Age-specific incidence of joint disease in paediatric patients with haemophilia: A single-centre real-world outcome based on consecutive US examination.

INTRODUCTION: Joint health is one of the most important factors contributing to a healthy life in patients with haemophilia. Recent study revealed that starting early prophylaxis was not enough to prevent joint disease in most paediatric patients with haemophilia. AIM: In this study, we aimed to determine the age-specific incidence of acute joint disease during childhood at single haemophilia treatment centre (HTC). METHOD: The joint health in 48 patients was evaluated based on consecutive US testing for 5 years at annual multidisciplinary comprehensive care. RESULTS: During the study period, 23 patients (47.9%) had no joint disease since the initial examination, whereas 13 patients (27.0%) showed development from negative to positive findings. The incidence of joint disease increased with age: 0% in preschool, 5.3% in elementary school, 14.3% in junior high school and 35% beyond high school age. Among the 13 patients who developed joint disease, two experienced acquired synovitis that resolved during the follow-up period. Statistical analysis revealed that the patients who routinely underwent follow-up by the HTC exhibited a significantly lower incidence of joint disease than did those followed up at other institutions (p < .001). CONCLUSION: These results indicated that close check-up, including routine joint examination using US as well as frequent assessment of pharmacokinetic profile at the HTC, might play an important role in avoiding joint disease among paediatric patients with haemophilia.

Chronic pain in patients with hemophilia: is it preventable?

: Current management of chronic pain in patients with hemophilia (PWH) focuses on pain relief with analgesics and symptom control. The clinical practice of managing chronic pain in PWH varies considerably across hemophilia treatment centers. Here, we aim to study the appropriate intervention of hemophilic arthropathy for prevention and treatment of chronic pain in PWH. Medline, Embase, Cochrane databases were searched for randomized controlled trials, and the European Hemophilia Therapy Standardization Board, The World Federation of Hemophilia, Nordic Hemophilia Guidelines, American Society of the International Pain Physicians and the Medical and Scientific Advisory Council guidelines were studied through November 2019 for chronic pain in PWH for a narrative review. We found no standardized approach for the prevention and management of chronic pain in PWH. Evidence suggests that prophylactic factor concentrate therapy, programmed exercise and educational intervention may help PWH manage their chronic pain.

Same-day discharge is not inferior to longer length of in-hospital stay for 90-day readmissions following shoulder arthroplasty.

BACKGROUND: Shoulder arthroplasty is a common orthopedic procedure, performed historically in the inpatient setting. However, interest in same-day discharge has increased. We sought to evaluate 90-day readmission, 90-day emergency department (ED) visit, 90-day deep infection, 90-day venous thromboembolism (VTE), and 1-year mortality after same-day shoulder arthroplasty compared with an inpatient stay. METHODS: We conducted a retrospective cohort study using data from an integrated health care system's Shoulder Arthroplasty Registry. A total of 6503 elective primary unilateral total shoulder and reverse total shoulder arthroplasties performed between 2005 and 2016 were included; 405 (6%) had same-day discharge. The likelihood of 90-day events, including readmission, ED visit, deep infection, and VTE, and 1-year mortality after same-day discharge was compared with 1- to 4-night inpatient stay using generalized estimating equations with noninferiority testing, adjusting for age, sex, body mass index, race, American Society of Anesthesiologists classification, select comorbidities, osteoarthritis, anesthesia type, procedure type, and surgeon effect. RESULTS: We failed to observe a difference between same-day discharge and 1- to 4-night stay in terms of 90-day readmission, 90-day ED visit, and 1-year mortality. Same-day discharge was not inferior to 1- to 4-night stay regarding 90-day readmission, but we did not have evidence to support noninferiority for 90-day ED visits or 1-year mortality. Ninety-day deep infections and VTE were too infrequent for adjusted analysis. CONCLUSIONS: We found same-day shoulder arthroplasty not to be inferior to an inpatient stay for 90-day readmission. Future investigation into the reasons for readmission and ED visit after same-day shoulder arthroplasty and interventions to mitigate these adverse events is needed.

Is There a Role for Preoperative Iron Supplementation in Patients Preparing for a Total Hip or Total Knee Arthroplasty?

BACKGROUND: Several treatment modalities exist for the treatment of perioperative anemia. We determined the effect of oral iron supplementation on preoperative anemia, and the use of blood-conserving interventions before total hip arthroplasty (THA) and total knee arthroplasty (TKA). METHODS: A total of 3435 total joint arthroplasties (1461 THAs and 1974 TKAs) were analyzed during 2 phases of a blood conservation program. The first phase used erythropoietin alfa (EPO) or intravenous (IV) iron for patients at risk for perioperative anemia. The second phase included these interventions, as well as preoperative iron supplementation. The effect on preoperative hemoglobin (Hb) and serum ferritin, as well as EPO and IV iron utilization, was determined. RESULTS: Oral iron therapy increased preoperative Hb level by 6 g/L (P < .001) and 7 g/L (P < .001) in the hip and knee cohorts, respectively. Serum ferritin level rose by 80 µg/L (P < .001) and 52 µg/L (P < .001) in the hip and knee cohorts, respectively. The number of patients with an Hb level <130 g/L was significantly reduced (P < .001 for both cohorts), as were patients with serum ferritin levels <35 µg/L (P = .002 for hip and P < .001 for knee cohorts). Utilization of EPO reduced from 16% to 6% (P < .001) and 18% to 6% (P < .001) in the hip and knee cohorts, respectively. Utilization of IV iron reduced from 4% to 2% (P = .05) and 5% to 2% (P < .001) in the hip and knee cohorts, respectively. CONCLUSION: Oral iron therapy reduced the burden of perioperative anemia and reduced utilization of other blood-conserving therapies before THA and TKA. Future research should delineate the cost-effectiveness of oral iron therapy.

[Musculoskeletal-related chest pain]. / Muskuloskeletal bedingter Thoraxschmerz.

BACKGROUND: Approximately 10-50% of chest pains are caused by musculoskeletal disorders. The association is twice as frequent in primary care as in emergency admissions. AIM: This article provides an overview of the most important musculoskeletal causes of chest pain and on the diagnostics and therapy. METHODS: A selective search and analysis of the literature related to the topic of musculoskeletal causes of chest pain were carried out. RESULTS AND CONCLUSION: Non-inflammatory diseases, such as costochondritis and fibromyalgia are frequent causes of chest pain. Inflammatory diseases, such as rheumatoid arthritis, spondyloarthritis and systemic lupus erythematosus are much less common but are more severe conditions and therefore have to be diagnosed and treated. The diagnostics and treatment often necessitate interdisciplinary approaches. Chest pain caused by musculoskeletal diseases always represents a diagnosis by exclusion of other severe diseases of the heart, lungs and stomach. Physiotherapeutic and physical treatment measures are particularly important, including manual therapy, transcutaneous electrical stimulation and stabilization exercises, especially for functional myofascial disorders.

Ochronotic arthropathy as a paradigm of metabolically induced degenerative joint disease. A case-based review.

Alkaptonuria is a rare, hereditary metabolic disorder in which a deficiency in the homogentisate 1,2-dioxygenase enzyme results in an accumulation of homogentisic acid. Deposition of excess homogentisic acid in different intra- and extra-articular structures with high content of connective tissue causes brownish-black pigmentation and weakening, ultimately resulting in tissue degeneration and finally osteoarthritis. Ochronotic arthropathy is considered a rapidly progressive, disabling condition in which weight-bearing joints and the thoracolumbar spine are predominantly affected. Patients often require multiple joint replacements, such as in the case of the patient presented here. At present, there is no definitive cure for ochronosis, and management is predominantly symptomatic.

Fibrin sealants or cell saver eliminate the need for autologous blood donation in anemic patients undergoing primary total knee arthroplasty.

INTRODUCTION: Reducing allogeneic blood transfusions remains a challenge in total knee arthroplasty. Patients with preoperative anemia have a particularly high risk for perioperative blood transfusions. MATERIALS AND METHODS: 176 anemic patients (Hb < 13.5 g/dl) undergoing total knee replacement were prospectively evaluated to compare the effect of a perioperative cell saver (26 patients), intraoperative fibrin sealants (5 ml Evicel, Johnson & Johnson Wound Management, Ethicon, Somerville, NJ) (45 patients), preoperative autologous blood donation (PABD) (21 patients), the combination of fibrin sealants and preoperative autologous blood donation (44) and no intervention (40 patients) on perioperative blood loss and transfusion requirements. RESULTS: All protocols resulted in significant reduction of allogeneic blood transfusions. Transfusion rates were similar with the use of PABD (19%), Evicel (18%), and cell saver (19%), all significantly lower than the control group (38 %, p < 0.05). Combining Evicel with PABD resulted in significantly higher wastage of autologous units (p < 0.05) with no significant reduction in allogeneic transfusion rate (14%). The use of fibrin sealant resulted in a significant reduction of blood loss compared to the PABD group (603 vs. 810 ml, p < 0.005) as well as the control group (603 vs. 822 ml, p < 0.005). CONCLUSIONS: While PABD proved to be the most cost-effective treatment option in anemic patients, fibrin sealants and cell saver show similar reduction in allogeneic transfusion rates compared to controls. The combination of fibrin sealants and PABD is not cost-effective and increases the number of wasted units.

Musculoskeletal manifestations in patients with malignant disease.

To detect and describe the incidence of musculoskeletal manifestations in different malignant diseases as well as their relation to the treatment received whether by chemotherapy or radiation therapy. Sixty patients with different malignant diseases were included in this study, 45 with solid tumors and 15 patients with hematological malignancy. The mean age was 46.55 +/- 11.04 years and the mean disease duration was 2 +/- 0.75 years. The patients were fully examined for any rheumatologic involvement, laboratory investigations were performed as well as dual energy X-ray absorptiometry study for bone densitometry. Treatment strategies were assessed including the chemotherapeutics, radiation therapy, and/or surgery. Myalgias and arthralgias were the most frequent followed by flexor tenosynovitis, frozen shoulder, and fibromyalgia syndrome. Hypertrophic osteoarthropathy was seen in five patients, cutaneous vasculitis in two patients as well as arthritis. Osteonecrosis was present in one of the lunate carpal bones of a patient with non-Hodgkin's lymphoma (1.67%) and receiving high dose steroids. Rheumatoid factor was positive in four patients, three of which had hepatitis C virus positivity and cryoglobulins. Anti-neutrophil cytoplasmic antibody was negative in all the studied patients. The bone mineral density was significantly reduced in the patients with malignancy compared to the control. Mild to moderate osteoporosis was present, being more evident in the spine and forearm. The bone loss was higher in those with solid tumors and even more obvious in those receiving aromatase inhibitors. Musculoskeletal manifestations occurring during malignancies and following the treatment represent a significant percentage of symptoms and signs which may raise a clue to differential diagnosis.

Comparative study of the influence of room-temperature and warmed fluid irrigation on body temperature in arthroscopic shoulder surgery.

PURPOSE: The purpose of this study was to evaluate the effect of irrigation fluid temperature on body temperature and other variables, and to determine their correlations. METHODS: A prospective randomized study was performed of 50 patients undergoing arthroscopic shoulder surgery who received irrigation fluid either with room temperature or warmed to 37 degrees C to 39 degrees C. Core body temperature was checked at regular intervals, and additional variables, such as length of anesthesia and surgery, amount of irrigation fluid and intravenous fluid used, amount of bleeding, weight gain, and postoperative pain were collected during surgery and postoperatively. RESULTS: The final core body temperature was 35.5 +/- 0.3 degrees C in the room-temperature fluid group and 36.2 +/- 0.3 degrees C in the warmed fluid group (P < .001). The temperature drop was 0.86 +/- 0.2 degrees C in the room-temperature fluid group and 0.28 +/- 0.2 degrees C in the warmed fluid group (P < .001). Hypothermia occurred in 91.3% of patients in the room-temperature fluid group; the incidence of hypothermia was much lower in the warmed fluid group (17.4%; P < .001). Of the variables measured, the patient's age and amount of irrigation fluid used correlated with core body temperature in the room-temperature fluid group. No variables correlated with core body temperature in the warmed fluid group. CONCLUSIONS: Hypothermia occurred more often in shoulder arthroscopic surgery with room-temperature fluid irrigation than with warmed fluid irrigation. The patient's age and amount of irrigation fluid used correlate with core body temperature when using room-temperature irrigation fluid. The use of warm irrigation fluid during arthroscopic shoulder surgery decreases perioperative hypothermia, especially in elderly patients. LEVEL OF EVIDENCE: Level I, therapeutic randomized controlled trial.

Haematogenous pyogenic bone and joint sepsis--reducing avoidable morbidity.

BACKGROUND AND OBJECTIVES: Delayed presentation of haematogenous bone and joint sepsis is common in our childhood population and leads to a large burden of avoidable morbidity extending into adult life. We set out to determine causative factors in these delays. DESIGN: A prospective study was undertaken over a 1-year period. SETTING: Ngwelezane Hospital, a regional hospital in Kwa-Zulu-Natal serving 9 rural district hospitals. SUBJECTS: Children under 15 years with their first presentation of bone and joint sepsis, comprising 80 consecutive cases. Tuberculosis cases were excluded. OUTCOME MEASURES: Children were categorised at follow-up into two groups. The first group had uncomplicated recoveries, with complete return of function and no clinical or radiological signs of unresorbed sequestra. The second group had complications, with evidence of one or more of the following: chronicity of infection, pathological fracture, deformity, growth plate disturbance, avascular necrosis or joint stiffness. RESULTS: Delay in obtaining definitive treatment correlated strongly with initial misdiagnosis. Only 4/25 septic hips were correctly diagnosed and referred expediently; 19/50 osteomyelitis cases were initially misdiagnosed and treated as cellulitis, and a further 19/50 were misdiagnosed as trauma. Predictably, delayed treatment correlated strongly with a complicated outcome. No significant associations were found between delays and distance to nearest primary health care facility, relative levels of socio-economic deprivation within the study group, maternal educational attainment, or traditional healer consultation. CONCLUSION: Health care professionals at all levels should be alerted to the continued high incidence of this disease. We propose some 'red flags' to assist primary health care workers in the diagnosis of this condition.

Evaluación de las infiltraciones realizadas en atención primaria / Evaluation of filtrations practised in primary care

Objetivos. Describir la evolución del dolor y de la impotencia funcional en la patología articular y periarticular tras infiltrar con corticoide y anestésico local; analizar el número de altas que se pueden dar en estos pacientes en situación de incapacidad laboral transitoria (ILT) durante la primera semana postinfiltración. Diseño. Estudio de intervención sin grupo control. Emplazamiento. Consultas de un centro de salud semiurbano (ABS Piera). Participantes. Sesenta y cinco pacientes mayores de 18 años de ambos sexos, con afección articular y periarticular. Intervención. Se infiltró localmente con acetónido de triamcinolona y bupivacaína al 2% a 65 pacientes. Mediciones principales. Factores sociodemográficos, diagnóstico, respuesta, número de infiltraciones por paciente, efectos secundarios y número de altas de ILT durante la primera semana postinfiltración. Resultados. Se infiltró predominantemente a varones (57%) con 31-65 años (67,7%), activos (70,7%) en trabajos manuales (78,4%). La tendinitis del manguito de los rotadores (46,2%) y la epicondilitis (27,7%) fueron los diagnósticos más frecuentes. Las medias y el intervalo de confianza (IC) obtenidos en la escala analógica visual (EAV) para el dolor fueron: inicialmente, 8,6 (7,4-9,8); a la semana, 1,4 (1-1,8); a los 3 meses, 2,2 (1,3-3,1), y al año, 2,3 (1,1-3,5). Las medias y el IC del 95% hallados para la impotencia funcional fueron: inicialmente, 8,2 (6,7-9,7); a la semana, 0,9 (0,7-1,1); a los 3 meses, 1,2 (0,9-1,5), y al año, 1,6 (1,4-1,8). El número de infiltraciones por paciente fue 1,6. No hubo efectos secundarios importantes. Se dieron 19 altas en 25 pacientes que estaban en ILT durante la primera semana postinfiltración. Conclusiones. Los pacientes mostraron disminución del dolor y de la impotencia funcional en la afección articular y periarticular después de la infiltración, permitiendo dar un número elevado de altas durante la primera semana postinfiltración

Objectives. To describe the evolution of the pain and the functional impotence in the articular and periarticular pathology after to infiltrate with local corticosteroid and anaesthetic; to analize the number of discharge certificates that maybe to give in the patients with employment transitory incapacity (ETI) during the first week post-infiltration. Design. Intervention without control group. Setting. Semiurban primary care physician's practices (ABS Piera). Participants. Men and women elder than 18 years old, with articular and periarticular pathology. Intervention. Were infiltrated with local triamcinolone acetonid and bupivacain 2% 65 patients. Main measurements. Were gathered socio-demographic factors, diagnostic, response, number of infiltrations for patient, secondary effects, and number of discharge certificates that were given in the patients in ETI situation during the first week post-infiltration. Results. Were infiltrated predominantly men (57%) with 31-65 years old (67.7%), employed (70.7%) in manual works (78.4%). Rotary joint tendinitis (46.2%) and epicondylitis (27.7%) were the most common diagnostics. Mean and CI (95%) obtained in the VAS for pain were: initially, 8.8 (7.4-9.8); week, 1.4 (1-1.8); 3 months, 2.2 (1.3-3.1), and year, 2.3 (1.1-3.5). Mean and CI (95%) found for functional impotence were: initially, 8.2 (6.7-9.7); week, 0.9 (0.7-1.1); 3 months, 1.2 (0.9-1.5), and year, 1.6 (1.4-1.8). The number of infiltrations for patient was 1.6. Hadn't important secondary effects. Were given 19 discharge certificates in 25 patients with ETI in the first week post-infiltration. Conclusions. The patients diminished the pain and the functional impotence in the articular and periarticular pathology after of the infiltration, allowing to give an elevate number of discharge certificates during the first week post-infiltration

[Evaluation of infiltrations performed in primary care]. / Evaluación de las infiltraciones realizadas en atención primaria.

OBJECTIVES: To describe the evolution of the pain and the functional impotence in the articular and periarticular pathology after to infiltrate with local corticosteroid and anaesthetic; to analize the number of discharge certificates that maybe to give in the patients with employment transitory incapacity (ETI) during the first week post-infiltration. DESIGN: Intervention without control group. SETTING: Semiurban primary care physician's practices (ABS Piera). PARTICIPANTS: Men and women elder than 18 years old, with articular and periarticular pathology. INTERVENTION: Were infiltrated with local triamcinolone acetonid and bupivacain 2% 65 patients. MAIN MEASUREMENTS: Were gathered socio-demographic factors, diagnostic, response, number of infiltrations for patient, secondary effects, and number of discharge certificates that were given in the patients in ETI situation during the first week post-infiltration. RESULTS: Were infiltrated predominantly men (57%) with 31-65 years old (67.7%), employed (70.7%) in manual works (78.4%). Rotary joint tendinitis (46.2%) and epicondylitis (27.7%) were the most common diagnostics. Mean and CI (95%) obtained in the VAS for pain were: initially, 8.8 (7.4-9.8); week, 1.4 (1-1.8); 3 months, 2.2 (1.3-3.1), and year, 2.3 (1.1-3.5). Mean and CI (95%) found for functional impotence were: initially, 8.2 (6.7-9.7); week, 0.9 (0.7-1.1); 3 months, 1.2 (0.9-1.5), and year, 1.6 (1.4-1.8). The number of infiltrations for patient was 1.6. Hadn't important secondary effects. Were given 19 discharge certificates in 25 patients with ETI in the first week post-infiltration. CONCLUSIONS: The patients diminished the pain and the functional impotence in the articular and periarticular pathology after of the infiltration, allowing to give an elevate number of discharge certificates during the first week post-infiltration.

The effect of active absorbable algal calcium (AAA Ca) with collagen and other matrix components on back and joint pain and skin impedance.

The effect of active absorbable algal calcium (AAA Ca) with collagen and other matrix components on aging-associated skin changes and backache and joint pain was tested in a case-controlled study of 40 test subjects and 40 age-matched control subjects (mean age, 65 years) complaining of backache and knee joint pain due to osteoarthritis, spondylosis deformans, and/or osteoporosis. Supplementation with 900 mg calcium (given as AAA Ca) and 3.5 g collagen and other matrix components, including glucosamine, daily for 4 months resulted in a marked alleviation of subjective pain, assessed by the face scale. A fall of skin impedance in response to exercise loads, such as standing up, walking, squatting, and climbing up and down stairs, reported as an objective manifestion of pain, was also alleviated. The basal skin impedance, which increases with age, was significantly reduced in response to the Ca-collagen-matrix supplementation, suggesting a change of skin properties similar to rejuvenation, along with subjective smoothening and moistening of the skin. Urinary excretion of N-terminal crosslinking telopeptide of type I collagen (NTx) was decreased in the Ca-collagen-matrix supplementation group, but not in the control group. In addition to calcium suppression of parathyroid hormone, preventing bone resorption, collagen, acting on the intestinal lymphatic system, may protect collagen from degradation through the inhibition of cytokine-induced release of metalloproteinases, including collagenase.

Amiloidosis como complicación de la psoriasis / Amyloidosis as a complication of psoriasis

Se presenta el caso de un paciente afecto de psoriasis cutánea y artropática severa que desarrolló una amiloidosis sistémica. Se revisan los 23 casos publicados hasta diciembre 1996 (AU)

Polyarthritis with cutaneous mucinosis and intrasynovial mucin deposits.

We report the first case of cutaneous and articular mucinosis with presence of mucin deposits within the synovium in an HIV-positive patients. Presentation was asymmetric polyarthritis, and subcutaneous nodules developed two months later. Treatment was with hydroxychloroquine. The outcome of both the skin and joint lesions was favourable.

An unusual cause for lumbar radiculopathy: a synovial facet joint cyst of the right L5 joint.

OBJECTIVE: To report a rare cause of lumbar radiculopathy. CLINICAL FEATURES: A 72-yr-old man suffered from pain that radiated down the posterior thigh and calf for 3 wk. The right foot and first toe extensors were weak and sensation was decreased over the dorsum of the foot. Straight leg raising was positive at 50 degrees on the right. Computed tomography with contrast revealed a large cyst with focal vacuum change with displacement of the dural sac at the L4-5 level. INTERVENTION AND OUTCOME: An L4-5 laminectomy and facetectomy was performed with relief of the patient's complaint. The patient resumed full activity at 3 months. CONCLUSION: An unusual cause of an L5 radiculopathy is discussed. Of the reported cases, surgical intervention has been the treatment of choice. Conservative treatment, including injections with corticosteroids and chiropractic management, have been reported to be successful. Further investigations using controls are needed to determine if conservative care is more cost-effective than surgical intervention.