Magnetic Resonance Imaging of synovitis in knees of patients with osteoarthritis without injected contrast agents using T1 quantification.

INTRODUCTION: To measure the range of T1 values of synovitis using three Tesla (3 T) magnetic resonance imaging (MRI) in patients with osteoarthritis to assess the potential of T1 mapping for identifying synovitis from other features in the knee on unenhanced magnetic resonance scans. METHODS: After receiving institutional ethical approval, 83 patients who met the American College of Rheumatology criteria for diagnosis of osteoarthritis of the knee were scanned using a 3 T Magnetic Resonance Imaging scanner. T1 maps were calculated from spoiled gradient echo images acquired with five different flip angles of 5°-25°. Mean values for the T1 measurements were calculated and compared to existing data from the published literature for anatomical and pathological structures of the knee. RESULTS: T1 values recorded in patients suffering from osteoarthritis demonstrated that T1 values for synovitis (confirmed on gadolinium enhanced images) fall in a narrow range (849-1277 ms, mean 1005 ms SD 91) delineating this from other structures of the knee such as muscle (T1 value range 1305-2638 ms, mean 1785 ms SD 304) and synovial fluid (T1 value range 3867-4129 ms, mean 3915 SD 899) at 3 T. CONCLUSION: T1 values measured in synovitis in patients with osteoarthritis of the knee demonstrated a range of values distinct to those measured in muscle and synovial fluid at 3 T. This offers potential for the use of T1 maps to delineate or quantify synovitis in patients who are unwilling or unable to receive injectable contrast agents.

The feasibility of a modified shoe for multi-segment foot motion analysis: a preliminary study.

BACKGROUND: The majority of multi-segment kinematic foot studies have been limited to barefoot conditions, because shod conditions have the potential for confounding surface-mounted markers. The aim of this study was to investigate whether a shoe modified with a webbed upper can accommodate multi-segment foot marker sets without compromising kinematic measurements under barefoot and shod conditions. METHODS: Thirty participants (15 controls and 15 participants with midfoot pain) underwent gait analysis in two conditions; barefoot and wearing a shoe (shod) in a random order. The shod condition employed a modified shoe (rubber plimsoll) with a webbed upper, allowing skin mounted reflective markers to be visualised through slits in the webbed material. Three dimensional foot kinematics were captured using the Oxford multi-segment foot model whilst participants walked at a self-selected speed. RESULTS: The foot pain group showed greater hindfoot eversion and less hindfoot dorsiflexion than controls in the barefoot condition and these differences were maintained when measured in the shod condition. Differences between the foot pain and control participants were also observed for walking speed in the barefoot and in the shod conditions. No significant differences between foot pain and control groups were demonstrated at the forefoot in either condition. CONCLUSIONS: Subtle differences between pain and control groups, which were found during barefoot walking are retained when wearing the modified shoe. The novel properties of the modified shoe offers a potential solution for the use of passive infrared based motion analysis for shod applications, for instance to investigate the kinematic effect of foot orthoses.

Remission induction comparing infliximab and high-dose intravenous steroid, followed by treat-to-target: a double-blind, randomised, controlled trial in new-onset, treatment-naive, rheumatoid arthritis (the IDEA study).

OBJECTIVES: In disease modifying antirheumatic drug (DMARD)-naive early rheumatoid arthritis (RA), to compare the efficacy of methotrexate (MTX) and infliximab (IFX) with MTX and intravenous corticosteroid for remission induction. METHODS: In a 78-week multicentre randomised controlled trial, double-blinded to week 26, 112 treatment-naive RA patients (1987 American College of Rheumatology classification criteria) with disease activity score 44 (DAS44)>2.4 were randomised to MTX + IFX or MTX + single dose intravenous methylprednisolone 250 mg. A treat-to-target approach was used with treatment escalation if DAS44>2.4. In the IFX group, IFX was discontinued for sustained remission (DAS44<1.6 for 6 months). The primary outcome was change in modified total Sharp-van der Heijde score (mTSS) at week 50. RESULTS: The mean changes in mTSS score at week 50 in the IFX and intravenous steroid groups were 1.20 units and 2.81 units, respectively (adjusted difference (95% CI) -1.45 (-3.35 to 0.45); p=0.132). Radiographic non-progression (mTSS<2.0) occurred in 81% vs 71% (OR 1.77 (0.56 to 5.61); p=0.328). DAS44 remission was achieved at week 50 in 49% and 36% (OR 2.13 (0.91 to 5.00); p=0.082), and at week 78 in 48% and 50% (OR 1.12 (0.47 to 2.68); p=0.792). Exploratory analyses suggested higher DAS28 remission at week 6 and less ultrasound synovitis at week 50 in the IFX group. Of the IFX group, 25% (14/55) achieved sustained remission and stopped IFX. No substantive differences in adverse events were seen. CONCLUSIONS: In DMARD-naive early RA patients, initial therapy with MTX+high-dose intravenous steroid resulted in good disease control with little structural damage. MTX+IFX was not statistically superior to MTX+intravenous steroid when combined with a treat-to-target approach.

Clinical effectiveness and dose response of image-guided intra-articular corticosteroid injection for hip osteoarthritis.

OBJECTIVES: To assess symptomatic change after intra-articular corticosteroid (IAST) injection at 2 doses in hip osteoarthritis (OA), and to examine dose response and predictors of response. METHODS: Patients with hip OA (90 women and 30 men and median age 64 yrs) referred for IAST fluoroscopic injection were included in this longitudinal, clinical trial. WOMAC scores, body mass index (BMI), conventional radiographic grade (Kellgren and Lawrence scoring) and ultrasound measures (including capsular thickness and osteophyte assessments) were recorded at baseline. In the first phase of the study, 75 patients were injected with 40 mg methylprednisolone; another 45 patients were injected with 80 mg in the second phase. Change in WOMAC scores from baseline to weeks 6 and 12 were calculated for each dose and then dose comparisons were made. Clinical responders (>15% reduction in baseline pain score) were identified in order to establish predictors of response. RESULTS: For the 40 mg dose, there was a statistically significant improvement in pain (P < 0.001) and stiffness (P < 0.001) but not disability at week 6, and only the improvement in stiffness at week 12 was maintained (P = 0.041). For the 80 mg dose, there was significant improvement in pain (P < 0.001), stiffness (P < 0.001) and disability (P < 0.001) at week 6, which was maintained for all domains at week 12 (P = 0.002; P = 0.001; P < 0.001). When the doses were compared, the 80 mg dose demonstrated a significant improvement compared with the 40 mg group for stiffness at week 12 (P = 0.026) and disability at both weeks 6 and 12 (P = 0.026; P = 0.004). Imaging findings did not relate to severity of symptoms or response to IAST. CONCLUSIONS: In these two hip OA cohorts, both the 40 mg and 80 mg IAST doses had a beneficial effect at week 6, while the 80 mg dose maintained this improvement at week 12. Comparison of the two dose groups provided some evidence of a dose response. Randomized controlled trials of IAST for hip OA are now required.

The relationship between limited MRI section analyses and volumetric assessment of synovitis in knee osteoarthritis.

AIM: To assess whether simple, limited section analysis can replace detailed volumetric assessment of synovitis in patients with osteoarthritis (OA) of the knee using contrast-enhanced magnetic resonance imaging (MRI). MATERIALS AND METHODS: Thirty-five patients with clinical and radiographic OA of the knee were assessed for synovitis using gadolinium-enhanced MRI. The volume of enhancing synovium was quantitatively assessed in four anatomical sites (the medial and lateral parapatellar recesses, the intercondylar notch and the suprapatellar pouch) by summing the volumes of synovitis in consecutive sections. Four different combinations of section analysis were evaluated for their ability to predict total synovial volume. RESULTS: A total of 114 intra-articular sites were assessed. Simple linear regression demonstrated that the best predictor of total synovial volume was the analysis containing the inferior, mid and superior sections of each of the intra-articular sites, which predicted between 40-80% (r(2) = 0.396, p < 0.001 for notch; r(2) = 0.818, p < 0.001 for medial parapatellar recess) of the total volume assessment. CONCLUSIONS: The results suggest that a three-section analysis on axial post-gadolinium sequences provides a simple surrogate measure of synovial volume in OA knees.

The validation of simple scoring methods for evaluating compartment-specific synovitis detected by MRI in knee osteoarthritis.

OBJECTIVES: Synovitis is common in osteoarthritis (OA) of the knee. In order to evaluate its importance, valid and reliable quantification methods are required. The aim of this study was to compare simple, semiquantitative synovitis scores with detailed volume assessments in subjects with knee OA using magnetic resonance imaging (MRI) as the investigative tool. METHODS: Thirty-five subjects with clinically diagnosed OA of the knee were assessed for synovitis using gadolinium-enhanced MRI. The volume measurement of synovitis was assessed at four sites (medial and lateral parapatellar recesses, intercondylar notch and suprapatellar pouch). The semiquantitative scoring of synovitis was scored on a 0-3 scale. Establishment of a correlative relationship was undertaken using Spearman's rho for the individual site-specific measurements. Ordinal regression modelling was undertaken in order to establish the capacity of the synovitis scoring to predict the volume measurement. RESULTS: A total of 140 sites were assessed. There were good correlations between the semiquantitative scores and the volume measurements, ranging from rho = 0.86 (P < 0.00) for the medial parapatellar recess to rho = 0.71 (P < 0.00) for the lateral parapatellar recess. The ordinal regression suggested that, while the synovitis scores predicted between 50 and 70% (R2 = 0.53, P < 0.00 to R2 = 0.71, P < 0.00) of the volume measurements, there was some minor overlap, particularly in the mid-range synovitis scores. CONCLUSIONS: These results suggest that semiquantitative synovitis scores are valid and will enable feasible evaluation of the synovium in OA cohorts.

The unmet need for anti-tumour necrosis factor (anti-TNF) therapy in ankylosing spondylitis.

OBJECTIVES: Anti-tumour necrosis factor (anti-TNF) therapy is effective in the treatment of ankylosing spondylitis (AS), but guidelines are needed because of the cost. The primary aim of this study was to evaluate the proportion of patients with AS who meet the criteria for anti-TNF therapy as well as to explore the relationship between disease activity, health status and quality of life in patients with AS who would potentially meet the criteria compared with those who would not. METHODS: All patients with a confirmed diagnosis of AS were identified via a search through the clinic correspondence database and sent postal questionnaires. Data captured included demographics, disease activity, aspects of functional impairment, activity limitation and quality of life using the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), pain scores (using a visual analogue scale), the Bath Ankylosing Spondylitis Functional Index (BASFI), Health Assessment Questionnaire (HAQ), short-form 36 (SF-36) and the Ankylosing Spondylitis Quality of Life (ASQoL) questionnaire. The unpaired Student's t-test, chi(2) test and Mann-Whitney U-test were performed for comparisons of groups where appropriate. RESULTS: Out of 325 mailed questionnaires, 246 (76%) were returned. The mean age of the patients who replied to the questionnaire was 52 yr (+/-12 yr) and 25% (62) were females. Mean BASDAI was 49 (+/-24) and 64% had a BASDAI > or = 40. There were significant differences between the groups with a BASDAI above and below 40 in pain by VAS, functional ability (BASFI, HAQ), health status (SF-36) and quality of life (ASQoL). Almost two-thirds (64%) of patients would meet the criteria for anti-TNF therapy under recommended guidelines. CONCLUSION: Patients with AS demonstrated poor functional status and poor quality of life. There is a large unmet need for effective therapy in AS, with almost two-thirds of patients meeting the proposed criteria for biological therapy. Patients with a BASDAI > or = 40 had a worse functional status and quality of life than those who have a BASDAI of <40. These results indicate that the need for effective intervention for AS is a priority area.

Effect of rescuer fatigue on performance of continuous external chest compressions over 3 min.

Guidelines for the performance of cardiopulmonary resuscitation (CPR) have been revised recently and now advocate that chest compressions are performed without interruption for 3 min in patients during asystole and pulseless electrical activity. The aim of the present study was to determine if rescuer fatigue occurs during 3 min of chest compressions and if so, the effects on the rate and quality of compressions. Forty subjects competent in basic life support (BLS) were studied. They performed continuous chest compressions on a Laerdal Skillmeter Resusci-Anne manikin for two consecutive periods of 3 min separated by 30 s. The total number of compressions attempted was well maintained at approximately 100 min(-1) throughout the period of study. However, the number of satisfactory chest compressions performed decreased progressively during resuscitation (P < 0.001) as follows: first min, 82 min(-1); second, 68 min(-1); third, 52 min(-1); fourth, 70 min(-1); fifth, 44 min(-1); sixth, 27 min(-1). We observed significant correlations between the number of satisfactory compressions performed and both height and weight of the rescuer. Female subjects achieved significantly fewer satisfactory compressions compared with males (P = 0.03). Seven subjects (five female, two male) were unable to complete the second 3-min period because of exhaustion. We conclude that rescuer fatigue adversely affects the quality of chest compressions when performed without interruption over a 3-min period and that this effect may be greater in females due to their smaller stature. Consideration should be given to rotating the rescuer performing chest compressions after 1 min intervals.

Inter-segment foot motion and ground reaction forces over the stance phase of walking.

OBJECTIVE: To compare the magnitude and patterns of motion of the rearfoot segment relative to the leg, forefoot segment relative to the rearfoot, height change in the medial longitudinal arch and ground reaction forces of normal adult males during the stance phase of walking. BACKGROUND: Knowledge of normal motion of the rearfoot and forefoot segments and of the arch during stance phase is important in clinical management. METHODS: Motion data were obtained from surface markers, and force data from a force plate, from the right limb of participants while walking at a self-selected pace. RESULTS: Stance phase range of motion across sagittal, frontal and transverse planes was 12 degrees, 4 degrees and 10 degrees for the forefoot, compared to 22 degrees, 8 degrees and 10 degrees for the rearfoot. Most motion occurred at the beginning and end of stance phase when support was via only the rearfoot or forefoot, and when forces were maximal. Arch height decreased from heel contact and increased after heel rise to its maximum at toe-off. CONCLUSIONS: The extent of forefoot segment motion confirms the significance of midfoot joints to normal foot function. Between foot flat and heel rise, the forefoot pattern of motion is indicative of foot stability. Typical foot motion does not obey descriptions of triplanar motion such as 'pronation' and 'supination'. RELEVANCE: Typical stance phase foot motion has been described according to a forefoot:rearfoot model and rearfoot:leg model of motion, together with profiles of medial longitudinal arch height and ground reaction forces. This information can be applied in the management of foot dysfunction and should stimulate research into midfoot motion and overall control of the foot.

Wound healing and infection in nail matrix phenolization wounds. Does topical medication make a difference?

After nail matrix ablation using phenolization, a medicated wound dressing (10% povidone iodine), an amorphous hydrogel dressing (Intrasite Gel), and a control dressing (paraffin gauze) were evaluated. Forty-two participants, randomly divided into three dressing groups, were evaluated. Healing time did not differ between the 10% povidone iodine (33 days), amorphous hydrogel (33 days), and the control dressing (34 days). For all groups, the clinical infection rate was lower than in previous studies, and there was no clinical difference between groups (one infection in the povidone iodine and control groups; none in the amorphous hydrogel group). However, in the amorphous hydrogel group, other complications, such as hypergranulation, were more likely. This investigation indicated that medicated or hydrogel dressings did not enhance the rate of healing or decrease infection rates.

The effect of high-Dye and low-Dye taping on rearfoot motion.

High-Dye and low-Dye taping are commonly used by clinicians to treat a variety of foot and ankle pathologies, particularly those associated with excessive rearfoot pronation. While the effects of taping on end range of motion have been extensively studied, relatively little is understood about the effect of the two styles of taping on rearfoot motion. Eighteen participants were analyzed in three conditions: 1) barefoot, 2) with high-Dye taping, and 3) with low-Dye taping. Two-dimensional motion of the rearfoot was assessed for each condition. The results indicated maximum inversion was increased with both high-Dye and low-Dye taping as compared with no taping. Only high-Dye taping, however, significantly reduced the maximum eversion of the rearfoot. The results suggest that high-Dye taping is an appropriate taping choice when control of eversion of the rearfoot is desired.

Foot orthosis prescription habits of Australian and New Zealand podiatric physicians.

This research project investigated the orthotic prescription habits of podiatric physicians in Australia and New Zealand. A 23-item questionnaire was distributed to all members of the Australian Podiatry Association and the New Zealand Society of Podiatrists. When asked what type of foot orthoses they prescribe most often, 72% of respondents reported functional foot orthoses; the next most common response was prefabricated orthoses (12%). A typical prescription for functional foot orthoses consisted of a modified Root style orthosis, balanced to the neutral calcaneal stance position, with the shell made from polypropylene and an ethyl vinyl acetate (EVA) rearfoot post applied. The majority of podiatric physicians surveyed used a commercial orthotic laboratory to fabricate their orthoses. However, New Zealand respondents were three times more likely to prescribe prefabricated foot orthoses, and males were twice as likely as females to manufacture the orthoses themselves rather than use a commercial orthotic laboratory.

Efficacy of foot orthoses. What does the literature tell us?

This paper reviews the literature relating to foot orthoses, in particular foot orthoses that attempt to alter biomechanical function. Whilst few well-controlled studies have been performed, the findings from the available literature are generally positive. The authors provide an overview of this literature and then summarise the findings. The literature is categorised into six research outcome areas: (i) patient satisfaction, (ii) pain and deformity, (iii) plantar pressures, (iv) position and motion, (v) muscle activity, and (vi) oxygen consumption. In addition, the difficulties associated with researching foot orthoses are discussed.

Syndrome of inappropriate secretion of antidiuretic hormone in malignancy.

OBJECTIVES: To provide a review of pathophysiology, epidemiology, signs and symptoms, diagnosis, treatment, and nursing management of the syndrome of inappropriate secretion of antidiuretic hormone (SIADH) in malignancy. DATA SOURCES: Research reports, review articles, and book chapters relevant to SIADH. CONCLUSIONS: The principle cause of hyponatremia in malignancy is SIADH. Early recognition and prompt treatment can prevent serious neurologic sequelae. Antineoplastic therapy and methods to correct hyponatremia constitute effective treatment strategies. IMPLICATIONS FOR NURSING PRACTICE: Nurses play a major role in nursing assessment, appropriate interventions and symptom control, and promoting resolution of problems and optimal quality of life in patients with malignancy complicated by SIADH.

Lithium as a potential adjuvant to 131I therapy of metastatic, well differentiated thyroid carcinoma.

As lithium inhibits the release of iodine from the thyroid but does not change iodine uptake, it may potentiate 131I therapy of thyroid cancer. The effects of lithium on the accumulation and retention of 131I in metastatic lesions and thyroid remnants were evaluated in 15 patients with differentiated thyroid carcinoma. Two 131I turnover studies were performed while the patients were hypothyroid. One was performed while the patient received lithium; the second served as a control study. From a series of gamma-camera images, it was found that lithium increased 131I retention in 24 of 31 metastatic lesions and in 6 of 7 thyroid remnants. A comparison of 131I retention during lithium with that during the control period showed that the mean increase in the biological or retention half-life was 50% in tumors and 90% in remnants. This increase occurred in at least 1 lesion in each patient and was proportionally greater in lesions with poor 131I retention. When the control biological half life was less than 3 days, lithium prolonged the effective half-life, which combines both biological turnover and isotope decay, in responding metastases by more than 50%. More 131I also accumulated during lithium therapy, probably as a consequence of its effect on iodine release. The increase in the accumulated 131I and the lengthening of the effective half-life combined to increase the estimated 131I radiation dose in metastatic tumor by 2.29 +/- 0.58 (mean +/- SEM) times. These studies suggest that lithium may be a useful adjuvant for 131I therapy of thyroid cancer, augmenting both the accumulation and retention of 131I in lesions.

Video assessment of rearfoot movements during walking: a reliability study.

OBJECTIVE: Rearfoot motion, particularly rearfoot pronation, has been associated with many foot and leg pathologies. The assessment of abnormal rearfoot pronation frequently involves the use of video assessment in both clinical and research settings, but the reliability of this assessment has not been addressed. DESIGN: In this study, 14 participants were videotaped during walking. Five clinicians individually viewed the recordings on two separate occasions and assessed whether the participant's rearfoot motion was abnormal. SETTING: University Gait Analysis Laboratory. PATIENTS OR OTHER PARTICIPANTS: Patients from the university's podiatry clinic were assessed for rearfoot motion by five experienced clinicians. INTERVENTION: Because this was a reliability study, no intervention was undertaken. MAIN OUTCOME MEASURES: Clinicians were asked to assess the videotape of the patients walking and indicate on a 3-point scale if they considered the person to be abnormally pronating. Retest and intertester results were compared. RESULTS: The results indicated that there was poor intertester agreement (kappa = .19). Retest agreement, while slightly higher, varied from poor to fair (kappa = -.12 to kappa = 59). CONCLUSIONS: Although video recordings have been thought to enhance reliability of assessment of rearfoot motion, the results indicated that the exclusive use of video recordings in the assessment of motion of the rearfoot was not reliable.

Blanket use of intranasal mupirocin for outbreak control and long-term prophylaxis of endemic methicillin-resistant Staphylococcus aureus in an open ward.

In December 1992, a thoracic ward in a Melbourne teaching hospital experienced an increase in patients infected with methicillin-resistant Staphylococcus aureus (MRSA). It was decided to attempt to control the outbreak by cohorting positive patients (infected and colonized), as well as nurse cohorting, emphasis on handwashing, and use of intranasal mupirocin initially three times a day for three days, then thrice weekly, for all patients in the ward (with or without MRSA). The campaign comprised for phases of 53, 45, 92 and 365 days, respectively. Patient and nurse cohorting stopped at the end of phase I. In phases I and II, surveillance nose swabs were taken on admission, then twice weekly; in phase III, on admission and weekly and in phase IV, on admission until the end of 1993. In phases I and II (98 days), only one patient acquired MRSA. When the frequency of mupirocin prophylaxis was decreased to once weekly (phase III), two patients acquired MRSA in 92 days (no significant difference): thrice weekly administration resumed (phase IV), during which there were three acquisitions in 365 days. The rates of nose colonization of admissions were 6.4%, 6.3%, 9.7% and 3.1% in phase I-IV, respectively. Only three patients were treated with vancomycin between July 1993 and June 1994 (significantly lower than historical rates, P = 0.0086). No mupirocin resistance was seen in MRSA isolates from this ward during phases I, II and III. In areas of low-level endemic MRSA, the blanket use of thrice-weekly intranasal mupirocin may be effective in decreasing serious infections with MRSA, and does not necessarily elicit mupirocin resistance.

Aspirin and warfarin for thromboembolic disease after total joint arthroplasty.

This study compares the benefits of aspirin and warfarin prophylactic agents for patients with thromboembolic disease after total joint arthroplasty. It is a prospective randomized study of 388 patients having total hip or total knee surgery. All consecutive patients having total hip or total knee surgery were entered into this study and evaluated with preoperative and postoperative ventilation perfusion scans and a postoperative venogram. The aspirin and warfarin treatment groups were compared by size and location of venographically revealed clots and changes in ventilation perfusion scans. The results showed that there was no difference in the size or location of deep venous thrombosis in the aspirin or warfarin treatment groups. The venogram was negative in 44.5% of patients; 28.8% had small ++calf clots, 16% had large calf clots, 3.9% had popliteal clots, and 6.7% had femoral clots. Patients with total knee replacement had a 2.6 times greater incidence of calf deep venous thrombosis than patients with total hip replacement. There was no difference between the aspirin and warfarin groups in the incidence of changes in ventilation perfusion scans (18.9%). There was no difference between the 2 groups in bleeding complications. The results suggest that aspirin and warfarin are equivalent in prophylaxis against thromboembolic disease, as determined by prevention of venographic changes or changes in ventilation perfusion scans.

Nuclear medicine in the diagnosis of deep venous thrombosis and pulmonary embolism.

Nuclear medicine techniques offer a variety of approaches to the diagnosis of deep venous thrombosis and pulmonary embolism. Several radionuclide methods are available to visualize venous structures, and many radiolabeled agents have been developed for direct visualization of blood clots, including platelets and monoclonal antibodies. Although still available on a limited basis, radiolabeled fibrinogen uptake studies have been replaced largely by newer methods. Ventilation-perfusion lung scanning remains the mainstay of nuclear medicine detection of pulmonary embolism as it has for the past two decades.