapy, were not available in the US and Canada, or did not offer stand-alone self-management programs. The Mobile App Rating Scale was used to assess mobile app quality. Results: A total of 1,512 apps were identified through the app stores. Six apps met inclusion criteria. My IBD Care: Crohn's and Colitis received the highest quality rating and LyfeMD received the highest overall app rating. Only these two apps provided behaviour tracking over time, and three (50 percent) apps provided good-quality information. Conclusions: While many IBD-related apps exist, few support self-management of diet and lifestyle behaviours. The My IBD Care and LyfeMD apps had the highest ratings and can be used to track lifestyle behaviours. The effectiveness of these apps to improve behaviours, and subsequently impact the disease course and quality of life, should be explored in future studies.

To Fiber or Not to Fiber: The Swinging Pendulum of Fiber Supplementation in Patients with Inflammatory Bowel Disease.

Evidence-based dietary guidance around dietary fiber in inflammatory bowel disease (IBD) has been limited owing to insufficient reproducibility in intervention trials. However, the pendulum has swung because of our increased understanding of the importance of fibers in maintaining a health-associated microbiome. Preliminary evidence suggests that dietary fiber can alter the gut microbiome, improve IBD symptoms, balance inflammation, and enhance health-related quality of life. Therefore, it is now more vital than ever to examine how fiber could be used as a therapeutic strategy to manage and prevent disease relapse. At present, there is limited knowledge about which fibers are optimal and in what form and quantity they should be consumed to benefit patients with IBD. Additionally, individual microbiomes play a strong role in determining the outcomes and necessitate a more personalized nutritional approach to implementing dietary changes, as dietary fiber may not be as benign as once thought in a dysbiotic microbiome. This review describes dietary fibers and their mechanism of action within the microbiome, details novel fiber sources, including resistant starches and polyphenols, and concludes with potential future directions in fiber research, including the move toward precision nutrition.

Review article: Putting some muscle into sarcopenia-the pathogenesis, assessment and clinical impact of muscle loss in patients with inflammatory bowel disease.

BACKGROUND: Sarcopenia, a loss of skeletal muscle mass or function, affects up to 50% of patients with inflammatory bowel disease (IBD) and is associated with poor clinical outcomes including increased hospitalizations, need for surgery and post-operative complications. Despite the high prevalence and clinical significance of sarcopenia in patients with IBD, few patients undergo routine muscle evaluation. AIM: The goal of this study was to review the mechanisms of sarcopenia in patients with IBD and understand novel modalities to assess and treat impaired muscle mass or function. METHODS: Pubmed and Cochrane databases were searched including articles published up to February 2023 utilizing the following keywords: "inflammatory bowel disease", "IBD", "Crohn's disease", "ulcerative colitis", "sarcopenia", "myosteatosis", "muscle health", and "frailty". RESULTS: The pathogenesis of sarcopenia in IBD is not well defined, however, there is evidence supporting the role of malabsorption, reduced protein intake, chronic inflammation, dysbiosis, decreased physical activity, medication effects and hormone signaling from visceral adiposity. Traditional sarcopenia assessment techniques include direct measurements on cross sectional imaging. However, given the time, cost and radiation exposure associated with cross sectional imaging, new bedside tools are now available to estimate muscle mass, including assessment of grip strength, mid upper arm circumference and body composition utilizing bioelectrical impedance analysis. In addition, novel biomarkers for assessing muscle mass and techniques utilizing point of care ultrasound have been proposed to make sarcopenia evaluation more streamlined in the IBD clinic. CONCLUSION: Sarcopenia is associated with poor clinical outcomes independent of IBD activity and therefore muscle health should be assessed in all IBD patients at routine intervals. Future studies to better our understanding of the pathophysiology as well as most effective management of sarcopenia in IBD will help guide clinical care and reduce disease related complications.

High Prevalence of Malnutrition and Micronutrient Deficiencies in Patients With Inflammatory Bowel Disease Early in Disease Course.

BACKGROUND: Patients with inflammatory bowel disease (IBD) are at an increased risk of malnutrition. The goal of this study was to define the prevalence of malnutrition and micronutrient deficiencies in recently diagnosed IBD patients and to compare the performance of existing malnutrition screening tools in identifying IBD patients at increased risk for malnutrition. METHODS: This was a retrospective cohort study of adult patients with recently diagnosed IBD (≤18 months disease duration). A diagnosis of malnutrition was made utilizing the European Society for Clinical Nutrition and Metabolism malnutrition criteria. Serum micronutrient levels were included. The sensitivity of 5 malnutrition screening tools in identifying patients at moderate-high risk of malnutrition was determined based on the European Society for Clinical Nutrition and Metabolism malnutrition definition. Descriptive statistics summarized the data and univariate analyses tested associations. RESULTS: A total of 182 patients were included for analysis; 65 (36%) met criteria for malnutrition. A total of 135 (74%) patients had ≥1 micronutrient level checked and 105 (78%) had ≥1 deficiency. Patients with prior surgery (odds ratio [OR], 4.5; P = .004), active Crohn's disease (OR, 2.8; P = .03), and diarrhea (OR, 2.1; P = .02) were more likely to be malnourished. The Malnutrition Universal Screening Tool and Saskatchewan IBD Nutrition Risk Tool had the highest sensitivity (100%) in predicting those at moderate-high risk of malnutrition at the time of screening. CONCLUSIONS: Patients with recently diagnosed IBD have a high prevalence of malnutrition and micronutrient deficiencies. Both the Malnutrition Universal Screening Tool and Saskatchewan IBD Nutrition Risk Tool can be used to identify those at increased risk of malnutrition. Future studies and screening tool development are necessary to identify those at risk of developing malnutrition to facilitate timely referral for nutritional evaluation and prevent disease related complications.

This retrospective cohort study identified that patients with recently diagnosed inflammatory bowel disease have a high prevalence of malnutrition as well as micronutrient deficiencies and compared the utility of 5 available malnutrition screening tools in this population.

MRI findings in painful metal-on-metal hip arthroplasty.

OBJECTIVE: The objective of our study was to compare the frequency of osseous and soft-tissue abnormalities in patients presenting with hip pain after resurfacing arthroplasty and after total hip arthroplasty (THA), correlate the MRI findings with histologic results, and determine which MRI findings are predictive of aseptic lymphocytic vasculitis-associated lesions. MATERIALS AND METHODS: The MRI examinations of patients with metal-on-metal hip prostheses placed at resurfacing arthroplasty (n=31) or THA (n=29) were reviewed for osteolysis, synovitis, extracapsular disease, synovial pattern, and mode of decompression into adjacent bursae. Regional muscles and tendons were assessed for tendinosis, tear, atrophy, and edema. Histologic and operative findings were reviewed in 19 patients (20 hips) who underwent revision surgery. Chi-square tests were performed to detect differences between the resurfacing arthroplasty and THA groups. The Wilcoxon rank sum test was performed to detect differences in MRI findings in patients with and those without aseptic lymphocytic vasculitis-associated lesions. RESULTS: Synovitis was detected in 77.4% of resurfacing arthroplasty hips and 86.2% of THA hips. Extracapsular disease was present in 6.5% of resurfacing arthroplasty hips and 10.3% of THA hips. Osteolysis was detected in 9.7% of resurfacing arthroplasty hips and 24.1% of THA hips. There was no difference in the incidence of synovitis (p=0.51), osteolysis (p=0.17), or extracapsular disease (p=0.67) between the resurfacing arthroplasty and THA groups. Patients with aseptic lymphocytic vasculitis-associated lesions had higher volumes of synovitis (p=0.04) than patients without aseptic lymphocytic vasculitis-associated lesions. Extracapsular disease and muscle edema were seen only in patients with aseptic lymphocytic vasculitis-associated lesions. CONCLUSION: Synovitis is common in patients with metal-on-metal hip prostheses and occurs with a similar incidence after resurfacing arthroplasty and after THA; osteolysis and extracapsular disease are uncommon. The MRI signs most suggestive of aseptic lymphocytic vasculitis-associated lesions are high volumes of synovitis, extracapsular disease, and intramuscular edema.

MRI of hip cartilage: joint morphology, structure, and composition.

BACKGROUND: Accurate, reproducible, and noninvasive assessment of hip cartilage is clinically relevant and provides a means by which to assess the suitability of candidates for arthroscopic or open surgical procedures and the response to such interventions over time. Given the relatively thin cartilage of the hip and the complex spherical anatomy, however, accurately assessing the cartilage poses a challenge for traditional MRI techniques. QUESTIONS/PURPOSES: We assessed the current status of imaging articular cartilage of the hip through a comprehensive review of recent literature. METHODS: We performed a literature review using PubMed. Topics included quantitative MRI, imaging of the hip cartilage and labrum, femoroacetabular impingement syndrome, and osteoarthritis of the hip. WHERE ARE WE NOW?: With the use of high in-plane and through-plane resolution, reproducible assessment of hip cartilage and labrum is clinically feasible. More recent quantitative MR techniques also allow for noninvasive assessment of collagen orientation and proteoglycan content in articular cartilage, thus providing insight into early matrix degeneration. These techniques can be applied to cohorts at risk for osteoarthritis, helping to predict cartilage degeneration before symptoms progress and osteoarthritic changes are visible on radiographs. WHERE DO WE NEED TO GO?: Prospective longitudinal data registries are necessary for developing predictive models of osteoarthritis and subsequent joint failure to assess the results of surgical intervention and predict the timing of arthroplasty. HOW DO WE GET THERE?: By establishing more hip cartilage registries, a correlation can be made between subjective measures and morphologic MRI to assess the cartilage, labrum, bone, and synovial lining of the hip.

Feasibility and impact of a quality improvement initiative to screen for malnutrition in an Inflammatory Bowel Disease clinic.

BACKGROUND AND AIMS: Inflammatory bowel disease (IBD) is a chronic inflammatory condition of the gastrointestinal tract that is associated with malnutrition. Malnutrition is associated with poor clinical outcomes in patients with IBD and therefore early identification of those at risk for malnutrition is crucial. We aimed to evaluate how frequently nutrition screening occurs in a large, tertiary care outpatient IBD center and to initiate an intervention to improve malnutrition screening for patients with IBD. METHODS: We used a traditional plan-do-study-act quality improvement technique to understand our current malnutrition screening practices and institute an intervention to improve screening. To do this, we utilized a modified Malnutrition Universal Screening Tool (mMUST) and integrated this into the electronic health record. We then evaluated the intervention and the impact on IBD related clinical outcomes. RESULTS: Prior to the intervention, few patients with IBD were screened for malnutrition. However, the number of patients screened for malnutrition significantly improved with the study intervention and those who were identified as high-risk had increased nutrition follow up including serum micronutrient evaluations and referral to a dedicated registered dietician. CONCLUSION: This study demonstrated the feasibility and impact of a malnutrition screening program in ambulatory IBD patients. Those patients identified as high risk for malnutrition who engaged in nutrition care had improved clinical outcomes including reduced hospitalizations and emergency room visits.

Efficacy and Safety of Dual Biologic Therapy in Patients With Inflammatory Bowel Disease: A Review of the Literature.

Using 2 or more treatment modalities to achieve a synergistic effect in patients with refractory inflammatory bowel disease (IBD) has been an area of focus for many years. This methodology, known as combination therapy, has been proposed for various therapeutic agents, most commonly biologics and immunomodulators. Although the mainstay of biologic therapy for IBD has traditionally focused on agents targeting tumor necrosis factor, the development of newer biologics with different targets, such as vedolizumab and ustekinumab, has introduced the possibility of concomitant dual biologic therapy. Dual biologic therapy has been proposed in the treatment algorithm for 2 types of patients with IBD: those with well-controlled luminal IBD and uncontrolled extraintestinal symptoms (secondary indications such as arthritis or psoriasis) and those with refractory, uncontrolled IBD. Thus far, the data on the efficacy and safety of dual biologic therapy as a treatment for Crohn's disease or ulcerative colitis remain quite limited. In fact, the overwhelming majority of the literature consists of case reports and case series. Given this paucity of high-level data, physicians have looked to larger studies on dual biologic therapy in other fields of medicine, such as rheumatology and dermatology. The goal of this article is to summarize the current literature on the use of dual biologics in IBD, address the potential adverse effects or risks associated with combination therapy, and highlight future directions in the use of this therapeutic modality.

IBD Journal Editorial Fellowship: A Practical Guide for Future Fellows.

Inflammatory Bowel Diseases offers an editorial fellowship for GI and IBD fellows with a background in clinical, translational, and basic research and who are interested to experience the editorial process. Herein, the inaugural fellows compile their experience as a guide for future applicants on the fellowship's responsibilities and highlights.

Perianal Fistulas in Patients With Crohn's Disease, Part 2: Surgical, Endoscopic, and Future Therapies.

The treatment of perianal fistulas remains a clinical challenge despite the significant advances that have been made in the management of luminal inflammatory bowel disease. In combination with medical therapies, surgical management of perianal fistulas is important for both infection control and definitive repair. Older surgical techniques include the placement of draining and cutting setons and endorectal advancement flaps. Newer surgical techniques that utilize lasers and video-assisted technology are being studied to help patients with chronic, refractory perianal fistulas. In addition to surgical management, less-invasive endoscopic techniques, including endoscopic fistulotomy and endoscopic clipping, are being investigated. Looking forward, allogeneic and autologous adult mesenchymal stem cells are being evaluated to induce fistula healing and improve rates of fistula closure. Here, in the second of a 2-part series on perianal fistulas in patients with Crohn's disease, we discuss the current surgical management of perianal fistulas as well as newer endoscopic techniques and future therapies.

Perianal Fistulas in Patients With Crohn's Disease, Part 1: Current Medical Management.

Despite significant advances in the treatment of luminal inflammatory bowel disease, the treatment of perianal fistulas remains a clinical challenge. Perianal fistulas are traditionally described using the Parks classification based on their relationship to the external and internal anal sphincters. Traditional therapy for perianal fistulas focuses on antibiotics such as metronidazole or ciprofloxacin. However, medical management has expanded over the years to include immunomodulators and, most recently, biologic agents. Newer techniques such as intrafistulous biologic injections are also being explored as potentially effective treatments for patients with fistulizing disease. Here, in the first of a 2-part series on perianal fistulas in patients with Crohn's disease, we discuss the anatomy and classification of perianal fistulas as well as current medical therapies, including antibiotics, immunomodulators, biologic agents, and novel therapeutic agents. The second part of the series will focus on the surgical modalities that are available for patients with perianal fistulas in addition to novel endoscopic techniques and future therapies that are being investigated for the treatment of fistulizing Crohn's disease.

An Overt, Obscure Gastrointestinal Bleed Caused by a Primary Small Bowel Fibroblastic Reticular Cell Sarcoma.

Small bowel bleeding should be considered in patients who continue to bleed despite a negative upper endoscopy and colonoscopy. The differential diagnosis of small bowel bleeding can include infection, inflammatory conditions, vascular malformations, and, rarely, malignancy. This report demonstrates a rare, primary, small bowel, reticular cell sarcoma presenting as an overt gastrointestinal bleed. These tumors are difficult to diagnose because they are rarely seen on traditional cross-sectional imaging and can present with multiple synchronous lesions throughout the intestinal tract.