Development of three-dimensional prints of arthritic joints for supporting patients' awareness to structural damage

["Rheuma (be-)greifen"- A multimodal teaching concept to improve rheumatology education for medical students]

BACKGROUND

The German Society for Rheumatology, through its campaign Rheuma2025, aims to improve student teaching in order to ensure patient care for rheumatological patients in the future.

OBJECTIVE

To assess whether a combination of traditional and innovative educational methods provide both an improvement in the quality of teaching and an increase in the attractiveness of rheumatology as a discipline.

MATERIAL AND METHODS

Establishment of the teaching concept "Rheuma (be-)greifen" consisting of five modules on patient history taking with acting patients, musculoskeletal ultrasound, arthrocentesis, 3D printing of pathological joints and virtual reality applications based on real patient cases in the curricular teaching of medical students.

RESULTS

The evaluation of the teaching concept with 93 students of medicine showed a consistently high acceptance of all modules, which were rated as very effective or rather effective. Direct patient-related modules, such as history taking with acting patients, musculoskeletal ultrasound and arthrocentesis, received even higher acceptance than the visualization methods utilizing 3D printing and virtual reality.

CONCLUSION

Innovative teaching methods can help to improve the acceptance of teaching in the field of rheumatology, especially when combined with classical teaching contents.

Cinematic rendering in rheumatic diseases—Photorealistic depiction of pathologies improves disease understanding for patients

Background

Patient education is crucial for successful chronic disease management. Current education material for rheumatic patients however rarely includes images of disease pathologies, limiting patients’ disease understanding. Cinematic rendering (CR) is a new tool that allows segmentation of standard medical images (DICOMs) into pictures that illustrate disease pathologies in a photorealistic way. Thus CR has the potential to simplify and improve the explanation of disease pathologies, disease activity and disease consequences and could therefore be a valuable tool to effectively educate and inform patients about their rheumatic and musculoskeletal disease (RMD).

Objectives

To examine the feasibility of creating photorealistic images using CR from RMD patients depicting typical rheumatic disease pathologies and, in a second step to investigate the patient-perceived educational potential of these photorealistic images in clinical routine.

Methods

We selected conventional, high-resolution (HR) and positron emission tomography (PET) computed tomography (CT) images of patients with rheumatoid arthritis (RA), psoriatic arthritis (PsA), axial spondyloarthritis (axSpA), and giant cell arteritis (GCA) that showed typical respective disease pathologies. These images were segmented using CR technique. In a prospective study, physicians used CR-enhanced and conventional original images to explain the depicted pathognomonic pathologies to patients with the respective rheumatic disease. Patients were then asked to complete a questionnaire evaluating the perceived usefulness of being presented with CR-enhanced images to better understand their underlying disease.

Results

CR images were successfully generated from above mentioned CT methods. Pathologies such as bone erosions, bony spurs, bone loss, ankylosis, and PET-based inflammation could be visualized in photorealistic detail. A total of 79 patients (61% females) with rheumatic diseases (RA 29%, PsA 29%, axSpA 24%, GCA 18%) were interviewed and answered the quantitative questionnaire. Mean age was 55.4 ± 12.6 years. Irrespective of disease, all patients agreed or highly agreed that CR-based images help to improve disease understanding, should be shown at disease onset, provide a rationale to regularly take medication and would like to have access to their own CR-enhanced images.

Conclusion

Conventional disease images can successfully be turned into photorealistic disease depictions using CR. Patients perceived CR images as a valuable addition to current patient education, enabling personalized disease education and potentially increased medication adherence.

Persistent hand pain despite adequate immunosuppression? The distinct value of occupational therapy in the era of biologics

PURPOSE OF REVIEW

Despite the tremendous advancement in the use of biologics, many patients with inflammatory arthritis do not achieve remission, and the risk of joint damage remains high. A multidimensional approach to treatment is essential. Joint disease in the hands and wrists may prevent patients from performing daily and valued life activities. This review will discuss the role of occupational therapists in inflammatory arthritis, recent updates on joint protection and assistive devices, as well as highlighting adjunctive treatment options for rheumatologists to help patients manage their symptoms.

RECENT FINDINGS

This article describes the meaningful role of occupational therapy and assistive devices in improving the outcomes for patients with inflammatory arthritis. We describe orthoses, assistive devices and adjunctive therapies utilized in inflammatory arthritis. We provide evidence supporting joint protection and occupational therapy as ways to help with these diseases. A multidisciplinary approach including the entire healthcare provider team, including occupational therapists, is essential to providing individualized treatment focusing on maximizing mobility in each patient's daily routine.

SUMMARY

Although larger studies are needed, assessment by hand-certified occupational therapists for instruction in joint protection techniques, assistive devices and customized orthoses and devices are important adjuncts to pharmacologic management in inflammatory arthritis.

The Disruption of Trust in the Digital Transformation Leading to Health 4.0

The specification and application of policies and guidelines for public health, medical education and training, and screening programmes for preventative medicine are all predicated on trust relationships between medical authorities, health practitioners and patients. These relationships are in turn predicated on a verbal contract that is over two thousand years old. The impact of information and communication technology (ICT), underpinning Health 4.0, has the potential to disrupt this analog relationship in several dimensions; but it also presents an opportunity to strengthen it, and so to increase the take-up and effectiveness of new policies. This paper develops an analytic framework for the trust relationships in Health 4.0, and through three use cases, assesses a medical policy, the introduction of a new technology, and the implications of that technology for the trust relationships. We integrate this assessment in a set of actionable recommendations, in particular that the trust framework should be part of the design methodology for developing and deploying medical applications. In a concluding discussion, we advocate that, in a post-pandemic world, IT to support policies and programmes to address widespread socio-medical problems with mental health, long Covid, physical inactivity and vaccine misinformation will be essential, and for that, strong trust relationships between all the stakeholders are absolutely critical.

The effect of visual interventions on illness beliefs and medication adherence for chronic conditions: A scoping review of the literature and mapping to behaviour change techniques (BCTs)

BACKGROUND

Maintaining health with chronic conditions often involves taking multiple medications; however, approximately 50% of patients with chronic conditions are non-adherent to medication. Patients' illness beliefs inform health behaviour, including medication-taking. Research has shown that visuals accompanying health information increased patient comprehension and the accuracy of illness perceptions. To date, the influence of visuals on illness beliefs and medication adherence has not been comprehensively reviewed.

OBJECTIVES

The review aimed to collate available literature on visualisation interventions for illness beliefs and medication adherence in chronic conditions and identify key intervention characteristics.

METHODS

A scoping review was conducted according to recommended guidelines and the PRISMA-ScR statement. Searches used keywords relating to 'illness', 'visual', 'adherence', 'illness perception', 'intervention', and 'medication'. Six databases were searched from inception to 2019; reference-list searching provided additional articles. Articles were included if the study population had a chronic health condition, the intervention included a visual element, had a measure of illness beliefs or medication adherence. Data regarding intervention characteristics and outcomes were extracted. Behaviour change techniques (BCTs) were identified to provide further insight into intervention characteristics.

RESULTS

Initially, 18,012 articles were identified. Screening led to 293 full-text articles, ultimately resulting in 45 studies for final analysis. Forty-four were quantitative studies, 1 was qualitative. Studies were grouped into those using visuals to conceptualise a condition, medication reminders and educational interventions. Almost two-thirds of visual interventions were effective post-intervention, 3 sustained post-1-year, although many studies only assessed impact immediately post-intervention. BCTs from 'Natural consequences', 'Socialsupport' and 'Feedback and monitoring' categories were prevalent in effective interventions for both outcomes, particularly the 'Salience of consequences' BCT.

CONCLUSIONS

This comprehensive scoping review found that visual interventions can positively influence illness beliefs and medication adherence. These findings highlight the need to further evaluate the impact and sustainability of visual interventions.

High-Resolution Peripheral Quantitative Computed Tomography for Bone Evaluation in Inflammatory Rheumatic Disease

High resolution peripheral quantitative computed tomography (HR-pQCT) is a 3-dimensional imaging modality with superior sensitivity for bone changes and abnormalities. Recent advances have led to increased use of HR-pQCT in inflammatory arthritis to report quantitative volumetric measures of bone density, microstructure, local anabolic (e.g., osteophytes, enthesiophytes) and catabolic (e.g., erosions) bone changes and joint space width. These features may be useful for monitoring disease progression, response to therapy, and are responsive to differentiating between those with inflammatory arthritis conditions and healthy controls. We reviewed 69 publications utilizing HR-pQCT imaging of the metacarpophalangeal (MCP) and/or wrist joints to investigate arthritis conditions. Erosions are a marker of early inflammatory arthritis progression, and recent work has focused on improvement and application of techniques to sensitively identify erosions, as well as quantifying erosion volume changes longitudinally using manual, semi-automated and automated methods. As a research tool, HR-pQCT may be used to detect treatment effects through changes in erosion volume in as little as 3 months. Studies with 1-year follow-up have demonstrated progression or repair of erosions depending on the treatment strategy applied. HR-pQCT presents several advantages. Combined with advances in image processing and image registration, individual changes can be monitored with high sensitivity and reliability. Thus, a major strength of HR-pQCT is its applicability in instances where subtle changes are anticipated, such as early erosive progression in the presence of subclinical inflammation. HR-pQCT imaging results could ultimately impact decision making to uptake aggressive treatment strategies and prevent progression of joint damage. There are several potential areas where HR-pQCT evaluation of inflammatory arthritis still requires development. As a highly sensitive imaging technique, one of the major challenges has been motion artifacts; motion compensation algorithms should be implemented for HR-pQCT. New research developments will improve the current disadvantages including, wider availability of scanners, the field of view, as well as the versatility for measuring tissues other than only bone. The challenge remains to disseminate these analysis approaches for broader clinical use and in research.

Radiological Society of North America (RSNA) 3D printing Special Interest Group (SIG): guidelines for medical 3D printing and appropriateness for clinical scenarios

Medical three-dimensional (3D) printing has expanded dramatically over the past three decades with growth in both facility adoption and the variety of medical applications. Consideration for each step required to create accurate 3D printed models from medical imaging data impacts patient care and management. In this paper, a writing group representing the Radiological Society of North America Special Interest Group on 3D Printing (SIG) provides recommendations that have been vetted and voted on by the SIG active membership. This body of work includes appropriate clinical use of anatomic models 3D printed for diagnostic use in the care of patients with specific medical conditions. The recommendations provide guidance for approaches and tools in medical 3D printing, from image acquisition, segmentation of the desired anatomy intended for 3D printing, creation of a 3D-printable model, and post-processing of 3D printed anatomic models for patient care.

Patient-Specific 3-Dimensional Modeling and Its Use for Preoperative Counseling of Patients Undergoing Hip Arthroscopy

Background

Femoroacetabular impingement (FAI) represents complex alterations in the bony morphology of the proximal femur and acetabulum. Imaging studies have become crucial in diagnosis and treatment planning for symptomatic FAI but also have limited patient understanding and satisfaction. Exploration of alternative patient counseling modalities holds promise for improved patient understanding, satisfaction, and ultimately for outcomes.

Purpose

To compare perceived understanding of functional anatomy and FAI pathomorphology among patients counseled with routine computed tomography (CT), generic hip models, and a 3-dimensional (3D) model printed in accordance with a patient's specific anatomy.

Study Design

Cohort study; Level of evidence, 2.

Methods

A prospective randomized analysis of patients presenting with radiographically confirmed FAI was conducted between November 2015 and April 2017. Patients were randomized into groups that received preoperative counseling with CT imaging alone, a generic human hip model, or a haptic 3D model of their hip. All groups were subjected to a novel questionnaire examining patient satisfaction and understanding on a variety of topics related to FAI. Data were compared with bivariate and multivariate analyses. Statistical significance was determined as P < .05.

Results

Thirty-one patients were included in this study (25 men, 6 women). Ten patients were randomized to the CT-only group, 11 to the generic hip model group, and 10 to receive custom 3D-printed models of their hips. Patients preoperatively counseled with isolated CT imaging or a generic hip model reported greater understanding of their pathophysiology and the role of surgical intervention when compared with those counseled with haptic 3D models (P = .03). At final follow-up, patients counseled with the use of isolated CT imaging or haptic 3D models reported greater increases and retention of understanding as compared with those counseled with generic hip models alone (P = .03).

Conclusion

Preoperative counseling with haptic 3D hip models does not appear to favorably affect patient-reported understanding or satisfaction with regard to FAI when compared with the use of CT imaging alone. Continued research into alternative counseling means may serve to further improve patient understanding and satisfaction on this complex anatomic phenomenon.

Attempting to remedy sub-optimal medication adherence in haemophilia: The rationale for repeated ultrasound visualisations of the patient's joint status

Haemophilia is marked by joint bleeding (haemarthrosis) leading to cartilage damage (arthropathy). Lifelong prophylaxis-initiated after the first bleeding episode-leads to a dramatic decrease in arthropathy in haemophilia patients. However, adherence to continuous intravenous administrations of factor VIII (FVIII) or FIX products is challenging, and patients potentially suffer from breakthrough bleedings while on prophylaxis. Newer FVIII/FIX products with enhanced convenience attributes and/or easier infusion procedures are intended to improve adherence. However, pharmacokinetic data should be harmonised with information from individual attitudes and treatment needs, to tailor intravenous dosing and scheduling in patients who receive extended half-life products. Nor is there sound evidence as to how subcutaneous non-FVIII/FIX replacement approaches (concizumab; emicizumab; fitusiran) or single intravenous injections of adeno-associated viral vectors (when employing gene therapy) will revolutionize adherence in haemophilia. In rheumatoid arthritis, repeated ultrasound examination of a patient's major joints is a valuable tool to educate patients and parents to understand the disease and provide an objective framework for clinicians to acknowledge patient's adherence. Joint ultrasound examination in haemophilia significantly correlates with cartilage damage, effusion, and synovial hypertrophy evaluated by magnetic resonance imaging. Furthermore, in patients with haemophilia undergoing prophylaxis with an extended half-life product for a ≈ 2.8 year period, a significant continued improvement in joint health is detected at the physical examination. This provides the rationale for studies on repeated ultrasound examinations of joint status to attempt to remedy sub-optimal medication adherence and help identify which approach is most suited on which occasion and for which patient.