PEGylation of Chrysin Improves Its Water Solubility while Preserving the In Vitro Biological Activity.

Chrysin is a natural flavonoid that despite having numerous biological properties, its therapeutic value is limited due to its very low solubility in aqueous media. In this work, chrysin was conjugated with methoxypolyethylene glycols (mPEGs) of different molecular weights (350, 500, 750, and 2000 g/mol), affording PEGylated chrysins with high yields and excellent purities. In all cases, an increase in the water solubility of the conjugates was observed, which was highest when 500 g/mol of mPEG was used in the PEGylation reaction. Furthermore, in aqueous solution, PEGylated chrysins formed aggregates of ellipsoid shape. Electrochemical studies showed that the redox properties were conserved after PEGylation. While in vitro antibacterial and antifungal studies probed that the intrinsic activity was conserved, in vitro antitumor activities against HepG2 (liver carcinoma cells) and PC3 (prostate cancer cell) showed that PEGylated chrysins retained the cytotoxic activity and the ability of induction of apoptosis for the evaluated human cancer cells.

Prevalence of different LI-RADS v2018 categories in high-risk patients undergoing CT- or MRI-based screening for hepatocellular carcinoma.

PURPOSE: To estimate the prevalence of Liver Imaging Reporting and Data System (LI-RADS, LR) v2018 categories reported on CT or MRI performed for hepatocellular carcinoma (HCC) screening. MATERIALS AND METHODS: This retrospective study included all reports for CT and MRI exams performed for HCC screening patients between 8/2018 and 4/2020. Patients with ultrasound, CT, or MRI of the abdomen within two years of the index exam were excluded. From each radiology report, we extracted number of reported liver observations, and LI-RADS v2018 category for each observation. RESULTS: There were 329 patients (170 [52%] male, mean age 59 years [SD 12]), of whom 177 (54%) had MRI with gadoxetate, 72 (22%) had MRI with extracellular contrast, 7 (2%) had MRI with unspecified contrast, and 73 (22%) had CT. Of 329 patients, 199 (60%) had no reported observations; 130 patients had 166 reported observations: 114 (68.7%) LR-1, 8 (4.8%) LR-2, 21 (12.6%) LR-3, 6 (3.6%) LR-4, 13 (7.8%) LR-5, 3 (1.8%) LR-M, and 1 (0.6%) LR-TIV. Of 114 LR-1 observations, 78 (68%) were cysts, 17 (15%) were hemangiomas, 12 (11%) were vascular shunts, 3 (3%) were focal nodular hyperplasia, 2 (2%) were siderotic nodules, 1 (1%) was a lipoma, and 1 (1%) was biliary hamartoma. There were 23 observations with probably or definitely malignant categories (LR-4, LR-5, LR-M or LR- TIV), reported in 20/329 (6%) of patients. CONCLUSION: In a cohort of at-risk patients undergoing contrast-enhanced CT/MRI for HCC screening, 60% of had no liver observations, and 6 % had probably or definitely malignant observations. IMPLICATIONS FOR PATIENT CARE: The prevalence of LI-RADS v2018 categories on CT or MR exams used for HCC screening can help develop screening criteria and assess cost-effectiveness of surveillance strategies with CT and MRI.

Compound Muscle Action Potential Amplitude as a Predictor of Functional and Patient-Reported Outcomes in Ulnar Neuropathy at the Elbow.

BACKGROUND: Ulnar neuropathy at the elbow (UNE) is a debilitating upper extremity condition that often leaves patients with residual symptoms even after surgical treatment. The role of electrodiagnostic studies in guiding the treatment of UNE is not well established, and conventional electrodiagnostic parameters may not reflect the severity of disease. Compound muscle action potential (CMAP) amplitude is a parameter that corresponds with axonal injury and motor symptoms and may more accurately predict the severity of neurologic injury. METHODS: This prospective multicenter study recruited 78 patients in the Surgery of the Ulnar Nerve project. Patients underwent electrodiagnostic testing and clinical assessment of motor and sensory function, and completed patient-reported outcome questionnaires, including the Michigan Hand Outcome Questionnaire; the Disabilities of the Arm, Shoulder and Hand questionnaire; and the Carpal Tunnel Questionnaire (CTQ). Correlations were measured among each of the electrodiagnostic parameters and outcomes and predictive models for each outcome were subsequently developed. RESULTS: Of all the electrodiagnostic parameters measured, only CMAP amplitude was predictive of scores on the Michigan Hand Outcome Questionnaire; Disabilities of the Arm, Shoulder and Hand questionnaire; CTQ function scale, and motor impairment in grip and pinch strength. None of the parameters were predictive of scores on the CTQ symptom scale or sensory impairments as measured with two-point discrimination or Semmes-Weinstein monofilament testing. CONCLUSIONS: CMAP amplitude, but not other conventional electrodiagnostic parameters, is predictive of functional outcomes in UNE. This electrodiagnostic measurement can alert the clinician to severe cases of UNE and inform surgical decision-making. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Electrodiagnostic Predictors of Outcomes After In Situ Decompression of the Ulnar Nerve.

PURPOSE: Patients with severe ulnar neuropathy at the elbow frequently experience suboptimal surgical outcomes. Clinical symptoms alone may not accurately represent the severity of underlying nerve injury, calling for objective assessment tools, such as electrodiagnostic studies. The goal of our study was to determine whether specific electrodiagnostic parameters can be used to predict the outcomes after in situ decompression of the ulnar nerve. METHODS: This prospective study enrolled consecutive patients aged ≥18 years diagnosed with ulnar neuropathy at the elbow. Patients completed a baseline battery of motor, sensory, functional, and electrodiagnostic tests before undergoing in situ decompression of the ulnar nerve. They were reassessed at 6 weeks, 3 months, 6 months, and 12 months after surgery. Forty-two patients completed at least 2 follow-up assessments and were included in the study. RESULTS: When controlling for other electrodiagnostic measurements and demographic factors, none of the electrodiagnostic parameters were predictive of outcomes at 12 months after surgery. Patients with decreased compound muscle action potential amplitudes demonstrated slower trends of recovery in grip strength, pinch strength, and overall scores on the Michigan Hand Outcomes Questionnaire as well as its function, work, and activities of daily living subscales, Disabilities of the Arm, Shoulder, and Hand questionnaire, and the Carpal Tunnel Questionnaire. Decreased motor nerve conduction velocity was predictive of slower recovery of 2-point discrimination and pinch strength. CONCLUSIONS: Compound muscle action potential amplitude, but not other conventional electrodiagnostic parameters, was predictive of functional outcomes after in situ decompression of the ulnar nerve. This parameter should play a role in determining the timing and prognosis of treatment for ulnar neuropathy at the elbow. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

An Outcomes Study of Proximal Interphalangeal Joint Silicone Implant Arthroplasty Using the Volar Approach.

BACKGROUND: Arthroplasty is performed at the proximal interphalangeal joint for the management of disabling osteoarthritis. This prospective cohort study evaluated outcomes of the silicone implant for the proximal interphalangeal joint using the volar approach. The authors hypothesize that the volar approach without extensor mechanism disruption will provide improved motion and maintain joint extension. METHODS: Consecutive candidates for proximal interphalangeal joint silicone implant arthroplasty using the volar approach were evaluated. The Michigan Hand Outcomes Questionnaire and functional measurements, including grip/pinch strength and arc of motion, were administered preoperatively and at 6 weeks and 3, 6, and 12 months postoperatively. RESULTS: Twenty-eight patients (35 joints) were included in the study. Eighteen patients (24 joints) were followed to 1 year postoperatively, with an entire cohort average of 10-month follow-up. Nineteen patients were white women, and the mean age was 64 years. The authors' hypothesis was supported by the results showing a mean gain in arc of motion of 7 degrees and a mean 5-degree extension lag improvement at 1 year. The mean postoperative arc of motion was 53 degrees with a 10-degree average extension lag. The median Michigan Hand Outcomes Questionnaire pain score improved from 70 (60 to 80) to 28 (5 to 45); scores also improved for each of the questionnaire domains. Median grip strength was unchanged. CONCLUSIONS: The volar approach to proximal interphalangeal joint arthroplasty is technically challenging but facilitates early aggressive rehabilitation. This is critical for providing improved flexion, especially in the ulnar digits without worsening extension lag. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

When primary repair is not enough: a comparison of synthetic patch and muscle flap closure in congenital diaphragmatic hernia?

PURPOSE: Primary closure is often inadequate for large congenital diaphragmatic hernia (CDH) and necessitates repair by prosthetic patch or autologous muscle flap. Our aim was to evaluate outcomes of open patch versus flap repair, specifically diaphragmatic reherniation. METHODS: A retrospective review (IRB #2017-6361) was performed on all CDH patients repaired from 2005 to 2016 at a single academic children's hospital. Patients were excluded from final analysis if they had primary or minimally invasive repair, expired, or were lost to follow-up. RESULTS: Of 171 patients, 151 (88.3%) survived to discharge, 9 expired after discharge and 11 were lost to follow up, leaving 131 (86.8%) long-term survivors. Median follow-up was 5 years. Open repair was performed in 119 (90.8%) of which 28 (23.5%) underwent primary repair, 34 (28.6%) patch repair, and 57 (47.9%) flap repair. Overall, 6/119 (5%) patients reherniated, 1/28 (3.6%) in the primary group, 3/34 (8.8%) in the patch group, and 2/57 (3.5%) in the flap group. Comparing prosthetic patch to muscle flap repair, there was no significant difference in the number of patients who recurred nor time to reherniation (3 vs. 2, p = 0.295; 5.5 ± 0.00 months vs. 53.75 ± 71.06 months, p = 0.288). One patient in the patch group recurred twice. CONCLUSIONS: Both muscle flap and patch repair of large CDH are feasible and durable with a relatively low risk of recurrence.

Left congenital diaphragmatic hernia-associated musculoskeletal deformities.

AIM: With the advancement in the treatment strategies of congenital diaphragmatic hernia (CDH), there is an increase in the survival rates. This fact leads to an increase in the morbidity and extrapulmonary complications in the long term such as failure to thrive, hernia recurrence, neurodevelopmental delay, gastrointestinal problems, and musculoskeletal anomalies. Herein, we aim to investigate the association between the long-term musculoskeletal complications in CDH patients regarding the defect size, repair type, and perinatal parameters. METHODS: After Institutional Review Board approval was obtained (2017-6361), a retrospective chart review was performed on CDH patients from 2003 to 2016. Patients who were operated due to left-sided isolated congenital diaphragmatic hernia and survived to date were included in the study. Data were collected on demographics, preoperative characteristics, operative interventions, and postoperative outcomes. Statistical analysis was performed with IBM SPSS Statistics 20.0.0 (Chicago, IL). RESULTS: There were 98 patients with left CDH of whom 33 (33.7%) had primary repair, 25 (25.5%) had patch repair, and 40 (40.8%) had muscle flap repair. The median age of the patients was 6.00 ± 3.83 years. 45 patients (45.9%) had large diaphragmatic defects, 28 patients (28.6%) had at least one type of musculoskeletal deformities, 2 of which were pectus carinatum, 16 were pectus excavatum, and 18 were scoliosis. CDH patients who had small diaphragmatic defects and repaired with a patch were less likely develop musculoskeletal deformities while who had primary abdominal closure after ventral hernia significantly have more pectus excavatum. CONCLUSION: Although there was a trend towards an increased risk of the pectus deformity and scoliosis in patients repaired with muscle flap, it did not reach statistical significance. There is a correlation between musculoskeletal deformities and the severity of the CDH.

Congenital diaphragmatic hernia: the good, the bad, and the tough.

OBJECTIVES: We aim to determine factors that are associated with better outcomes of CDH patients. METHODS: A retrospective review was performed on all CDH patients admitted to our institution between 2003 and 2016. This study was performed at a single institution which has a fetal care center. Patients admitted with CDH with at least 1-year follow-up during the analysis were included in the study. RESULTS: Twenty-six (13.8%) patients had a hernia sac, 124 (59%) patients had liver herniation, and 56 (25.1%) patients had an accompanying syndrome. Overall survival to discharge was 73.1% while overall survival to date was 69.5%. The presence of a hernia sac, liver herniation, and accompanying syndromes showed as independent predictors influencing the survival, B 1.968, p = 0.04, OR 7.158, 95% CI 0.907-56.485, B - 1.178, p = 0.01, OR 3.932, 95% CI 1.798-8.602 and B - 1.032, p = 0.05, OR 2.795, 95% CI 0.976-7.764, respectively. CONCLUSION: In our CDH cohort, the presence of a hernia sac was proven to be associated with better outcomes, while thoracic herniation of the liver was associated with worse outcomes. The accompanying syndromes although being more difficult to manage had a little effect on the outcome of the disease itself.

Seven-Year Outcomes of the Silicone Arthroplasty in Rheumatoid Arthritis Prospective Cohort Study.

OBJECTIVE: Rheumatoid arthritis (RA) causes destruction of the metacarpophalangeal (MCP) joints, leading to hand deformities, pain, and loss of function. This study prospectively assessed long-term functional and health-related quality-of-life outcomes in RA patients with severe deformity at the MCP joints. METHODS: RA patients between ages 18 to 80 years with severe deformity at the MCP joints were referred to 1 of the 3 study sites. Subjects who elected to undergo silicone metacarpophalangeal joint arthroplasty (SMPA) while continuing with medical management were followed in the SMPA cohort. Subjects who elected to continue with medical management alone without surgery were followed in the non-SMPA cohort. Objective measurements included grip and pinch strength as well as arc of motion, ulnar drift, and extensor lag of the MCP joints. Patient-reported outcomes included the Michigan Hand Questionnaire (MHQ) and the Arthritis Impact Measurement Scales questionnaire. Radiographs of SMPA implants were assessed and graded as intact, deformed, or fractured. RESULTS: MHQ scores showed large improvements post-SMPA, and baseline-adjusted expected outcomes in the SMPA group were significantly better at year 7 in function, aesthetics, satisfaction, and overall score compared to non-SMPA. SMPA subjects did not improve in grip or pinch strength, but achieved significant improvement and maintained the improvement long term in ulnar drift and extensor lag. CONCLUSION: Benefits of the SMPA procedure are maintained over 7 years with low rates of implant fracture or deformity. Non-SMPA patients remained stable in their hand function over the 7-year study duration.

Exopolysaccharide from Lactobacillus fermentum Lf2 and its functional characterization as a yogurt additive.

Lactobacillus fermentum Lf2 is a strain which is able to produce high levels (approximately 1 g/l) of crude exopolysaccharide (EPS) when it is grown in optimised conditions. The aim of this work was to characterize the functional aspects of this EPS extract, focusing on its application as a dairy food additive. Our findings are consistent with an EPS extract that acts as moderate immunomodulator, modifying s-IgA and IL-6 levels in the small intestine when added to yogurt and milk, respectively. Furthermore, this EPS extract, in a dose feasible to use as a food additive, provides protection against Salmonella infection in a murine model, thus representing a mode of action to elicit positive health benefits. Besides, it contributes to the rheological characteristics of yogurt, and could function as a food additive with both technological and functional roles, making possible the production of a new functional yogurt with improved texture.

How Rheumatoid Arthritis Patients Make Decisions Regarding Hand Reconstruction: A Qualitative Study from the Silicone Arthroplasty in Rheumatoid Arthritis Project.

BACKGROUND: Previous studies have determined specific factors influencing patients with rheumatoid arthritis to choose to undergo reconstructive hand surgery. However, little is known about how rheumatoid arthritis patients are counseled by physicians regarding surgical options and the concerns that cause patients to decide not to undergo hand surgery reconstruction. The authors conducted a qualitative study to investigate the decision-making process rheumatoid arthritis patients undergo when deciding about surgical treatment, including the specific involvement from their physicians in the decision. METHODS: Participants were recruited from the ongoing international collaborative Silicone Arthroplasty in Rheumatoid Arthritis study. Twenty semistructured interviews were conducted, and data were analyzed using grounded theory methodology. RESULTS: Eight of the 11 participants that underwent metacarpophalangeal joint arthroplasty indicated that improving hand function was the primary reason they chose to undergo surgery. Four of these participants were concerned about the aesthetics of their hands, whereas five of the eight participants who discussed their reasoning for not undergoing surgery felt aesthetics was not a good enough reason to undergo surgery. Three participants indicated that a negative perception of hand surgery by their rheumatologists discouraged them from the procedure. Finally, most (14 of 18) participants chose to make the final decision about surgery without involvement from their physician. CONCLUSIONS: The decision of whether or not to undergo surgery can be personal, and patients may prefer to make the final decision independently. It is important that rheumatoid arthritis patients receive collaborative counseling from their rheumatologists and hand surgeons to ensure they are making a knowledgeable decision.

Relationship between Patient Expectations and Clinical Measures in Patients Undergoing Rheumatoid Hand Surgery from the Silicone Arthroplasty in Rheumatoid Arthritis (SARA) Study.

BACKGROUND: The purpose of this study was to evaluate the relationship between preoperative patient expectations and clinical measures in patients undergoing rheumatoid hand surgery. METHODS: Patients were recruited as a part of a larger prospective multicenter study to evaluate outcomes of silicone metacarpophalangeal joint arthroplasty (SMPA). Patients in the surgical cohort completed a baseline expectation questionnaire asking about expectations for function, work, pain, and aesthetics after SMPA. Responses were categorized into groups of low, middle, and high expectations for each domain and for cumulative expectations across all domains. Other study measurements were taken at baseline and 1 year, including the Michigan Hand Outcomes Questionnaire (MHQ) and objective clinical measurements (i.e., grip strength, pinch strength, the Jebsen-Taylor Hand Function Test, ulnar drift, and extensor lag). RESULTS: Preoperative expectations and clinical measures were complete for 59 patients at baseline and 45 patients at 1-year follow-up. Preoperative expectation level was related to baseline patient-reported domains of activities of daily living and hand satisfaction measured by the MHQ (p = 0.04 and p = 0.07, respectively). Patients had relatively similar satisfaction with hand function postoperatively regardless of preoperative expectation level. No consistent relationship was seen between preoperative expectations and objective measures at baseline and 1-year follow-up. CONCLUSIONS: High preoperative expectations were not a risk factor for dissatisfaction postoperatively. Preoperative expectation level may be considered for stratifying baseline patient-reported hand function in patients with similar objective hand function.

Timing of High-Dose Rate Brachytherapy With External Beam Radiotherapy in Intermediate and High-Risk Localized Prostate CAncer (THEPCA) Patients and Its Effects on Toxicity and Quality of Life: Protocol of a Randomized Feasibility Trial.

BACKGROUND: Prostate cancer is the most common cancer in males in the UK and affects around 105 men for every 100,000. The role of radiotherapy in the management of prostate cancer significantly changed over the last few decades with developments in brachytherapy, external beam radiotherapy (EBRT), intensity-modulated radiotherapy (IMRT), and image-guided radiotherapy (IGRT). One of the challenging factors of radiotherapy treatment of localized prostate cancer is the development of acute and late genitourinary and gastrointestinal toxicities. The recent European guidelines suggest that there is no consensus regarding the timing of high-dose rate (HDR) brachytherapy and EBRT. The schedules vary in different institutions where an HDR boost can be given either before or after EBRT. Few centers deliver HDR in between the fractions of EBRT. OBJECTIVE: Assessment of acute genitourinary and gastrointestinal toxicities at various time points to better understand if the order in which treatment modality is delivered (ie, HDR brachytherapy or EBRT first) has an effect on the toxicity profile. METHODS: Timing of HDR brachytherapy with EBRT in Prostate CAncer (THEPCA) is a single-center, open, randomized controlled feasibility trial in patients with intermediate and high-risk localized prostate cancer. A group of 50 patients aged 18 years old and over with histological diagnosis of prostate cancer (stages T1b-T3BNOMO), will be randomized to one of two treatment arms (ratio 1:1), following explanation of the study and informed consent. Patients in both arms of the study will be treated with HDR brachytherapy and EBRT, however, the order in which they receive the treatments will vary. In Arm A, patients will receive HDR brachytherapy before EBRT. In Arm B (control arm), patients will receive EBRT before HDR brachytherapy. Study outcomes will look at prospective assessment of genitourinary and gastrointestinal toxicities. The primary endpoint will be grade 3 genitourinary toxicity and the secondary endpoints will be all other grades of genitourinary toxicities (grades 1 and 2), gastrointestinal toxicities (grades 1 to 4), prostate-specific antigen (PSA) recurrence-free survival, overall survival, and quality of life. RESULTS: Results from this feasibility trial will be available in mid-2016. CONCLUSIONS: If the results from this feasibility trial show evidence that the sequence of treatment modality does affect the patients' toxicity profiles, then funding would be sought to conduct a large, multicenter, randomized controlled trial. TRIAL REGISTRATION: International Standard Randomized Controlled Trial Number (ISRCTN): 15835424; http://www.isrctn.com/ISRCTN15835424 (Archived by WebCite at http://www.webcitation.org/6Xz7jfg1u).

A 5-Year Cost-Effectiveness Analysis of Silicone Metacarpophalangeal Arthroplasty in Patients with Rheumatoid Arthritis.

BACKGROUND: There is a paucity of research evaluating the cost-effectiveness of surgical interventions for rheumatoid arthritis patients. Previous reports have challenged the sustainability of improved outcomes after silicone metacarpophalangeal arthroplasty. The authors conducted an economic evaluation of the long-term health outcomes after silicone metacarpophalangeal arthroplasty. METHODS: The authors performed a 5-year prospective cohort study of 170 patients with rheumatoid arthritis (73 surgical and 97 nonsurgical). Objective functional measurements and patient-rated outcomes using the Michigan Hand Outcomes Questionnaire and the Arthritis Impact Measurement Scale 2 were collected at 3 and 5 years. A cost-effectiveness analysis using direct costs from Medicare outpatient claims data (2006 to 2010) was performed to estimate the incremental cost-effectiveness ratios for both the Michigan and Arthritis Impact Measurement Scale 2 measurements. RESULTS: At 5 years, the authors observed a statistically significant difference in upper extremity outcomes (Michigan Hand Outcomes Questionnaire) between the two groups, with surgical patients having higher outcomes. Costs associated with improved outcomes 5 years after surgery were $787 to $1150 when measured by the Michigan Hand Outcomes Questionnaire and $49,843 to $149,530 when measured by the Arthritis Impact scale. The incremental cost-effectiveness ratios did not substantially increase with their observed surgical revision rate of 5.5 percent (approximately 4 percent increase in incremental cost-effectiveness ratio) or with previously published long-term revision rates of 6.2 percent (approximately 6 percent increase in incremental cost-effectiveness ratio). CONCLUSIONS: Short-term improvements in upper extremity outcomes after silicone metacarpophalangeal arthroplasty are maintained over the 5-year follow-up period. These outcomes are achieved at a relatively low cost, even with the addition of potential surgical complications.

Effects of prandial challenge on triglyceridemia, glycemia, and pro-inflammatory activity in persons with chronic paraplegia.

CONTEXT/OBJECTIVE: Exaggerated postprandial lipemia has been reported after spinal cord injury (SCI). We examined metabolite and accompanying pro-inflammatory biomarker responses to repeat feeding of typical high-fat meals in individuals with chronic paraplegia. DESIGN: Descriptive trial. METHODS: Metabolites (triglycerides, glucose, and insulin) and inflammatory biomarkers (interleukin-6 and high-sensitivity C-reactive protein (hsCRP)) were measured under fasting conditions in 11 recreationally active individuals with chronic (>1 year) paraplegia. Subjects received high-fat meals at time point 0 and again at minute 240. Antecubital venous blood was obtained at time points -30 (fasting), 0 (first meal), 30, 60, 90, 120, 240 (second meal), 360, and 480 minutes. Correlations were examined among the study variables. Exploratory subgroup analysis was performed for subjects with levels of postprandial glucose greater than >200 mg/dl. RESULTS: Triglycerides showed a significant rise 4 hours after eating. Basal inflammatory markers were elevated, and did not undergo additional change during the testing. Additionally, subjects with excessive postprandial glucose responses showed higher hsCRP levels than those having typical glucose responses both for fasting (11.8 ± 6.5 vs. 2.9 ± 2.7 mg/l, P = 0.064) and postprandial (11.1 ± 4.9 vs. 3.7 ± 3.8 mg/l, P = 0.018) values. CONCLUSIONS: Despite elevations in metabolic response markers, inflammatory markers did not change significantly after consumption of population-representative (i.e. hypercaloric) mixed-nutrient meals. Levels of fasting CRP in the high-risk range are consistent with other reports in persons with SCI and continue to pose concern for their cardiovascular disease risk. The possible association between postprandial metabolic responses and inflammatory states warrants further investigation to identify individual component risks for this secondary health hazard.

Patient expectations and long-term outcomes in rheumatoid arthritis patients: results from the SARA (Silicone Arthroplasty in Rheumatoid Arthritis) study.

Little evidence exists to understand the influence of patient expectations on outcomes for silicone metacarpophalangeal arthroplasty (SMPA). The purpose of this paper is to compare long-term treatment outcome experiences regarding hand function/appearance for a surgical and nonsurgical cohort of rheumatoid arthritis (RA) patients and contrast them to expectations at baseline. This sample is part of a larger multicenter prospective cohort study of RA patients enrolled from 2004 to 2008. A total of 169 RA patients with severe deformities at the metacarpophalangeal (MCP) joints were recruited in the original study. Expectations for SMPA were collected at enrollment. A follow-up patient-reported questionnaire was completed at long-term follow-up. Baseline expectation questionnaires were collected from 137 patients, and follow-up data from 84 patients (average 6.7 years follow-up). At baseline, a significantly higher percent of patients who chose surgery expected to do "Anything I want" or "More activities than I do now" 1 year from enrollment than those who chose nonsurgical treatment. At follow-up, surgical patients remained more likely to indicate that they were currently able to do "Anything" or "More activities" than nonsurgical patients. A higher percentage of surgical patients were "very satisfied" or "quite satisfied" with their treatment compared to nonsurgical patients. RA subjects who chose SMPA reported greater expectations for surgery prior to surgery and also greater levels of hand function and satisfaction at long-term follow-up.

Predictors of functional outcomes after simple decompression for ulnar neuropathy at the elbow: a multicenter study by the SUN study group.

OBJECTIVE: To identify predictors of surgical outcome for ulnar neuropathy at the elbow (UNE). DESIGN: Prospective cohort followed for 1 year. SETTING: Clinics. PARTICIPANTS: Patients diagnosed with UNE (N=55). INTERVENTION: All subjects had simple decompression surgery. MAIN OUTCOME MEASURES: The primary outcome measure was patient-reported outcomes, such as overall hand function through the Michigan Hand Outcomes Questionnaire (MHQ). Predictors included age, duration of symptoms, disease severity, and motor conduction velocity across the elbow. RESULTS: Multiple regression models with change in the overall MHQ score as the dependent variable showed that at 3 months postoperative time, patients with <3 months duration of symptoms showed 12 points (95% confidence interval [CI], 0.9-23.5) greater improvement in MHQ scores than those with ≥3 months symptom duration. Less than 3 months of symptoms was again associated with 13 points (95% CI, 2.9-24) greater improvement in MHQ scores at 6 months postoperative, but it was no longer associated with better outcomes at 12 months. A worse baseline MHQ score was associated with significant improvement in MHQ scores at 3 months (coefficient, -0.38; 95% CI, -.67 to -.09), and baseline MHQ score was the only significant predictor of 12 month MHQ scores (coefficient, -.40; 95% CI, -.79 to -.01). CONCLUSIONS: Subjects with <3 months of symptoms and worse baseline MHQ scores showed significantly greater improvement in functional outcomes as reported by the MHQ. However, duration of symptoms was only predictive at 3 or 6 months because most patients recovered within 3 to 6 months after surgery.

The effect of swan neck and boutonniere deformities on the outcome of silicone metacarpophalangeal joint arthroplasty in rheumatoid arthritis.

BACKGROUND: Rheumatoid arthritis patients with swan neck deformities are postulated to have greater metacarpophalangeal joint arc of motion because of their need to flex the joint to make a fist, whereas the boutonniere deformity places the fingers into the flexed position, creating less demand on the joint for grip. This study analyzes the effect of these deformities on the joint's arc of motion and hand function. METHODS: The authors measured the metacarpophalangeal joint arc of motion in 73 surgical patients. Data were allocated into groups by finger and hand deformity. Linear regression models were used to analyze the effect of the deformity on the joint's arc of motion. Functional outcomes were measured by the Michigan Hand Outcomes Questionnaire and the Jebson-Taylor Test. RESULTS: Nineteen fingers had boutonniere deformity, 95 had swan neck deformities, and 178 had no deformity. The no-deformity group had the least arc of motion at baseline (16 degrees) compared with the boutonniere (26 degrees) and swan neck (26 degrees) groups. Mean arc of motion in the no-deformity group compared with the boutonniere group at baseline was statistically significant, but all groups had similar arc of motion at long-term follow-up. Only mean Jebson-Taylor Test scores at baseline between the boutonniere and no-deformity groups were significantly different. CONCLUSIONS: The results did not support the hypothesis that swan neck deformities have better arc of motion compared with boutonniere deformity. Boutonniere deformity has worse function at baseline, but there was no difference in function among groups at long-term follow-up.

An outcome study for ulnar neuropathy at the elbow: a multicenter study by the surgery for ulnar nerve (SUN) study group.

BACKGROUND: Many instruments have been developed to measure upper extremity disability, but few have been applied to ulnar neuropathy at the elbow (UNE). OBJECTIVE: We measured patient outcomes following ulnar nerve decompression to (1) identify the most appropriate outcomes tools for UNE and (2) to describe outcomes following ulnar nerve decompression. METHODS: Thirty-nine patients from 5 centers were followed prospectively after nerve decompression. Outcomes were measured preoperatively and at 6 weeks, 3 months, 6 months, and 12 months postoperatively. Each patient completed the Michigan Hand Questionnaire (MHQ), Carpal Tunnel Questionnaire (CTQ), and Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaires. Grip, key-pinch strength, Semmes-Weinstein monofilament, and 2-point discrimination were measured. Construct validity was calculated by using Spearman correlation coefficients between questionnaire scores and physical and sensory measures. Responsiveness was assessed by standardized response means. RESULTS: Key-pinch (P = .008) and Semmes-Weinstein monofilament testing of the ulnar ring (P < .001) and small finger (radial: P = .004; ulnar: P < .001) improved following decompression. Two-point discrimination improved significantly across the radial (P = .009) and ulnar (P = .007) small finger. Improved symptoms and function were noted by the CTQ (preoperative CTQ symptom score 2.73 vs 1.90 postoperatively, P < .001), DASH (P < .001), and MHQ: function (P < .001), activities of daily living (P = .003), work (P = .006), pain (P < .001), and satisfaction (P < .001). All surveys demonstrated strong construct validity, defined by correlation with functional outcomes, but MHQ and CTQ symptom instruments demonstrated the highest responsiveness. CONCLUSION: Patient-reported outcomes improve following ulnar nerve decompression, including pain, function, and satisfaction. The MHQ and CTQ are more responsive than the DASH for isolated UNE treated with decompression.