Radiographic and Clinical Outcomes of the Shoulder in Long-Term Follow-Up of Brachial Plexus Birth Injury.

PURPOSE: The purpose of this study was to examine radiographic and functional outcomes of the shoulder in brachial plexus birth injury (BPBI) patients at long-term follow-up. METHODS: Medical records were reviewed at the Shriners Hospital in St. Louis to identify patients older than 18 years with a diagnosis of BPBI. Twenty-five patients were included in this study. Evaluations included radiographic examination, clinical examination, and outcome measures including the Mallet classification, visual analog scale (VAS) for shoulder pain, American Shoulder and Elbow Shoulder score (ASES), quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH), Simple Shoulder Test (SST), and Patient-Reported Outcomes Measurement Information System (PROMIS) domain measures. RESULTS: The mean age of the patients included was 44 years. Average follow-up was 37 years. No patient had primary nerve reconstruction surgery. Thirteen patients had a history of shoulder surgery at an average age of 6 years. There was a wide spectrum of deformity seen radiographically. Fifty-five percent of patients had evidence of glenoid retroversion, posterior humeral translation, or a biconcave glenoid. An additional 20% of patients had complete posterior dislocation of the humeral head. Despite the degenerative changes seen on radiographs, the mean VAS for pain was low, at 2. The mean ASES shoulder score was 54. The mean QuickDASH score was 30. Mean PROMIS Physical Function, Pain Interference, Depression, and Anxiety scores were near the means for the general population, with similar outcomes in patients treated with shoulder surgery compared with those treated without surgery. CONCLUSIONS: Adult BPBI patients experience minimal shoulder pain despite deformity and degenerative changes on shoulder radiographs. Whereas there are significant deficits in range of motion and function, PROMIS scores in adult BPBI patients are normal. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Sarcoidosis Th17 cells are ESAT-6 antigen specific but demonstrate reduced IFN-γ expression.

RATIONALE: Sarcoidosis is a granulomatous disease of unknown etiology. Many patients with sarcoidosis demonstrate antigen-specific immunity to mycobacterial virulence factors. Th-17 cells are crucial to the immune response in granulomatous inflammation, and have recently been shown to be present in greater numbers in the peripheral blood and bronchoalveolar lavage (BAL) fluid (BALF) of sarcoidosis patients than healthy controls. It is unclear whether Th-17 cells in sarcoidosis are specific for mycobacterial antigens, or whether they have similar functionality to control Th-17 cells. METHODS: Flow cytometry was used to determine the numbers of Th-17 cells present in the peripheral blood and BALF of patients with sarcoidosis, the percentage of Th-17 cells that were specific to the mycobacterial virulence factor ESAT-6, and as well as to assess IFN-γ expression in Th-17 cells following polyclonal stimulation. RESULTS: Patients with sarcoidosis had greater numbers of Th-17 cells in the peripheral blood and BALF than controls and produced significantly more extracellular IL-17A (p = 0.03 and p = 0.02, respectively). ESAT-6 specific Th-17 cells were present in both peripheral blood and BALF of sarcoidosis patients (p < 0.001 and p = 0.03, respectively). After polyclonal stimulation, Th-17 cells from sarcoidosis patients produced less IFN-γ than healthy controls. CONCLUSIONS: Patients with sarcoidosis have mycobacterial antigen-specific Th-17 cells peripherally and in sites of active sarcoidosis involvement. Despite the Th1 immunophenotype of sarcoidosis immunology, the Th-17 cells have reduced IFN-γ expression, compared to healthy controls. This reduction in immunity may contribute to sarcoidosis pathogenesis.

Patient-Reported Outcomes Measurement Information System physical function correlates with Toronto Extremity Salvage Score in an orthopaedic oncology population.

BACKGROUND: The National Institute of Health's Patient-Reported Outcomes Measurement Information System (PROMIS) uses computerised-adaptive testing to reduce survey burden and improve sensitivity. PROMIS is being used across medical and surgical disciplines but has not been studied in orthopaedic oncology. QUESTIONS/PURPOSES: The aim of the study was to compare PROMIS measures with upper extremity (UE) and lower extremity (LE) Toronto Extremity Salvage Score (TESS) by assessing the following: (1) responder burden, (2) correlation between scores and (3) floor/ceiling effects. PATIENTS AND METHODS: This cross-sectional trial analysed all 97 adult patients treated surgically for a bone or soft tissue tumour at a tertiary institution between November 2015 and March 2016. TESS (UE or LE) and PROMIS (Physical Function, Pain Interference and Depression) surveys were administered preoperatively. Pearson correlations between each PROMIS domain and TESS were calculated, as were floor/ceiling effects of each outcome measure. RESULTS: (1) Completion of three PROMIS questionnaires required a mean total of 16.8 (+/- 5.8 standard deviation) questions, compared with 31 and 32 questions for the LE and UE TESS questionnaires, respectively. (2) The PROMIS Physical Function scores demonstrated a strong positive correlation with the LE TESS (r = 0.84; 95% confidence interval [CI], 0.72-0.91; p < 0.001) and moderate positive correlation with the UE TESS (r = 0.64; 95% CI, 0.34-0.83; p = 0.055). The PROMIS Depression scores demonstrated a weak negative correlation with both the LE TESS (r = -0.38; 95% CI, -0.61 to -0.10; p = 0.010) and with UE TESS (r = -0.38; 95% CI, -0.67 to -0.01; p = 0.055). The PROMIS Pain Interference scores demonstrated a strong negative correlation with the LE TESS (r = -0.71; 95% CI, -0.83 to -0.52; p < 0.001) and a moderate negative correlation with the UE TESS (r = -0.62; 95% CI, -0.81 to -0.30; p = 0.001). (3) The UE TESS had a range of scores from 16 to 100 with a 27% ceiling effect and no floor effect, and the LE TESS had a range from 10 to 98 with no floor or ceiling effect. There was no floor or ceiling effect for any PROMIS measures. CONCLUSIONS: In an orthopaedic oncology population, the PROMIS Physical Function and Pain Interference scores correlate with the TESS and have the benefit of reduced survey burden and ceiling effect. The PROMIS Depression scores may provide additional information regarding patient outcomes not captured by the TESS. LEVEL OF EVIDENCE: Level III. THE TRANSLATIONAL POTENTIAL OF THIS ARTICLE: Patient reported outcome measures asses patients' symptoms, function and health-related quality of life and are designed to capture more clinical information than can be gathered by objective medial testing alone. As reimbursements and the understanding of patient outcomes are becoming tied to performance on PROMIS measures, it is an important step to establish how PROMIS measures correlate and compare to traditional legacy measures.