Evaluation of Trends in Knee Arthroscopy from 2004 to 2019 in Ontario, Canada

BACKGROUND: How changes in recommendations for the use of knee arthroscopy have influenced real-world practice remains unclear. We assessed temporal trends in knee arthroscopy volume, costs, and rates of progression to knee arthroplasty following arthroscopy in Ontario, Canada. METHODS: We used diagnostic codes from population-based administrative databases from Ontario, Canada, to identify patients who underwent knee arthroscopy from April 1, 2004 to March 31, 2019. We calculated arthroscopy volume, costs, and rates of progression to knee arthroplasty within 1, 2, and 5 years following arthroscopy. RESULTS: A total of 408,040 arthroscopy procedures were included. The number of procedures declined 8.9% from 24,070 in 2004/2005 to 21,930 in 2018/2019. The volume of arthroscopy for osteoarthritis declined by 77.9% between 2007/2008 and 2018/2019. For degenerative meniscus disorders, the volume increased by 57.6% between 2004/2005 and 2013/2014, and then declined by 34.6% between 2013/2014 and 2018/2019. Among patients with osteoarthritis, rates of progression to knee arthroplasty were 3.8%, 9.6%, and 16.0%, at 1, 2, and 5 years, respectively, compared with rates among patients with degenerative meniscal disorders, which were 1.6%, 4.1%, and 7.3% at 1, 2, and 5 years, respectively. Over this period, progression to knee arthroplasty rates declined across diagnosis groups. These trends remained after adjusting for patient, surgeon, and hospital characteristics. CONCLUSIONS: In Ontario, Canada, utilization of knee arthroscopy declined between 2004/2005 and 2018/2019, with a concomitant decline in the rates of progression to knee arthroplasty within 1 to 5 years. Among the possible interpretations, our data are consistent with the hypothesis that clinical practice evolved as evidence-based recommendations against the use of knee arthroscopy for degenerative diagnoses were promulgated. (Funded by the Toronto General and Western Hospital Foundation through the University Health Network–Schroeder Arthritis Institute.)

Circulating microRNAs differentiate fast-progressing from slow-progressing and non-progressing knee osteoarthritis in the Osteoarthritis Initiative cohort

Introduction:

The objective of this study is to identify circulating microRNAs that distinguish fast-progressing radiographic knee osteoarthritis (OA) in the Osteoarthritis Initiative cohort by applying microRNA-sequencing.

Methods:

Participants with Kellgren–Lawrence (KL) grade 0/1 at baseline were included (N = 106). Fast-progressors were defined by an increase to KL 3/4 by 4-year follow-up (N = 20), whereas slow-progressors showed an increase to KL 2/3/4 only at 8-year follow-up (N = 35). Non-progressors remained at KL 0/1 by 8-year follow-up (N = 51). MicroRNA-sequencing was performed on plasma collected at baseline and 4-year follow-up from the same participants. Negative binomial models were fitted to identify differentially expressed (DE) microRNAs. Penalized logistic regression (PLR) analyses were performed to select combinations of DE microRNAs that distinguished fast-progressors. Area under the receiver operating characteristic curves (AUC) were constructed to evaluate predictive ability.

Results:

DE analyses revealed 48 microRNAs at baseline and 2 microRNAs at 4-year follow-up [false discovery rate (FDR) < 0.05] comparing fast-progressors with both slow-progressors and non-progressors. Among these were hsa-miR-320b, hsa-miR-320c, hsa-miR-320d, and hsa-miR-320e, which were predicted to target gene families, including members of the 14-3-3 gene family, involved in signal transduction. PLR models included miR-320 members as top predictors of fast-progressors and yielded AUC ranging from 82.6 to 91.9, representing good accuracy.

Conclusion:

The miR-320 family is associated with fast-progressing radiographic knee OA and merits further investigation as potential biomarkers and mechanistic drivers of knee OA.

A218 THE RISK OF RECURRENT HEPATOCELLULAR CARDINOMA IN POST-LIVER TRANSPLANT PATIENTS RECEIVING CAPECITABINE TREATMENT

Background

Little is known on how to reduce the risk of hepatocellular carcinoma (HCC) recurrence post liver transplantation (LT). We examined if adjuvant oral Capecitabine reduces the risk of recurrent HCC in a high-risk group post-LT.

Aims

To examine if adjuvant oral Capecitabine reduces the risk of recurrent HCC in a high-risk group post-LT.

Methods

A retrospective study was performed from a pre-existing liver transplant database from the Liver Transplant Unit at London Health Sciences Center, London; Canada. This database contains demographic, clinical parameters and follow-up of all patients transplanted for HCC. Data was extracted for patients who underwent LT between January 2000 – April 2018 and included follow up until May 31^st, 2020. High-risk of tumor recurrence was defined as a RETREAT score ≥5 or PARFITT score ≥10.5. Log rank test compared the recurrence of HCC or death among patients who were and were not prescribed Capecitabine.

Results

Out of 168 LT for HCC, 25 patients were identified as high-risk group for recurrence. The median age was 63 years (IQR=60–65). 19 (76%) patients had viral hepatitis including Hepatitis B and Hepatitis C as their primary disease while 4 (16%) patients had NASH. The remaining 2 (8%) patients had Autoimmune Hepatitis. 7 (28%) patients received Capecitabine while 18 (72%) did not. All patients were followed for a median of 22 months (IQR=8.9–57.5). No statistical significance difference was found between the two groups with respect to HCC recurrence or death (p=0.56).

Conclusions

Among patients with high risk features for recurrence of HCC, adding Capecitabine therapy added to conventional immunosuppression had no overall effect on reducing overall tumor recurrence or survival.

Funding Agencies

None

A tool for evaluating novel osteoarthritis therapies using multivariate analyses of human cartilage-synovium explant co-culture

OBJECTIVE

There is a need to incorporate multiple tissues into in vitro OA models to evaluate novel therapeutics. This approach is limited by inherent donor variability. We present an optimized research tool: a human OA cartilage-synovium explant co-culture model (OA-EXM) that employs donor-matched lower and upper limit response controls combined with statistical approaches to address variability. Multiple rapid read-outs allow for evaluation of therapeutics while cataloguing cartilage-synovium interactions.

DESIGN

48-h human explant cultures were sourced from OA knee arthroplasties. An OA-like cartilage-synovium co-culture baseline was established relative to donor-matched upper limit supraphysiological pro-inflammatory cytokine and lower limit OA cartilage or synovium alone controls. 100 nM dexamethasone treatment validated possible "rescue effects" within the OA-EXM dual tissue environment. Gene expression, proteoglycan loss, MMP activity, and soluble protein concentrations were analyzed using blocking and clustering methods.

RESULTS

The OA-EXM demonstrates the value of the co-culture approach as the addition of OA synovium increases OA cartilage proteoglycan loss and expression of MMP1, MMP3, MMP13, CXCL8, CCL2, IL6, and PTGS2, but not to the extent of supraphysiological stimulation. Conversely, OA cartilage does not affect gene expression or MMP activity of OA synovium. Dexamethasone shows dual treatment effects on synovium (pro-resolving macrophage upregulation, protease downregulation) and cartilage (pro-inflammatory, catabolic, and anabolic downregulation), and decreases soluble CCL2 levels in co-culture, thereby validating OA-EXM utility.

CONCLUSIONS

The OA-EXM is representative of late-stage OA pathology, captures dual interactions between cartilage and synovium, and combined with statistical strategies provides a rapid, sensitive research tool for evaluating OA therapeutics.

'Your mascara is running'

Chromhidrosis is a rare disorder, which can have significant psychosocial consequences for patients, particularly when it affects the face, as it can be mistaken for scarring, dirt or erroneous make-up application. Chromhidrosis can be divided into apocrine, eccrine and pseudo subtypes. We present a case of apocrine chromhidrosis localized to the bilateral cheek area.

COVID-19 outcomes in people with diabetes in Wales: a secondary analysis of the ABCD audit

Background: People with diabetes and coronavirus disease 2019 (COVID-19) have a significantly greater risk of death and/or intensive care unit (ICU) admission. The Association of British Clinical Diabetologists (ABCD) recently audited outcomes for people hospitalised in the UK with diabetes and COVID-19. Methods: The ABCD COVID-19 and diabetes audit was a retrospective audit of patients admitted to UK hospitals with diabetes and COVID-19 between March and December 2020. Data related to patients admitted in Wales were compared with patients admitted in England and Scotland. Results: In Wales, 40/82 (48.7%) patients with diabetes had COVID-19-related mortality compared with 1,149/2,916 (39.1%) in the UK group (p=0.08). The Welsh cohort were more likely to be Caucasian, have a higher body mass index and HbA1c, be diagnosed with diabetic retinopathy and prescribed a sodium-glucose co-transporter 2 inhibitor or insulin than those in England and Scotland. Patients admitted to the ICU in Wales were more likely to be male and have type 2 diabetes. Conclusions: Patients admitted to hospital with diabetes and COVID-19 in Wales had a poorer outcome compared with England and Scotland. This disparity may reflect social inequality, differences in cardiovascular risk factors and/or differences in diabetes medications between hospitalised patients in Wales and the UK.

A UK nationwide study of people with type 1 diabetes admitted to hospital with COVID-19 infection

AIMS/HYPOTHESIS

The aim of this work was to describe the clinical characteristics of adults with type 1 diabetes admitted to hospital and the risk factors associated with severe coronavirus disease-2019 (COVID-19) in the UK.

METHODS

A retrospective cohort study was performed using data collected through a nationwide audit of people admitted to hospital with diabetes and COVID-19, conducted by the Association of British Clinical Diabetologists from March to October 2020. Prespecified demographic, clinical, medication and laboratory data were collected from the electronic and paper medical record systems of the participating hospitals by local clinicians. The primary outcome of the study, severe COVID-19, was defined as death in hospital and/or admission to the adult intensive care unit (AICU). Logistic regression models were used to generate age-adjusted ORs.

RESULTS

Forty UK centres submitted data. The final dataset included 196 adults who were admitted to hospital and had both type 1 diabetes and COVID-19 on admission (male sex 55%, white 70%, with mean [SD] age 62 [19] years, BMI 28.3 [7.3] kg/m² and last recorded HbA_1c 76 [31] mmol/mol [9.1 (5.0)%]). The prevalence of pre-existing microvascular disease and macrovascular disease was 56% and 39%, respectively. The prevalence of diabetic ketoacidosis on admission was 29%. A total of 68 patients (35%) died or were admitted to AICU. The proportions of people that died were 7%, 38% and 38% of those aged <55, 55-74 and ≥75 years, respectively. BMI, serum creatinine levels and having one or more microvascular complications were positively associated with the primary outcome after adjusting for age.

CONCLUSIONS/INTERPRETATION

In people with type 1 diabetes and COVID-19 who were admitted to hospital in the UK, higher BMI, poorer renal function and presence of microvascular complications were associated with greater risk of death and/or admission to AICU. Risk of severe COVID-19 is reassuringly very low in people with type 1 diabetes who are under 55 years of age without microvascular or macrovascular disease. IN PEOPLE WITH TYPE 1 DIABETES AND COVID-19 ADMITTED TO HOSPITAL IN THE UK, BMI AND ONE OR MORE MICROVASCULAR COMPLICATIONS HAD A POSITIVE ASSOCIATION AND LOW SERUM CREATINE LEVELS HAD A NEGATIVE ASSOCIATION WITH DEATH/ADMISSION TO INTENSIVE CARE UNIT AFTER ADJUSTING FOR AGE.

Factors associated with unsuccessful return-to-work following work-related upper extremity injury

BACKGROUND

Returning to work following occupational injury is a key outcome for both workers' compensation boards and injured workers. Predictive factors for returning remain unclear.

AIMS

To describe factors associated with unsuccessful return-to-work (RTW) in a hand injury population to identify target areas through which occupational rehabilitation programmes can help injured workers achieve successful RTW outcomes.

METHODS

Demographic data, functional, pain and psychosocial scores were recorded for injured workers discharged between April 2011 and September 2015 from a multidisciplinary upper extremity treatment programme. The primary outcome of RTW status was assessed at programme discharge. Bivariate analyses and multivariable logistic regression were used to identify factors associated with being unable to RTW.

RESULTS

Of 872 participants who met the inclusion criteria, 65% were male and the mean age was 46 (standard deviation [SD] 11) years. In unadjusted bivariate analyses, the group with an unsuccessful RTW outcome had higher mean baseline pain, catastrophizing and QuickDASH scores; a higher baseline prevalence of depression, and reported a high level of pain more frequently than those who were working at discharge. In the adjusted logistic regression model, not working at baseline, higher QuickDASH score and presence of depression at baseline were independently associated with unsuccessful work status outcome.

CONCLUSIONS

Negative baseline work status, greater self-reported functional disability and presence of depression were associated with greater odds of unsuccessful RTW following a workplace upper extremity injury. Integrating mental healthcare provision with occupational rehabilitation is a potential programmatic approach to improve RTW.

An audit of people admitted to hospital with diabetes and coronavirus (SARS-CoV-2): data collection methods. The Association of British Clinical Diabetologists (ABCD) Nationwide Audit

We describe the rationale, aims and objectives and the methodology of data collection for the ABCD nationwide audit of individuals admitted to hospital with coronavirus (SARS-CoV-2; COVID-19) and diabetes. The audit was inspired and undertaken by the urgent need to understand the clinical course of COVID-19 in patients with diabetes admitted to hospital in the UK during the pandemic. We wished to understand the clinical behaviour of diabetes per se, post hospital admission and the factors with may be associated with admission to the Intensive Care Unit (ICU) and death due to COVID-19. This was a clinically-led audit. We used existing infrastructure and expertise to collect data using an electronic tool specifically designed and piloted by the steering group members. The clinical variables were chosen to fulfil the main aim of this audit as stated above, and factors influencing the clinical course of COVID-19 in individuals with both type 1 and type 2 diabetes at the time of admission to hospital and during the whole length of stay, until discharge or death from COVID-19. The data collected so far represent a large, multicentre audit with more than 3,500 admissions during the pandemic. We plan to continue collecting additional data and publish ongoing reports of interest to diabetes clinicians with the aim of enhancing knowledge and understanding and thereby improving clinical care of, and outcomes for, people with diabetes who are admitted to hospital with COVID-19 in the UK.

Prospects for beyond the Standard Model physics searches at the Deep Underground Neutrino Experiment: DUNE Collaboration

The Deep Underground Neutrino Experiment (DUNE) will be a powerful tool for a variety of physics topics. The high-intensity proton beams provide a large neutrino flux, sampled by a near detector system consisting of a combination of capable precision detectors, and by the massive far detector system located deep underground. This configuration sets up DUNE as a machine for discovery, as it enables opportunities not only to perform precision neutrino measurements that may uncover deviations from the present three-flavor mixing paradigm, but also to discover new particles and unveil new interactions and symmetries beyond those predicted in the Standard Model (SM). Of the many potential beyond the Standard Model (BSM) topics DUNE will probe, this paper presents a selection of studies quantifying DUNE's sensitivities to sterile neutrino mixing, heavy neutral leptons, non-standard interactions, CPT symmetry violation, Lorentz invariance violation, neutrino trident production, dark matter from both beam induced and cosmogenic sources, baryon number violation, and other new physics topics that complement those at high-energy colliders and significantly extend the present reach.

What Goes Bump in the Night: An Evaluation of Emergency Department Visits Following Total Joint Arthroplasty

BACKGROUND

Interest in postoperative healthcare utilization has increased following the implementation of episode-of-care funding for elective orthopedic surgery. Most efforts have focused on readmission; however, little has been reported on emergency department (ED) presentation. We analyzed elective, primary total hip or knee arthroplasty (THA and TKA) cases to determine the rate, reasons, risk factors, timing, and hospital cost associated with 30-day ED presentations.

METHODS

An observational study of patients who underwent primary, elective TKA and THA between January 1, 2016, and December 31, 2017, was performed. The primary outcome was an ED visit within 30-days of the index operation. Secondary outcomes included reasons, risk factors, timing, and hospital cost of ED visits. A multivariable logistic regression was undertaken to determine patient factors associated with ED presentation.

RESULTS

Overall, 1690 patients were included, of which 9.2% presented to the ED within 30-days of surgery. Approximately two-thirds of the visits were after-hours, and most were discharged home without readmission (81.4%). The most commonly reported reasons were wound concerns (30.1%) and pain (20.5%). Older age (OR 1.1, P = .03) and preoperative dyspnea (OR 2.1, P < .001) increased the odds of ED visits. The mean cost of an ED visit was significantly greater after-hours (P = .015).

CONCLUSION

Overall, 1 in 10 patients undergoing TKA/THA presented to the ED within 30-days of surgery, of which over 80% were not readmitted, and most occurred after-hours where cost is greatest. Our observations suggest ED visits following TKA/THA are common, and most are likely preventable. Future efforts should focus on developing interventions to reduce these visits.

Proteinase-Mediated Macrophage Signaling in Psoriatic Arthritis

Objective

Multiple proteinases are present in the synovial fluid (SF) of an arthritic joint. We aimed to identify inflammatory cell populations present in psoriatic arthritis (PsA) SF compared to osteoarthritis (OA) and rheumatoid arthritis (RA), identify their proteinase-activated receptor 2 (PAR2) signaling function and characterize potentially active SF serine proteinases that may be PAR2 activators.

Methods

Flow cytometry was used to characterize SF cells from PsA, RA, OA patients; PsA SF cells were further characterized by single cell 3’-RNA-sequencing. Active serine proteinases were identified through cleavage of fluorogenic trypsin- and chymotrypsin-like substrates, activity-based probe analysis and proteomics. Fluo-4 AM was used to monitor intracellular calcium cell signaling. Cytokine expression was evaluated using a multiplex Luminex panel.

Results

PsA SF cells were dominated by monocytes/macrophages, which consisted of three populations representing classical, non-classical and intermediate cells. The classical monocytes/macrophages were reduced in PsA compared to OA/RA, whilst the intermediate population was increased. PAR2 was elevated in OA vs. PsA/RA SF monocytes/macrophages, particularly in the intermediate population. PAR2 expression and signaling in primary PsA monocytes/macrophages significantly impacted the production of monocyte chemoattractant protein-1 (MCP-1). Trypsin-like serine proteinase activity was elevated in PsA and RA SF compared to OA, while chymotrypsin-like activity was elevated in RA compared to PsA. Tryptase-6 was identified as an active serine proteinase in SF that could trigger calcium signaling partially via PAR2.

Conclusion

PAR2 and its activating proteinases, including tryptase-6, can be important mediators of inflammation in PsA. Components within this proteinase-receptor axis may represent novel therapeutic targets.