Radiographs and Corticosteroid Injections at a New Patient Visit for Care of Carpal Tunnel Syndrome and Ulnar Neuropathy at the Elbow.

Introduction The benefit of radiographs or steroid injection for idiopathic carpal tunnel syndrome (CTS) or ulnar neuropathy at the elbow (UNE) is open to debate. We assessed: (1) Radiographs ordered and injections performed at a new patient visit for patients presenting with either idiopathic CTS or UNE; (2) The estimated payment reduction if we omit these interventions; and (3) Patient age, sex, geographic region, and work status associated with radiographs or injections at a new patient visit for patients presenting with either idiopathic CTS or UNE. Materials and Methods Using a large database of commercial insurance claims, we identified patients with a new visit for either CTS ( N = 9,522), UNE ( N = 2,507), or both ( N = 962; 8.7%). We identified injections and radiographs, and estimated total payments for these interventions. We created three multivariable logistic regression models for each diagnosis to identify factors associated with the interventions. Results Nearly one third of patients had radiographs at a new patient visit (30% and 32% for idiopathic CTS and UNE, respectively). Nearly 10% of patients with CTS and 2.6% with UNE received an injection. Both radiographs and injections representing annual minimum payments of over $345,000 and $294,000, respectively. Among people with CTS, radiographs were independently more common in the South and less common in the West. Injection for CTS was associated with younger age; North, Central, and South regions; and retired employment status. For people with UNE, radiographs were independently associated with younger age; South or West region; and retired or working employment status. Injection for UNE was associated with retired employment status. Conclusion The prevalence of radiographs and injections suggests opportunities for savings, which might benefit clinicians with bundled or capitated payments and patients with large copayments or deductibles. The observed variation may reflect debate about whether these interventions are worthwhile. Level of Evidence Diagnostic; Retrospective Database Level III study.

Agreement on fixation of pediatric supracondylar humerus fractures.

BACKGROUND: Pediatric supracondylar humerus fractures (pSCHFs) may be challenging injuries to treat because of the potential residual deformity. There is debate regarding the technical aspects of adequate closed reduction and crossed Kirschner wire (K-wire) fixation. PURPOSE: Do surgeons have an agreement on the aspects of the fixation of pSCHFs? METHODS: Radiographs of 20 patients from a cohort of 154 patients with pSCHFs treated with closed reduction and crossed K-wire fixation were selected. Forty-four surgeons viewed the postoperative radiographs and diagnosed the presence or absence of technical flaws and made a recommendation for or against reoperation. An expert panel of three orthopedic and trauma surgeons provided a reference standard for technical factors. Furthermore, final outcome 2 years after trauma was assessed. RESULTS: There was limited agreement on potential technical flaws (ICC 0.15-0.28), radiographic measures of alignment (ICC for anterior humeral line and Baumann angle of 0.37 and 0.23 respectively), the quality of postoperative reduction, position of the elbow in cast, and recommendation for repeat surgery (ICCs between 0.23 and 0.40). Sensitivity and specificity for these questions ranged from 0.59 to 0.90. There was no correlation between the voted quality of postoperative reduction and loss of reduction or final function. CONCLUSIONS: Surgeons have limited agreement on the quality of postoperative results in pSCHFs and the indication for reoperation. Reviewing postoperative radiographs may present a good learning opportunity and could help improve skills, but it is not a validated method for quality control and has to be seen in light of clinical outcome.

Patient and Clinician Perceptions about Remote Video Visits for Musculoskeletal Problems: A Qualitative Study.

BACKGROUND: An understanding of patient and clinician opinions about remote video musculoskeletal consultations might help determine how to increase appeal and utilization. The purpose of this study was to evaluate perceptions of remote video musculoskeletal consultations. Our research questions was what are patient and clinician facilitators and barriers for the use of remote video consultations? METHODS: Prior to the COVID-19 pandemic 27 English speaking adult patients seeking ambulatory care for a musculoskeletal problem, and 10 English-speaking musculoskeletal clinicians were interviewed using a guide. Interviews were audio-recorded, transcribed, and coded using applied thematic analysis. RESULTS: Patient and clinician incentives for remote video consultations included increased convenience, lower costs, less waiting time, and a better experience. Patient and clinician barriers to remote video consultations included concerns about familiarity with technology, lack of personal interaction and physical examination, inability to perform procedures, difficulties with reimbursement (clinicians), as well as technical, logistical, and privacy issues. CONCLUSION: This qualitative study performed prior to the pandemic found that adoption of remote video consultation for musculoskeletal problems may improve with seamless, efficient, and effective care, at an affordable price, particularly if the human connection is similar to what occurs in person.

Development of a Short Form of the Negative Pain Thoughts Questionnaire (NPTQ).

BACKGROUND: Thoughts affect pain intensity and the magnitude of activity intolerance for a given nociception. The Negative Pain Thoughts Questionnaire (NPTQ) measures common unhelpful cognitive biases regarding pain. A shorter version of the NPTQ could be used in daily practice to improve health by identifying important misconceptions. METHODS: One hundred and thirty-seven patients seeking specialty musculoskeletal care completed questionnaires addressing demographics, negative pain thoughts, worst-case thinking, resiliency, the magnitude of self-reported activity intolerance, and pain intensity. Patients were randomly allocated to a learning cohort (110 patients, 80%) and a validation cohort (27 patients, 20%). Based on factor analysis of the learning cohort, 4 questions were selected to create the NPTQ short form (NPTQ-SF). Floor and ceiling effects of the NPTQ and NPTQ-SF were analyzed. Psychometric properties of the NPTQ-SF were tested with use of Spearman correlations with the NPTQ. The internal consistency of the NPTQ and NPTQ-SF was analyzed with use of the Cronbach α coefficient. To test external validity, we calculated Spearman correlations with pain intensity, activity intolerance, the Pain Catastrophizing Scale, and the Brief Resiliency Scale in the validation cohort. RESULTS: The Cronbach α was 0.90 for the NPTQ and 0.85 for the NPTQ-SF. The Spearman correlation between NPTQ and NPTQ-SF scores was 0.91 in the learning cohort and 0.93 in the validation cohort. In the validation cohort, there was no difference in the strength of the correlations of the NPTQ and NPTQ-SF with other questionnaires. CONCLUSIONS: These findings support the use of a brief, 4-question measure of unhelpful cognitive biases regarding pain in both research and patient care. The NPTQ-SF would benefit from external validation in an independent cohort. CLINICAL RELEVANCE: The notable influence of common misconceptions (i.e., cognitive bias) on musculoskeletal symptoms can be measured with a brief questionnaire and used as a point of discussion with patients.

Factors Associated with Patient Willingness to Conduct a Remote Video Musculoskeletal Consultation.

BACKGROUND: Remote video consultations on musculoskeletal illness are relatively convenient and accessible, and use fewer resources. However, there are concerns about technological and privacy issues, the possibility of missing something important, and equal access to all patients. We measured patient characteristics associated with willingness to conduct a remote video musculoskeletal upper extremity consultation. METHODS: One hundred and five patients seeking specialty musculoskeletal care completed questionnaires addressing (1) demographics, (2) access to a device, internet, and space to conduct a remote video consultation, (3) health literacy, (4) pain intensity, (5) magnitude of limitations of the upper extremity, (6) self-efficacy, and (7) rated willingness to conduct a remote video musculoskeletal consultation (11-point ordinal scale). A multivariable linear regression analysis sought factors independently associated with patient willingness to conduct remote video musculoskeletal upper extremity consultations. RESULTS: Patient education level (4 years of college) and accessibility to a space suitable for remote video consultations were independently associated with interest in remote video consultations. Sociodemographic factors, health literacy, accessibility to a device or internet, and amount of perceived pain and disability were not. CONCLUSION: We speculate that education level and suitable space might be surrogates for trust and privacy concerns. Future research might measure the ability of interventions to gain trust and ensure privacy to increase willingness to engage in remote video musculoskeletal consultations.

Patient and clinician incentives and barriers for opioid use for musculoskeletal disorders a qualitative study on opioid use in musculoskeletal setting.

INTRODUCTION: Strategies for pain alleviation have relied heavily on opioids in the recent decades. One consequence is a crisis of opioid misuse, overdose, and overdose related death. This study sought patient and clinician incentives and barriers to the use of opioids in musculoskeletal illness. METHODS: In this qualitative study, twenty-eight patients and eight clinicians participated in a semi-structured interview seeking incentives and barriers for opioid use and prescription in musculoskeletal illness. Interviews were conducted by a trained qualitative interviewer. The interview data were transcribed and analyzed using a thematic analysis framework. RESULTS: Patient incentives for opioid use included doctor's orders, opioids being the only effective way to alleviate pain, alleviating symptoms of depression and anxiety, being able to keep a job, and lower cost of opioids relative to alternative treatment options. Patient barriers included associated risks (side effects, addiction) and wanting to control pain intensity. Clinician incentives for prescribing opioids included adequate pain alleviation, patient satisfaction, relatively inexpensive costs of opioids, convenience and doing what was taught by the clinician's superior. Lacking time and resources to adequately inform patients on appropriate opioid use and alternative treatments, likely results in more opioid prescribing than arguably necessary. Barriers for opioid prescribing included specific patient characteristics (psychiatric background, history of opioid misuse) and illness characteristics (nature of the injury, medical contra-indications). CONCLUSION: Patients feel that opioids should be used with caution. Clinicians in this study reported a tendency to default to opioids out of habit and convenience. Both patients and clinicians were aware that opioids are often misused to treat emotional pain.

Predictive value of cytokines for developing complications after polytrauma.

AIM: To investigate posttraumatic cytokine alterations and their value for predicting complications and mortality in polytraumatized patients. METHODS: Studies on the use of specific cytokines to predict the development of complications and mortality were identified in MEDLINE, EMBASE, Web of Science and the Cochrane Library. Of included studies, relevant data were extracted and study quality was scored. RESULTS: Forty-two studies published between 1988 and 2015 were identified, including 28 cohort studies and 14 "nested" case-control studies. Most studies investigated the cytokines interleukin (IL)-6, IL-8, IL-10 and tumor necrosis factor (TNF-α). IL-6 seems related to muliorgan dysfunction syndrome, multiorgan failure (MOF) and mortality; IL-8 appears altered in acute respiratory distress syndrome, MOF and mortality; IL-10 alterations seem to precede sepsis and MOF; and TNF-α seems related to MOF. CONCLUSION: Cytokine secretion patterns appear to be different for patients developing complications when compared to patients with uneventful posttraumatic course. More research is needed to strengthen the evidence for clinical relevance of these cytokines.