Ensemble Learning Method for the Continuous Decoding of Hand Joint Angles

Human-machine interface technology is fundamentally constrained by the dexterity of motion decoding. Simultaneous and proportional control can greatly improve the flexibility and dexterity of smart prostheses. In this research, a new model using ensemble learning to solve the angle decoding problem is proposed. Ultimately, seven models for angle decoding from surface electromyography (sEMG) signals are designed. The kinematics of five angles of the metacarpophalangeal (MCP) joints are estimated using the sEMG recorded during functional tasks. The estimation performance was evaluated through the Pearson correlation coefficient (CC). In this research, the comprehensive model, which combines CatBoost and LightGBM, is the best model for this task, whose average CC value and RMSE are 0.897 and 7.09. The mean of the CC and the mean of the RMSE for all the test scenarios of the subjects' dataset outperform the results of the Gaussian process model, with significant differences. Moreover, the research proposed a whole pipeline that uses ensemble learning to build a high-performance angle decoding system for the hand motion recognition task. Researchers or engineers in this field can quickly find the most suitable ensemble learning model for angle decoding through this process, with fewer parameters and fewer training data requirements than traditional deep learning models. In conclusion, the proposed ensemble learning approach has the potential for simultaneous and proportional control (SPC) of future hand prostheses.

Determination and characterization of patient subgroups based on pain trajectories in hand osteoarthritis

OBJECTIVES

To investigate pain, pain trajectories and their determinants in hand osteoarthritis (OA).

METHODS

Data from the HOSTAS (Hand OSTeoArthritis in Secondary care) consisting of consecutive hand OA patients were used. Australian Canadian Osteoarthritis Hand Index (AUSCAN) pain was measured yearly for four years. Patients with complete AUSCAN at ≥2 time points were eligible for longitudinal analysis. Associations between variables of interest and baseline AUSCAN pain were investigated with linear regression. Development of pain over time was modelled using latent class growth analysis (LCGA). Associations of LCGA classes with variables of interest were analysed using multinomial logistic regression adjusted for baseline pain.

RESULTS

A total of 484/538 patients [mean (s.d.) age 60.8 (8.5) years, 86% women, mean (s.d.) AUSCAN pain 9.3 (4.3)] were eligible for longitudinal analysis. Sex, marital and working status, education, disease duration and severity, anxiety and depression scores, lower health-related quality of life (HR-QoL), specific illness perceptions and coping styles were associated with baseline pain. LCGA yielded three classes, characterized by average pain levels at baseline; average pain remained stable over time within classes. Classes with more pain were positively associated with BMI, tender joint count, symptom duration, hand function scores and depression scores, negatively with physical HR-QoL, and education level.

CONCLUSION

Baseline pain was associated with patient and disease characteristics, and psychosocial factors. LCGA showed three pain trajectories in hand OA patients, with different baseline pain levels and stable pain over time. Classes were distinguished by BMI, education level, disease severity, depression and HR-QoL.

Measuring Arm and Hand Joint Kinematics to Estimate Impairment During a Functional Reach and Grasp Task after Stroke

BACKGROUND

Current approaches to characterizing deficits in upper limb movements after stroke typically focus either on changes in a functional measure, for example, how well a patient can complete a task, or changes in impairment, for example, isolated measurements of joint range of motion. However, there can be notable dissociations between static measures of impairment versus those of function.

OBJECTIVE

We develop a method to measure upper limb joint angles during performance of a functional task and use measurements to characterize joint impairment in the context of a functional task.

METHODS

We developed a sensorized glove that can precisely measure select finger, hand, and arm joints while participants complete a functional reach-to-grasp task involving manipulation of a sensorized object.

RESULTS

We first characterized the accuracy and precision of the glove's joint angle measurements. We then measured joint angles in neurologically intact participants (n = 4 participants, 8 limbs) to define the expected distribution of joint angle variation during task execution. These distributions were used to normalize finger, hand, and arm joint angles in stroke participants (n = 6) as they performed the task. We present a participant-specific visualization of functional joint angle variance which illustrated that stroke participants with nearly identical clinical scores exhibited unique patterns of joint angle variation.

CONCLUSIONS

Overall, measuring individual joint angles in the context of a functional task may inform whether changes in functional scores over recovery or rehabilitation are driven by changes in impairment or the development of compensatory strategies, and provide a quantified path toward personalized rehabilitative therapy.

Analysis of Hand Joint Space Morphology in Women and Men with Hereditary Hemochromatosis

Hereditary hemochromatosis (HH) causes unbalanced iron deposition in many organs including the joints leading to severe cartilage loss and bone damage in the metacarpophalangeal joints (MCPJ). High-resolution peripheral quantitative computed tomography (HR-pQCT) and its joint space width (JSW) quantification algorithm quantifies in vivo 3D joint morphology. We therefore aimed to (i) determine feasibility and performance of the JSW algorithm in HH, (ii) quantify joint space morphology, and (iii) investigate the relationship between morphological and clinical parameters in HH. Here, we performed an exploratory study on 24 HH patients and sex- and age-matched controls using HR-pQCT imaging of MCPJ. Mineralized bone structure was automatically segmented from the grayscale image data and periosteal surface bone masks and joint space masks were generated. Mean, minimal, and maximal joint space width (JSW; JSW.MIN; JSW.MAX), JSW heterogeneity (JSW.SD), JSW asymmetry (JSW.AS), and joint space volume (JSV) were computed. Demographics and, for HH patients, disease-specific parameters were recorded. Segmentation of JS was very good with 79.7% of MCPJs successfully segmented at first attempt and 20.3% requiring semi-manual correction. HH men showed larger JSV at all MCPs (+ 25.4% < JSV <  + 41.8%, p < 0.05), larger JSW.MAX at MCP 3-4 (+ 14%, 0.006 < p < 0.062), and wider JSW (+ 13%, p = 0.043) at MCP 4 relative to HH women. Compared to controls, both HH men and HH women showed larger JSW.AS and smaller JSW.MIN at all MCP levels, reaching significance for HH men at MCP 2 and 3 (JSW.AS: + 323% < JSW.AS <  + 359%, 0.020 < p < 0.043; JSW.MIN: - 216% < JSW.MIN < - 225%, p < 0.043), and for women at MCP 3 (JSW.AS: + 180%, p = 0.025; JSW.MIN: - 41.8%, p = 0.022). Time since HH diagnosis was correlated positively with MCP 4 JSW.AS and JSW.SD (0.463 < ρ < 0.499, p < 0.040), and the number of phlebotomies since diagnosis was correlated with JSW.SD at all MCPs (0.432 < ρ < 0.535, p < 0.050). HR-pQCT-based JSW quantification in MCPJ of HH patients is feasible, performs well even in narrow JS, and allows to define the microstructural joint burden of HH.

Detecting hand joint ankylosis and subluxation in radiographic images using deep learning: A step in the development of an automatic radiographic scoring system for joint destruction

We propose a wrist joint subluxation/ankylosis classification model for an automatic radiographic scoring system for X-ray images. In managing rheumatoid arthritis, the evaluation of joint destruction is important. The modified total Sharp score (mTSS), which is conventionally used to evaluate joint destruction of the hands and feet, should ideally be automated because the required time depends on the skill of the evaluator, and there is variability between evaluators. Since joint subluxation and ankylosis are given a large score in mTSS, we aimed to estimate subluxation and ankylosis using a deep neural network as a first step in developing an automatic radiographic scoring system for joint destruction. We randomly extracted 216 hand X-ray images from an electronic medical record system for the learning experiments. These images were acquired from patients who visited the rheumatology department of Keio University Hospital in 2015. Using our newly developed annotation tool, well-trained rheumatologists and radiologists labeled the mTSS to the wrist, metacarpal phalangeal joints, and proximal interphalangeal joints included in the images. We identified 21 X-ray images containing one or more subluxation joints and 42 X-ray images with ankylosis. To predict subluxation/ankylosis, we conducted five-fold cross-validation with deep neural network models: AlexNet, ResNet, DenseNet, and Vision Transformer. The best performance on wrist subluxation/ankylosis classification was as follows: accuracy, precision, recall, F1 value, and AUC were 0.97±0.01/0.89±0.04, 0.92±0.12/0.77±0.15, 0.77±0.16/0.71±0.13, 0.82±0.11/0.72±0.09, and 0.92±0.08/0.85±0.07, respectively. The classification model based on a deep neural network was trained with a relatively small dataset; however, it showed good accuracy. In conclusion, we provided data collection and model training schemes for mTSS prediction and showed an important contribution to building an automated scoring system.

Is superficial radial nerve affected in patients with hand osteoarthritis?

INTRODUCTION

Patients with superficial radial neuropathy (SRN) have pain and abnormal sensation on the hand similar to hand osteoarthritis (HOA).

PURPOSE OF THE STUDY

The aim of the present study was to evaluate the presence of SRN in patients with HOA and to determine the factors associated with electrophysiological parameters of the radial nerve.

STUDY DESIGN

This is a case-control study.

METHODS

A total of 138 patients were included in this study. Only the dominant hand of each patient was evaluated. Patients were divided into 2 groups: Group 1 (without SRN) or Group 2 (with SRN) by electrophysiological examination. The presence of osteoarthritis in the first carpometacarpal (1st CMC) joint was investigated. Radiological features of the hands were evaluated with Kellgren-Lawrence grading system. Sonographically, the presence of synovitis in the 1st CMC joint was examined with gray scale and synovial blood flow signal by power Doppler imaging. Erosion and osteophyte scoring were performed for 15 joints. The 1st extensor compartment of wrist's cross-sectional area was measured.

RESULTS

SRN was detected in 68.8% of the patients. High Kellgren-Lawrence scores (P = .027), presence of synovitis in the 1st CMC joint (P = .003), and increased cross-sectional area of the 1st extensor compartment of wrist (P = .005) were found to be independent risk factors for reduced superficial radial nerve conduction velocity.

CONCLUSIONS

Sensory symptoms in patients with HOA might be due to the involvement of the superficial branch of the radial nerve.

The biomechanics of osteoarthritis in the hand: Implications and prospects for hand therapy

BACKGROUND

The unique anatomy of the human hand makes it possible to carefully manipulate tools, powerfully grasp objects, and even throw items with precision. These apparent contradictory functions of the hand, high mobility for manual dexterity vs high stability during forceful grasping, imply that daily activities impose a high strain on a relatively instable joint. This makes the hand susceptible to joint disorders such as osteoarthritis. Both systemic (eg, genetics, hormones) and mechanical factors (eg, joint loading) are important in the development of osteoarthritis, but the precise pathomechanism remains largely unknown. This paper focuses on the biomechanical factors in the disease process and how hand therapists can use this knowledge to improve treatment and research.

CONCLUSION

Multiple factors are involved in the onset and development of osteoarthritis in the hand. Comprehension of the biomechanics helps clinicians establish best practices for orthotics intervention, exercise, and joint protection programs even in de absence of clear evidence-based guidelines. The effect and reach of hand therapy for OA patients can be expanded substantially when intervention parameters are optimized and barriers to early referrals, access reimbursement, and adherence are addressed. Close and early collaboration between hand therapists and primary care, women's health, rheumatology, and hand surgery providers upon diagnosis, and with hand surgeons pre and postoperatively, combined with advances in the supporting science and strategies to enhance adherence, appear to be a promising way forward.

Validation of the Portuguese version of the Functional Index for Hand Osteoarthritis (FIHOA)

INTRODUCTION

Hand osteoarthritis (HOA) is a prevalent rheumatic disease that may cause significant disability. The Functional index for HOA (FIHOA) is a validated questionnaire to evaluate loss of function in patients with HOA.

OBJECTIVE

To undertake a cross-cultural adaptation and validation of FIHOA into Portuguese.

PATIENTS AND METHODS

First, the original French version of FIHOA had been forward-backward translated into Portuguese, according to the guidelines for cross-cultural adaptation. Secondly, patients with primary HOA were consecutively recruited in three Portuguese rheumatology outpatient clinics between May 2016 and April 2018. The final consensual Portuguese version of FIHOA was administered to 52 patients. A numerical rating scale (NRS - 0 to 100mm) for hand pain and for perceived hand dysfunction was also registered. Ten randomly selected patients were re-administered the same tools 5 to 15 days later. Internal consistency, test-retest reliability, internal construct validity and external validity related to dysfunction NRS were evaluated.

RESULTS

Fifty-two patients were evaluated: all right-handed, 96% women, mean age of 63 (10) years and 8 (6) years of disease duration. Mean (SD) pain and dysfunction were 47 (25) and 46 (25), respectively, with 68% patients being symptomatic. Mean (SD) FIHOA was 7 (5). Cronbach's alpha for internal consistency was high and adequate (0.87) and corrected item-total correlation revealed adequate performance. For reliability, Spearman's rho coefficient was 0.88 and total intraclass correlation coefficient (ICC) between test and retest was 0.87, showing good reliability. Factor analysis revealed three factors accounting for 71% of the variance of the score, with the first one (including questions 1, 2, 3 and 10) being responsible for 47% of the variance. Spearman's rho between FIHOA and dysfunction NRS was 0.5, showing a moderate but significant correlation and moderate external validity.

CONCLUSION

The Portuguese version of FIHOA is a consistent, reliable, and valid instrument to measure loss of function in HOA Portuguese patients.

Effect of first dorsal interosseous strengthening on clinical outcomes in patients with thumb osteoarthritis: a study protocol for a randomized controlled clinical trial

BACKGROUND

Thumb carpometacarpal osteoarthritis (CMC OA) is characterized by chronic progressive degeneration of the joint cartilage, with high prevalence. Patients present with pain at the base of the thumb, morning stiffness, and muscle weakness, symptoms that affect hand function and therefore interfere in activities and social participation. Movements that involve grip or lateral pinch are the most affected and directly impact independence, self-care, and leisure activities. In the literature consulted, several protocols with exercises for these patients were found. However, most do not compare the same intervention modality and only provide basic methodological information, with no consistent information on training load and load progression. In addition, most protocols only address the strengthening of the abductor and extensor thumb muscles and pinching or grasping exercises. However, some biomechanical and electromyographic studies have demonstrated the important role of the first dorsal interosseous muscles as stabilizers of the thumb carpometacarpal joint.

METHODS

This is a randomized, controlled, double-blind, and parallel clinical trial that will include 56 participants, over 40 years old, with radiographic evidence of thumb base osteoarthritis. Participants will be randomly allocated into two groups: control and intervention. The following evaluations will be conducted: the Australian/Canadian Hand Osteoarthritis Index, Canadian Occupational Performance Measure, Nine-Hole Peg Test, grip and pinch strength associated with muscle activation assessment, and Bilateral Upper Limb Function Test at four different times: baseline, session 13, session 18, and follow-up. Treatment will take place over 6 weeks, with reassessments in the fourth and sixth weeks and 3 months after the end of the intervention (follow-up). Qualitative variables will be expressed as frequency and percentage, and quantitative variables as mean and standard deviation. Intergroup comparison of the intervention will be performed by repeated measures ANOVA, considering the effect of the two groups and four assessments, and interactions between them.

DISCUSSION

This study will demonstrate whether the specific strengthening of the first dorsal interosseous muscle has a superior and positive effect on the clinical picture of patients with CMC OA. Additionally, if specific strengthening of the muscle is not superior to the traditional protocol in the literature, it will also be determined whether the two protocols are equivalent in terms of the best clinical picture.

TRIAL REGISTRATION

Brazilian Registry of Clinical Trials (ReBEC) RBR-8kgqk4 . Prospectively registered on 15 January 2020.

EULAR recommendations for intra-articular therapies

OBJECTIVES

To establish evidence-based recommendations to guide health professionals using intra-articular therapies (IAT) in adult patients with peripheral arthropathies.

METHODS

A multidisciplinary international task force established the objectives, users and scope and the need for background information, including systematic literature reviews) and two surveys addressed to healthcare providers and patients throughout Europe. The evidence was discussed in a face-to-face meeting, recommendations were formulated and subsequently voted for anonymously in a three-round Delphi process to obtain the final agreement. The level of evidence was assigned to each recommendation with the Oxford levels of evidence.

RESULTS

Recommendations focus on practical aspects to guide health professionals before, during and after IAT in adult patients with peripheral arthropathies. Five overarching principles and 11 recommendations were established, addressing issues related to patient information, procedure and setting, accuracy, routine and special aseptic care, safety issues and precautions to be addressed in special populations, efficacy and safety of repeated joint injections, use of local anaesthetics and aftercare.

CONCLUSION

We have developed the first evidence and expert opinion-based recommendations to guide health professionals using IAT. We hope that these recommendations will be included in different educational programmes, used by patient associations and put into practice via scientific societies to help improve uniformity and quality of care when performing IAT in peripheral adult joints.

Clinical Utility of an Exoskeleton Robot Using Three-Dimensional Scanner Modeling in Burn Patient: A Case Report

Hands are the part of the body that are most commonly involved in burns, and the main complications are finger joint contractures and nerve injuries. Hypertrophic scarring cannot be avoided despite early management of acute hand burn injuries, and some patients may need the application of an exoskeleton robot to restore hand function. To do this, it is essential to individualize the customization of the robot for each patient. Three-dimensional (3D) technology, which is widely used in the field of implants, anatomical models, and tissue fabrication, makes this goal achievable. Therefore, this report is a study on the usefulness of an exoskeleton robot using 3D technology for patients who lost bilateral hand function due to burn injury. Our subject was a 45-year-old man with upper limb dysfunction of 560 days after a flame and chemical burn injury, with resultant impairment of manual physical abilities. After wearing an exoskeleton robot made using 3D printing technology, he could handle objects effectively and satisfactorily. This innovative approach provided considerable advantages in terms of customization of size and reduction in manufacturing time and costs, thereby showing great potential for use in patients with hand dysfunction after burn injury.

Identifying discriminative features for diagnosis of Kashin-Beck disease among adolescents

INTRODUCTION

Diagnosing Kashin-Beck disease (KBD) involves damages to multiple joints and carries variable clinical symptoms, posing great challenge to the diagnosis of KBD for clinical practitioners. However, it is still unclear which clinical features of KBD are more informative for the diagnosis of Kashin-Beck disease among adolescent.

METHODS

We first manually extracted 26 possible features including clinical manifestations, and pathological changes of X-ray images from 400 KBD and 400 non-KBD adolescents. With such features, we performed four classification methods, i.e., random forest algorithms (RFA), artificial neural networks (ANNs), support vector machines (SVMs) and linear regression (LR) with four feature selection methods, i.e., RFA, minimum redundancy maximum relevance (mRMR), support vector machine recursive feature elimination (SVM-RFE) and Relief. The performance of diagnosis of KBD with respect to different classification models were evaluated by sensitivity, specificity, accuracy, and the area under the receiver operating characteristic (ROC) curve (AUC).

RESULTS

Our results demonstrated that the 10 out of 26 discriminative features were displayed more powerful performance, regardless of the chosen of classification models and feature selection methods. These ten discriminative features were distal end of phalanges alterations, metaphysis alterations and carpals alterations and clinical manifestations of ankle joint movement limitation, enlarged finger joints, flexion of the distal part of fingers, elbow joint movement limitation, squatting limitation, deformed finger joints, wrist joint movement limitation.

CONCLUSIONS

The selected ten discriminative features could provide a fast, effective diagnostic standard for KBD adolescents.

Obesity and diabetes are associated with disability in women with hand osteoarthritis. Results from the EpiReumaPt nationwide study

BACKGROUND

Hand osteoarthritis (HOA) is a highly prevalent rheumatic disease that predominates in females and causes pain and loss of functional capacity. Obesity and metabolic syndrome have been previously suggested to associate with the severity of HOA, but clarity on these associations is yet to be achieved.

OBJECTIVE

Test the association between obesity and other components of the metabolic syndrome and disability in women with hand osteoarthritis (HOA).

DESIGN

Individuals from EpiReumaPt epidemiological community-based study (2011-2013) are representative of the Portuguese population. Women with diagnosis of primary HOA were included.

PRIMARY OUTCOME

hand functional status, assessed by Cochin questionnaire.

SECONDARY OUTCOMES

hand pain, assessed by visual analogue scale and tender hand joint count (THJ). Explanatory variables: obesity, diabetes mellitus, arterial hypertension and hypercholesterolemia. Possible associations between obesity and the other components of metabolic syndrome with Cochin score, hand pain and THJ were tested in a multivariable linear regression model. Potential confounders considered: age, education level and countrywide distribution.

RESULTS

473 women with primary HOA were included. Forty percent were overweight and 29% obese. Ninety-three (19.8%) participants had diabetes, 261 (55.8%) reported hypertension and 261 (55.9%) hypercholesterolemia. Mean Cochin score was 15.5±14.8, mean pain VAS was 4.7±2.6 and mean THJ 1.4±3. In the multivariable analysis, obesity (β 4.6 CI 0.7;8.5) and diabetes (β 4.0 CI 0.4;7.6) were found to significantly associate with HOA functional disability. In addition, diabetes, but not obesity, associated with hand pain. There was no association between obesity or diabetes with THJ.

CONCLUSION

In a Portuguese female population with primary HOA, obesity and diabetes mellitus independently associated with a worse hand functional status. These data add to evidence suggesting a role of metabolic factors in the severity of HOA.

Research on Discrete Semantics in Continuous Hand Joint Movement Based on Perception and Expression

Continuous movements of the hand contain discrete expressions of meaning, forming a variety of semantic gestures. For example, it is generally considered that the bending of the finger includes three semantic states of bending, half bending, and straightening. However, there is still no research on the number of semantic states that can be conveyed by each movement primitive of the hand, especially the interval of each semantic state and the representative movement angle. To clarify these issues, we conducted experiments of perception and expression. Experiments 1 and 2 focused on perceivable semantic levels and boundaries of different motion primitive units from the perspective of visual semantic perception. Experiment 3 verified and optimized the segmentation results obtained above and further determined the typical motion values of each semantic state. Furthermore, in Experiment 4, the empirical application of the above semantic state segmentation was illustrated by using Leap Motion as an example. We ended up with the discrete gesture semantic expression space both in the real world and Leap Motion Digital World, containing the clearly defined number of semantic states of each hand motion primitive unit and boundaries and typical motion angle values of each state. Construction of this quantitative semantic expression will play a role in guiding and advancing research in the fields of gesture coding, gesture recognition, and gesture design.

Common Complaints of the Hands and Feet

Primary care providers frequently care for complaints of the hands and feet. Here, the author describes the typical presentations of hand osteoarthritis, carpal tunnel syndrome, ganglion cysts, plantar fasciitis, onychomycosis, and Morton neuroma. Useful physical examination techniques are described. The history and physical examination are usually sufficient to diagnose these conditions without the need for more advanced testing. All of these conditions have evidence-based therapy that can be initiated by the primary care provider. These treatments as well as reasons to refer to a specialist are reviewed.

Efficacy of hydroxychloroquine in hand osteoarthritis: A protocol for systematic review and meta-analysis of randomized clinical trial

BACKGROUND

Symptoms of hand osteoarthritis result in activity limitations and lower quality of life. Hydroxychloroquine, which has been used successfully in the treatment of many autoimmune diseases, can suppress inflammation and might also be beneficial in hand osteoarthritis.

METHODS

We plan to perform a systematic review and meta-analysis of randomized clinical trial to determine the symptom-modifying effect of hydroxychloroquine in hand osteoarthritis. We will search PubMed, EMBASE, Cochrane Library, and Web of Science using a comprehensive strategy. The related conference proceedings and reference lists of the included studies will also be checked to identify additional studies. Two reviewers will screen retrieved records, extract information and assess the risk of bias independently. Stata v15.1 software will be used to conduct data synthesis.

RESULTS

This study will be submitted to a peer-reviewed journal for publication.

CONCLUSION

We hope it will provide a relatively comprehensive reference for clinical practice and future relevant clinical trials.

INPLASY REGISTRATION NUMBER

INPLASY2020110005.

Are we overlooking osteoarthritis? - A comparative study of pain, function and quality of life in patiens with hand osteoarthritis and rheumatoid arthritis

Osteoarthritis (OA) is frequently regarded by patients and health care providers as a normal consequence of ageing and a minor condition. In contrast, rheumatoid arthritis (RA) is a pathological condition that usually requires prolonged treatment and regular Rheumatology follow-up. Pain and physical limitations are hallmarks of both conditions and some previous studies suggest that OA and RA may have a similar burden for both groups of patients although those works usually do not take into account the inflammatory activity of RA. With this work, the authors compare levels of pain, physical disability and health-related quality of life in patients with primary hand osteoarthritis (hOA) and with RA - active disease (aRA) or in remission (rRA). The results show that hOA may have similar or even higher burden of pain than RA even with clinically relevant inflammatory activity in hand joints. Rather than suggesting that OA could be as severe as RA (or more or less severe), this brief study highlights OA as a cause of severe pain, which should lead us to try to achieve better symptom control for these patients and encourage rheumatologists to endeavor efforts to perform more studies in the field of OA.

Metabolic and inflammatory links to rotator cuff tear in hand osteoarthritis: A cross sectional study

Objectives

To estimate the prevalence and associated factors of rotator cuff tear (RCT) in patients with hand osteoarthritis (HOA).

Methods

Between June 2013 and December 2015, we recruited 1150 participants in rural area of South Korea. Of the 1150 participants, 307 participants with HOA were analyzed. Plain radiography of both hands, magnetic resonance imaging of both shoulders, and serum levels of high-sensitive C-reactive protein (hsCRP) and high-density lipoprotein (HDL) were obtained for all patients. HOA and RCT were diagnosed by clinical and radiologic findings.

Results

The prevalence of RCT in patients with HOA (192/307, 62.5%) was higher than that in those without HOA (410/827, 49.5%, p<0.001). Among the 307 patients with HOA, the patients with RCT were older, and had higher hsCRP and lower HDL levels than the patients without RCT. Multiple logistic regression analysis confirmed significant associations of age (odds ratio [OR], 1.06; 95% confidence interval [CI], 1.02–1.11), serum hsCRP levels ≥0.6mg/L (OR, 1.68; CI, 1.00–2.80), and low HDL levels (male, <50 mg/dL; female, <40 mg/dL) (OR, 1.93; CI, 1.05–3.56) with RCT in patients with HOA. For patients below 60 years old, the prevalence of RCT was 2.8-fold higher in the low HDL group than normal HDL group (p = 0.048). Finally, the prevalence of RCT was 2.6-fold higher in patients with HOA with both elevated hsCRP and low HDL levels compared with those with neither (p<0.05).

Conclusions

Our findings suggest inflammation and metabolic factors were associated with the prevalence of RCT in HOA patients.

2019 American College of Rheumatology/Arthritis Foundation Guideline for the Management of Osteoarthritis of the Hand, Hip, and Knee

OBJECTIVE

To develop an evidence-based guideline for the comprehensive management of osteoarthritis (OA) as a collaboration between the American College of Rheumatology (ACR) and the Arthritis Foundation, updating the 2012 ACR recommendations for the management of hand, hip, and knee OA.

METHODS

We identified clinically relevant population, intervention, comparator, outcomes questions and critical outcomes in OA. A Literature Review Team performed a systematic literature review to summarize evidence supporting the benefits and harms of available educational, behavioral, psychosocial, physical, mind-body, and pharmacologic therapies for OA. Grading of Recommendations Assessment, Development and Evaluation methodology was used to rate the quality of the evidence. A Voting Panel, including rheumatologists, an internist, physical and occupational therapists, and patients, achieved consensus on the recommendations.

RESULTS

Based on the available evidence, either strong or conditional recommendations were made for or against the approaches evaluated. Strong recommendations were made for exercise, weight loss in patients with knee and/or hip OA who are overweight or obese, self-efficacy and self-management programs, tai chi, cane use, hand orthoses for first carpometacarpal (CMC) joint OA, tibiofemoral bracing for tibiofemoral knee OA, topical nonsteroidal antiinflammatory drugs (NSAIDs) for knee OA, oral NSAIDs, and intraarticular glucocorticoid injections for knee OA. Conditional recommendations were made for balance exercises, yoga, cognitive behavioral therapy, kinesiotaping for first CMC OA, orthoses for hand joints other than the first CMC joint, patellofemoral bracing for patellofemoral knee OA, acupuncture, thermal modalities, radiofrequency ablation for knee OA, topical NSAIDs, intraarticular steroid injections and chondroitin sulfate for hand OA, topical capsaicin for knee OA, acetaminophen, duloxetine, and tramadol.

CONCLUSION

This guideline provides direction for clinicians and patients making treatment decisions for the management of OA. Clinicians and patients should engage in shared decision-making that accounts for patients' values, preferences, and comorbidities. These recommendations should not be used to limit or deny access to therapies.

Infective Endocarditis with No Underlying Disease for Which Bacterial Endophthalmitis Have Been the First Symptom

Bacterial endophthalmitis is a rare complication of infective endocarditis (IE). We herein report a case of IE with no underlying disease for which endophthalmitis could have been the first symptom. A 58-year-old man was admitted to our hospital with a fever, vision disturbances, and pain in the left hand joint. His left eye was removed because fusion on the cornea progressed. Streptococcus agalactiae was detected in blood cultures, fluid cultures from his left hand joint, and the removed eye. Bacterial endophthalmitis may present as the first symptom of IE and develop without underlying disease due to S. agalactiae infection.

The Maternal and Paternal Effects on Clinically and Surgically Defined Osteoarthritis

OBJECTIVE

It is currently unknown whether osteoarthritis (OA) is inherited mainly from the mother, father, or both. This study was undertaken to explore the effect of maternal and paternal factors on hip, knee, and hand OA in offspring.

METHODS

Participants from the Musculoskeletal Pain in Ullensaker Study (MUST) (69% female; mean ± SD age 64 ± 9 years) and a Norwegian OA twin study (Nor-Twin) (56% female; 49 ± 11 years) reported whether their mother and/or father had OA. Using a recurrence risk estimation approach, we calculated whether maternal and paternal OA increased the risk of 1) surgically defined hip and knee OA (i.e., total joint replacement) and 2) clinically defined hip, knee, and hand OA (i.e., the American College of Rheumatology criteria) using logistic regression. Relative risks (RRs) with 95% confidence intervals (95% CIs) were calculated.

RESULTS

Maternal OA consistently increased the risk of offspring OA across different OA locations and severities. Having a mother with OA increased the risk of any OA in daughters (RR 1.13 [95% CI 1.02-1.25] in the MUST cohort; RR 1.44 [95% CI 1.05-1.97] in the Nor-Twin cohort) but not (or with less certainty) in sons (RR 1.16 [95% CI 0.95-1.43] in the MUST cohort; RR 1.31 [95% CI 0.71-2.41] in the Nor-Twin cohort). Having a father with OA was less likely to increase the risk of any OA in daughters (RR 1.00 [95% CI 0.85-1.16] in the MUST cohort; RR 1.52 [95% CI 0.94-2.46] in the Nor-Twin cohort) and sons (RR 1.08 [95% CI 0.83-1.41] in the MUST cohort; RR 0.93 [95% CI 0.35-2.48] in the Nor-Twin cohort).

CONCLUSION

OA in the mother increased the risk of surgically and clinically defined hip, knee, and hand OA in offspring, particularly in daughters. Our findings imply that heredity of OA may be linked to maternal genes and/or maternal-specific factors such as the fetal environment.

Evaluation of the PROMIS Upper Extremity Computer Adaptive Test Against Validated Patient-Reported Outcomes in Patients With Basilar Thumb Arthritis

PURPOSE

The Patient-Reported Outcomes Measurement Information System (PROMIS) Upper Extremity (UE) computer adaptive test was developed to reduce test burden and improve precision. We hypothesized that, in patients with thumb basilar joint arthritis (BJA), (1) PROMIS UE would correlate with established patient-outcomes (PROs), (2) PROMIS UE would require less time and fewer questions than current metrics, (3) there would be no floor or ceiling effects, and (4) PROMIS UE would not correlate with radiographic disease severity.

METHODS

Patients presenting with a primary diagnosis of thumb BJA completed the Quick Disabilities of the Arm Shoulder and Hand (QuickDASH), Thumb Disability Examination (TDX), Patient-Rated Wrist Hand Evaluation (PRWHE), and PROMIS UE. Radiographic disease severity as described by the Eaton scoring system was recorded. The relationships among PROs were described with Spearman correlation coefficients. The presence of a floor or ceiling effect was confirmed if greater than 15% of patients achieved the lowest or the highest possible score, respectively.

RESULTS

One hundred patients with thumb BJA formed the sample for this study. A good to excellent correlation was identified between PROMIS UE and QuickDASH. There were good correlations between PROMIS UE and TDX as well as PRWHE. The PROMIS UE was significantly less time consuming (average: 58.5 seconds vs QuickDASH, 92.2; TDX, 62.6; and PRWHE, 144.7), and required fewer questions than current metrics (average: 4.9 questions vs QuickDASH, 11; TDX, 20; and, 15). In addition, there were no appreciable floor or ceiling effects. Radiographic disease severity did not correlate with PROMIS UE.

CONCLUSIONS

The PROMIS UE has a good to excellent correlation with QuickDASH and good correlations with PRWHE and TDX. In addition, PROMIS UE required less time and fewer questions than established PROs. There were no floor or ceiling effects. Used as a single PRO, PROMIS UE may be a practical alternative to legacy scales in patients with thumb BJA.

CLINICAL RELEVANCE

The PROMIS UE PRO instrument may be a valuable addition in the assessment of patients with basilar thumb arthritis.

A new decision tree for diagnosis of osteoarthritis in primary care: international consensus of experts

Background and aims

Although osteoarthritis (OA) is managed mainly in primary care, general practitioners (GPs) are not always trained in its diagnosis, which leads to diagnostic delays, unnecessary resource utilization, and suboptimal patient outcomes.

Methods

To address this situation, an International Rheumatologic Board (IRB) of 8 experts from 3 continents developed guidelines for the diagnosis of OA in primary care. The focus was three major topologies: hip, knee, and hand/finger OA. The IRB used American College of Rheumatology diagnostic criteria.

Results

Care pathways based on clinical and radiological findings were developed to identify intervention thresholds for GPs/specialists. To optimize usefulness in the primary care setting, the guidelines were formatted as an uncomplicated, but comprehensive one-page decision tree for each topology, highlighting key aspects of the evaluation process and incorporating red flags. In a two-phase validation stage, the draft guidelines were evaluated by rheumatologists and GPs for project execution, content and perceived benefit. The strength of the guidelines lies in their user-friendly diagram and potential for broad application. Such guidelines will allow GPs to make an easy but definite diagnosis of OA and offer clear guidance about situations requiring an expert opinion. The guidelines have potential to improve patient outcomes and reduce the number of unnecessary procedures.

Discussion and conclusions

This project demonstrated the feasibility of developing easy-to-use and effective visual decision trees to facilitate the diagnosis and management of OA of the hip, knee and hand/finger in primary care. The next step should be to conduct a large impact study of implementation of these recommendations in the diagnostic management of OA in general practice in different areas.

Analysis of cases of Lyme arthritis in patients hospitalized in Infectious Diseases Department, University Hospital in Cracow

Lyme disease is an emerging problem in Poland. Analysis has been undertaken of the medical documentation of 86 patients hospitalized in the Infectious Diseases Department, University Hospital in Cracow in 2013-2016, suspected of Lyme arthritis. It has especially considered medical history including potential exposure to the infection, detailed characteristics of the symptoms, diagnostic challenges and results of the treatment. Only some patients had a history of erythema migrans and not all of them recalled tick-bite. The majority of the patients had affected large joints, especially knee joints, and polyarthritis was rarely observed. Symptoms were resolved completely or partially after antibiotic treatment in most patients. The diagnosis of Lyme arthritis in areas endemic for Lyme disease is still a diagnostic challenge in patients with other rheumatic diseases, including osteoarthritis.

Successfully treating hand primary tuberculous synovitis by synovectomy combined antituberculous therapy: A case report

RATIONALE

Primary tuberculous infection in hand and wrist is a rare disease. Few articles reported on hand primary tuberculous synovitis.

PATIENT CONCERNS

A 68-year-old Chinese male, without history of tuberculosis (TB), had complained of pain and swelling in right palm and little finger for 3 months. Patient came to our hospital on 9th Oct 2016. X-ray just showed soft tissue swelling in little finger. Magnetic resonance imaging (MRI) showed synovitis around flexor tendon of little finger, volar palm, and carpal tunnel. Notably, it also implied nodular images in little finger sizing 5 mm × 11 mm. Laboratory tests revealed C-reactive protein (CRP): 22 mg/L, erythrocyte sedimentation rate (ESR): 49 mm/h, and white blood cells (WBC): 11.8 × 10/L.

DIAGNOSES

He was diagnosed with primary hand tuberculous synovitis.

INTERVENTIONS

The patient received aspiration biopsy in right palm guided by ultrasound on 13rd Oct and pathological examination indicated Mycobacterium tuberculosis (MTB) infection. We performed radical synovetomy and collected abnormal tissue for pathological examination on 18th Oct. Finally, result showed MTB infection, which was the same with the result of first pathological examination. Then, this patient received antituberculous treatment.

OUTCOMES

One year after operation, pain and swelling relieve and no recurrence of the clinical symptoms happened.

LESSONS

Primary tuberculous synovitis of hand and wrist is rare, MTB infection should be considered as an infectious agent, especially in developing countries. Radical synovectomy and antituberculous treatment regain a satisfactory outcome.

Hyperlipidaemia and incident osteoarthritis of the hand: a population-based case-control study

OBJECTIVE

Preclinical evidence suggests that increased cholesterol levels might be involved in the pathophysiology of osteoarthritis of the hand (HOA), but evidence from observational studies remains scarce. We aimed to analyse the association between hyperlipidaemia and incident HOA.

DESIGN

We conducted a matched (1:1) case-control study using the UK-based Clinical Practice Research Datalink (CPRD). Cases were patients aged 30-89 years with an incident diagnosis of HOA between 1995 and 2014. In multivariable conditional logistic regression analyses, we calculated odds ratios (OR) for incident HOA in patients with hyperlipidaemia, categorized by gender, age, previous duration of hyperlipidaemia, and recent statin treatment.

RESULTS

Among 19,590 cases and 19,590 controls, we observed an increased risk of HOA in patients with hyperlipidaemia (OR 1.37, 95% confidence intervals (CI) 1.28-1.47), when compared to patients without hyperlipidaemia. Thus, of all HOA cases in our study population, 3.6% may have been attributable to the presence of hyperlipidaemia (population attributable risk). Most patients with HOA were elderly, but the strength of the association between HOA and hyperlipidaemia inversely correlated with increasing age, with the highest OR of 1.72 (95% CI 1.24-2.38) in patients aged 29-49 years. Categorization by previous hyperlipidaemia duration, as well as sub-classification of patients with hyperlipidaemia into those with and without recent statin use did not meaningfully change the effect estimate.

CONCLUSIONS

Our results suggest that hyperlipidaemia may be an independent risk factor for new onset HOA.

Transient Vasospastic Response Following the Injection of Corticosteroid into the Hand

A sixty-year-old right hand dominant woman with longstanding left basal joint arthritis and right small trigger finger presented for corticosteroid injections to both areas. She had previously received injections with no adverse effects and good relief of symptoms. Following this most recent injection of corticosteroid, she experienced transient ischemia of the left hand and the right long and ring fingers. Corticosteroid injections can rarely cause local vasospasm, even when not inadvertently injected into the vascular system. This condition is self-limited following supportive treatment.

Exercise for hand osteoarthritis

BACKGROUND

Hand osteoarthritis (OA) is a prevalent joint disease that may lead to pain, stiffness and problems in performing hand-related activities of daily living. Currently, no cure for OA is known, and non-pharmacological modalities are recommended as first-line care. A positive effect of exercise in hip and knee OA has been documented, but the effect of exercise on hand OA remains uncertain.

OBJECTIVES

To assess the benefits and harms of exercise compared with other interventions, including placebo or no intervention, in people with hand OA. Main outcomes are hand pain and hand function.

SEARCH METHODS

We searched six electronic databases up until September 2015.

SELECTION CRITERIA

All randomised and controlled clinical trials comparing therapeutic exercise versus no exercise or comparing different exercise programmes.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials, extracted data, assessed risk of bias and assessed the quality of the body of evidence using the GRADE approach. Outcomes consisted of both continuous (hand pain, physical function, finger joint stiffness and quality of life) and dichotomous outcomes (proportions of adverse events and withdrawals).

MAIN RESULTS

We included seven studies in the review. Most studies were free from selection and reporting bias, but one study was available only as a congress abstract. It was not possible to blind participants to treatment allocation, and although most studies reported blinded outcome assessors, some outcomes (pain, function, stiffness and quality of life) were self-reported. The results may be vulnerable to performance and detection bias owing to unblinded participants and self-reported outcomes. Two studies with high drop-out rates may be vulnerable to attrition bias. We downgraded the overall quality of the body of evidence to low owing to potential detection bias (lack of blinding of participants on self-reported outcomes) and imprecision (studies were few, the number of participants was limited and confidence intervals were wide for the outcomes pain, function and joint stiffness). For quality of life, adverse events and withdrawals due to adverse events, we further downgraded the overall quality of the body of evidence to very low because studies were very few and confidence intervals were very wide.Low-quality evidence from five trials (381 participants) indicated that exercise reduced hand pain (standardised mean difference (SMD) -0.27, 95% confidence interval (CI) -0.47 to -0.07) post intervention. The absolute reduction in pain for the exercise group, compared with the control group, was 5% (1% to 9%) on a 0 to 10 point scale. Pain was estimated to be 3.9 points on this scale (0 = no pain) in the control group, and exercise reduced pain by 0.5 points (95% CI 0.1 to 0.9; number needed to treat for an additional beneficial outcome (NNTB) 9).Four studies (369 participants) indicated that exercise improved hand function (SMD -0.28, 95% CI -0.58 to 0.02) post intervention. The absolute improvement in function noted in the exercise group, compared with the control group, was 6% (0.4% worsening to 13% improvement). Function was estimated at 14.5 points on a 0 to 36 point scale (0 = no physical disability) in the control group, and exercise improved function by 2.2 points (95% CI -0.2 to 4.6; NNTB 9).One study (113 participants) evaluated quality of life, and the effect of exercise on quality of life is currently uncertain (mean difference (MD) 0.30, 95% CI -3.72 to 4.32). The absolute improvement in quality of life for the exercise group, compared with the control group, was 0.3% (4% worsening to 4% improvement). Quality of life was 50.4 points on a 0 to 100 point scale (100 = maximum quality of life) in the control group, and the mean score in the exercise group was 0.3 points higher (3.5 points lower to 4.1 points higher).Four studies (369 participants) indicated that exercise reduced finger joint stiffness (SMD -0.36, 95% CI -0.58 to -0.15) post intervention. The absolute reduction in finger joint stiffness for the exercise group, compared with the control group, was 7% (3% to 10%). Finger joint stiffness was estimated at 4.5 points on a 0 to 10 point scale (0 = no stiffness) in the control group, and exercise improved stiffness by 0.7 points (95% CI 0.3 to 1.0; NNTB 7).Three studies reported intervention-related adverse events and withdrawals due to adverse events. The few reported adverse events consisted of increased finger joint inflammation and hand pain. Low-quality evidence from the three studies showed an increased likelihood of adverse events (risk ratio (RR) 4.55, 95% CI 0.53 to 39.31) and of withdrawals due to adverse events in the exercise group compared with the control group (RR 2.88, 95% CI 0.30 to 27.18), but the effect is uncertain and further research may change the estimates.Included studies did not measure radiographic joint structure changes. Two studies provided six-month follow-up data (220 participants), and one (102 participants) provided 12-month follow-up data. The positive effect of exercise on pain, function and joint stiffness was not sustained at medium- and long-term follow-up.The exercise intervention varied largely in terms of dosage, content and number of supervised sessions. Participants were instructed to exercise two to three times a week in four studies, daily in two studies and three to four times daily in another study. Exercise interventions in all seven studies aimed to improve muscle strength and joint stability or function, but the numbers and types of exercises varied largely across studies. Four studies reported adherence to the exercise programme; in three studies, this was self-reported. Self-reported adherence to the recommended frequency of exercise sessions ranged between 78% and 94%. In the fourth study, 67% fulfilled at least 16 of the 18 scheduled exercise sessions.

AUTHORS' CONCLUSIONS

When we pooled results from five studies, we found low-quality evidence showing small beneficial effects of exercise on hand pain, function and finger joint stiffness. Estimated effect sizes were small, and whether they represent a clinically important change may be debated. One study reported quality of life, and the effect is uncertain. Three studies reported on adverse events, which were very few and were not severe.

Tenosynovitis caused by Scedosporium apiospermum infection misdiagnosed as an Alternaria species: a case report

BACKGROUND

Scedosporium apiospermum, which can usually be isolated from soil, polluted stream water and decaying vegetation, is increasingly recognized as an opportunistic dematiaceous fungus. The mortality rate of infection in immunocompromised hosts is over 50%. S. apiospermum is commonly responsible for dermal and epidermal infections (i.e., mycetoma) after traumatic penetration.

CASE PRESENTATION

A 73-year-old woman was admitted to our hospital complaining of painful swelling and tenderness on the dorsum of the proximal left wrist and hand. The symptoms had persisted for approximately 2 months. A physical examination revealed a 4 x 3 cm, poorly defined, erythematous papule, which was fluctuant, with pustules and crusts on the dorsum of the left hand.

CONCLUSIONS

We report a very rare case of tenosynovitis caused by S. apiospermum infection. We identified the infectious agent via molecular DNA sequencing. The infectious agent was initially misidentified as an Alternaria species by microscopic examination with lactophenol cotton blue (LPCB) staining. The infection was successfully treated with debridement and adjuvant fluconazole therapy.

Physician Beliefs about Physical and Mental Competency of Patients Applying for Concealed Weapon Permits

Law enforcement officials have asked health care providers to evaluate patient applications for concealed weapon permits. The current study was designed to examine physician beliefs regarding competency to carry a concealed weapon for patients with specific physical and mental conditions. Among 222 North Carolina physicians who participated in this survey (40% response rate), large variation and uncertainty existed for determining competency. Physicians most frequently chose mild dementia, post-traumatic stress disorder, and recent depression as conditions that would render a patient not competent to carry a concealed weapon. Male physicians and those owning a gun were more likely to deem a patient competent. Almost a third of physicians were unsure about competence for most conditions. Physicians asked to assess competency of patients to carry a concealed weapon have quite disparate views on competency and little confidence in their decisions. If physicians are expected to assess patient competence to carry a concealed weapon, more objective criteria and training are needed.

OARSI Clinical Trials Recommendations: Design and conduct of clinical trials for hand osteoarthritis

Hand osteoarthritis (OA) is a very frequent disease, but yet understudied. However, a lot of works have been published in the past 10 years, and much has been done to better understand its clinical course and structural progression. Despite this new knowledge, few therapeutic trials have been conducted in hand OA. The last OARSI recommendations for the conduct of clinical trials in hand OA dates back to 2006. The present recommendations aimed at updating previous recommendations, by incorporating new data. The purpose of this expert opinion, consensus driven exercise is to provide evidence-based guidance on the design, execution and analysis of clinical trials in hand OA, where published evidence is available, supplemented by expert opinion, where evidence is lacking, to perform clinical trials in hand OA, both for symptom and for structure-modification. They indicate core outcome measurement sets for studies in hand OA, and list the methods and instruments that should be used to measure symptoms or structure. For both symptom- and structure-modification, at least pain, physical function, patient global assessment, HR-QoL, joint activity and hand strength should be assessed. In addition, for structure-modification trials, structural progression should be measured by radiographic changes. We also provide a research agenda listing many unsolved issues that seem to most urgently need to be addressed from the perspective of performing "good" clinical trials in hand OA. These updated OARSI recommendations should allow for better standardizing the conduct of clinical trials in hand OA in the next future.

Self-management approaches for osteoarthritis in the hand: a 2×2 factorial randomised trial

BACKGROUND

Osteoarthritis is the leading cause of disability in older adults. Evidence of effectiveness for self-management of hand osteoarthritis is lacking.

METHODS

In this randomised, factorial trial, we evaluated the effectiveness of joint protection versus no joint protection, and hand exercise versus no hand exercise in adults, 50 years of age or older, with hand osteoarthritis. Following a population survey (n=12 297), eligible individuals were randomly assigned (1:1:1:1) to: leaflet and advice; joint protection; hand exercise; joint protection plus hand exercise. Joint protection and hand exercises were delivered by nine occupational therapists, over four group sessions. The primary outcome was the OARSI/OMERACT responder criteria at 6 months. Outcomes were collected blind to allocation (3, 6, 12 m). Analysis was by intention to treat.

RESULTS

Of 257 participants randomised (65:62:65:65) (mean age (SD) 66 years (9.1); female 66%) follow-up was 85% at 6 m (n=212). Baseline characteristics and loss to follow-up were similar between groups. There were no reported treatment side effects. At 6 m 33% assigned joint protection were responders compared with 21% with no joint protection (p=0.03). Of those assigned hand exercises, 28% were responders compared with 25% with no exercises (n.s.). Differences in secondary outcomes were not statistically significant, except for improvement in pain self-efficacy with joint protection (3 m p=0.002; 6 m p=0.001; 12 m p=0.03).

CONCLUSIONS

These findings show that occupational therapists can support self-management in older adults with hand osteoarthritis, and that joint protection provides an effective intervention for medium term outcome. (Funded by the Arthritis Research UK ISRCTN 33870549).

An integrated approach to osteoarthritis pain

Informed therapeutic choices can help patients with osteoarthritis pain in 2 common locations-the hand and the knee-stay active.

An unusual clinical presentation of subacute granulomatous thyroiditis

Subacute granulomatous thyroiditis is an inflammatory thyroid condition that is presumed to be caused by a viral infection or postviral inflammatory process. It is characterized by neck pain, usually a tender diffuse goiter, and thyrotoxicosis. A case is presented of subacute granulomatous thyroiditis in an adult woman who had no neck pain but presented with morning stiffness in the small joints of the right hand, intermittent abdominal pain, malaise, fever, and myalgia. After the diagnosis had been established, she was treated with propranolol and acetylsalicylic acid, and has fully recovered. In conclusion, this disease may be difficult to diagnose, especially if there is a combination of fever and increased aminotransferases, which can lead to a wrong diagnostic approach.

Topical herbal therapies for treating osteoarthritis

BACKGROUND

Before extraction and synthetic chemistry were invented, musculoskeletal complaints were treated with preparations from medicinal plants. They were either administered orally or topically. In contrast to the oral medicinal plant products, topicals act in part as counterirritants or are toxic when given orally.

OBJECTIVES

To update the previous Cochrane review of herbal therapy for osteoarthritis from 2000 by evaluating the evidence on effectiveness for topical medicinal plant products.

SEARCH METHODS

Databases for mainstream and complementary medicine were searched using terms to include all forms of arthritis combined with medicinal plant products. We searched electronic databases (Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, AMED, CINAHL, ISI Web of Science, World Health Organization Clinical Trials Registry Platform) to February 2013, unrestricted by language. We also searched the reference lists from retrieved trials.

SELECTION CRITERIA

Randomised controlled trials of herbal interventions used topically, compared with inert (placebo) or active controls, in people with osteoarthritis were included.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials for inclusion, assessed the risk of bias of included studies and extracted data.

MAIN RESULTS

Seven studies (six different medicinal plant interventions; 785 participants) were included. Single studies (five studies) and non-comparable studies (two studies) precluded pooling of results.Moderate evidence from a single study of 174 people with hand osteoarthritis indicated that treatment with Arnica extract gel probably results in similar benefits as treatment with ibuprofen (non-steroidal anti-inflammatory drug) with a similar number of adverse events. Mean pain in the ibuprofen group was 44.2 points on a 100 point scale; treatment with Arnica gel reduced the pain by 4 points after three weeks: mean difference (MD) -3.8 points (95% confidence intervals (CI) -10.1 to 2.5), absolute reduction 4% (10% reduction to 3% increase). Hand function was 7.5 points on a 30 point scale in the ibuprofen-treated group; treatment with Arnica gel reduced function by 0.4 points (MD -0.4, 95% CI -1.75 to 0.95), absolute improvement 1% (6% improvement to 3% decline)). Total adverse events were higher in the Arnica gel group (13% compared to 8% in the ibuprofen group): relative risk (RR) 1.65 (95% CI 0.72 to 3.76).Moderate quality evidence from a single trial of 99 people with knee osteoarthritis indicated that compared with placebo, Capsicum extract gel probably does not improve pain or knee function, and is commonly associated with treatment-related adverse events including skin irritation and a burning sensation. At four weeks follow-up, mean pain in the placebo group was 46 points on a 100 point scale; treatment with Capsicum extract reduced pain by 1 point (MD -1, 95% CI -6.8 to 4.8), absolute reduction of 1% (7% reduction to 5% increase). Mean knee function in the placebo group was 34.8 points on a 96 point scale at four weeks; treatment with Capsicum extract improved function by a mean of 2.6 points (MD -2.6, 95% CI -9.5 to 4.2), an absolute improvement of 3% (10% improvement to 4% decline). Adverse event rates were greater in the Capsicum extract group (80% compared with 20% in the placebo group, rate ratio 4.12, 95% CI 3.30 to 5.17). The number needed to treat to result in adverse events was 2 (95% CI 1 to 2).Moderate evidence from a single trial of 220 people with knee osteoarthritis suggested that comfrey extract gel probably improves pain without increasing adverse events. At three weeks, the mean pain in the placebo group was 83.5 points on a 100 point scale. Treatment with comfrey reduced pain by a mean of 41.5 points (MD -41.5, 95% CI -48 to -34), an absolute reduction of 42% (34% to 48% reduction). Function was not reported. Adverse events were similar: 6% (7/110) reported adverse events in the comfrey group compared with 14% (15/110) in the placebo group (RR 0.47, 95% CI 0.20 to 1.10).Although evidence from a single trial indicated that adhesive patches containing Chinese herbal mixtures FNZG and SJG may improve pain and function, the clinical applicability of these findings are uncertain because participants were only treated and followed up for seven days. We are also uncertain if other topical herbal products (Marhame-Mafasel compress, stinging nettle leaf) improve osteoarthritis symptoms due to the very low quality evidence from single trials.No serious side effects were reported.

AUTHORS' CONCLUSIONS

Although the mechanism of action of the topical medicinal plant products provides a rationale basis for their use in the treatment of osteoarthritis, the quality and quantity of current research studies of effectiveness are insufficient. Arnica gel probably improves symptoms as effectively as a gel containing non-steroidal anti-inflammatory drug, but with no better (and possibly worse) adverse event profile. Comfrey extract gel probably improves pain, and Capsicum extract gel probably will not improve pain or function at the doses examined in this review. Further high quality, fully powered studies are required to confirm the trends of effectiveness identifed in studies so far.

A seroimmunological profile of erosive hand osteoarthritis

OBJECTIVES

erosive hand osteoarthritis (EHOA) is an inflammatory disorder involving joints of the hands, which may be accompanied by acute phase reactants. The relationship between EHOA and classical osteoarthritis (OA) is still controversial, since some authors consider EHOA as a distinct disease, other as a subset of OA, and some as a border entity between OA and rheumatoid arthritis (RA). Scarce data are available about the seroimmunological profile of the disease, which could aid to identify a possible role of the immune system in EHOA pathogenesis, and could also allow to better differentiate EHOA both from OA and RA.

MATERIAL AND METHODS

blood was drawn from the following patients: 37 with EHOA, 35 with OA and 45 with RA. All sera were tested for rheumatoid factor, anti-cyclic citrullinated peptide antibodies (anti-CCP), antinuclear antibodies (ANA), anti-extractable nuclear antigens (anti-ENA) and anti-neutrophil cytoplasmic antibodies (ANCA).

RESULTS

ANCA were never detected in OA, whereas they were found in 7 (19%) EHOA and 8 (18%) RA patients; the difference between EHOA and OA was statistically significant (p<0.01). Anti-CCP antibodies, which were consistently negative in OA, were positive in 2 EHOA (5%) at a low titre and in 23 (51%) RA patients, usually at a very high titre. The difference between EHOA and OA was not statistically significant, while the number of RA positive patients was significantly higher (p<0.001).

CONCLUSIONS

our findings suggest that the seroimmunological profile of EHOA is different from that of OA. In EHOA patients ANCA and anti-CCP antibodies might be either markers of inflammation involving neutrophils and/or markers of an underlying autoimmune process.

Serological markers of erosive hand osteoarthritis

This review focuses on biomarkers in erosive hand osteoarthritis (EHOA), a subset of hand osteoarthritis (HOA), that primarily affects interphalangeal joints and is characterized by abrupt onset, severe pain and functional impairment, as well as signs of inflammation, in particular stiffness, swelling, erythema, paraesthesiae, and worse outcome. Inflammatory features and radiographic erosions are the main diagnostic hallmarks of this particular disease subset. As in other fields of OA, EHOA biomarkers can be classified as dry and soluble. Soluble biomarkers which are found in serum, synovial fluid and urine can be specific indicators of joint inflammation and degradation. With regard to inflammatory markers, C-reactive protein and myeloperoxidase have been found to be increased in EHOA, with respect to non-erosive HOA. All these markers have, moreover, been found to be correlated with disease activity. Another interesting marker linked to inflammation is hyaluronic acid, considered to be a marker of synovitis, which is frequently found in EHOA. The most useful cartilage markers in both erosive and non-erosive HOA, seems to be collagen (Coll) 2-1, Coll 2-1NO(2) and Col2-3/4C(short). Immunogenetic markers were also determined and an association between EHOA and a single nucleotide polymorphism on the gene encoding interleukin-1β was found in HLA and there was an increased frequency of HLA-B44 and HLA-DRB1*07 in EHOA.

Factors associated with the severity and progression of self-reported hand pain and functional difficulty in community-dwelling older adults: a systematic review

BACKGROUND

Hand problems are common in older adults and cause significant pain and disruption to everyday living. The aim of this systematic review was to summarize evidence on the factors associated with the severity and progression of self-reported hand pain and functional difficulty in population-based studies of older adults.

METHODS

MEDLINE, EMBASE, CINAL, BNI, AMED, HMIC, PsycINFO and ISI Web of Knowledge were searched up to January 2011 for relevant articles. The search strategy combined text words for hand, pain, function and epidemiological study. Inclusion criteria were applied and articles in the review assessed for quality using the QUality In Prognosis Studies (QUIPS) assessment tool. Data extraction included: author, year of publication, study location, participant inclusion criteria, risk factor and outcome measurement, and association with hand pain and/or function.

RESULTS

Seven articles from five studies met the inclusion criteria from 5,679 citations. All studies were cross-sectional and provided no information on progression of hand pain and function over time. Factors associated with limited hand function were older age, female gender, manual occupation, neck or shoulder pain, clinical and radiographic osteoarthritis, weaker hand strength, hand pain, history of Parkinson's disease, stroke, diabetes or rheumatoid arthritis, and illness perceptions (namely, frustration, impact and symptom count). Key factors associated with hand pain severity were age, impact, frustration, patient expectation of a long disease time course and self-reported diagnosis of the cause of the hand problem.

CONCLUSIONS

Both demographic and clinical factors were found to be related to self-reported hand pain severity and functional difficulty in older adults; however, the results were derived from a small number of studies, with no information on progression of hand pain and functional difficulty over time.

Osteoarthritis: an update with relevance for clinical practice

Osteoarthritis is thought to be the most prevalent chronic joint disease. The incidence of osteoarthritis is rising because of the ageing population and the epidemic of obesity. Pain and loss of function are the main clinical features that lead to treatment, including non-pharmacological, pharmacological, and surgical approaches. Clinicians recognise that the diagnosis of osteoarthritis is established late in the disease process, maybe too late to expect much help from disease-modifying drugs. Despite efforts over the past decades to develop markers of disease, still-imaging procedures and biochemical marker analyses need to be improved and possibly extended with more specific and sensitive methods to reliably describe disease processes, to diagnose the disease at an early stage, to classify patients according to their prognosis, and to follow the course of disease and treatment effectiveness. In the coming years, a better definition of osteoarthritis is expected by delineating different phenotypes of the disease. Treatment targeted more specifically at these phenotypes might lead to improved outcomes.

The presence of total knee or hip replacements due to osteoarthritis enhances the positive association between hand osteoarthritis and atherosclerosis in women: the AGES-Reykjavik study

OBJECTIVE

This study examines the relationship between total knee replacements (TKR), total hip replacements (THR) or replacements of either joint (total joint replacement; TJR) due to osteoarthritis and atherosclerosis in a large population-based study.

METHODS

The participants were 2195 men and 2975 women, mean age 76 ± 6 years. The osteoarthritis data were analysed in relation to measures of atherosclerosis, including carotid artery intima media thickness and plaque severity (ultrasound), coronary and aortic calcifications (CT), cerebral white matter lesions (MRI) and a history of previous cardiac and cerebral events.

RESULTS

The prevalence of TKR was 223 (4.3%) and THR 316 (6.1%). The presence of TJR in women was associated with a non-significant trend towards increased carotid plaque severity, coronary calcifications and periventricular white matter hyperintensities (PVH) but not with a history of cardiac or cerebral events. No associations were seen in men. When TJR were grouped according to the presence or absence of hand osteoarthritis (HOA) there was a highly significant association in the order -TJR/-HOA < +TJR/-HOA < -TJR/+HOA < +TJR/+HOA, for carotid plaque severity, coronary calcifications and PVH.

CONCLUSION

The presence of TJR did not show a significant independent association with atherosclerosis but enhanced the strength of the positive association between HOA and subclinical atherosclerosis in women.

Current concepts in the surgical management of rheumatoid and osteoarthritic hands and wrists

Rheumatoid arthritis (RA) is a progressively destructive disease. Gradual loss of hand function in RA patients affects their ability for self-care and interferes with their productivity in society. The continuing improvement in the medical management of RA has markedly decreased the incidence of RA hand surgery. In contrast to RA, osteoarthritis (OA) has less inflammatory reaction in the joints and is characterized by degradation of cartilage, resulting in joint destruction and osteophyte formation. The initial treatment of OA is medication and therapy. Steroid injection into affected joints can provide short-term relief, though repeat injections carry a cumulative risk of weakening the soft tissue. In this article the authors share their extensive experience in RA and OA hand surgery to provide a clear discussion of the indications and outcomes of its practice.

Flare-up of hand osteoarthritis caused by zoledronic acid infusion

Zoledronic acid is effective for osteoporosis at a single annual intravenous dose. It usually causes few adverse effects; the most common are related to acute phase reactions. We reported the case of a 64-year-old woman who presented flare-up of hand osteoarthritis after zoledronic acid infusions. Despite the fact that arthralgia is a common side effect of intravenous bisphosphonates, development of inflammatory signs in osteoarthritic joints is a rare event. We hypothesized that this side effect is caused by a release of cytokines secondary to activation of gamma-delta T lymphocytes.

Clinical study on the effect of infrared radiation of a tiled stove on patients with hand osteoarthritis

OBJECTIVE

To explore the effect of infrared radiation of a tiled stove on patients with hand osteoarthritis (OA).

METHODS

A randomized controlled crossover study was performed with 45 patients with hand OA. This sample was randomly assigned to two groups: group A [first 3 hours spent three times a week during 3 weeks in a heated tiled stove room ('Stove Period') and after 2 weeks without treatment this group was observed for another 3 weeks ('Control Period')]; and group B (first assigned to the control period and the stove period following the treatment-free period). Assessments included the visual analogue scale (VAS) for general pain, pain in the hands, and global hand function, grip strength, the Moberg Picking-up Test (MPUT), the Australian/Canadian Osteoarthritis Hand Index (AUSCAN), and the Medical Outcomes Study (MOS) 36-item Short-Form Health Status Survey (SF-36).

RESULTS

Fourteen (31%) patients improved on the VAS for general pain at the end of the tiled stove period as compared to 10 patients (22%) during the control period (p = 0.314, chi2-test). The AUSCAN pain domain showed a significant improvement after the tiled stove period (p = 0.034). Others pain parameters analysed (VAS for pain in hands and SF-36 bodily pain) showed moderate but not significant improvement (p = 0.682 and p = 0.237, respectively) compared to the control period.

CONCLUSION

This study did not prove positive effects of the tiled stove exposure, although the numerical improvement in all pain measures suggests some possible positive effects on this symptom of hand OA.