Associations among preoperative MRI features and functional status following arthroscopic partial meniscectomy.

BACKGROUND: Arthroscopic partial meniscectomy (APM) is the most frequently performed orthopedic procedure. Functional outcomes of APM are variable, particularly among patients with underlying knee osteoarthritis. While most patients undergoing APM have knee magnetic resonance imaging (MRI) performed preoperatively, the prognostic value of knee MRI in predicting the functional outcomes of APM has not been evaluated. METHODS: We studied patients who had APM performed by one of five participating surgeons at one institution in 2002. The preoperative MRI scans of these patients were assessed using a standardized rating system by an independent observer who was not involved in the care of the patients and who was blinded to patient outcomes. Patients completed a questionnaire in the summer of 2003, 6-18 months postoperatively. The questionnaire included the Knee Injury and Osteoarthritis Outcome Score (KOOS) and items on satisfaction with the results of surgery. We used bivariate and multivariate techniques to evaluate the associations between MRI findings, other preoperative findings, and the functional status and pain scales of the KOOS. RESULTS: Eighty-three patients were included in the analyses. The outcome of surgery was variable with average KOOS functional score of 77 and range of 15-100. One-quarter of patients were somewhat or very dissatisfied with the results of surgery and 17% were using a cane at the time of follow-up. In bivariate analyses, preoperative predictors of KOOS function score at follow-up included preoperative functional status and several MRI findings including the extent of cartilage damage, bone marrow edema in the medial compartment, and length of the tear. Multivariate analyses showed that after adjusting for preoperative functional status, the extent of cartilage signal abnormality in the medial compartment on MRI remained an independent predictor of functional status, 6-18 months following surgery. Specifically, preoperative functional status explained 21% of the variability in follow-up KOOS functional status score and the extent of medial tibial cartilage damage on MRI explained an additional 16%. Analyses of knee pain 1 year following APM yielded similar findings, with preoperative functional status accounting for 17% of the variability in pain scores and medial tibial cartilage damage accounting for an additional 13%. CONCLUSIONS: Preoperative MRI findings of cartilage damage have independent prognostic value in predicting the functional outcome of APM. This study was limited by a cross-sectional design with retrospective recall of preoperative functional status. Thus, the findings need to be confirmed in prospective investigations.

Predictors of outcomes of carpal tunnel release.

OBJECTIVE: To identify factors that are predictive of the outcomes of greatest importance to patients-i.e., symptom relief, functional improvement, and satisfaction with the outcomes of surgery-following carpal tunnel release. METHODS: We analyzed data from the Maine Carpal Tunnel Study, a community-based study of the outcomes of treatment for carpal tunnel syndrome. In a cohort of patients who underwent carpal tunnel release, a preoperative physical examination was performed and questionnaires were completed preoperatively and at 6, 18, and 30 months postoperatively. The questionnaires assessed symptom severity, upper extremity functional limitations, mental health, general physical health status, the relative severity of individual symptoms, satisfaction with the results of surgery, sociodemographic factors, and for those subjects who were in the workforce, aspects of the work environment. The associations between preoperative factors and the 3 principal outcomes (symptom severity, upper extremity functional limitations, and satisfaction with the results of surgery, all evaluated at 18 months postoperatively) were assessed with bivariate and multivariate linear regression and logistic regression analyses. RESULTS: Two hundred forty-one subjects were enrolled and 188 (78%) completed followup surveys 18 months postoperatively. Two-thirds of the patients reported being completely or very satisfied with the outcomes of surgery at 6, 18, and 30 months postoperatively. A range of clinical and work-related variables were associated with outcomes. In multivariate analyses, greater preoperative upper extremity functional limitation was predictive of greater functional limitations postoperatively. Worse mental health status was significantly associated with more severe symptoms and lower satisfaction. Alcohol use was also associated with more severe symptoms and lower satisfaction. Among workers, involvement of an attorney was significantly associated with greater functional limitation, more severe symptoms, and lower satisfaction. Recipients of worker's compensation who did not hire an attorney had generally good outcomes. Of note, physical examination parameters were not predictive of the outcomes of surgery. CONCLUSION: The outcomes of carpal tunnel release in community-based practices are excellent. Predictors of the outcomes of surgery are disease-specific and generic clinical factors as well as work-related factors. The strongest predictors of less favorable outcomes are worse scores on patient-reported measures of upper extremity functional limitation and mental health status, alcohol use, and the involvement of an attorney. Clinicians should carefully evaluate patients' functional status, mental health status, health habits, and attorney involvement prior to performing carpal tunnel release, and discuss with patients the prognostic implications of these parameters.

Measuring the whole or the parts? Validity, reliability, and responsiveness of the Disabilities of the Arm, Shoulder and Hand outcome measure in different regions of the upper extremity.

UNLABELLED: The Disabilities of the Arm, Shoulder and Hand (DASH) outcome measure was developed to evaluate disability and symptoms in single or multiple disorders of the upper limb at one point or at many points in time. PURPOSE: The purpose of this study was to evaluate the reliability, validity, and responsiveness of the DASH in a group of diverse patients and to compare the results with those obtained with joint-specific measures. METHODS: Two hundred patients with either wrist/hand or shoulder problems were evaluated by use of questionnaires before treatment, and 172 (86%) were re-evaluated 12 weeks after treatment. Eighty-six patients also completed a test-retest questionnaire three to five days after the initial (baseline) evaluation. The questionnaire package included the DASH, the Brigham (carpal tunnel) questionnaire, the SPADI (Shoulder Pain and Disability Index), and other markers of pain and function. Correlations or t-tests between the DASH and the other measures were used to assess construct validity. Test-retest reliability was assessed using the intraclass correlation coefficient and other summary statistics. Responsiveness was described using standardized response means, receiver operating characteristics curves, and correlations between change in DASH score and change in scores of other measures. Standard response means were used to compare DASH responsiveness with that of the Brigham questionnaire and the SPADI in each region. RESULTS: The DASH was found to correlate with other measures (r > 0.69) and to discriminate well, for example, between patients who were working and those who were not (p<0.0001). Test-retest reliability (ICC = 0.96) exceeded guidelines. The responsiveness of the DASH (to self-rated or expected change) was comparable with or better than that of the joint-specific measures in the whole group and in each region. CONCLUSIONS: Evidence was provided of the validity, test-retest reliability, and responsiveness of the DASH. This study also demonstrated that the DASH had validity and responsiveness in both proximal and distal disorders, confirming its usefulness across the whole extremity.

Lyme disease and preventive behaviors in residents of Nantucket Island, Massachusetts.

BACKGROUND: To determine the age-specific prevalence of Lyme disease and whether preventive behaviors on Nantucket Island correlate with Lyme disease, we surveyed island residents. METHODS: A survey with questions on Lyme disease symptoms, history, and preventive behaviors was mailed to all residents. Respondents were stratified by likelihood of having had Lyme disease. A subsample was selected for examination, and then classified according to the Lyme disease national surveillance case definition. RESULTS: The overall lifetime prevalence of Lyme disease for Nantucket residents was 15% (CI, 10%-19.8%): 19% among females, and 11% among males. The prevalence was highest among age groups 0-16 and 30-49 years. Overall, 86% of the population practiced at least one behavior. The most frequently reported preventive behavior was checking oneself for ticks (80%), followed by wearing protective clothing (53%), avoiding tick areas (34%), and using tick repellent (11%). Younger individuals practiced fewer preventive behaviors than older individuals (p=0.001). Although males reported greater tick exposure than females, females uniformly practiced preventive behaviors more frequently (p=0.001). The practice of preventive behaviors was not associated with a history of Lyme disease, but finding more than 5 ticks per year on oneself was (p=0.001). CONCLUSION: Lyme disease is highly prevalent on Nantucket Island. Young people are particularly at risk and health education should emphasize preventive behaviors less frequently practiced: using tick repellent, avoiding tick areas, and wearing protective clothing.

Coexposure to Borrelia burgdorferi and Babesia microti does not worsen the long-term outcome of lyme disease.

Previous studies suggest that concurrent Lyme disease and babesiosis produce a more sever illness than either disease alone. The majority of babesiosis infections, however, are subclinical. Our objective was to characterize on the basis of a total-population survey of Nantucket Island, Massachusetts, whether coexposure to Lyme disease and babesiosis causes more severe illness or poorer long-term outcomes than Lyme disease alone. In this retrospective cohort study, residents indicating a history of Lyme disease were compared with randomly selected population controls on a standardized medical history, blinded physical examination, and serological studies for Borrelia burgdorferi and Babesia microti. Serological evidence of exposure to babesiosis was not associated with increased severity of acute Lyme disease. The groups did not differ with regard to the prevalence of constitutional, musculoskeletal, or neurological symptoms a mean of 6 years after acute Lyme disease. Prior Lyme disease and serological exposure to B. microti are not associated with poorer long-term outcomes or more persistent symptoms Lyme disease alone.

Musculoskeletal and neurologic outcomes in patients with previously treated Lyme disease.

BACKGROUND: Previous follow-up studies of patients with Lyme disease suggest that disseminated infection may be associated with long-term neurologic and musculoskeletal morbidity. OBJECTIVE: To determine clinical and functional outcomes in persons who were treated for Lyme disease in the late 1980s. DESIGN: Population-based, retrospective cohort study. SETTING: Nantucket Island, Massachusetts. PARTICIPANTS: 186 persons who had a history of Lyme disease (case-patients) and 167 persons who did not (controls). MEASUREMENTS: Standardized medical history, physical examination, functional status measure (Medical Outcomes Study 36-item Short Form Health Survey [SF-36]), mood state assessment (Profile of Mood States), neurocognitive tests, and serologic examination. RESULTS: The prevalence of Lyme disease among adults on Nantucket Island was estimated to be 14.3% (95% CI, 9.3% to 19.1%). In multivariate analyses, persons with previous Lyme disease (mean time from infection to study evaluation, 6.0 years) had more joint pain (odds ratio for having joint pain in any joint, 2.1 [CI, 1.2 to 3.5]; P = 0.007), more symptoms of memory impairment (odds ratio for having any memory problem, 1.9 [CI, 1.1 to 3.5]; P = 0.003), and poorer functional status due to pain (odds ratio for 1 point on the SF-36 scale, 1.02 [CI, 1.01 to 1.03]; P < 0.001) than persons without previous Lyme disease. However, on physical examination, case-patients and controls did not differ in musculoskeletal abnormalities, neurologic abnormalities, or neurocognitive performance. Persons with previous Lyme disease who had persistent symptoms after receiving treatment (n = 67) were more likely than those who had completely recovered to have had fever, headache, photosensitivity, or neck stiffness during their acute illness (87% compared with 13%; odds ratio, 2.4 [CI, 1.0 to 5.5]; P = 0.045); however, the performance of the two groups on neurocognitive tests did not significantly differ. CONCLUSIONS: Because persons with previous Lyme disease exhibited no sequelae on physical examination and neurocognitive tests a mean of 6.0 years after infection, musculoskeletal and neurocognitive outcomes seem to be favorable. However, long-term impairment of functional status can occur.

Predictors of surgical outcome in degenerative lumbar spinal stenosis.

STUDY DESIGN: A prospective, observational study. OBJECTIVES: To identify outcome predictors of surgery for degenerative lumbar spinal stenosis. SUMMARY OF BACKGROUND DATA: Degenerative lumbar spinal stenosis is the most frequent indication for spine surgery in the elderly. More than 25% of surgical patients have a poor outcome, yet little is known about factors that predict the outcome of surgery. METHODS: Surgery was performed on 199 patients with degenerative lumbar spinal stenosis, and they were observed for 2 years after surgery in four referral centers. Surgery consisted of decompressive laminectomy with or without arthrodesis. Outcomes included validated measures of symptom severity, walking capacity, and satisfaction with the results of surgery. Potential predictors of outcome included sociodemographic factors and physical examination, as well as radiographic, psychological, social, and clinical history variables. RESULTS: The proportion of patients with severe pain decreased from 81% before surgery to 31% by 2 years afterward. The most powerful preoperation predictor of greater walking capacity, milder symptoms, and greater satisfaction was the patient's report of good or excellent health before surgery. Low cardiovascular comorbidity also predicted a favorable outcome. CONCLUSIONS: Patient's assessments of their own health and comorbidity are the most cogent outcome predictors of surgery for spinal stenosis.

Rheumatologist-patient communication about exercise and physical therapy in the management of rheumatoid arthritis.

OBJECTIVE: Little is known about the features and role of exercise discussions between rheumatologists and patients. The goals of this study were to: 1) describe rheumatologists' and patients' attitudes and beliefs regarding exercise and physical therapy for rheumatoid arthritis (RA); 2) describe frequency and length of exercise discussions; 3) determine the accuracy of recall for exercise discussions; and 4) assess the influence of attitudes regarding exercise on communication about exercise. METHODS: Goals 1-3 were addressed with analysis of baseline questionnaires and audiotaped encounters. The influence of attitudes and beliefs regarding exercise on the frequency and length of exercise discussions was assessed prospectively. Patients and rheumatologists were enrolled from a large tertiary care institution. Clinical encounters were audiotaped, transcribed, coded, and analyzed to identify specific characteristics of the exercise discussions. RESULTS: One hundred thirty-two patients and 25 rheumatologists participated in the study. Rheumatologists and patients discussed exercise in 53% of the encounters. Rheumatologists' beliefs regarding the usefulness of exercise for RA varied, with the least positive beliefs being reported for aerobic exercise. Exercise discussions were more likely to occur if the patient was currently exercising, odds ratio (OR) = 2.4; 95% confidence interval (CI) (1.2-4.9), and when the rheumatologist believed aerobic exercises were useful in managing RA, OR = 1.4; 95% CI (1.1-1.9). Current exercise behavior was associated with patients' positive attitude toward exercise (chi 2 1 = 8.4; P = 0.004) and perceived social support for exercise (chi 2 1 = 4.5; P = 0.04). When rheumatologists initiated exercise discussions, there was nearly twice as much discussion (beta = -8.4; P = 0.001). CONCLUSIONS: Exercise talk was influenced by patients' and rheumatologists' beliefs and attitudes regarding the effectiveness of exercise and physical therapy in managing RA, patient experience with exercise, and by characteristics of the rheumatologist.

Outcomes of total hip and knee replacement: preoperative functional status predicts outcomes at six months after surgery.

OBJECTIVE: To determine whether patients with knee or hip osteoarthritis (OA) who have worse physical function preoperatively achieve a postoperative status that is similar to that of patients with better preoperative function. METHODS: This study surveyed an observational cohort of 379 consecutive patients with definite OA who were without other inflammatory joint diseases and were undergoing either total hip or knee replacement in a US (Boston) and a Canadian (Montreal) referral center. Questionnaires on health status (the Short Form 36 and Western Ontario and McMaster Universities Osteoarthritis Index) were administered preoperatively and at 3 and 6 months postoperatively. Physical function and pain due to OA were deemed the most significant outcomes to study. RESULTS: Two hundred twenty-two patients returned their questionnaires. Patients in the 2 centers were comparable in age, sex, time to surgery, and proportion of hip/knee surgery. The Boston group had more education, lower comorbidity, and more cemented knee prostheses. Patients undergoing hip or knee replacement in Montreal had lower preoperative physical function and more pain than their Boston counterparts. In patients with lower preoperative physical function, function and pain were not improved postoperatively to the level achieved by those with higher preoperative function. This was most striking in patients undergoing total knee replacement. CONCLUSION: Surgery performed later in the natural history of functional decline due to OA of the knee, and possibly of the hip, results in worse postoperative functional status.

The natural history of exercise-induced anaphylaxis: survey results from a 10-year follow-up study.

BACKGROUND: Exercise-induced anaphylaxis (EIA) is a unique physical allergy that is triggered by exertion, the clinical spectrum and modifying factors of which have been previously studied. At the time of initial description, it was postulated that other factors contributed to this disorder. OBJECTIVE: We sought to determine the clinical course and potential modifying factors in EIA. METHODS: In 1993, we conducted a cross-sectional analysis of 671 individuals with exercise-associated symptoms for more than a decade using a validated 75-item questionnaire. Subjects met criteria for EIA if they had anaphylactic symptoms, including hypotension or upper airway obstruction, urticaria, or angioedema with physical exertion but without a passive increase in core body temperature. RESULTS: Of 365 (54%) questionnaire respondents, 279 (87%) met criteria for EIA (199 females and 80 males). At the time of study entry, subjects with EIA (mean age, 37.5 years; range, 13 to 77 years) had an average of 10.6 years of symptoms, which were most frequently triggered by aerobic activities such as jogging or brisk walking (78% and 42%, respectively). On average, subjects reported that the frequency of attacks had decreased (47% of subjects) or stabilized (46% of subjects) since onset. One hundred (41%) subjects reported being completely free of attacks in the past year. Subjects reduced their attacks by avoiding exercise during extremely hot or cold weather (44%), avoiding ingestion of certain foods before exercise (37%), and restricting exercise during their allergy season (36%) or humid weather (33%). The most common pharmacologic agents used to manage symptoms were H1 antagonists (56%) and/or epinephrine (31%). However, 28% used no treatment at all. CONCLUSION: EIA is an episodic condition in which the frequency of attacks tends to stabilize or decrease over time. Improvement appears to result from individual modification of exercise and avoidance of known environmental and ingestible precipitants.

Outcomes of children treated for Lyme disease.

OBJECTIVE: To study the outcome of Lyme disease (LD) in children identified in a total population survey of an endemic island. METHODS: We conducted a population-based retrospective cohort study off the coast of Massachusetts. Twenty-five children who met the Centers for Disease Control case definition for prior LD were compared with 26 children without LD from the same community. All children with LD received antibiotics during the acute phase of their disease. All 51 children were invited for a clinical evaluation, including 12-lead electrocardiogram (EKG), and measurement of antibodies to Borrelia burgdorferi by antibody-capture ELISA and Western blot. RESULTS: At a mean of 3.2 years from the initial manifestation of LD, children with prior LD did not have a higher prevalence of musculoskeletal or neurological symptoms, examination abnormalities, abnormal EKG, or behavioral difficulties, compared to children with no history of LD. CONCLUSION: Children who receive appropriate antimicrobial therapy for LD appear to have no demonstrable longterm morbidity.

The POSNA pediatric musculoskeletal functional health questionnaire: report on reliability, validity, and sensitivity to change. Pediatric Outcomes Instrument Development Group. Pediatric Orthopaedic Society of North America.

The goal of orthopaedic interventions is to improve the functional health of patients, particularly physical function. The American Academy of Orthopaedic Surgeons and the Pediatric Orthopaedic Society of North America (POSNA) commissioned a work group to construct functional health outcomes scales for children and adolescents, focusing on musculoskeletal health. The work group developed scales assessing upper extremity function, transfers and mobility, physical function and sports, comfort (pain free), happiness and satisfaction, and expectations for treatment. Parent and adolescent self-report forms were developed and tested on 470 subjects aged 2-18 years. The POSNA scales demonstrated good reliability, construct validity, sensitivity to change over a 9-month period, and ability to outperform a standard instrument, the Child Health Questionnaire physical functioning scale. They were useful for a wide variety of ages and diagnoses. They appear to be ideally suited for orthopaedic surgeons to assess the functional health and efficacy of treatment of their patients at baseline and follow-up.

The prognostic importance of patient pre-operative expectations of surgery for lumbar spinal stenosis.

UNLABELLED: The influence of psychosocial variables in the outcome of surgery for lumbar stenosis (LSS) has not been evaluated. We studied 257 patients with LSS pre-operatively and at 6 months to: (a) relate patient expectations of surgery to baseline function and pain; and (b) determine how patient expectations and pre-operative function interact to predict post-operative outcomes. RESULTS: On average, patients experienced substantial pain relief, improved function and satisfaction. Patients with many pre-operative expectations, particularly patients with low baseline function, reported more improvement in post-operative function than patients with few expectations. More ambitious expectations for physical function were also associated with improved function and satisfaction at 6 months. Conversely, having more numerous pain relief expectations was associated with more pain and less satisfaction with pain relief. CONCLUSION: Patient expectations influence recovery from surgery at 6 months. To improve outcomes and satisfaction, clinicians should discuss expectations with patients pre-operatively.

Maine Carpal Tunnel Study: outcomes of operative and nonoperative therapy for carpal tunnel syndrome in a community-based cohort.

A prospective, community-based, observational study of the outcome of surgical and nonoperative management was conducted. The study included 429 patients with carpal tunnel syndrome recruited in physicians' offices throughout Maine. Patients were assessed at baseline and at 6, 18, and 30 months following presentation using validated scales that measured symptom severity, functional status, and satisfaction. Seventy-seven percent of eligible survivors from the original cohort were monitored for 30 months. Surgically treated patients demonstrated improvements of 1.2 to 1.6 points on the 5-point Symptom Severity and Functional Status scales (23% to 45% improvement in scores), which persisted over the 30-month follow-up period. The nonoperatively managed patients showed little change in clinical status at 6, 18, and 30 months. While workers' compensation recipients had worse outcomes than nonrecipients, 36 of 68 (53%) workers' compensation recipients were completely or very satisfied with the results of the procedure 30 months after surgery. There were no significant differences in outcome between patients treated with endoscopic versus open carpal tunnel release. Among worker's compensation recipients, 12 of 68 (18%) surgical patients and 4 of 32 (13%) nonoperatively treated patients remained out of work because of carpal tunnel syndrome at 30 months. Thus, carpal tunnel surgery offered excellent symptom relief and functional improvement in this prospective community-based sample, irrespective of the surgical approach, even in workers' compensation recipients. Work absence remained high in both surgically and nonoperatively managed workers' compensation recipients.

Prevalence and predictors of long-term work disability due to carpal tunnel syndrome.

The objective of this study was to describe patterns and predictors of work absence in the prospective, community-based Maine Carpal Tunnel Study. Three hundred fifteen patients with carpal tunnel syndrome (CTS) were recruited from physicians' offices throughout Maine. The patients completed questionnaires at entry and after 6, 18, and 30 months. The questionnaires included scales measuring symptom severity, functional status, general and mental health status, exposure to physical stressors, work status, and other indicators. The analyses examined univariate and multivariate correlates of work absence. The mean age was 43, 72% of subjects were female, 71% underwent carpal tunnel release, and 45% were receiving Workers' Compensation. Fifty-two percent worked in managerial or technical occupations, 15% in service occupations, and 13% in heavy labor or machine operation. Forty-five percent of patients changed jobs or were absent from work (aside from postoperative recovery) during the 30-month follow-up. In multivariate logistic regression models, correlates of work absence at 18 months included worse functional status of the hand at study entry and at 6-month follow-up, involvement of an attorney at the time of enrollment (P < 0.002 for each), and work absence at 6 months (P = 0.03). Worse upper extremity functional status and having a contested Workers' Compensation claim are critical predictors of work absence and should be principal targets of interventions to reduce work disability in CTS.

A placebo controlled crossover trial of subcutaneous salmon calcitonin in the treatment of patients with fibromyalgia.

The objective of this study was to evaluate the relative efficacy and tolerability of subcutaneously (s.c.) administered salmon calcitonin (sCT) in the treatment of patients with fibromyalgia. Eleven patients who fulfilled the American College of Rheumatology classification criteria for fibromyalgia were studied in a double-blind, crossover trial in which they alternatively received salmon calcitonin (100 IU s.c.) and isotonic saline (1 cc s.c.) for four weeks, with a four weeks wash-out period between the treatments. None of the 11 outcomes measures (seven analog scales, dolorimetry score, and three SIP scores) showed a significant improvement with sCT. The principal side effect observed with sCT was nausea in ten patients and erythema in four patients. These data suggest that sCT given at a dose of 100 IU daily for one month is not effective in the treatment of fibromyalgia.

Comparative responsiveness of generic versus disease-specific and weighted versus unweighted health status measures in carpal tunnel syndrome.

OBJECTIVES: The authors evaluated the relative responsiveness to change of generic versus disease-specific and unweighted versus weighted health status measures in carpal tunnel syndrome (CTS). METHODS: Data were obtained from 196 subjects followed in a prospective community-based cohort study in Maine who underwent carpal tunnel release (The Maine Carpal Tunnel Syndrome Study). Patients were evaluated before and 6 months after surgery. The disease-specific, unweighted severity score was derived from the validated Carpal Tunnel Syndrome Assessment Questionnaire. Patients were asked to rate the importance of each symptom included in the severity score. Each severity question was weighted by its importance, creating a disease-specific weighted score. Generic instruments were the SF-36, SF-12, and a Quality of Life Rating Scale. Sensitivity to change was calculated with the standardized response mean (SRM, mean change/standard deviation of change) as well as the effect size (ES, mean change/standard deviation of baseline values). The ability of the instruments to distinguish clinically important differences was assessed by correlating the changes in scores with global ratings on satisfaction and perceived improvement as external criteria. RESULTS: The disease-specific weighted score (SRM: 1.56, ES: 1.99) was more responsive than the unweighted score (SRM: 1.36, ES: 1.57). The Quality of Life Rating Scale, SF-36, and SF-12 subscales were less sensitive to change, with standardized response means and effect sizes that ranged from -0.23 to 0.88. The ability to distinguish clinically important differences was higher for the two disease-specific scales. The coefficients of correlation with the external criteria ranged from 0.50 to 0.56 for the unweighted score and 0.56 to 0.62 for the weighted score and were significantly stronger than the correlations between external measures and the most responsive subscale of the SF-36 (Bodily Pain subscale, r = 0.36). The SF-12 health survey performed as well as the SF-36 in term of responsiveness and ability to distinguish clinically important change. CONCLUSIONS: Disease-specific measures were superior to generic measures in capturing clinical change after carpal tunnel release, and a weighted score was slightly more responsive than the unweighted score. The SF-12 showed comparable psychometric properties compared with the longer 36-item Short-Form Survey.

Lack of cardiac manifestations among patients with previously treated Lyme disease.

BACKGROUND: Cardiac involvement is common in acute Lyme disease, and case reports suggest that cardiac abnormalities might also occur years after the primary infection. OBJECTIVE: To determine the prevalence of cardiac abnormalities in persons with previously treated Lyme disease. DESIGN: Population-based, retrospective cohort study with controls. SETTING: Nantucket Island, Massachusetts. PARTICIPANTS: From among 3703 adult respondents to a total-population (n = 6046) mail survey, 336 (176 case-patients and 160 controls) were randomly selected for clinical evaluation. MEASUREMENTS: Current cardiac symptoms and major or minor abnormal electrocardiographic features, including heart rate; rhythm; axis; PR, QRS, and QT intervals; QRS structure; atrioventricular blocks; and ST-segment and T-wave changes. RESULTS: Persons with Lyme disease (case-patients, n = 176) (mean duration from disease onset to study evaluation, 5.2 years) and persons without evidence of previous Lyme disease (controls, n = 160) did not differ significantly in their patterns of current cardiac symptoms and electrocardiographic findings, including heart rate (P > 0.2), PR interval (P = 0.15), QRS interval (P > 0.2), QT interval (P > 0.2), axis (P > 0.2), presence of arrhythmias (P > 0.2), first-degree heart block (P = 0.12), bundle-branch block (P > 0.2), and ST-segment abnormalities (P > 0.2). In multivariate analyses that adjusted for age, sex, and previous heart disease, a history of previously treated Lyme disease was not associated with either major (odds ratio, 0.78; P > 0.2) or minor (odds ratio, 1.09; P > 0.2) electrocardiographic abnormalities. CONCLUSION: Persons with a history of previously treated Lyme disease do not have a higher prevalence of cardiac abnormalities than persons without a history of Lyme disease.

Associations between spinal deformity and outcomes after decompression for spinal stenosis.

STUDY DESIGN: Prospective observational study. OBJECTIVES: To examine associations between radiographic parameters (scoliosis and olisthesis) and outcomes of surgery for degenerative spinal stenosis. SUMMARY OF BACKGROUND DATA: Preoperative degenerative scoliosis generally is thought to be associated with an unfavorable outcome of surgery for spinal stenosis. Data on the relationship between an increase in olisthesis after laminectomy for spinal stenosis and outcomes of surgery are sparse and conflicting. METHODS: Radiographs were obtained before surgery and at least 6 months after surgery and coded for preoperative scoliosis and change in olisthesis after surgery. The reviewers of radiographs were blind to outcome information. Patients completed questionnaires on demographic and clinical data as well as on back pain, lower extremity pain, walking capacity, and satisfaction with surgery. Associations between radiographic data and patient reported outcomes were examined with the Spearman rank correlation and confirmed with multiple linear regression models that adjusted for potential confounders. RESULTS: Ninety patients met eligibility criteria. Preoperative scoliosis was associated with less improvement in back pain at 6 months and at 24 months after surgery. An increase in olisthesis after surgery was associated with greater improvement in lower extremity pain at 6 months and at 24 months after surgery. An increase in olisthesis also was associated with greater improvement in walking capacity at 6 months and at 24 months after surgery. In multivariable analyses that adjusted for potential confounders, a change in olisthesis was not associated significantly with greater improvement in any of the outcomes. CONCLUSION: The data support the widely held view that preoperative scoliosis is associated with an unfavorable outcome after decompression for degenerative lumbar spinal stenosis. Increase in olisthesis was not associated with unfavorable results. In fact, there was a weak trend toward better outcomes with greater slip. These data indicate that minor increases in olisthesis after surgery for spinal stenosis generally are tolerated well.