MSK System Research Articles

Sex differences in musculoskeletal injury and disease risks across the lifespan: Are there unique subsets of females at higher risk than males for these conditions at distinct stages of the life cycle?

Sex differences have been reported for diseases of the musculoskeletal system (MSK) as well as the risk for injuries to tissues of the MSK system. For females, some of these occur prior to the onset of puberty, following the onset of puberty, and following the onset of menopause. Therefore, they can occur across the lifespan. While some conditions are related to immune dysfunction, others are associated with specific tissues of the MSK more directly. Based on this life spectrum of sex differences in both risk for injury and onset of diseases, a role for sex hormones in the initiation and progression of this risk is somewhat variable. Sex hormone receptor expression and functioning can also vary with life events such as the menstrual cycle in females, with different tissues being affected. Furthermore, some sex hormone receptors can affect gene expression independent of sex hormones and some transitional events such as puberty are accompanied by epigenetic alterations that can further lead to sex differences in MSK gene regulation. Some of the sex differences in injury risk and the post-menopausal disease risk may be "imprinted" in the genomes of females and males during development and sex hormones and their consequences only modulators of such risks later in life as the sex hormone milieu changes. The purpose of this review is to discuss some of the relevant conditions associated with sex differences in risks for loss of MSK tissue integrity across the lifespan, and further discuss several of the implications of their variable relationship with sex hormones, their receptors and life events.

P160 Clinical and sociodemographic associates of depression and anxiety in SLE

Abstract Background/Aims In our recent systematic review, we have shown a high prevalence for depression (35%) and anxiety (26%) in systemic lupus erythematosus (SLE) . A better understanding of the SLE phenotypic manifestations associated with depression and anxiety may lead to earlier diagnosis and treatment interventions. Our objective is to determine the overall prevalence of anxiety and depression in a cohort of SLE patients, stratified by SLE-implicated organ systems and to study their associations. Methods Patients attending the Toronto Lupus Clinic from August 2017 to January 2019 were studied. Depression and Anxiety were diagnosed with Centre for Epidemiological Studies-Depression Scale (cut-off26), BECK Depression Inventory-II (cut-off18), and the BECK Anxiety Inventory (cut-off19). Disease activity was measured with the SLE Disease Activity Index 2000 (SLEDAI-2K). SLE phenotypic manifestations were stratified based on the organ systems of cumulative 10-year SLEDAI-2K. Separate multivariate logistic regression analyses (for depression [D], anxiety [A], and co-morbid anxiety and depression [AD]) were performed to study the factors associated factors, including age at enrolment, sex, ethnicity, disease duration, inception status (enrolled in the clinic within 1 year of SLE diagnosis), fibromyalgia, and SLE phenotypic manifestations, comparing their significance to the group with neither A or D. Results 341 patients (89.7% female), with mean age 45.917.8 years were studied. The prevalence of A and D in the cohort was 34% and 27% respectively, while 21% of the total cohort was found to have AD. Among the 3 outcome groups, MSK system involvement has a significantly higher prevalence when compared to the group with neither A or D (p-values< 0.05). Skin system involvement was also significantly more prevalent among A, D, and AD groups, in comparison to the normal group. Patients with A had significantly higher odds of skin system involvement compared to the normal group (OR = 1.8; 95% CI: 1.1, 3.0). Patients with D had higher odds of MSK (OR = 1.9; 95% CI: 1.1, 3.5) and skin system involvement (OR = 1.8; 95% CI: 1.04, 3.2) compared to the group with neither A or D. Additionally, the odds of skin system involvement was significantly higher among patients with AD, compared to the group with neither (OR = 2.0, 95% CI: 1.2, 3.9). In all three models, employment and fibromyalgia were also significant. Age at enrolment was significant in the D and AD models, while inception patient status was significant in the D model exclusively. Conclusion SLE phenotypic manifestation, specifically those involving patients’ skin or MSK systems, along with fibromyalgia, socio-demographic factors, and inception status were associated with anxiety or depression. Routine patient screening and evaluation, especially among patients with shorter disease duration, for these associated factors may facilitate the diagnosis of these mental health disorders, and allow for more timely diagnosis and intervention strategies. Disclosure D.F. Eldeiry: None. M. Zandy: None. O.E. Tayer-Shifman: None. A. Kwan: None. S. Marzouk: None. J. Su: None. K. Bingham: None. Z. Touma: Grants/research support; Young operating and young investigator salary award of the Arthritis Society, new investigator research grant of Physicians' Services Inc Foundation, the CIORA, Rocca Family, Kaiser Family. Other; The Toronto Lupus Clinic Research Program is supported financially by the University Health Network, the Lou Rocca Family, and the Lupus Foundation of Ontario.

High-Frequency and Ultra-High Frequency Ultrasound: Musculoskeletal Imaging up to 70 MHz.

Musculoskeletal (MSK) ultrasound has well-established advantages, able to investigate very small structures with high resolution and a quick and real-time dynamic evaluation with the possibility of contralateral comparison. Thus ultrasound has kept its own almost exclusive fields of application in daily clinical practice, and it is considered the first-level imaging technique to assess tendons, bursae, and capsuloligamentous structures of small peripheral joints as well as peripheral nerves. Up to now, however, clinical MSK ultrasound imaging could not go beyond the first 1 to 2 cm under the skin, using high-frequency probes up to 18 to 20 MHz with spatial resolution just below millimeters. We present the impressive technical advancements leading to image resolution as low as 30 µm using ultra-high frequency ultrasound (UHFUS) probes up to 70 MHz. High-frequency ultrasound and UHFUS, with frequencies ranging from 22 to 70 MHz, are promising tools to evaluate very superficial structures. In the MSK system, only two articles have assessed its value in limited case series. Future developments may be aimed to better assess ultrastructural changes of very superficial peripheral nerves and other thin structures such as pulleys, retinacula, and tendons.

Prevalence of Musculoskeletal Disorders in Workers In An Industry in Ahmednagar District, Maharashtra.

Introduction: Musculoskeletal disorders are a major public health problem in industrialized and developing countries. The present study was aimed to find out the prevalence of acute and chronic WMSD’s in Industrial workers. Methodology: This cross-sectional observational study was carried out in 60 workers of the Adon Block department workers of the electrical & automation industry, Ahmednagar. Pre-structured occupational Performa was filled by asking questions in the worker’s local language. The Nordic pain Questionnaire was filled by asking the subjects to mark the sites of pain on body chart paper. The risk factors for work-related musculoskeletal problems were assessed by the working posture of workers and repetitive movements in industrial set up. The data collected were interpreted and analyzed. Results: In the present study, 60 workers were selected, of which a number of females were 39 (65%) while males were 21 (35%). The Neck (20.2%) followed by the shoulder (14.9%), elbow (14.4%) and knee (14.4%) were most commonly involved. There was a statistically significant variation in the number of workers involved according to the posture (sitting vs standing) and part of the MSK system involved. Conclusion: The WMSD’s are common in Adon block department workers. The involvement of neck, shoulder, lower back and arm was common in sitting position, while the involvement of upper back, elbow and knee were common in standing position. The disorders are commonly seen in workers irrespective of their duration of work and gender.
 Keywords: Musculoskeletal disorders; Industry Workers; Nordic pain Questionnaire; Ahmednagar.

Advanced Techniques in Musculoskeletal Oncology: Perfusion, Diffusion, and Spectroscopy.

The imaging characterization of musculoskeletal tumors can be challenging, and a significant number of lesions remain indeterminate when conventional imaging protocols are used. In recent years, clinical availability of functional imaging methods has increased. Functional imaging has the potential to improve tumor detection, characterization, and follow-up. The most frequently used functional methods are perfusion imaging, diffusion-weighted imaging (DWI), and MR proton spectroscopy (MRS). Each of these techniques has specific protocol requirements and diagnostic pitfalls that need to be acknowledged to avoid misdiagnoses. Additionally, the application of functional methods in the MSK system has various technical issues that need to be addressed to ensure data quality and comparability. In this article, the application of contrast-enhanced perfusion imaging, DWI, and MRS for the evaluation of bone and soft tissue tumors is discussed, with emphasis on acquisition protocols, technical difficulties, and current clinical indications.

Soft tissue sarcoma of the head & neck: nomogram validation and analysis of staging systems.

Soft tissue sarcomas of the head and neck (STSHN) comprise a rare group of malignancies. Our objective is to determine the utility of soft tissue sarcoma staging systems within the head and neck, and to validate an individualized soft tissue sarcoma nomogram within head and neck primary sites. Previously-untreated patients with STSHN diagnosed and treated between 1982 and 2012 were eligible (n = 319, median follow-up 46 months). Clinical variables were extracted from a prospectively-maintained database. The performance of AJCC/UICC and MSK staging systems and a soft tissue sarcoma-specific nomogram were assessed. Four-year overall survival (OS), disease specific survival (DSS), and recurrence-free survival (RFS) were 72%, 76%, and 71%, respectively. AJCC/UICC and MSK staging systems accurately stratified outcomes (OS, DSS, and RFS; P < 0.001 for all comparisons). The nomogram stratified outcomes by quartile (P < 0.001), and predicted risk of death at 4, 8 and 12 years (P < 0.001). Concordance indices for overall survival for the AJCC/UICC system, MSK system, and the nomogram were 0.71, 0.70, and 0.78, respectively. Oncologic outcomes among groups of patients with STSHN can be accurately predicted using both the AJCC/UICC and MSK staging systems. A soft tissue sarcoma-specific nomogram provides reliable, individualized prognostic information for patients with STSHN.

AB0975 Power and Colour Doppler Findings in Lower Extremity Entheses of Healthy Children – Effect of Measurement Distance from Bone and Joint Position

BackgroundMusculoskeletal ultrasound has significant potential in the assessment of the pediatric entheses. Doppler signals at the site of tendon insertions are often considered as signs of pathology for enthesitis as...

A29: Power and Colour Doppler Findings in Lower Extremity Entheses of Healthy Children—Effect of Measurement Distance from Insertion and Joint Position

Background/Purpose:Musculoskeletal ultrasound has significant potential in the assessment of the pediatric entheses. Doppler signals at the site of tendon insertions are often considered as signs of pathology for enthesitis as well as apophysitis. The normal pediatric enthesis can nevertheless exhibit Doppler signals as well and this might be especially relevant during periods of rapid growth with increased mechanical strain. Limited and partially confliciting data is available for Doppler charactistics of the normal pediatric enthesis. This may be due to technical factors, variable definitions of the anatomic location of the enthesis and variable positioning of the patient. The aim of this study was to examine relevant entheses of the knee and ankle joint in healthy children at the peak of linear growth and determine the effect of measurement distance from the insertion and position of the joint.Methods:35 males and females with an age range of 11–14 years volunteered for this study. All participants were free of musculoskeletal symptoms, medical conditions or medication affecting the MSK system, MSK injuries in the past three months and did not participate in sports more than three times per week. The Insertion of the Quadriceps tendon into the patella, the proximal and distal patella tendon insertion and the Achilles tendon insertion were examined with standardized settings in Power as well as Colour Doppler Ultrasound using an Esaote Mylab 70 XVG Gold machine with a linear probe ranging from 6 to 18 MHz. Both extremities were assessed in neutral as well as 30 degrees flexion. All images were acquired by a single examiner and read by two readers. A subset of volunteers was reassessed 2 days later. On all images the presence of Doppler signals was assessed directly at the bone/cartilage interface as well as within a distance of 2mm, 5mm and 10mm.Results:No Doppler signals were seen directly at the bone/cartilage surface in any of the enthesis. The highest prevalence of signals was found in the quadriceps tendon. Comparing neutral with 30 degrees flexion 30% vs. 40% of participants displayed Doppler signals within 10 mm of the insertion, 30% vs. 35% within 5 mm and 20% vs. 10% within 2 mm. A similar percentage of Doppler signals was seen within 2 mm of the tibial tuberosity although with 10% of volunteers displaying signals in neutral vs 20% in flexed position. At 10 mm distance these percentages were 30 % in flexed vs 20% in neutral position. In contrast no Doppler signals were seen at the insertion of the proximal Patella tendon and the Achilles tendon. No significant differences were seen between Colour and Power Doppler.Conclusion:The specificity of Doppler findings in Apophysitis or Enthesitis is expected to be much higher in the proximal Patella tendon and Achilles tendon than in other entheses. At all Entheses Doppler signals very close to the bone/cartilage surfaces are rarely observed in healthy children. In contrast, the tendon insertions at the proximal patella and the tibial tuberosity display a high prevalence of Doppler signals at a distance of more than 2 mm from the insertion possibly related to mechanical strain occurring physiologically. In order to increase sensitivity the exam should be performed in various positions of the joint.

AB1409 Confidence levels of internal medicine trainees in rheumatological skills and diagnosis: A singapore perspective

BackgroundMusculoskeletal (MSK) disease is one of the most common problems encountered in primary care and specialist consultations. Clinical assessment is essential to approaching MSK complaints and central to management. However...

Musculoskeletal examination—an ignored aspect. Why are we still failing the patients?

Over the past two decades, rheumatologists from around the world have not only championed the musculoskeletal system examination but also modified the undergraduate teaching curriculum. This has led to the development and adoption of the gait, arms, legs and spine (GALS) screening along with regional examination techniques. The purpose of this study is to review current practice, determining the frequency of patient exposure to appropriate examination and confidence of junior doctors when dealing with MSK conditions. Two district-general hospitals (non-teaching) and one teaching hospital in North-East London were chosen. At each site, 50 patient notes were reviewed from the acute admission wards for medicine and surgery and the medical assessment unit. Factors considered included whether GALS screenings had taken place, documentation of MSK examinations and assessment of confidence of junior doctors in assessing MSK conditions. GALS screenings were performed for 4% of patients on the medical assessment unit, 7% of acute medical and 0% of acute surgical patients on admission. Examination of the MSK system yielded better results with 16%, 22% and 10% on each of the respective wards. Interviews with junior doctors found 10% routinely screening for MSK conditions, despite 87% feeling confident in taking MSK histories. This prospective audit of clinical practice highlights that patients failed to have a minimal assessment of the MSK system through GALS screenings. When examining the MSK system, results were somewhat better, although still fewer than expected. It is curious that the majority of junior doctors in training felt confident in dealing with MSK disease but few did it in practice. This begs the question of whether current teaching curricula and strategies are adequate. At a time where there is ever-increasing national momentum to address issues on obesity and cardiovascular health, our patients are still deprived of a standard MSK examination by the medical faculty.

IR challenges in the MSK system

As the capability of medical imaging equipment improves, and relatively new modalities such as cone beam CT with guidance becomes more widely available, the range and complexity of image guided orthopedic procedures continues to expand. Challenges include the predictable technical and anatomic issues, as well as the complex operational and political issues associated with moving and integrating an interventional radiology service into the traditional operating room environment.

Effects of partial-band noise interference on hybrid DS/SFH MSK system in Rayleigh fading channel

The effects of partial-band noise interference on the hybrid DS/SFH MSK system in a Rayleigh fading channel are analysed and discussed. In an AWGN channel, the worst case BER is caused by the partial-band interference for large signal-to-interference ratio (SIR), and full-band interference for small SIR, respectively, independent of signal-to-noise ratio (SNR); whereas, in a Rayleigh fading channel, the full-band interference always results in the worst BER, independent of both SNR and SIR.

Bit error rate and power penalty in MSK coherent optical communication systems with a single interfering echo

AbstractIf an echo is generated during transmission, then along with the principal wave (directly transmitted wave), an echo with a certain time delay arrives at the receiver, which causes degradation of receiver performance.In this paper, the bit error rate for optical MSK communication systems with a limiter‐discriminator‐integrator‐type receiver is analyzed and the influence of echo is evaluated qualitatively as well as quantitatively.In general, there exists a floor value on the error rate curve due to the phase fluctuation of laser light in the coherent optical communication systems, which is not reduced upon increasing the received optical power. It is shown that this floor value increases due to the presence of echo and its value is a maximum when the delay time of echo with respect to the principal wave is an integral multiple of the bit duration. Moreover, when the spectral linewidth of the light with high bit rate is narrow, then the effect of echo becomes even stronger.A relationship between the received optical power and bit error rate is derived, and the power penalty is determined for given echo amplitude, delay time, and linewidth‐bit duration product. the conditions under which the effect of echo cannot be neglected are clarified. Moreover, the optical MSK system is compared with the optical DPSK system and it is shown that the MSK signal is degraded by echo greater than the DPSK‐signal.The special feature of this paper is an exact analysis of the case when some phase correlation exists between the principal wave and echo due to coding considerations.

Simple Expression for Interchannel and Intersymbol Interference Degradation in MSK Systems with Application to Systems with Gaussian Filters

In this paper, we derive a simple expression for the degradation in signal-to-noise ratio caused by intersymbol and adjacent channel interference in MSK systems for which the total response is nonnegative and the response is such that only two intersymbol and one adjacent channel terms are dominant. An MSK system with Gaussian filters in transmitter and receiver satisfy this condition. The resulting expression is simple because we simultaneously maximize the signal value from the main channel (by selecting the sampling time) and the degradation caused by the signals in the interfering channels. For such systems we derive the relation between the optimal filter bandwidth and channel frequency separation. Numerical results are presented for the case of Gaussian filters in both transmitter and receiver or receiver only and either one or two adjacent interfering channels.

Comparison of Performance of 16-ary QASK and MSK Over a Frequency Selective Rician Fading Channel

The probability of error of both a 16-ary QASK system and an MSK system, each operating over a Rician fading channel, is considered. The channel model has two key features: short term variations are modeled by making the channel frequency selective, and long term variations are accounted for by allowing the specular component of the received signal to fade according to a Rayleigh density. The improvement gained by using maximal-ratio diversity combining is derived, as well as the degrading effects of an adjacent channel. Finally, a comparison between MSK and 16-ary QASK operating over the same channel is presented, and it is shown that MSK results in a smaller probability of error.