The role of patient-reported outcomes in peripheral nerve surgery

Measuring the outcome of peripheral nerve surgery is challenging because of the spectrum of functional impairment is dependent on the level and severity of the lesion. There are no nerve-specific patient-reported outcome measures, and no universally accepted outcome measurement both in terms of the parameters to be assessed and the methods and timing of the assessment. Nevertheless, the use of patient-reported outcome measures is fundamental to better understand the needs and expectations of patients, to take advantage of all treatment opportunities to offer the best possible support to these patients. This paper outlines current concepts in the measurement of outcome in peripheral nerve surgery.

The correlation between 4 adherence measurements methods in patients with rheumatoid arthritis using methotrexate

AIMS

Methotrexate (MTX) is the cornerstone in the treatment of rheumatoid arthritis (RA) patients. However, adherence to MTX therapy is not optimal, and instruments to assess medication nonadherence are warranted. To date there is no consensus on the best method to determine adherence to MTX. The aim of this study was to assess the correlation between adherence assessed with a Medication Event Monitoring System (MEMS) vs. pill count, MTX-polyglutamate (PG) concentration and Compliance Questionnaire-Rheumatology (CQR) in patients with established RA. Second, the correlations between these methods and the Disease Activity Scores of 28 joints (DAS28) were examined.

METHODS

Adult RA patients currently treated with MTX were included. Multivariable linear and logistic regression were used, with adherence assessed with MEMS as dependent variable vs. pill count, MTX-PG concentrations, CQR as independent variables and DAS28 vs. each of the 4 adherence measurements. Covariates were included, such as comedication, age and use of corticosteroids.

RESULTS

In total, 190 consecutive RA patients were included. Pill count was correlated with adherence assessed with MEMS (linear regression, β = 0.588, 95% confidence interval = 0.255-0.921, P < .001), whereas CQR and MTX-PGs were not. Logistic regression confirmed the correlation between dichotomized adherence and pill count only (β = 4.47, 95% confidence interval = 1.31-7.64, P =  .006). No other correlations were found, either for all adherence outcomes or DAS28.

CONCLUSION

Measuring adherence with MEMS is correlated with pill count, whereas other methods were not correlated with MEMS or with DAS28. Pill count can be used to estimate adherence to MTX therapy, in case MEMS is not achievable.

Impact of daily physical therapy over 2 weeks on spinal mobility including objective electronic measurements and function in patients with axial spondyloarthritis

Background

Patients with axial spondyloarthritis (axSpA) are often compromised by impaired function and mobility. The standardized 2-week inpatient program 'multimodal rheumatologic complex treatment' (MRCT) was designed for patients with axSpA. The Epionics SPINE (ES) is an objective tool validated to assess mobility.

Objective

To investigate the impact of MRCT on physical function and mobility including range of motion (RoM) and kinematics (RoK).

Design

Single-center interventional, observational trial.

Methods

Patients with axSpA presenting with high disease activity and impaired physical function were consecutively recruited to undergo MRCT. Assessments performed before (V1) and after (V2) the intervention included Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), Bath Ankylosing Spondylitis functional index (BASFI), Bath Ankylosing Spondylitis Metrology Index (BASMI), the ankylosing spondylitis physical performance index (ASPI), the Short Physical Performance Battery (SPPB), and ES measurements.

Results

At baseline, the 80 patients included had: BASDAI 5.5 ± 1.5, BASFI 5.6 ± 2.0, BASMI 4.2 ± 1.8, SPPB 13.8 ± 1.8, and ASPI 37.3 ± 18.1 s. Clinically relevant improvements between V1 versus V2 were noted for BASFI, BASMI, and all other assessments (p < 0.001), and also for ES measures of RoK (all p < 0.003) and RoM (all p < 0.04), while a positive trend was seen for flexion and extension (RoM). There was no significant effect of changes in medication (all p > 0.05).

Conclusion

The 2-weeks MRCT was associated with definite improvements of function and mobility. Importantly, the effect of this extensive physical activity was confirmed by using the ES as an objective tool to assess spinal mobility. The ES demonstrated for the first time that the RoK of spinal mobility can significantly improve related to an exercise intervention.

Trial registration

Ethical Committee: Ruhr-Universität (reference-number: 19-6735-BR).

Cross-cultural adaptation and validation of the Norwegian Dizziness Catastrophizing Scale in persons with dizziness

BACKGROUND AND PURPOSE

Dizziness Catastrophizing Scale (DCS) is a questionnaire covering catastrophizing thoughts related to dizziness. The aims of this study were to cross-culturally adapt the DCS into Norwegian (DCS-N) and to examine the internal consistency, content and construct validity, and test-retest reliability of the instrument.

METHOD

Patients (18-67 years) with long-term dizziness were recruited from an ear, nose, and throat (ENT) clinic in Western Norway. Validity of the DCS-N was assessed by evaluating data quality (missing, floor and ceiling effects), content validity (relevance, comprehensiveness, and comprehensibility), structural validity (principal component analysis), internal consistency (Cronbach's alpha), and construct validity (predefined hypotheses). Test-retest reliability was examined by intraclass correlation coefficient (ICC1.1 ), standard error of measurement (SEM), smallest detectable change (SDC), and limits of agreement.

RESULTS

In total, 97 women and 53 men, mean age (SD) 46.5 (12.7) with dizziness were included (in the study). A subgroup of 44 patients participated in test-retest assessment. Overall, the DCS-N was easy to comprehend. The principal component analysis supported a one-factor solution and internal consistency was satisfactory (α 0.93). Construct validity was acceptable; all the predefined hypotheses were confirmed. Test-retest reliability demonstrated ICC1.1 of 0.90 and a SEM of 4.9. SDC was estimated to be ±13.6.

DISCUSSION

The DCS-N demonstrated acceptable measurement properties for assessing catastrophizing thoughts in patients with long-term dizziness. Further studies should examine the responsiveness of the DCS-N and a factor analysis should be undertaken in a larger population.

Limited Clinical Value of Anti-Retinal Antibody Titers and Numbers in Autoimmune Retinopathy

Purpose

To assess the possible correlation of anti-retinal antibody titers and number of anti-retinal antibodies with outcome measurements including visual acuity, subjective vision loss, visual field, and electroretinography in patients with autoimmune retinopathy.

Design

Single-center, retrospective cross-sectional study.

Patients and Methods

Patients with autoimmune retinopathy who underwent anti-retinal antibody testing at least twice during their follow-up were enrolled. Anti-retinal antibody titers and numbers were grouped as improved, stable, or worsened. Outcomes included Snellen visual acuity, patient-reported vision loss, Humphrey visual field mean deviations, and electroretinography parameters.

Results

Thirty-one eyes among 16 patients with autoimmune retinopathy were included. Between-group analyses of visual acuity, subjective vision loss, visual field, and electroretinography outcomes did not reveal any significant differences by anti-retinal antibody titer or number group at a 95% confidence interval.

Conclusion

Changes in anti-retinal antibody titers or numbers were not associated with any vision outcome. Repeated anti-retinal antibody testing may be unnecessary after diagnosis of autoimmune retinopathy and detection of an anti-retinal antibody.

The Apgar score in clinical research: for what, how and by whom it is used

OBJECTIVES

To review how the Apgar score is used in published clinical research as well as who uses it, and how this may have changed between 1989-90 and 2018-19.

METHODS

Pubmed search for English publications using MeSH Terms "apgar score" OR "apgar" AND "score" AND "humans" for epochs 1989-90 & 2018-19. The location and specialty of first author, primary purpose and how the Apgar score was used was recorded.

RESULTS

There was a 61% increase in number of publications in 2018-19 compared to 1989-90, from all regions except North America. The most common purpose for using the Apgar was to assess newborn status after pregnancy/delivery interventions. There were 50 different definitions of a significant score. Definition of significance was influenced by specialty in 2018-19 and by study purpose in both epochs.

CONCLUSIONS

Most studies using the Apgar score are focused on the mother. There is no consistent definition of a significant score. Development of any future newborn assessment tools should account for the multiple purposes for which the Apgar score is used.

The Effect of Body Mass Index on Brain Volume and Cognitive Function in Relapsing-Remitting Multiple sclerosis: A CombiRx Secondary Analysis

Background

Multiple sclerosis (MS) is an autoimmune disease leading to physical, emotional and cognitive disability. High body mass index (BMI) may impact cognitive function and brain volume in MS. Yet, there is paucity of evidence addressing the impact of BMI on cognitive function and brain volume in MS.

Objectives

The purpose of this study was to examine the effects of BMI on normal appearing brain volume and cognitive function in patients with relapsing–remitting MS.

Methods

A secondary data analysis of the NIH CombiRx study was conducted. Multivariate regression and mixed model analyses were executed to analyze the effect of BMI on brain volume and cognitive function.

Results

The mean baseline age of the 768 participants was 38.2(SD = 9.4) years. 73% were female and 88.8% were Caucasian. The mean BMI was 28.8 kg/m²(SD = 6.7). The multivariate regression and mixed model analyses failed to show a clinical effect of BMI on brain volume and cognitive function.

Conclusion

BMI did not show an effect on cognitive function and brain volume among MS patients. Although there is increased interest in the effects of modifiable factors on the course of MS, the effects of BMI on brain volume and cognitive function are debatable and warrant further research.

ClinicalTrials.gov NCT00211887

Surface Electromyography Applied to Gait Analysis: How to Improve Its Impact in Clinics?

Surface electromyography (sEMG) is the main non-invasive tool used to record the electrical activity of muscles during dynamic tasks. In clinical gait analysis, a number of techniques have been developed to obtain and interpret the muscle activation patterns of patients showing altered locomotion. However, the body of knowledge described in these studies is very seldom translated into routine clinical practice. The aim of this work is to analyze critically the key factors limiting the extensive use of these powerful techniques among clinicians. A thorough understanding of these limiting factors will provide an important opportunity to overcome limitations through specific actions, and advance toward an evidence-based approach to rehabilitation based on objective findings and measurements.

Desperate need for better management of Fournier's gangrene

Introduction

To compare earlier and later patient groups with Fournier's gangrene, specifically with the incidence of rising antibiotic resistance rates in mind. Primary endpoints were to compare therapy, outcomes, and resistance rates.

Material and methods

A multicentric, retrospective, multi-national study was performed. Two groups with different time frames of treatment were defined: Group 1 (n = 50) and Group 2 (n = 104). Demographics and outcomes were analysed using Student-t test, chi-square test, or Fisher exact test. Survival data were estimated using the Kaplan Meier method and compared by Log rank testing.

Results

There were no significant demographic differences. Nor was there any significant difference in therapy or outcomes in the groups except for the duration of intensive care unit treatment, which lasted a mean 6.3 days in Group 1 and 11.5 days in Group 2 (p = 0.018). Survival time did not improve over the years (p = 0.268). We fortunately did not observe an increased rate of multi-resistant organisms (p = 1.000). This study's limitations are mainly due to its retrospective study design.

Conclusions

Despite increasing antibiotic resistance rates worldwide, it was not apparent in our population. But the situation for these patients is alarming, since final outcome failed to improve over the last ten years despite more intensive critical-care therapy.

Reliability and validity of the Turkish version of the Foot Function Index in patients with foot disorders

Background/aim: The Foot Function Index (FFI) is a valid, reliable, and widely used self-reported questionnaire for the foot. The purpose of this study was to provide evidence for the validity and reliability of the Turkish version of the FFI (FFI-TR) among patients with foot disorders such as plantar fasciitis, hallux valgus, pes planus, and hammertoe deformities. Materials and methods: One hundred and fifty-nine patients with foot disorders were enrolled. The psychometric properties of the previously translated and adapted FFI-TR were assessed. The internal consistency and test-retest reliability were evaluated. Construct validity was examined for correlations with the Short Form-36 (SF-36) questionnaire. Results: Cronbach's alpha ranged between 0.821 and 0.938. Reproducibility was satisfactory, with intraclass correlation coefficient values between 0.960 and 0.985. Weak correlations were found between FFI-TR and some SF-36 subscales for validity (|rho| < 0.30). There was a ceiling effect for the activity limitation subscale. There were no floor effects for any items or application times. Good accuracy was determined for all scores. Conclusion: FFI-TR is a reliable and valid scale. This tool can be used in routine practice and clinical research for evaluating foot disorders and foot-related functional impairments.

'Progressive MS - macro views': The need for novel clinical trial paradigms to enable drug development for progressive MS

This article outlines the principal challenges to establish a standard phase-2 approach for progressive multiple sclerosis (PMS) and presents referring strategies to accelerate the registration process via a guidance approved by regulatory agencies. Accordingly, the contribution of 'big datasets' for a better understanding of the natural history of primary-progressive multiple sclerosis (PPMS) and secondary-progressive multiple sclerosis (SPMS) and of their prognostic factors and the value of novel biomarkers are discussed. The establishment of new industry-academic initiatives, such as independent consortia under the umbrella of Progressive MS Alliance (PMSA), with the endorsement of MS organizations and Scientific Societies (e.g. European Committee for Treatment and Research in Multiple Sclerosis (ECTRIMS)) may be crucial to overcome some of the current challenges. Within this frame, the continuous interaction with regulatory agencies is instrumental for the formal validation of the many developments suitable to improve clinical trialling in PMS.

[The application of mandarin acceptable noise level and COS in hearing aid fitting for presbyacusis]

Objective:The purpose of this study was to inquiry into the application of mandarin acceptable noise level(M-ANL) and client oriented scale of improvement in evaluation of hearing aid fitting for presbyacusis. Method:Thirty-two adults with presbycusis who used the hearing aid for the first time were selected for the study. M-ANL tests were done prior to the hearing aid fitting. Six weeks later, these patients were asked to fill in questionnaire of client oriented scale of improvement (COSI).The subjects were divided into 3 groups according to the time of hearing aid using in their daily lives: less than one hour per day, 1 to 4 hours per day and more than 4 hours per day. The relativity of M-ANL and the score of COSI were compared. Result:①There were significant differences of the M-ANL among 3 groups(P<0.05); ②The scores of COSI of group 1(less than one hour per day) was lower than group 2(1 to 4 hours per day), while there were no significant differences between the scores of group 2(1 to 4 hours per day) and group 3(more than 4 hours per day); ③There was good correlation between the score of M-ANL and COSI. Conclusion:M-ANL can forecast the satisfaction of hearing aids fitting. And COSI can play an effective role in outcome measurement.

Orthopedic Trauma and Aging: It Isn't Just About Mortality

The elderly (age 70+) patient with orthopedic trauma is a rapidly growing subset of patients in the United States. Due to increased medical comorbidities and decreased physiological reserve, morbidity and mortality after trauma may significantly differ from those patients younger than 70 years old. A retrospective review was performed to investigate the effect of age on orthopedic trauma. A total of 870 records of patients with orthopedic trauma from 2006 to 2009 at our Level One trauma center were reviewed. A database was created to include demographics, type and number of comorbid conditions at presentation, injuries, intensive care unit (ICU) and hospital length of stay, and description of the fracture. Patients aged 70 years and older had an increased number of comorbidities per person (3.3214-P < .0001). Length of stay in patients aged 70 years and older was not significantly greater than that of the younger patients. They spent an average of 14.76 days in the hospital compared to 13.42 days for the combined younger patients (P = .45), but they spent significantly (P < .0001) more of their stay in the ICU (52.74% vs 34.9% for the younger cohorts). The number of fractures per patient was lower (1.66) in the 70 and older age-group when compared to younger populations (P < .0001). The 70 and older group was more likely to have their injury due to a fall and less likely to have solid organ injuries. As the number of elderly patients increase, continued research in the management of elderly patients with trauma can lead to protocols and practice guidelines to improve outcomes.

The state of point-of-care testing: a European perspective

Point-of-care testing (POCT) refers to any diagnostic test administered outside the central laboratory at or near the location of the patient. By performing the sample collection and data analysis steps in the same location POCT cuts down on transport and processing delays, resulting in the rapid feedback of test results to medical decision-makers. Over the past decades the availability and use of POCT have steadily increased in Europe and throughout the international community. However, concerns about overall utility and the reliability of benefits to patient care have impeded the growth of POCT in some areas. While there is no agreed-upon standard for how success should be judged, the increases in speed and mobility provided by POCT can lead to substantial advantages over traditional laboratory testing. When properly utilized, POCT has been shown to yield measurable improvements in patient care, workflow efficiency, and even provide significant financial benefits. However, important organizational and quality assurance challenges must be addressed with the implementation of POCT in any health care environment. To ensure maximal benefits it may be necessary to evaluate critically and restructure existing clinical pathways to capitalize better on the rapid test turnaround times provided by POCT.

Alemtuzumab improves contrast sensitivity in patients with relapsing-remitting multiple sclerosis

BACKGROUND

Alemtuzumab is a monoclonal antibody directed against CD52 that depletes T and B lymphocytes.

OBJECTIVE

To evaluate the treatment effect of alemtuzumab on low-contrast vision in relapsing-remitting multiple sclerosis (RRMS) patients.

METHODS

This was a pre-defined exploratory analysis within a randomized, rater-blinded trial (CAMMS223) that was run at 49 academic medical centers in the US and in Europe. Patients with untreated, early, RRMS (McDonald, n = 334) were randomized 1:1:1 to subcutaneous interferon beta-1a (IFNB-1a), or alemtuzumab 12 mg or 24 mg. Visual contrast sensitivity was measured for each eye at baseline and quarterly, with Pelli-Robson charts.

RESULTS

The eyes of patients in the pooled alemtuzumab group (versus IFNB-1a) had a greater than 2-fold higher rate of both 3-month and 6-month sustained visual improvement, of at least 0.3 log units (2 triplets, 6 letters) (At 3 months the hazard ratio (HR) = 2.26; CI = 1.19 to 4.31; P = 0.013; and at 6 months the HR = 2.44; CI =1.16 to 5.15; P = 0.019), and they had a lower risk of 3- and 6-month sustained worsening of at least 0.15 log units (1 triplet, 3 letters) (At 3 months the HR = 0.58; CI = 0.38 to 0.89; P = 0.012; and at 6 months HR = 0.55; CI=0.35 to 0.87; P = 0.010). Over the 36-month study period, the eyes of patients in the pooled alemtuzumab group improved in mean contrast sensitivity to a greater extent than those in the IFNB-1a group (0.080 log units versus 0.038 log units; P = 0.0102).

CONCLUSIONS

Alemtuzumab was associated with a greater chance of improved contrast sensitivity in patients with RRMS and may delay the worsening of visual function. Contrast sensitivity testing was sensitive to treatment effects, even within an active comparator study design. These results support the validity of low-contrast vision testing as a clinical outcome in MS trials.