Sex Differences in Stroke Care and Outcome 2005-2018: Observations From the Swedish Stroke Register

BACKGROUND AND PURPOSE

Previous studies of stroke management and outcome in Sweden have revealed differences between men and women. We aimed to analyze if differences in stroke incidence, care, and outcome have altered over time.

METHODS

All stroke events registered in the Swedish Stroke Register 2005 to 2018 were included. Background variables and treatment were collected during the acute hospital stay. Survival data were obtained from the national cause of death register by individual linkage. We used unadjusted proportions and estimated age-adjusted marginal means, using a generalized linear model, to present outcome.

RESULTS

We identified 335 183 stroke events and a decreasing incidence in men and women 2005 to 2018. Men were on average younger than women (73.3 versus 78.1 years) at stroke onset. The age-adjusted proportion of reperfusion therapy 2005 to 2018 increased more rapidly in women than in men (2.3%-15.1% in men versus 1.4%-16.9% in women), but in 2018, women still had a lower probability of receiving thrombolysis within 30 minutes. Among patients with atrial fibrillation, oral anticoagulants at discharge increased more rapidly in women (31.2%-78.6% in men versus 26.7%-81.9% in women). Statins remained higher in men (36.9%-83.7% in men versus 32.3%-81.2% in women). Men had better functional outcome and survival after stroke. After adjustment for women's higher age, more severe strokes, and background characteristics, the absolute difference in functional outcome was <1% and survival did not differ.

CONCLUSIONS

Stroke incidence, care, and outcome show continuous improvements in Sweden, and previously reported differences between men and women become less evident. More severe strokes and older age in women at stroke onset are explanations to persisting differences.

Scar Assessment Tools: How Do They Compare?

Healing after dermal injury is a complex but imperfect process that results in a wide range of visible scars. The degree of disfigurement is not the sole determinant of a scar's effect on patient well-being, with a number of other factors being critical to outcome. These include cosmetic appearance, symptoms such as itch and pain, functional loss, psychological or social problems, and quality of life. An accurate assessment of these domains can help clinicians measure outcomes, develop, and evaluate treatment strategies. A PubMed literature search was performed up to 31st March 2020. Ten objective scar measurements, four Clinician-Reported Outcome Measures (CROMs), six Patient-Reported Outcome Measures (PROMs), and one combined measure were evaluated for their reliability, clinical relevance, responsiveness to clinical change, and feasibility. Many quantitative tools were limited in their clinical relevance and feasibility, whereas few qualitative CROMs and PROMs have undergone rigorous assessment. This review examines currently available assessment tools, focusing primarily on subjective scar measurements (CROMs, PROMs), and offers a perspective on future directions in the field.

Patient Reported Traditional Chinese Medicine Spleen Deficiency Syndrome (TCM-SDS) Scale for Colorectal Cancer: Development and Validation in China

Introduction:

Spleen Deficiency Syndrome (SDS) is recognized as one of the most common Traditional Chinse Medicine (TCM) syndromes in patients with colorectal cancer (CRC). However so far there is no existing patient-reported outcome (PRO) to evaluate SDS. Our study aimed to develop and validate a PRO TCM-SDS scale for CRC in China.

Methods:

We developed an initial 8-item TCM-SDS scale for CRC based on literature review and consultation with experts. We then pilot tested the scale (n = 40) and performed item revision. We conducted a survey study among CRC patients from oncology clinics at a TCM Hospital to further determine the reliability and validity of the scale.

Results:

Among 100 patients finally enrolled and analyzed in the survey study, 46% were female with median age of 60 years old, 77% had left side tumors and 23% had stage IV disease. Factor loading indicated that there were three domains within TCM-SDS scale. The final TCM-SDS scale involves 5 items including “I feel loss of appetite,” “I feel abdomen fullness,” “I feel my arms and legs lack strength,” “I feel short of breath when talking,” and “My stool is formless” (Cronbach’s alpha coefficient 0.76). We calculated the total score of the scale by summing the 5 individual items and normalizing them to a value maximum of 10, with higher scores indicating greater burden of spleen deficiency syndrome. The average spleen deficiency score for all patients was 3.55 ± 1.54. Among them, those who had stage IV disease had higher scores than stage I-III patients (4.30 vs 3.38, P = .015). Test-retest reliability after 2 weeks showed Pearson coefficient of 0.67 and all items were highly related (P < .001). Compared with healthy controls, CRC patients had significantly higher spleen deficiency scores (3.55 vs 3.23, P = .045).

Conclusion:

The patient-reported TCM-SDS scale for CRC showed adequate initial reliability and validity. The development of the scale provided an outcome measurement tool, which could facilitate future studies to better evaluate the role of TCM in treating CRC.

Clinical Characteristics of COPD Patients According to COPD Assessment Test (CAT) Score Level: Cross-Sectional Study

PURPOSE

The chronic obstructive pulmonary disease (COPD) assessment test (CAT) is widely used to assess the impact of COPD symptoms on health status. Whilst the CAT consists of eight different items, details on the distribution of each item are limited. This study aimed to investigate the distribution and clinical implication of each CAT item, stratified by CAT severity group, in stable COPD patients.

PATIENTS AND METHODS

This was a cross-sectional study at a single referral hospital in South Korea. Spirometry confirmed COPD patients with CAT measured at the first clinical visit were retrospectively identified. Patients were categorized into three groups: low (0 ≤ CAT < 10), medium (10 ≤ CAT < 20), and high (20 ≤ CAT ≤ 40) impact group. For the purpose of this analysis, the first four items (cough, sputum, chest tightness, and dyspnea) and the remaining four items (activities, confidence, sleep and energy) were also grouped as "pulmonary" and "extra-pulmonary", respectively.

RESULTS

A total of 815 patients were included, and mean (SD) forced expiratory volume in 1 s (FEV1) was 62.8 (17.4) % pred. Among them, 300 patients (36.8%) were in the high impact group and had a greater exacerbation history and lower lung function. The proportion of "extra-pulmonary" items score was greater in patients with higher total CAT scores, with the activity and confidence items showing higher scores.

CONCLUSION

In our study, in addition to dyspnea, activity limitation is a particular problem in individual patients with higher CAT total scores, for which physicians need to pay more attention. Our study suggests that whilst CAT total score captures the overall impact of COPD, each item of the CAT contains potentially useful information in understanding the patient's symptom burden.

Quality of Life as an Indicator for Care Delivery in Clinical Oncology Using FHIR

INTRODUCTION

Health-related quality of life (HR-QoL) as a parameter for patient well-being is becoming increasingly important.[1] Nevertheless, it is mainly used as an endpoint in studies rather than as an indicator for adjustments in therapy. In this paper we will present an approach to gradually integrate quality of life (QoL) as a control element into the care delivery of oncology.

CONCEPT

Acceptance, usability, interoperability and data protection were identified and integrated as key indicators for the development. As an initial approach, a questionnaire tool was developed to provide patients a simplified answering of questionnaires and physicians a clearer presentation of the results.

IMPLEMENTATION

As communication standard HL7 FHIR was used and known security concepts like OpenID Concept were integrated. In a usability study, first results were achieved by asking patients in the waiting room to answer a questionnaire, which will be discussed with the physician in the appointment. This study was conducted in 2019 at theSLK Clinics Heilbronn and achieved 86% participation of all respondents with an average age of 67 years.

DISCUSSION

Although the evaluation study could prove positive results in usability and acceptance, it is necessary to aim for longitudinal surveys in order to include QoL as a control element in the therapy. However, a longitudinal survey through questionnaires leads to decreasing compliance and increasing response bias. [2] For this reason, the concept needs to be expanded. With sensors a continuous monitoring can be carried out and the data can be mapped to the individual, interpreted by machine learning.

CONCLUSION

Questionnaires are a concept that has been successfully applied in studies for years. However, since care delivery poses different challenges, the integration of new concepts is inevitable. The authors are currently working on an extension of the use of questionnaires with patient generated data through sensors.

Patient-Reported Outcome Following Operative and Conservative Treatment of Calcaneal Fractures: A Retrospective Analysis of 79 Patients at Short- to Midterm Follow-Up

Background: Fractures of the calcaneus are severe injuries of the hindfoot, mostly resulting from high-energy axial loads, which still present enormous challenges to modern trauma surgery. Possible variables influencing the outcome are the type of fracture, age, and quality of fracture reduction. These might also be factors affecting the self-reported patient outcome, but large studies are still lacking. Therefore, the aim of this study was to analyze the patient-reported outcome of calcaneal fractures following operative and conservative treatment.

Methods: All patients suffering from calcaneal fractures between 2002 and 2015 were enrolled in this retrospective analysis. The calcaneal fractures were classified according to Sanders and the AO classification system. For further analysis, two groups were formed: group I involved complex intra-articular fractures defined by the involvement of the posterior calcaneal facet, while group II consisted of extra-articular and process calcaneal fractures. Data were collected via the patient registry, radiographs, and a standardized questionnaire (Foot and Ankle Outcome Score, FAOS). For outcome analysis, non-parametric Mann–Whitney U-test was performed, and Spearman's rank correlation coefficient was calculated.

Results: In total, the functional outcome of 79 patients with calcaneal fractures was analyzed. In group 1 (n = 43), the mean FAOS score was 65.5 ± 18.9. The surgically treated patients with a Sanders type II calcaneal fracture had a mean FAOS score of 72.9 ± 17.2, type III fractures had 65.6 ± 20.8, and type IV had 61.1 ± 19 (p = 0.15). The reoperation rate was 22%, most frequently caused by wound complications (10%). The mean follow-up time was 64.5 ± 44 months. The mean FAOS score of group 2 (n = 36) was 75.2 ± 18.4, and 83% of the patients (=30) were managed conservatively. Only one out of six operatively managed patients had a reoperation due to regular implant removal. The mean follow-up time was 31 ± 25.9 months.

Conclusion: Intra-articular calcaneal fractures are severe injuries of the hindfoot leading to a fair to poor functional outcome in the majority of the patients. Complications regarding wound healing are the most common causes for revisional surgery. Extra-articular calcaneal fractures are a heterogenous entity commonly managed non-operatively. Overall, they show a better functional outcome in comparison to intra-articular calcaneal fractures.

Quality of Life in SMA Patients Under Treatment With Nusinersen

Background: Spinal Muscular Atrophy (SMA) is a severe neurodegenerative disease, characterized by progressive muscle weakness and atrophy. The approval of the antisense oligonucleotide (ASO) nusinersen now provides an effective pharmacological approach with the potential to slow down or stop disease progression with a potentially major impact on patients' well-being.

Objective: This study evaluates quality of life (QoL) in pediatric and adult patients over the course of therapy with nusinersen.

Methods: Twenty-six SMA patients treated with nusinersen were evaluated regarding global QoL (gQoL), health-related QoL (HRQoL) and depressiveness. Assessments were conducted three times over the first 6 months of treatment. Applied were different questionnaires: the Anamnestic Comparative Self-Assessment (ACSA) for gQoL, the Short Form-36 Health Survey (SF-36) for HRQoL in adult patients and the ALS Depression Inventory 12 Items (ADI-12) for depressiveness. The sample was matched with 22 healthy controls.

Results: Despite severe physical restrictions, patients reported high levels of QoL and low levels of depressiveness at study entry. Early disease onset and low levels of physical functioning were associated with better gQoL and lower levels of depressiveness. A significant decrease of gQoL in patients was evident over the course of the study. Still, adult patients reported a significant increase in perceived health.

Conclusions: Our study provides first insight that SMA patients experience a gQoL superior to healthy controls at start of therapy. This might indicate patients' high hopes and expectations toward treatment. gQoL returns to a level similar to that of healthy controls over the course of therapy.

Construct validity and reproducibility of the Prescription Opioid Misuse And Abuse Questionnaire (POMAQ)

OBJECTIVE

The Prescription Opioid Misuse and Abuse Questionnaire was developed to identify prescription opioid abuse and misuse among patients with chronic pain, however, evidence of construct validity and reproducibility is needed.

METHODS

Chronic pain patients were recruited from five Department of Defense Military Health System clinics across the United States. Construct validity was examined using subjective clinician-reported and patient-reported measures as well as objective information (e.g. hair/urine drug screens and electronic medical records). Test-retest reliability was assessed across 2 timepoints among a subgroup of patients with stable chronic pain.

RESULTS

Of 3,263 screened patients, 938 (28.7%) met eligibility and were enrolled; 809 (86.2%) completed the Prescription Opioid Misuse and Abuse Questionnaire. Construct validity was supported by comparison to other validated questionnaires and hair and urine screens which yielded high agreements with patient reports on the Prescription Opioid Misuse and Abuse Questionnaire. Electronic medical record data supported patients' Prescription Opioid Misuse and Abuse Questionnaire responses regarding physician and emergency room visits and opioid refills. The Prescription Opioid Misuse and Abuse Questionnaire had excellent test-retest reliability; the percentage agreement between the two Prescription Opioid Misuse and Abuse Questionnaire administrations was high (>90%) for most questions.

DISCUSSION

Results suggest that the Prescription Opioid Misuse and Abuse Questionnaire is a valid and reproducible tool that can be used to assess the presence of prescription opioid misuse and abuse among patients with chronic pain.

Personal Accounts of Young-Onset Colorectal Cancer Organized as Patient-Reported Data: Protocol for a Mixed Methods Study

BACKGROUND

Young-onset colorectal cancer is a contemporary issue in need of substantial research input. The incidence of colorectal cancer in adults younger than 50 years is rising in contrast to the decreasing incidence of this cancer in older adults. People with young-onset colorectal cancer may be at that stage of life in which they are establishing their careers, building relationships with long-term partners, raising children, and assembling a financial base for the future. A qualitative study designed to facilitate triangulation with extant quantitative patient-reported data would contribute the first comprehensive resource for understanding how this distinct patient population experiences health services and the outcomes of care throughout the patient pathway.

OBJECTIVE

The aim of this study was to undertake a mixed-methods study of qualitative patient-reported data on young-onset colorectal cancer experiences and outcomes.

METHODS

This is a study of web-based unsolicited patient stories recounting experiences of health services and clinical outcomes related to young-onset colorectal cancer. Personal Recollections Organized as Data (PROD) is a novel methodology for understanding patients' health experiences in order to improve care. PROD pivots qualitative data collection and analysis around the validated domains and dimensions measured in patient-reported outcome and patient-reported experience questionnaires. PROD involves 4 processes: (1) classifying attributes of the contributing patients, their disease states, their routes to diagnosis, and the clinical features of their treatment and posttreatment; (2) coding texts into the patient-reported experience and patient-reported outcome domains and dimensions, defined a priori, according to phases of the patient pathway; (3) thematic analysis of content within and across each domain; and (4) quantitative text analysis of the narrative content.

RESULTS

Relevant patient stories have been identified, and permission has been obtained for use of the texts in primary research. The approval for this study was granted by the Macquarie University Human Research Ethics Committee in June 2020. The analytical framework was established in September 2020, and data collection commenced in October 2020. We will complete the analysis in March 2021 and we aim to publish the results in mid-2021.

CONCLUSIONS

The findings of this study will identify areas for improvement in the PROD methodology and inform the development of a large-scale study of young-onset colorectal cancer patient narratives. We believe that this will be the first qualitative study to identify and describe the patient pathway from symptom self-identification to help-seeking through to diagnosis, treatment, and to survivorship or palliation for people with young-onset colorectal cancer.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/25056.

Predisposing Factors for Sexual Dysfunction in Multiple Sclerosis

Sexual dysfunction (SD) in people with multiple sclerosis (pwMS) has a detrimental impact on individual health-related quality of life (HRQoL). It is not clear whether SD in multiple sclerosis (MS) is an independent symptom or merely a byproduct of other symptoms such as depression or anxiety. This cross-sectional study of 93 pwMS determines risk factors for SD in MS based on prevalence, HRQoL, and associated disease outcomes. Diagnosis of SD was determined based on the Multiple Sclerosis Intimacy and Sexuality Questionnaire-19 (MSISQ-19) and correlated with physical disability (measured by Expanded Disability Status scale, EDSS), depression and anxiety [Hospital Anxiety and Depression Scale (HADS)], and HRQoL [Multiple Sclerosis Quality of Life-54 (MSQoL-54)]. Multivariate regression models were performed to determine independent risk factors for SD in pwMS. Almost half of the participants in this study (46%) reported SD. HRQoL was significantly poorer in patients with MS suffering from SD (median [IQR] MSQoL-54 scores: physical subscale 52 [41–68] vs. 81 [69–89], p < 0.001; mental subscale 50 [38–82] vs. 86 [70–89], p < 0.001). In the multivariate model, EDSS was the only independent risk factor for SD (OR 18.1 for EDSS ≥4 [95% CI 3.3–31.4, p < 0.001]), while depression and anxiety were not. We conclude that the risk for SD is growing with increasing EDSS and is independent of depression or anxiety. Screening for SD becomes particularly relevant in patients with growing disability.

Early experiences of nusinersen for the treatment of spinal muscular atrophy: Results from a large survey of patients and caregivers

Background

This study aimed to examine the early experience of nusinersen for spinal muscular atrophy (SMA) from the patient and caregiver perspective.

Methods

A 54‐item online survey was administered to adult patients and caregivers of pediatric patients diagnosed with SMA.

Results

Overall, respondents (56 patients and 45 caregivers) were satisfied with nusinersen. Satisfaction was highest on changes in energy, stamina, and motor function and lowest on treatment administration and overall time commitment. Differences were noted for treatment effect sustained over time as reported by adult patients vs caregivers reporting on behalf of pediatric patients. Respondents reported insurance approval as a key barrier to access, particularly among adult patients.

Conclusions

Despite therapeutic advances, there remain significant unmet needs for SMA. Challenges with administration and barriers to access potentially limit the number of patients treated or delay treatment. Continued efforts are needed to develop more treatment options and to improve access to treatments.

Cross-cultural adaptation and validation of the Spanish version of the Johns Hopkins Fall Risk Assessment Tool

PURPOSE

To perform a cross-cultural adaptation and validation of the Johns Hopkins Fall Risk Assessment Tool to develop its Spanish version (JHFRAT-Sp).

MATERIAL AND METHODS

Two hundred eleven participants aged 60 years or older participated in this observational study. After translation and transcultural adaptation of the JHFRAT-Sp, the internal consistency, criterion validity and construct validity were calculated using the Falls Efficacy Scale International, Foot Health Status Questionnaire (FHSQ), Health Questionnaire EuroQol (5Dimensions and VAS), Short Form-12v2 and Health Assessment Questionnaire.

RESULTS

The internal consistency was 0.986. The test-retest analysis ranged from 0.971 to 0.983. The error measures presented values in MDC90 and SEM of 0.602 and 1.404%, respectively. The chi-Square value was 120.662 (p < 0.001). The extraction method by principal components showed a solution of four factors. Regarding the criterion validity, the correlation value ranged from r = 0.200 (FHSQ-Vigour) to r = 0.891 (EuroQol-VAS).

CONCLUSIONS

The JHFRAT was translated and adapted culturally from the original version to Spanish. The psychometric analysis carried out in the JHFRAT-Sp showed excellent reliability, as well as satisfactory results both in the measurement error analysis and in the construct and criterion validities. Spanish researchers and clinicians may use this tool to analyse the risk of falling. IMPLICATIONS FOR REHABILITATION A transcultural translation and adaptation of the JHFRAT questionnaire into Spanish (JHFRAT-Sp) has been carried out. The JHFRAT-Sp questionnaire is shown as a tool with very satisfactory psychometric characteristics, which would allow its use by both researchers and clinicians for the evaluation and monitoring of patients at risk of falls. The results that can be extracted from the use of JHFRAT-Sp, can be compared with the same type of patients who have used the same questionnaire but in other clinical or research environments that have the validated version of JHFRAT in their native language, such as English, Chinese or Portuguese (Brazilian).

Health-related quality of life trajectory of treatment-naive patients with Merkel cell carcinoma receiving avelumab

Aim: To evaluate changes in health-related quality of life (HRQoL) in a Phase II trial (NCT02155647) of treatment-naive patients with metastatic Merkel cell carcinoma treated with avelumab (15-month follow-up). Materials & methods: Mixed-effect Models for Repeated Measures were applied to HRQoL data (FACT-M; EQ-5D-5L) to assess changes over time. Clinically derived progression-free survival was compared with HRQoL deterioration-free survival. Results: Overall, we saw relative stability in HRQoL among 116 included patients, with nonprogression associated with statistically and clinically meaningful better HRQoL compared with progressive disease. Deterioration-free survival rates (49-72% at 6 months, 40-58% at 12 months) were consistently higher/better compared with progression-free survival rates (41/31% at 6/12 months). Conclusion: These findings show unique longitudinal HRQoL data for treatment-naive metastatic Merkel cell carcinoma patients treated with avelumab. Clinical trial registration: NCT02155647 (ClinicalTrials.gov).

Patient-reported symptom burden of chronic graft versus host disease: a systematic literature review

INTRODUCTION

Chronic graft-versus-host disease (GVHD) is a life-threating complication of allogeneic hematopoietic stem cell transplantation (HSCT) leading to high morbidity and quality of life issues. We conducted a systematic literature review on the patient reported symptom burden of chronic GVHD.

AREAS COVERED

English-language articles published between 2005 and November 2018 were searched using CENTRAL, EMBASE and MEDLINE. Studies that used the 2005 or 2015 National Institute of Health consensus criteria for the diagnosis and staging of chronic GVHD were included.

EXPERT OPINION

Patient reported symptom burden was widely assessed in the literature (n = 38). The Lee Chronic GVHD Symptom Scale was the most frequently used instrument (n = 28), followed by the NIH Patient-reported Symptom scores (n = 11). Association of symptom burden with clinical outcome assessment endpoints (e.g. mortality) and with quality of life measures was investigated by fairly low number of studies with limited generalizability. By systematically investigating the influencing factors of symptom burden this review helps to better understand patients' perceptions and may help improving the management and care of chronic GVHD. However, data on influencing factors was quite diverse, which indicates that specific questions identified as research gaps need to be incorporated in randomized clinical trials in a more systematic way.

Patient reported outcomes in patients with head and neck cancer treated with concurrent chemoradiation with weekly versus bolus cisplatin

BACKGROUND

Patient Reported Outcome (PRO) data comparing bolus (B-CP) with weekly (W-CP) cisplatin concurrent with radiation are lacking.

METHODS

We performed a retrospective study comparing PRO among 99 patients with head and neck radiation, 26% who received concurrent B-CP and 73% treated with W-CP.

RESULTS

W-CP patients had a higher Charlson comorbidity index (CCI) (P = .004). There were no differences in median cisplatin dose, PROs, percutaneous endoscopic gastrostomy (PEG) dependence or hospitalization between arms. Patients with a greater decline in their self-reported dysphagia score were more often PEG dependent at the end of radiation therapy (P = .03). There was also a trend toward PEG dependence with a higher maximum dysphagia score and greater change in aspiration score (P = .06). The maximum decline in white cell count and absolute neutrophil count were greater in the W-CP group (P = .04, P = .01).

CONCLUSION

Both B-CP and W-CP are well tolerated. PROs do not suggest a benefit to W-CP.

Design and Evaluation of the Electronic Patient-Generated Index

BACKGROUND

The patient-generated index (PGI) is an individualized measure of health-related quality of life. Previous work testing the PGI in the oncology setting identified threats to content validity due to navigational and computational completion errors using the paper format.

OBJECTIVE

The purpose of this pilot study was to refine and evaluate the usability and acceptability of an electronic PGI (ePGI) prototype in the outpatient radiation oncology setting.

METHODS

This pilot study used adaptive agile web design, cognitive interview, and survey methods.

RESULTS

Three iterations of testing and refining the ePGI were required. Fifteen patients completed the refined ePGI using touch screen tablets with little or no coaching required. Nearly all participants rated the ePGI as "easy" or "very" easy to use, understand, and navigate. Up to one half stated they did not share this type of information with their clinician but felt the information on the ePGI would be useful to discuss when making decisions about their care. Eight clinicians participated, all of whom felt the ePGI was a useful tool to initiate dialogue about quality of life issues, reveal infrequent or unusual effects of treatment, and assist with symptom management.

DISCUSSION

The pilot study indicates the ePGI may be useful for use at the point of care. Larger studies are needed to explore the influence it may have in decision-making and restructuring patient/provider communication.

Adjusted win ratio with stratification: Calculation methods and interpretation

The win ratio is a general method of comparing locations of distributions of two independent, ordinal random variables, and it can be estimated without distributional assumptions. In this paper we provide a unified theory of win ratio estimation in the presence of stratification and adjustment by a numeric variable. Building step by step on the estimate of the crude win ratio we compare corresponding tests with well known non-parametric tests of group difference (Wilcoxon rank-sum test, Fligner-Policello test, van Elteren test, test based on the regression on ranks, and the rank analysis of covariance test). We show that the win ratio gives an interpretable treatment effect measure with corresponding test to detect treatment effect difference under minimal assumptions.

Influence of time to admission to a comprehensive stroke centre on the outcome of patients with intracerebral haemorrhage

Introduction

In patients with spontaneous intracerebral haemorrhage, it is uncertain if diagnostic and therapeutic measures are time-sensitive on their impact on the outcome. We sought to determine the influence of the time to admission to a comprehensive stroke centre on the outcome of patients with acute intracerebral haemorrhage.

Patients and methods

We studied a prospective database of consecutive patients with intracerebral haemorrhage attended at two comprehensive stroke centres (2005-2017). We excluded patients with an unwitnessed time of onset of the intracerebral haemorrhage, or previous modified Rankin Scale >3 or in those in whom withdrawal of life-sustaining interventions were decided <24 h from admission. We recorded the time from the intracerebral haemorrhage onset to admission, demographic, clinical, radiological data, the functional outcome (favourable when modified Rankin Scale ≤3) and mortality at 90 days. We conducted a propensity score-matching analysis to evaluate functional outcome and mortality.

Results

We included 487 patients (mean age 72.3 ± 13.9 years), and 53.2% were men. Compared to patients with an admission >110 min, patients who were admitted ≤110 min were significantly younger, and had higher National Institutes of Health Stroke Scale scores. Moreover, patients admitted ≤110 min were more likely to have basal ganglia intracerebral haemorrhage, and to show neurological deterioration. The propensity score groups were well matched. We did not find an association between time to admission and the favourable outcome (OR: 1.42 (95% CI: 0.93-2.16)) or mortality (OR: 0.64 (0.41-0.99)) at 90 days.

Conclusions

Our results suggest that in patients with intracerebral haemorrhage and known symptom onset who are admitted to a comprehensive stroke centre, an early admission (≤110 min) does not influence the outcome at 90 days.

In-Office KTP Laser for Treating Hereditary Hemorrhagic Telangiectasia-Associated Epistaxis

OBJECTIVE

To evaluated the efficacy and safety of in-office potassium titanyl phosphate (KTP) laser treatment for the management of epistaxis in hereditary hemorrhagic telangiectasia (HHT) patients.

METHODS

A retrospective case series of all HHT patients over age of 18 who underwent in-office KTP laser treatment from July 1, 2017 to December 31, 2019 was performed. The primary outcome measure was the epistaxis severity score (ESS) pre- and post-procedure. Secondary outcome measures included patient reported pain (on a 10-point Likert-type scale), and procedural adverse events and complications.

RESULTS

A total of 16 patients underwent KTP in-office laser treatment during the review period. There was both a clinically and statistically significant decrease in the ESS after in-office laser treatment, baseline ESS -7.24, SD 1.71, follow up ESS -4.92, SD 1.83 (mean difference 2.94, 95% confidence interval, 1.83-4.04, P < .0001). There were no reported adverse events or complications associated with the procedure. The mean pain score reported was 0.19, SD 0.75. The average blood loss was 10.8 mL, SD 37.3. The majority of patients (62.5%, 10/16) had no blood loss during the procedure.

CONCLUSION

Clinically and statistically significant decreases were noted in the ESS of HHT patients after in-office KTP laser photocoagulation. The procedure was well tolerated by patients, without any adverse events or complications.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:E689-E693, 2021.

Bankart versus Latarjet operation as a revision procedure after a failed arthroscopic Bankart repair

Background

An arthroscopic Bankart operation is the most common operative procedure to treat shoulder instability. In case of recurrence, both Bankart and Latarjet procedures are used as revision procedures. The purpose of this study was to compare the re-recurrence rate of instability and clinical results after arthroscopic revision Bankart and open revision Latarjet procedures following failed primary arthroscopic Bankart operations.

Methods

Consecutive patients operatively treated for shoulder instability at Turku University Hospital between 2002 and 2013 were analyzed. Patients who underwent a primary arthroscopic Bankart operation followed by a recurrence of instability and underwent a subsequent arthroscopic Bankart or open Latarjet revision operation with a minimum of 1 year of follow-up were called in for a follow-up evaluation. The re-recurrence of instability, Subjective Shoulder Value, and Western Ontario Shoulder Instability index were assessed.

Results

Of 69 patients, 48 (dropout rate, 30%) were available for follow-up. Recurrent instability symptoms occurred in 13 patients (43%) after the revision Bankart procedure and none after the revision Latarjet procedure. A statistically and clinically significant difference in the Western Ontario Shoulder Instability index was found between the patients after the revision Bankart and revision Latarjet operations (68% and 88%, respectively; P = .0166).

Conclusions

The redislocation rate after an arthroscopic revision Bankart operation is high. Furthermore, patient-reported outcomes remain poor after a revision Bankart procedure compared with a revision Latarjet operation. We propose that in cases of recurring instability after a failed primary Bankart operation, an open Latarjet revision should be considered.

Femorotibial rotational mismatch of the Oxford unicompartmental knee in the flexion position is a risk for poor outcomes

BACKGROUND

Femorotibial rotational mismatch has been reported to cause unsatisfactory outcomes after total knee arthroplasty. However, to our knowledge, no previous reports have described the relationship between the femorotibial rotational mismatch and clinical outcomes of Oxford unicompartmental knee arthroplasty (UKA).

METHODS

In total, we studied 52 knees with primary varus knee osteoarthritis that underwent Oxford UKA with a navigation system. Tibial component internal rotation angles relative to the femoral component at extension and flexion angle of 90° were measured using a navigation system. We evaluated the relationship between the clinical outcomes and femorotibial rotational mismatch angles. Additionally, we evaluated the relationships between the outcomes and rotational alignments of the femur and tibial components measured by computed tomography (CT).

RESULTS

The tibial component internal rotational angle relative to the femoral component was significantly larger at a flexion angle of 90° than on extension (P < .001) and showed negative correlations with the Knee Society Functional Score and the pain and sports subscales of the Knee Injury and Osteoarthritis Outcome Score. Rotational alignment of the femur and tibial components on computed tomography was not associated with clinical outcomes.

CONCLUSION

The tibial component internal rotational angle relative to the femoral component in the flexion position was negatively correlated with clinical outcome. Surgeons should pay attention to a rotational mismatch between components in the flexion position during the Oxford UKA procedure. Navigation systems will be effective in reducing the femorotibial rotational mismatch and improving clinical outcomes.

Severe joint deformity and patient global assessment of disease are associated with discrepancies between sonographic and clinical remission: A cross-sectional study of rheumatoid arthritis patients

OBJECTIVE

Although recent clinical trials showed that ultrasound (US) remission is not required to achieve good outcomes at the group level, it currently remains unclear whether the prognosis of individual patients in clinical remission, but not US remission, i.e. those with subclinical sonographic synovitis (SSS), is favorable. However, it is no longer acceptable to perform US on all patients in order to identify those with SSS. Therefore, the present study was initiated to elucidate the conditions under which SSS is frequently detected.

METHODS

In total, 563 consecutive RA patients were recruited. Bilateral 2-5 MCP, wrist, ankle, and 2-5 MTP joints were scanned by US, and Gray scale and Power Doppler (PD) images were scored semi-quantitatively. Clinical data were obtained by physicians who were blind to US results. Changes in the modified Total Sharp Score (mTSS) of tocilizumab (TCZ) users were calculated.

RESULTS

A total of 402 patients were included. SSS was more frequently detected in patients with more severe joint deformity, even if they were in remission. In contrast, a high Patient Global Assessment of Disease (PtGA) did not reflect SSS. Furthermore, the relationship between PtGA and PD scores was weak. Although the frequency of SSS was high in TCZ user, the presence of SSS in TCZ users not always results in the progression of mTSS.

CONCLUSIONS

While remission is overestimated in patients with severe joint deformity, underestimations may occur in those who do not fulfill remission criteria because of a high PtGA.

The evolution of radiological measurements and the association with clinician and patient reported outcome following distal radius fractures in non-osteoporotic patients: what is clinically relevant?

Introduction: Following distal radius fractures in young non-osteoporotic patients, clinical relevancy of outcome has been scarcely reported. Outcome can be put in perspective by using measurement errors of radiological measurements and Minimal Important Change when reporting on clinician and patient reported outcome. Aim of this study was to assess the clinical relevance of radiological measurements, clinician and patient reported outcomes following distal radius fractures in young non-osteoporotic patients.Methods: Retrospective cohort study. Non-osteoporotic patients following a distal radius fracture were selected. Radiographs of both wrists were obtained at baseline, 6 weeks and at follow-up. Active range of motion and grip strength measurements were obtained at the follow-up visit and 4 questionnaires were answered to assess pain, upper extremity functioning, and health status.Results: Seventy-three patients (32 women, 41 men) with a mean age of 33.5 (SD 9.2) years at the time of injury were included. Median follow up was 62 months (IQR 53.0-84.5). Several radiological measurements evolved statistically significantly over time, however none exceeded measurement errors. Flexion/extension difference of injured compared to uninjured wrist (mean difference 11.2°, t = -7.5, df = 72, p < 0.001), exceeded Minimal Important Change, while grip strength differences did not. When comparing patients with DRFs to healthy controls, only the differences on Patient Reported Wrist Evaluation subscales "pain", "function" and total scores exceeded minimal important change (8, 10 and 13 points, respectively). Multivariable regression analysis revealed statistically significant relationships between residual step-off and respectively diminished flexion/extension (B = -36.8, 95% CI -62; -11.1, p  =  0.006), diminished radial/ulnar deviation (B = -17.9, 95% CI -32.0; -3.9, p  =  0.013) and worse ShortForm-36 "mental component score" (B = -15.4, 95% CI -26.6; -4.2, p < 0.001).Conclusion: Radiological measurements following distal radius fractures seem to evolve over time, but differences were small and were probably not clinically relevant. Range of motion, in particular flexion/extension, was impaired to such extend that it was noticeable for a patient, whereas grip strength was not impaired. The Patient Reported Wrist Evaluation was clinically relevantly diminished. Residual articular incongruency seems to influence range of motion.Implications for rehabilitationReporting Minimal Important Change regarding clinician and patient reported outcome following distal radius fractures is of more clinical value than reporting on statistical significance.Following distal radius fractures, the changes in radiological measurements do not seem to reflect a clinical relevant change.Range of motion, in particular flexion/extension, should be measured following distal radius fractures, as this might be impaired in a clinically relevant way.Measuring grip strength is of less importance following distal radius fractures, because grip strength does not seem to be affected.Residual articular incongruency seems to influence range of motion and therefore should be reduced to a minimum when treating non-osteoporotic patients.

One-year follow-up after urethroplasty, with the focus on both lower urinary tract and erectile function

Background: Urethral stricture disease (USD) represents a complex urological problem. Urethroplasty is considered the gold standard for the treatment of USD. Most available studies report outcome data obtained from retrograde urethrography and uroflowmetry. Only a limited number of papers describe the effect of urethroplasty on erectile function and their results are inconsistent. The goal of this prospective study was to evaluate the effect of urethroplasty on both lower urinary tract and erectile function using objective parameters and standardized patient-reported outcome measurement tools.Materials and Methods: A total of 55 consecutive patients with USD were enrolled into the study. Patients underwent ventral onlay urethroplasty, urethroplasty according to the Asopa technique, dorsal onlay urethroplasty, cutaneous flap urethroplasty using the Orandi technique or anastomotic repair. All patients were evaluated using uroflowmetry, urethrography, the PROM-USS questionnaire and the International Index of Erectile Function-5 questionnaire (IIEF-5) pre-operatively and consequently post-op, in 3-month intervals. This study presents the comparison of baseline pre-op parameters and parameters 12 months after the surgery using the Wilcoxon signed rank test, Wilcoxon rank sum test and the Kruskal-Wallis one-way analysis of variance.Results: A significant improvement in uroflowmetry parameters, all domains of the PROM-USS questionnaire, as well as the overall score of the IIEF-5 was observed. No statistically significant differences between sub-groups were found when comparing treatment results in patients with short versus long strictures and patients with penile urethra stricture versus bulbar or membranous urethra stricture.Conclusions: Urethroplasty yielded very good functional results with respect to both lower urinary tract and erectile functions.

Preventing the need for revision surgery after penile plication reconstruction of Peyronie's deformities

BACKGROUND

The need for repeat penile plication (PP) for persistent penile deformity has previously been associated with (I) poor initial erectile response to intracavernosal injection (ICI), (II) an inadequate number of corrective sutures, and (III) a lack of sutures along the proximal shaft of the penis. We present our current experience with PP after implementing corrective measures to assess whether our need for revision surgery was reduced.

METHODS

We performed a retrospective review of patients who underwent PP for Peyronie's disease (PD) between 2009-2018 and had a minimum follow-up of 6 months. We updated our surgical technique in 2016 by (I) using supplemental intracorporal saline injections if the initial erection response to prostaglandin E1 injection was inadequate, (II) increasing numbers of corrective plication sutures, and (III) emphasizing more proximal suture placement. Patients were stratified into two groups and outcomes compared (prior technique versus current technique).

RESULTS

Of 472 PP patients who met inclusion criteria, 340 (72%) plication patients before 2016 were compared to 132 (28%) performed after 2016. The revision rate in the current cohort (1.5%, 2/132) decreased by more than half compared to the previous cohort (3.8%, 13/340). Mean preoperative angle of curvature was similar between the two groups (50.4 vs. 51.4 degrees, P=0.64), while the average residual postoperative degree was smaller in the current group (7.36 vs. 2.14 degrees, P<0.001). Fewer sutures were used in the early cohort than in the current (7.63 vs. 8.38, P=0.04). After revision, all cases were functionally straight, with a mean postoperative curvature of 4 degrees at a median follow-up of 10.6 months (IQR, 2.08-20.7).

CONCLUSIONS

Ensuring adequate rigidity with additional ICI and focusing a greater number of corrective sutures in a more proximal location appears to help prevent the need for revision plication surgery.