To estimate the accuracy, sensitivity, specificity, and interobserver agreement of dual-energy computed tomography (CT) in detection of uric acid crystals in joints or periarticular structures in ...patients with arthralgia and patients suspected of having gout, with joint aspiration results as reference standard.
With institutional review board approval, patient consent, and HIPAA compliance, 94 patients (age range, 29-89 years) underwent dual-source, dual-energy (80 and 140 kVp) CT of a painful joint. A material decomposition algorithm was used to identify uric acid. Two blinded musculoskeletal radiologists evaluated the dual-energy CT images and classified the examination findings as positive or negative for the presence of uric acid crystals. Reference standard was the result of joint aspiration.
Forty-three of 94 patients (46%) underwent attempted joint aspiration within 1 month of dual-energy CT. Aspiration was successful in 31 of 43 patients (72%). In 12 of 31 patients (39%), uric acid crystals were identified at joint aspiration; in 19 patients, they were not. Readers 1 and 2 had no false-negative findings for uric acid at dual-energy CT. Sensitivity was 100% (12 of 12; 95% confidence interval (CI): 74%, 100%) for both readers. Specificity was 89% (17 of 19; 95% CI: 67%, 99% ) for reader 1 and 79% (15 of 19; 95% CI: 54%, 94%) for reader 2, with near-perfect agreement between the readers (κ = 0.87; range, 0.70-1.00) in the 31 patients who underwent aspiration.
Initial retrospective assessment suggests that dual-energy CT is a sensitive, noninvasive, and reproducible method for identifying uric acid deposits in joints and periarticular soft tissues in patients suspected of having gout.
This article reviews some of the advances that have taken place in understanding back disorders, with a particular emphasis on low back pain, as this area has been most represented in the literature ...in the preceding year (September 2003 to September 2004).
Epidemiological studies continue to provide insights into the prevalence of back pain and have identified many individual, psychosocial, and occupational risk factors for its onset. Psychological factors have an important role in the transition from acute to chronic pain and related disability. Recent advances show that there is a significant genetic effect on severe low back pain in the community. Data emerging from candidate gene studies show an association between lumbar disc disease and mutations of genes encoding the alpha-2 and alpha-3 subunits of collagen IX.
Back pain is among the most common conditions for which patients seek medical care. Interventions based on behavioral and cognitive principles and exercise programs are effective in improving disability in chronic back pain. Although progress has been made in understanding the role of genetic mutations in disorders such as lumbar disc disease, further investigation of the interaction between genetic and environmental factors such as physical stress is needed.
Most patients with osteoarthritis seek medical attention because of pain. The safest initial approach is to use a simple oral analgesic such as acetaminophen (perhaps in conjunction with topical ...therapy). If pain relief is inadequate, oral nonsteroidal anti-inflammatory drugs or intra-articular injections of hyaluronic acid-like products should be considered. Intra-articular corticosteroid injections may provide short-term pain relief in disease flares. Alleviation of pain does not alter the underlying disease. Attention must also be given to nonpharmacologic measures such as patient education, weight loss and exercise. Relief of pain and restoration of function can be achieved in some patients with early osteoarthritis, particularly if an integrated approach is used. Patients with advanced disease may eventually require surgery, which generally provides excellent results.
To develop a COVID-19-specific deterioration index for hospitalized patients: the COVID Hospitalized Patient Deterioration Index (COVID-HDI). This index builds on the proprietary Epic Deterioration ...Index, which was not developed for predicting respiratory deterioration events among patients with COVID-19.
A retrospective observational cohort was used to develop and validate the COVID-HDI model to predict respiratory deterioration or death among hospitalized patients with COVID-19. Deterioration events were defined as death or requiring high-flow oxygen, bilevel positive airway pressure, mechanical ventilation, or intensive-level care within 72 hours of run time. The sample included hospitalized patients with COVID-19 diagnoses or positive tests at Kaiser Permanente Southern California between May 3, 2020, and October 17, 2020.
Machine learning models and 118 candidate predictors were used to generate benchmark performance. Logit regression with least absolute shrinkage and selection operator and physician input were used to finalize the model. Split-sample cross-validation was used to train and test the model.
The area under the receiver operating curve was 0.83. COVID-HDI identifies patients at low risk (negative predictive value NPV > 98.5%) and borderline low risk (NPV > 95%) of an event. Of all patients, 74% were identified as being at low or borderline low risk at some point during their hospitalization and could be considered for discharge with or without home monitoring. A high-risk group with a positive predictive value of 51% included 12% of patients. Model performance remained high in a recent cohort of patients.
COVID-HDI is a parsimonious, well-calibrated, and accurate model that may support clinical decision-making around discharge and escalation of care.
Objective
Schmorl's nodes (SN) are common, but little is known of their relationship with degenerative change and back pain or genetic and environmental factors influencing their expression. We ...studied healthy female twin volunteers to determine the prevalence and clinical features associated with SN.
Methods
Serial sagittal T1‐ and T2‐weighted magnetic resonance images of the lower thoracic and lumbar spine were analyzed in 516 healthy female twins (150 monozygotic and 366 dizygotic). The images were scored for lumbar degenerative change. Presence of SN was noted at cranial and caudal vertebral levels T9 to L5. Data on physical activity and back pain were collected by questionnaire. Heritability of SN was calculated using variance components modeling.
Results
SN were found in 30% of subjects. Of the 374 SN, 153 (41%) were in the lumbar spine and 221 (59%) were in the thoracic spine. SN heritability was >70%. There was a positive association between SN and lumbar disc disease (LDD). SN were more frequent in subjects with back pain (for ≥2 SN: odds ratio OR 2.68, 95% confidence interval 95% CI 1.11–6.47, P = 0.03), but this was largely accounted for by the association of SN with LDD (OR 1.97, 95% CI 0.78–5.0, P = 0.15 adjusted for LDD). No independent association of SN with back pain was identified.
Conclusion
SN are common in middle‐aged women and are strongly genetically determined. They are associated with lumbar degenerative change, which is a risk factor for back pain, but are not themselves an independent risk factor for back pain.
Objectives. To compare the prevalence of gastrointestinal (GI) disorders in rheumatoid arthritis (RA) versus non-RA subjects and to describe determinants of GI disorders in RA. Methods. The bowel ...disease questionnaire was completed by RA and non-RA subjects. RA patients also completed the health assessment questionnaire (HAQ). Results. The study responders included 284 RA and 233 non-RA subjects. Abdominal pain/discomfort, postprandial fullness, nausea, and stool leakage were significantly more common in RA versus non-RA (odds ratios OR = 1.8; 1.9; 4.0; 8.2, resp.). The use of laxatives, proton pump inhibitors, NSAIDs, acetaminophen, and narcotics was more commonly reported in RA versus non-RA (OR = 2.0; 1.7; 3.0; 2.0; 1.9, resp.). Age < 60 and HAQ ≥ 1 were associated with dyspepsia, irritable bowel syndrome, gastroesophageal reflux disease, and GI symptom complex overlap in RA. Conclusion. Several upper and lower GI disorders were significantly more prevalent in RA versus non-RA subjects. Age <60 and physical function impairment (HAQ ≥ 1) were associated with GI disorders in RA.
Osteoarthritis (OA) is the most common articular disease, and it continues to be a major public health problem related to pain, disability, loss of time from work, and economics. Most patients with ...OA seek medical attention because of pain. In the past few years, changes in the treatment of OA have been substantial. More effective nonnarcotic analgesics, cyclooxygenase-2-specific inhibitors, nutraceuticals, and intra-articular hyaluronates are some of the new medications and agents that are now available. The understanding and use of nonpharmacological interventions, including patient education, exercise programs, and weight reduction when appropriate, have also improved. Relief of pain and restoration of function can be accomplished in many patients, particularly with an integrated approach. This article focuses on medical treatment approaches for OA, both pharmacological and nonpharmacological.
To determine whether availability of journals on MEDLINE as FUTON (full text on the Net) affects their impact factor.
A comprehensive search identified 324 cardiology, nephrology, and ...rheumatology/immunology journals on-line until May 2003. The status of these journals was ascertained in MEDLINE as having FUTON, abstracts only, and NAA (no abstract available). Impact factors for all available journals from the Institute for Scientific Information (ISI) were abstracted.
Of the 324 journals, 124 (38.3%) were FUTON, 138 (42.6%) had abstracts only, and 62 (19.1%) had NAA. The mean (±SEM) impact factor was 3.24 (±0.32), 1.64 (±0.30), and 0.14 (±0.45), respectively. Of the 324 current journals, 159 existed in both the pre- and the post-Internet era. An analysis of the change (ie, δ) in impact factor from the pre- to post-Internet era revealed a trend between journals with FUTON and abstracts only (
P=.17, Wilcoxon rank sum test). Similar analyses of the δ of cardiology journals revealed a statistically significant difference between journals with FUTON and abstracts only (
P=.04, Wilcoxon rank sum test).
FUTON bias is the tendency to peruse what is more readily available. This is the first study to show that on-line availability of medical literature may increase the impact factor and that such increase tends to be greater in FUTON journals. Failure to consider this bias may affect a journal's impact factor. Also, it could limit consideration of medical literature by ignoring relevant NAA articles and thereby influence medical education akin to publication or language bias.
The pathophysiologic factors of primary Raynaud phenomenon (RP) are unknown. Preliminary evidence from skin biopsy suggests small-fiber neuropathy (SFN) in primary RP. We aimed to quantitatively ...assess SFN in participants with primary RP. Consecutive patients with an a priori diagnosis of primary RP presenting to our outpatient rheumatology clinic over a 6-month period were invited to participate. Cases of secondary RP were excluded. All participants were required to have normal results on nailfold capillary microscopy. Assessment for SFN was accomplished with autonomic reflex screening, which includes quantitative sudomotor axonal reflex test (QSART), and cardiovagal and adrenergic function testing, thermoregulatory sweat test (TST), and quantitative sensory test (QST) for vibratory, cooling, and heat-pain sensory thresholds. Nine female participants with a median age of 38 years (range 21–46 years) and a median symptom duration of 9 years (range 5 months–31 years) were assessed. Three participants had abnormal results on QSART, indicating peripheral sudomotor autonomic dysfunction. Two participants had evidence of large-fiber involvement with heat-pain thresholds on QST. Heart rate and blood pressure responses to deep breathing, Valsalva maneuver, and 70° tilt were normal for all participants. Also, all participants had normal TST results. In total, three of the nine participants had evidence of SFN. The presence of SFN raises the possibility that a subset of patients with primary RP have an underlying, subclinical small-fiber dysfunction. These data open new avenues of research and therapeutics for this common condition.
Gout has been recognized for centuries but is also a modern day scourge. It is the most common type of inflammatory arthritis in men and appears to be increasing in both incidence and prevalence ...(Arromdee et al. in J Rheumatol 29(11):2403–2406, 2002). Despite these facts, few advances have been made in the diagnosis and treatment of gout for over 50 years. Difficult cases of gout challenge available therapeutic options. It is only recently that the Food and Drug Administration has approved febuxostat as a treatment option for patients intolerant of allopurinol. We describe a difficult case of tophaceous gout notable for several reasons: utilization of rasburicase as uricolytic treatment to dramatically reduce tissue urate burden; treatment of gout flares with interleukin-1β inhibition; and quantification of tissue urate with novel dual energy computed tomography technology before and after uricolytic therapy.
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