Standard Clinical Follow-up Research Articles

Atrial fibrillation future clinic. Novel platform to integrate smart device electrocardiogram into clinical practice

BackgroundDirect-to-consumer devices allow patients to record electrocardiograms (ECG) and detect atrial fibrillation (AF). Clinical adoption of these devices has been limited owing to the lack of efficient workflow.ObjectiveTo assess a new care model for following patients after AF ablation that uses a smartphone ECG coupled with a novel cloud-based platform.MethodsThis was a pilot study to describe AF detection, healthcare utilization, use of additional ECGs and cardiac monitors, and changes in anxiety after AF ablation. Patients presenting 3–4 months after early successful AF ablation were randomized into a control group with standard clinical follow-up or a self-monitoring group using smartphone ECG (Kardia Mobile, KM) coupled with a cloud-based platform (KardiaPro, KP) that alerted the physician when AF was detected and followed for 6 monthsResultsA total of 100 patients were randomized: 51 to the KM/KP group and 48 to the control group (1 withdrew). AF was detected in 18 patients (18.2%), 11 (21.6%) in the KM/KP group and 7 (14.6%) in the control group (P = .42). AF detection occurred at a median of 68 and 91 days in the KM/KP and control groups, respectively (P = .93). These differences were not statistically significant. Healthcare utilization and changes in anxiety were similar between the groups. More patients required additional ECGs or cardiac monitors in the control group (27.1%) compared to the KM/KP group (5.9%) (P = .004).ConclusionsSmartphone ECG with a cloud-based platform can be incorporated into the care of post–AF ablation patients without increasing anxiety and with less need for additional traditional monitors.

IMG-18. ASSESSMENT OF SUSPECTED DISEASE PROGRESSION USING MULTIPARAMETRIC 18F-CHOLINE PET/MRI IN CHILDHOOD AND TEENAGE-YOUNG ADULT GLIOMAS

OBJECTIVESEvaluation of post-treatment glioma burden remains a significant challenge in children, teenagers and young adults (TYA). The aim of this study was to evaluate the utility of ChoPET/MRI for evaluation of suspected disease progression in childhood and TYA gliomas.METHODS27 patients (mean age 14 years, range 6–21 years) with suspected glioma disease progression were evaluated with ChoPET/MRI (n=59). Relative cerebral blood volume (rCBV), apparent diffusion coefficient (ADC) and maximum standardised uptake values (SUVmax) in enhancing (enh) and non-enhancing (ne) tumour and normal-appearing white matter (wm) were calculated (rCBVenh, rCBVne, rCBVwm, ADCenh, ADCne, ADCwm, SUVenh, SUVne, SUVwm). 2 blinded radiologists scored tumour probability (1 = unlikely; 5 = definitely). Sensitivity and specificity calculated with gold standard histopathology or clinical follow-up.RESULTSAccuracy for the detection of residual/recurrent tumour on conventional MRI was 96.3% (91.7% ≤14 years, 100% ≥15 years) and ChoPET was 73.1% (66.7% ≤14 years, 80.0% ≥15 years). Lack of agreement was observed in 9/27 patients, with ChoPET superior to MRI in 1 case of a posterior fossa tumour. Tumour component analysis demonstrated significantly higher SUVenh and SUVne than SUVwm (SUVenh: p<0.001; SUVne: p=0.004, equivalent to results were observed for ADV and rCBV (ADCenh, ADCne: p<0.001 vs ADCwm; rCBVenh, rCBVne: p<0.001 vs rCBVwm).CONCLUSIONSMRI is more sensitive than ChoPET in the evaluation of suspected disease progression in TYA gliomas. However, quanititative ChoPET is able to detect enhancing and non-enhancing tumour and may be helpful in evaluating posterior fossa disease where MRI is equivocal.

Can we clinically identify patients at risk of malignant transformation of skin tumors in Brooke–Spiegler syndrome?

Brooke-Spiegler syndrome (BSS) is a rare inherited autosomal dominant disease characterized by the development of multiple adnexal cutaneous neoplasms. BSS has been linked to mutations in CYLD gene, which is a tumor suppressor gene located on chromosome 16q12-q13. An increased risk of malignant transformation of adnexal cutaneous tumors in BSS patients has been reported. However, no reported genetic markers identify patients at risk of cutaneous malignancy. This study reviews published cases of BSS to investigate the role of clinical parameters as biomarkers of skin malignancy. A comprehensive review of the clinical aspects of BSS is based on 55 case reports. Our analysis revealed only age as a predictor of malignancy; however, this is also a general risk factor for development of malignancy and therefore of limited value as a screening tool. The study highlights the need for standardized clinical follow-up of patients.

Quality of Life and Glucose Control After 1 Year of Nationwide Reimbursement of Intermittently Scanned Continuous Glucose Monitoring in Adults Living With Type 1 Diabetes (FUTURE): A Prospective Observational Real-World Cohort Study.

In 2016, nationwide reimbursement of intermittently scanned continuous glucose monitoring (isCGM) for people living with type 1 diabetes treated in specialist diabetes centers was introduced in Belgium. We undertook a 12-month prospective observational multicenter real-world study to investigate impact of isCGM on quality of life and glycemic control. Between July 2016 and July 2018, 1,913 adults with type 1 diabetes were consecutively recruited in three specialist diabetes centers. Demographic, metabolic, and quality of life data were collected at baseline, 6 months, and 12 months of standardized clinical follow-up. The primary end point was evolution of quality of life from baseline to 12 months. Secondary outcome measures were, among others, change in HbA1c, time spent in different glycemic ranges, occurrence of acute diabetes complications, and work absenteeism. General and diabetes-specific quality of life was high at baseline and remained stable, whereas treatment satisfaction improved (P < 0.0001). Admissions for severe hypoglycemia and/or ketoacidosis were rare in the year before study (n = 63 out of 1,913; 3.3%), but decreased further to 2.2% (n = 37 out of 1,711; P = 0.031). During the study, fewer people reported severe hypoglycemic events (n = 280 out of 1,913 [14.6%] vs. n = 134 out of 1,711 [7.8%]; P < 0.0001) or hypoglycemic comas (n = 52 out of 1,913 [2.7%] vs. n = 18 out of 1,711 [1.1%]; P = 0.001) while maintaining HbA1c levels. Fewer people were absent from work (n = 111 out of 1,913 [5.8%] vs. n = 49 out of 1,711 [2.9%]; P < 0.0001). Time spent in hypoglycemia significantly decreased in parallel with less time in range and more time in hyperglycemia. Eleven percent (n = 210) of participants experienced skin reactions, leading to stopping of isCGM in 22 participants (1%). Nationwide unrestricted reimbursement of isCGM in people with type 1 diabetes treated in specialist diabetes centers results in higher treatment satisfaction, less severe hypoglycemia, and less work absenteeism, while maintaining quality of life and HbA1c.

Ten Years’ Experience in Vena Cava Filter Placement – Sample Characterization and Long-term Follow-up

Introduction: Vena cava filter (VCF) has been widely used since it was introduced in 1967. However, there is a general lack of information regarding VCF holders characteristics and their long-term outcomes, and there is not a standardized clinical or imagiological follow-up of these patients. Methods: This is a retrospective analysis of patients who had a VCF placed from 2008 to 2018 at Santa Marta Hospital (Lisbon, PT). Variables collected were patient demographics, indication for filter, filter used. Primary end-point was global survival. Secondary end-point was filter related complications. A substudy was performed to determine late filter related complications in alive patients by abdominal venous duplex ultrasound and abdominal x-ray. Cumulative rates of events were determined by Kaplan-Meier method. Results: From 2008 to 2018, 124 patients underwent VCF placement. Male:female ratio was 1:1. 104 patients (84%) had active venous thromboembolic event (VTE) at time of VCF placement. The most prevalent VTE risk factors were: previous documented VTE (38; 31%), recent hospitalization (63; 51%) and active neoplasm (46; 37%). The most common indications for VCF placement were: anticoagulant contraindication (69; 56%) and persisting pulmonary embolism (PE) despite anticoagulation (29; 23%). Excluding patients whose access site was not specified (16), femoral vein was punctured in 96 patients (89%) and internal jugular vein in 12 patients (11%). VCF was placed on infrarrenal inferior vena cava (IVC) in 100% of patients. Excluding patients whose filter type was not specified, permanent filter was placed in 66 patients (80%). VenaTech LP (B-Braun®) was placed in 34 patients and TrapEase (Cordis®) in 17 patients. A retrievable filter was placed in 17 patients (20%). Celect (Cook®) was placed in 2 patients and OptEase (Cordis®) in 15 patients. There was a VCF retrieval trial in 5 patients, three with success. Survival rate was 86.0±3.2% at 1 month, 63.3±4.5% at 1 year and 55.4±4.8% at 5 years. We found no PE events or VCF related-mortality during follow-up. Patients with active cancer had lower survival rates (28.7±8.5% at 5 years; p<0.001). Survival rates were similar regardless other VTE risk factors and filter indication or type. At present time of our substudy, 32 alive patients were evaluated at median time of 58 months after VCF placement. 2 patients had lower limb DVT in the meantime, one of which have active and the other previous colorrectal cancer. There were no signs of PE. 18 patients (56%) are anticoagulated, 10 with a DOAC (56%). We documented 5 asymptomatic VCF complications: 2 filter occlusions (with patent IVC proximal and distal to VCF), 3 filter tilts (one in a patient that underwent a trial of VCF retrieval). There was no documented filter fracture, penetration or migration. Conclusion: Main absolute indications for VCF placement continue to be VTE in presence of contraindication for anticoagulation and persisting PE despite anticoagulation. Persistent VTE and risk factors for recurrence, lack of follow-up and reported complications of filter retrieval may account for increased use of permanent VCF and retrievable VCF left permanently in place. In spite of known long-term adverse events of VCF (migration, fracture, tilt, penetration, thrombosis), their low incidence and absence of related symptoms challenge a standard of care follow-up for VCF holders. Very low survival rates of VCF holders who have active neoplasm challenge the benefits of VCF placement in patients with dismal prognosis.

Multiparametric 18F-Choline PET/MR in childhood and teenage-young adult gliomas: assessment of suspected disease progression

Abstract Aim Evaluation of post-treatment glioma burden remains a significant challenge in childhood, Teenage and Young Adults (TYA). Although amino acid PET impacts on glioma imaging, 18fluoro-Choline Positron Emission Tomography (ChoPET) is more widely available. The aim was to evaluate the utility of ChoPET/MRI for suspected disease progression in childhood and TYA gliomas. Methods 27 consecutive patients with suspected glioma disease progression were evaluated with ChoPET/MR and 59 scans included. Relative cerebral blood volume (rCBV), ADC and SUVmax in enhancing (enh), non-enhancing (ne) tumour volumes and normal appearing white matter (wm) were calculated (rCBVenh, rCBVne, rCBVwm, ADCenh, ADCne, ADCwm, SUVenh, SUVne, SUVwm). Blinded nuclear medicine and neuroradiologist scored the images on tumour probability (1:unlikely-5:definitely). Receiver Operating Characteristic (ROC) analysis considering as gold standard histopathology or clinical follow-up was performed. Results Combined ChoPET/MR accuracy was 100% for residual tumour, conventional MR accuracy was 96.3% (91.7% &lt;14years, 100% ≥15years) and ChoPET accuracy was 73.1% (66.7% &lt;14years, 80.0% ≥15 years). Lack ack of agreement in 9/27 with ChoPET superior to MR in 1 case. Tumour component analysis demonstrated significantly higher SUVenh and SUVne than SUVwm (SUVenh: p&lt;0.001,SUVne: p=0.003) equivalent to ADC (ADCenh, ADCnenh: p&lt;0.001) and rCBV (rCBVenh, rCBVnenh: p&lt;0,001). Conclusions Combined ChoPET/MR has 100% accuracy in TYA gliomas with suspected disease progression. ChoPET is able to detect enhancing and non-enhancing tumour but it is more reliable for evaluating enhancing disease &gt;15 years. In selected cases where MRI is equivocal, a quantitative multi-modality ChoPET/MR better defines both enhancing and non-enhancing tumour for improved assessment of childhood and TYA gliomas.

Outcome of Operative Treatment of Displaced Midshaft Clavicle Fracture Compared With Conservative Treatment

Background: Clavicles fracture accounts for 2.6%–5% of adult fractures. Fractures in the middle-third represent 69%–82% of all clavicle fractures.This prospective comparative study was done to evaluate the effectiveness of treatment options of conservative and operative method by plate for displaced midshaft of clavicle fractures in adult. Materials and methods: 76 patients between 18 to 70 years of age with a displaced midshaft fracture of clavicle were enrolled in this study. They were randomized in two groups to be treated with either triangular sling or operative fixation by anatomical plate.We analyzed the outcome of both groups by standard clinical and radiological follow-up at least one year with DASH score. Results: Mean age in conservative group was 52.2±13.2 years and 32.1±9.3 years in operative group. There was male predominance in both groups 71.7% (54). Mean time to radiographic union was 19.9±3.2 weeks in conservative group and 14.9±2.7 weeks in operative group. The total complications were 26.3% where 2.6% (01) nonunion in the operative group compared with 13.2% (05) in the conservative group. At one year of follow up, operative group were more likely to be satisfied with clinical and radiological outcome than conservative group by DASH score. Conclusions: Operative fixation of displaced mid shaft fracture of clavicle in adult showed improved functional outcome, faster return to daily activities and lower rate of complications compared with nonoperative treatment.&#x0D; JCMCTA 2019 ; 30 (1) : 21-26

MRI-Guided Stereotactic Laser Ablation of Deep-Seated Cerebral Cavernous Malformations

Abstract INTRODUCTION Magnetic resonance imaging (MRI)-guided stereotactic laser ablation (SLA) is a minimally invasive alternative to open surgery for symptomatic cerebral cavernous malformations (CCMs). While SLA of neocortical and medial temporal lesions is described, we examined the safety and effectiveness of SLA of deep-seated symptomatic CCMs in patients considered to be poor candidates for open resection. METHODS We analyzed 4 patients who presented with neurological symptoms associated with a CCM in deep brain structures. Each patient underwent CCM SLA with an effort to exclude adjacent brain parenchyma followed by standard clinical and imaging follow-up. RESULTS Three patients presented with chronic medically refractory headache and small lesions (0.1-2.6 cm3) consistent with CCM in thalamus (2) or putamen (1). A fourth patient presented with recurrent bleeding and hemiparesis associated with a large CCM (4.3 cm3) of the subthalamus/midbrain. Symptoms durations were 0.5 to 7 yr. SLA was performed using Visualase (Medtronic, Inc.); perilesional brain was monitored to avoid thermal injury. Out of 4 patients, all demonstrated a decrease in CCM volume and improvement of neurological symptoms at 5 to 23 mo follow-up. Two patients (one thalamus, one putamen), experienced evidence of hemorrhage during ablation (apparent with intraoperative MRI), limiting the extent of ablation in one case. Both patients were stabilized and made full recoveries. The ablation in subthalamus/midbrain was not associated with bleeding but did exacerbate hemiparesis, requiring rehabilitation. Hospital stays ranged from 2 to 5 d. CONCLUSION In a retrospective series, MR thermography guided SLA of symptomatic deep brain CCM was technically feasible. Unlike a prior series of more superficial epileptogenic CCM in which no hemorrhages were observed, SLA of deep CCM may carry higher risk of bleeding and neurological deficits. Larger, longer-term studies are required.

Predicting disease progression in high-grade glioma with neuropsychological parameters: the value of personalized longitudinal assessment

PurposeProgressive disease in patients with high-grade glioma may be reflected in cognitive decline. However, the cognitive functions most sensitive to progression may differ between patients. We investigated whether decline on a personalized selection of tests predicted progressive disease according to RANO criteria in high-grade glioma patients.MethodsStarting one day before surgery, patients underwent neuropsychological assessment every three months during standard treatment and clinical follow-up. We first made a personalized selection of three tests that showed the highest Reliable Change Index (RCI) values, i.e., most positive change, at the first post-surgical assessment for each patient. In subsequent follow up, a decline of RCI ≤ − 1 on at least two of the three tests in the selection was considered cognitive decline. We performed a discrete Cox proportional hazards model including a time-dependent coefficient cognitive decline (vs. stability) and covariate age to predict progressive disease.ResultsTwenty five patients were included. Cognitive decline on the personalized test selection preceded or had occurred by the time progression was established in 9/15 patients with RANO confirmed progressive disease (60%). Decline was absent in 8/10 patients (80%) with stable disease during participation. The independent hazard ratio for progression in case of cognitive decline was 5.05 (p < 0.01) compared to stable performance.ConclusionsUsing only three patient-specific neuropsychological tests, we found a fivefold increased chance of disease progression in case of cognitive decline as compared to stable performance. Brief, patient-tailored cognitive assessment may be a noninvasive addition to disease monitoring without overburdening patients and clinical care.

Is antegrade nailing a proper option in 2- and 3-part proximal humeral fractures?

To report our experience with antegrade short locked intramedullary nail for treatment of proximal humeral fractures and to review the current literature. From January 2012 to July 2013, 41 patients affected by two and three-part proximal humeral fractures were treated with surgical internal fixation with short locked intramedullary nails. Outcome analysis included standard clinical follow-up, Constant shoulder score and plain radiographs. The mean follow-up was 30months (range 24-42). Moreover, a review of the literature was carried out. The mean Constant shoulder score was 81.5, excellent functional outcomes in 24/38 patients. All the fractures healed in an average time of 3.7months. Five patients underwent additional operations, complications included hardware penetration into the joint (n = 2), backed out screw (n = 1), shoulder impingement due to protrusion of the nail (n = 2) and superficial infection (n = 1). The literature review showed 530 patients affected by proximal humeral fracture and treated with intramedullary nail with mean age of 65years, mean follow-up of 22.2months and a Constant shoulder score of 72.9 points; the major complications reported were backing out of the screws, shoulder impingement and joint protrusion of the screws. Antegrade short locked intramedullary nail allows stable fixation, minimal soft tissue dissection, early mobilization of the shoulder and good outcomes. It is an efficacious therapeutic solution for 2- and 3-part proximal humeral fractures.

Safety and effectiveness of stereotactic laser ablation for epileptogenic cerebral cavernous malformations.

Magnetic resonance (MR) thermography-guided laser interstitial thermal therapy, or stereotactic laser ablation (SLA), is a minimally invasive alternative to open surgery for focal epilepsy caused by cerebral cavernous malformations (CCMs). We examined the safety and effectiveness of SLA of epileptogenic CCMs. We retrospectively analyzed 19 consecutive patients who presented with focal seizures associated with a CCM. Each patient underwent SLA of the CCM and adjacent cortex followed by standard clinical and imaging follow-up. All but one patient had chronic medically refractory epilepsy (median duration 8years, range 0.5-52years). Lesions were located in the temporal (13), frontal (five), and parietal (one) lobes. CCMs induced magnetic susceptibility artifacts during thermometry, but perilesional cortex was easily visualized. Fourteen of 17 patients (82%) with >12months of follow-up achieved Engel class I outcomes, of which 10 (59%) were Engel class IA. Two patients who were not seizure-free from SLA alone became so following intracranial electrode-guided open resection. Delayed postsurgical imaging validated CCM involution (median 83% volume reduction) and ablation of surrounding cortex. Histopathologic examination of one previously ablated CCM following open surgery confirmed obliteration. SLA caused no detectable hemorrhages. Two symptomatic neurologic deficits (visual and motor) were predictable, and neither was permanently disabling. In a consecutive retrospective series, MR thermography-guided SLA was an effective alternative to open surgery for epileptogenic CCM. The approach was free of hemorrhagic complications, and clinically significant neurologic deficits were predictable. SLA presents no barrier to subsequent open surgery when needed.

The role of mifepristone in the management of meningiomas: A systematic review of literature.

Surgery is challenging in patients with multiple or recurrent meningiomas. With the discovery of progesterone receptors (PR) on meningioma cells, there is an increased interest in the hormonal treatment using mifepristone, a PR blocker. A systematic review of clinical studies evaluating the efficacy and side effects of mifepristone in recurrent, unresectable, or multiple meningiomas was done. The primary outcome of this review was to study the efficacy in terms of tumor regression and clinical symptoms. Secondarily, we also reviewed the frequency and severity of different side effects reported by various studies. A total of 7 studies, including one Phase III randomized controlled trial, were found relevant to the topic. Though a few studies showed some response in terms of clinical improvement and tumor size reduction, the response was either minimal or temporary. The only subset showing a good response was the "diffuse meningiomatosis" group. None of the studies evaluated the relation of the PR isoform with mifepristone responsiveness. However, long-term mifepristone administration was well tolerated in most of the patients. Use of mifepristone as a hormonal agent for meningiomas has produced mixed results. We propose that the possible mechanisms of action of mifepristone on meningioma cells must be studied in further detail by in-vitro studies. This may help in the identification of a mifepristone responsive subset of meningioma. This must be followed up with appropriately designed clinical studies with detailed baseline evaluation and standardized clinical and radiological follow-up.

Functional outcomes of conservative versus operative management of displaced midshaft clavicular fracture: a comparative study

Purpose Management of displaced midthird clavicle fractures is still controversial. Recent studies have shown a high incidence of symptomatic malunion and nonunion following nonoperative treatment of displaced midshaft clavicular fractures, with other studies showing no much improvement in shoulder function following operative treatment. The aim of this study is to compare patient-oriented and surgeon-based outcomes after nonoperative treatment with results following operative treatment of acute completely displaced midshaft clavicular fractures. Patients and methods This retrospective study was carried out on 91 patients with a displaced midshaft fracture of the clavicle distributed into two groups, with the first group managed conservatively and the second group with open reduction and internal fixation. Outcome analysis included standard clinical follow-up and the Constant shoulder score, the disability of the arm, shoulder and hand score, as well as radiological evaluation. Deformity evaluation included measurement of displacement, shortening, and angulation in both immediate posttrauma radiograph and final radiographs. Results Mean follow-up duration was 28.7±13.3 months in the nonoperative group and 20.4±5 months in the operative group. The mean time to radiographic union was 16.4±3.3 weeks in the nonoperative group compared with 15.6±3 weeks in the operative group (P=0.00). All fractures in the operative group united compared with six nonunions (12.5%) in the nonoperative group, and 12 symptomatic malunions (25%) occurred in the nonoperative group. Constant shoulder scores were significantly better for the operative group at all follow-ups (P=0.00). The disability of the arm, shoulder and hand score showed also significant improvement within the operative group (P=0.00). Conclusion In this study, primary open reduction and internal plate fixation of acute displaced midshaft clavicular fractures resulted in improved outcomes − including both patient-oriented outcome and surgeon-based outcome − and a decreased rate of nonunion and symptomatic malunion compared with nonoperative treatment. Shorting and displacement were found significantly related to decreased shoulder function.

A Comparative Study of Conservative and Surgical Management of Displaced Midshaft Clavicle Fracture

Introduction: Since long, closed midshaft clavicle fractures, whether undisplaced or displaced, have been treated conservatively with figure of “8” bandage and sling. However, in the past few decades, management trends show an uprise in surgical management of displaced midshaft clavicle fracture with rigid internal fixation providing early pain relief and avoiding deformity, non-union (NU), and sequelae. Materials and Methods: A total of 60 patients with displaced midshaft clavicle fracture were included in the study. Patients were randomly allocated to the non-operative and operative group with 30 patients in each group. Non-operative management was performed with clavicle brace (figure of 8 bandage) while open reduction internal fixation with plate fixation was the preferred operative treatment. Patients were followed up at 2, 4, and 6 weeks and then at 3, 6, and 12 months. Outcome analysis included standard clinical follow-up, the constant shoulder (CS) score and the disabilities of the arm, shoulder, and hand (DASH) score, and plain radiographs. Statistical analysis was done using Student’s “t” test and SPSS software. The results were considered to be significant at P &lt; 0.05. Results: There was a statistically significant difference in functional outcome between the two groups at 3-month follow-up (CS; P = 0.0469 and DASH; P = 0.0406), though no such difference was recorded at 1-year follow-up (CS; P = 0.2731 and DASH; P = 0.4915). It implies that the patients in operative group improved functionally and returned to normal activities earlier than the non-operative group. Even patient satisfaction regarding shoulder appearance (cosmesis) was more in the operative group (100%) than in non-operative group (60%). The complications were more in the non-operative group (23), such as symptomatic malunion in 2 cases (8%), NU in 5 cases (20%), shortening in 3 cases (12%), and muscle wasting in 2 cases (8%), whereas only four complications were recorded in the operative group, of which two were implant related. Conclusion: Surgical management of displaced midshaft clavicle fracture has definite short-term benefits with respect to functional outcome, early return to preinjury activities, and a lower rate of malunion and NU. Furthermore, due to difficulties of non-operative treatment including pain and instability at fracture site, tightness of clavicle brace, difficulties in self-hygiene, and high percentage of NU, especially in high-energy fractures; operative treatment is a good option in displaced midshaft clavicle fracture, especially in active adult patients. Keywords: Clavicle fracture, Conservative management, Surgical management.

Clinical and ultrasonographic predictors for achieving minimal disease activity in patients with psoriatic arthritis: the UPSTREAM (Ultrasound in PSoriatic arthritis TREAtMent) prospective observational study protocol

IntroductionPsoriatic arthritis (PsA) occurs in 10%–15% of people with psoriasis and accounts for 10%–20% of early arthritis clinics referral. Only a few prognostic factors of therapeutic response in patients with...

Natural history of patients with non cirrhotic portal hypertension: Comparison with patients with compensated cirrhosis

BackgroundThe knowledge of natural history of patients with portal hypertension (PH) not due to cirrhosis is less well known than that of cirrhotic patients. AimTo describe the clinical presentation and the outcomes of 89 patients with non-cirrhotic PH (25 with non-cirrhotic portal hypertension, INCPH, and 64 with chronic portal vein thrombosis, PVT) in comparison with 77 patients with Child A cirrhosis. MethodsThe patients were submitted to a standardized clinical, laboratory, ultrasonographic and endoscopic follow-up. Variceal progression, incidence of variceal bleeding, portal vein thrombosis, ascites and survival were recorded. ResultsAt presentation, the prevalence of varices, variceal bleeding and ascites was similar in the 3 groups. During follow-up, the rate of progression to varices at risk of bleeding (p < 0.0001) and the incidence of first variceal bleeding (p = 0.02) were significantly higher in non-cirrhotic then in cirrhotic patients. A PVT developed in 32% of INCPH patients and in 18% of cirrhotics (p = 0.02). ConclusionsIn the patients with non-cirrhotic PH variceal progression is more rapid and bleeding more frequent than in cirrhotics. Patients with INCPH are particularly prompt to develop PVT. This observational study suggests that the management of patients with non-cirrhotic PH should take into consideration the natural history of portal hypertension in these patients and cannot be simply derived by the observation of cirrhotic patients.

Sodium intake and multiple sclerosis activity and progression in BENEFIT.

To assess whether a high-salt diet, as measured by urinary sodium concentration, is associated with faster conversion from clinically isolated syndrome (CIS) to multiple sclerosis (MS) and MS activity and disability. BENEFIT was a randomized clinical trial comparing early versus delayed interferon beta-1b treatment in 465 patients with a CIS. Each patient provided a median of 14 (interquartile range = 13-16) spot urine samples throughout the 5-year follow-up. We estimated 24-hour urine sodium excretion level at each time point using the Tanaka equations, and assessed whether sodium levels estimated from the cumulative average of the repeated measures were associated with clinical (conversion to MS, Expanded Disability Status Scale [EDSS]) and magnetic resonance imaging (MRI) outcomes. Average 24-hour urine sodium levels were not associated with conversion to clinically definite MS over the 5-year follow-up (hazard ratio [HR] = 0.91, 95% confidence interval [CI] = 0.67-1.24 per 1g increase in estimated daily sodium intake), nor were they associated with clinical or MRI outcomes (new active lesions after 6 months: HR = 1.05, 95% CI = 0.97-1.13; relative change in T2 lesion volume: -0.11, 95% CI = -0.25 to 0.04; change in EDSS: -0.01, 95% CI = -0.09 to 0.08; relapse rate: HR = 0.78, 95% CI = 0.56-1.07). Results were similar in categorical analyses using quintiles. Our results, based on multiple assessments of urine sodium excretion over 5 years and standardized clinical and MRI follow-up, suggest that salt intake does not influence MS disease course or activity. Ann Neurol 2017;82:20-29.

Prospective study on cost-effectiveness of home-based motor assessment in Parkinson’s disease

Introduction Treatment adjustments in Parkinson’s disease (PD) are in part dependent on motor assessments. The aim of this study was to evaluate the cost-effectiveness of home-based motor monitoring plus standard in-office visits versus in-office visits alone in patients with advanced PD. Methods The procedures consisted of a prospective, one-year follow-up, randomized, case-control study. A total of 40 patients with advanced PD were randomized into two groups: 20 patients underwent home-based motor monitoring by using wireless motion sensor technology, while the other 20 patients had in-office visits. Motor and non-motor symptom severities, quality of life, neuropsychiatric symptoms, and comorbidities were assessed every four months. Direct costs were assessed using a standardized questionnaire. Cost-effectiveness was assessed using the incremental cost-effectiveness ratio (ICER). Results Both groups of PD patients were largely comparable in their clinical and demographic variables at baseline; however, there were more participants using levodopa-carbidopa intestinal gel in the home-based motor monitoring group. There was a trend for lower Unified Parkinson’s Disease Rating Scale functional status (UPDRS II) scores in the patients monitored at home compared to the standard clinical follow-up (p = 0.06). However, UPDRS parts I, III, IV and quality-adjusted life-years scores were similar between both groups. Home-based motor monitoring was cost-effective in terms of improvement of functional status, motor severity, and motor complications (UPDRS II, III; IV subscales), with an ICER/UPDRS ranging from €126.72 to €701.31, respectively. Discussion Home-based motor monitoring is a tool which collects cost-effective clinical information and helps augment health care for patients with advanced PD.

Delayed complications and functional outcome of isolated sternal fracture after emergency department discharge: a prospective, multicentre cohort study

The aim of this study was to determine the incidence of delayed complications, specifically hemothorax, and functional outcome in patients with isolated sternal fracture discharged from the emergency department (ED) compared to patients with other minor thoracic trauma. This prospective cohort study was conducted in four university-affiliated Canadian EDs. Patients ages 16 and older discharged from the ED with an isolated minor thoracic injury were included and categorized as isolated sternal fracture, rib fracture, or no fracture. A standardized clinical and radiological follow-up was performed at 7 and 14 days as well as a phone follow-up at 30 and 90 days post-injury. Functional outcome was determined using the Medical Outcome Short-Form Health Survey (SF-12). A total of 969 patients were included, of whom 32 (3.3%) had an isolated sternal fracture, 304 (31.3%) had rib fracture, and 633 (65.3%) had no fracture. Within 14 days, 112 patients presented with a delayed hemothorax: 12.5% of sternal fracture patients, 23% of rib fracture(s) patients, and 6% of minor thoracic injury patients without fracture (p<0.05). At 90 days, 57.1% of patients with sternal fracture had moderate to severe disability compared to 25.4% and 21.2% for both of the other groups, respectively (p<0.001). In this prospective study, we found that 12.5% (n=4, p<0.05) of patients with sternal fracture developed a delayed hemothorax, but the clinical significance of this remains questionable. The proportion of patients with sternal fracture who had moderate to severe disability was significantly higher than that of patients with other minor thoracic trauma.

Current Opinions on Fracture Follow-up: A Survey of OTA Members Regarding Standards of Care and Implications for Clinical Research.

To determine current practice standards among Orthopaedic Trauma Association surgeons for postoperative fracture follow-up and to investigate the implications of these standards on clinical research. Survey. Web-based survey. One hundred eighty-four orthopaedic trauma surgeons. A web-based questionnaire was distributed to Orthopaedic Trauma Association members to identify standard postoperative radiographic and clinical follow-up duration. Assuming uneventful, complete fracture healing at 3 months, data were collected for 3 generic fracture types (diaphyseal, extra-articular metaphyseal, and intra-articular) and 3 specific fractures (femoral shaft, intertrochanteric, and tibial plateau). Suggested follow-up for clinical research was also investigated. For extra-articular fractures, standard radiographic and clinical follow-up were considered to be 6 months or less by greater than 70% of respondents. For intra-articular fractures, standard radiographic and clinical follow-up was considered to be 6 months or less by greater than 39% of respondents. The most common responses for radiographic follow-up were 3 months for extra-articular fractures (33%) and 12 months for intra-articular fractures (34%). The most common responses for clinical follow-up were 6 months for extra-articular fractures (37%) and 12 months for intra-articular fractures (35%). The majority (55%) indicated that follow-up to clinical and radiographic healing or the establishment of a nonunion should be the minimum follow-up for clinical fracture studies and 66% recommended follow-up to at least 1 year for functional outcome studies. Most surgeons follow-up patients with lower extremity extra-articular fractures (with uneventful healing) radiographically for 3-6 months and clinically for 6 months and slightly longer for intra-articular fractures. Many surgeons cease radiographic and clinical follow-up by 6 months. Therefore, retrospective fracture healing studies can only reasonably expect follow-up for 6 months. Publication requirements for longer follow-up of fracture-related studies would likely eliminated retrospective studies from consideration. Most surgeons support obtaining at least 1-year follow-up for clinical studies that include functional outcome. Therapeutic Level V. See Instructions for Authors for a complete description of levels of evidence.