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Lapner M.,St. Josephs Health Care London
Instructional course lectures

The radial head is the most commonly fractured bone of the elbow, with most fractures occurring in women older than 50 years. The radial head is an important stabilizer for valgus, axial, and posterolateral rotational forces. Loss of articular segments of the radial head negatively affects elbow kinematics and stability. Most fractures are treated nonsurgically. Indications for nonsurgical treatment include nondisplaced and isolated displaced fractures without a block to motion. Fragment excision is indicated when a mechanical block from a small, displaced fragment impedes elbow motion. If technically possible, open reduction and internal fixation is preferred for larger fragments, whereas radial head arthroplasty is reserved for comminuted fractures if reconstruction of the fragments is not possible. Radial head excision can be considered for isolated, displaced, and comminuted fractures in patients with low functional demands; in the presence of infection; or after other treatment modalities have failed. Complications include stiffness, heterotopic ossification, infection, and instability. The indications for surgical versus nonsurgical management of radial head fractures remain controversial. Source

Objective. To determine the minimally important difference (MID) for the Health Assessment Questionnaire-Disability Index (HAQ-DI), pain, fatigue, sleep, and global visual analog scale (VAS; 0-100 mm) in patients with psoriatic arthritis (PsA) using a patient-reported overall health status anchor. Patient-reported outcomes are often used to gauge the effect of PsA in clinical trials. There is currently no knowledge about the MID for patient-reported outcomes in PsA. Methods. Patients with a diagnosis of PsA who had answered questions about outcomes at 2 consecutive visits and an overall health status question ("How would you describe your overall status since your last visit: much better, better, the same, worse, much worse?") were included. MID was calculated as the mean change between visits for those who rated their disease as "better" or "worse." Results. Two hundred patients met inclusion criteria, of whom 17.5% rated their status as "better" and 25.0% rated their status as "worse" than the previous visit. MID estimates for improvement/ worsening (SD) respectively were -0.131 (0.411)/0.131 (0.309) for HAQ-DI, -9.37 (24.37)/13.96 (22.05) for pain VAS, -8.15 (23.52)/3.63 (27.62) for fatigue VAS, -10.97 (29.74)/13.81 (27.32) for sleep VAS, and -8.41 (21.17)/11.53 (21.03) for global VAS. Spearman's ρ correlation coefficients between the anchor and mean change were 0.374 (HAQ-DI), 0.448 (pain VAS), 0.239 (fatigue VAS), 0.326 (sleep VAS), 0.490 (global VAS); p < 0.01. Conclusion. This is the first study investigating MID of patient-reported outcomes in PsA. MID for HAQ-DI, pain, and global VAS were shown to be the best predictors for a patient's perception of overall changes in disease status. The Journal of Rheumatology Copyright © 2010. All rights reserved. Source

Lapner M.,St. Josephs Health Care London
Instructional course lectures

The treatment of comminuted, distal humeral fractures in elderly patients with osteoporotic bone is challenging. Total elbow arthroplasty or hemiarthroplasty are reliable treatment options with favorable outcomes for fractures that are not amenable to open reduction and internal fixation. Total elbow arthroplasty is a reliable option for a comminuted distal humeral fracture in an elderly patient with osteoporosis and low functional demands. Longer-term studies have shown good to excellent results and a low risk of complications. Specific indications for hemiarthroplasty are evolving, but include comminuted coronal shear or low transverse fractures in patients who have higher functional demands than those that can be met by total elbow arthroplasty. Further studies with longer-term follow-ups are needed to compare the benefits of hemiarthroplasty with total elbow arthroplasty. Source

To determine the clinical impact of muscle involvement in a large systemic sclerosis (SSc) cohort. Using the Canadian Scleroderma Research Group (CSRG) database, SSc patients with either elevated creatine kinase (CK) or a prior history of myositis/myopathy were identified. Regression and Kaplan-Meier analyses were performed to determine characteristics associated with muscle involvement in SSc and survival outcome. In 1145 patients with SSc, 5.6% had an elevated CK. This subset was more likely to be male (24.5% in elevated CK vs. 12.6% in normal CK, p < 0.013), younger (52 vs. 56 years, p < 0.045), have diffuse cutaneous SSc (dcSSc; 40.4% vs. 37.9%, p < 0.002), tendon friction rubs (30.0% vs. 13.4%, p < 0.001), and forced vital capacity (FVC) < 70% (23.9% vs. 13.1%, p < 0.039), be ribonucleoprotein (RNP) antibody positive (12.0% vs. 5.0%, p < 0.032), topoisomerase1 (topo1)-antibody positive (26.0% vs. 14.4%, p < 0.026), have a higher modified Rodnan skin score (MRSS; 16.14 vs. 9.81, p < 0.001), and a higher Health Assessment Questionnaire (HAQ) score (0.98 vs. 0.79, p < 0.011). Survival was reduced for patients with elevated CK (p < 0.025). Nearly 10% of patients in the CSRG cohort had a prior history of myositis/myopathy. This subset also had findings similar to those with elevated CK and increased mortality (p < 0.003). Muscle involvement in SSc has a poor prognosis impacting survival, especially in men with early dcSSc with topo1 and RNP autoantibodies and interstitial lung disease (ILD). Source

Haraoui B.,Institute Of Rhumatologie Of Montreal | Pope J.,St. Josephs Health Care London
Seminars in Arthritis and Rheumatism

Objectives: The early diagnosis and treatment of rheumatoid arthritis (RA) are important goals for rheumatologists. This article provides a review of the literature describing evolving concepts in the treatment of early RA, studies that evaluate treatment strategies using a predefined target, and methods to identify patients who are at higher risk for progressive joint damage. Methods: We conducted a PubMed search for randomized trials using the terms "early rheumatoid arthritis" and subsequently "tight control" to compare the outcomes of studies using early intervention with biologics and disease-modifying antirheumatic drugs (DMARDs) in early RA and also to compare outcomes of strategies of treatment using a predefined target. Results: The study designs and outcomes of clinical trials of DMARDs and biologic agents in early RA are presented. Early, prompt therapy with combination DMARDs or biologics combined with methotrexate leads to improved outcomes for patients with early RA. In studies where treatment was targeted to a specific outcome, such as remission, the target was achieved more often with targeted treatment than when patients received routine care. Patients who are more likely to experience a rapid disease course that is associated with joint destruction can be identified based on clinical and laboratory variables shown to be predictors of rapid progression. Conclusions: Early assessment and close monitoring of patients with early RA, targeting remission where possible, are important to optimize long-term outcomes. Specific treatment can be selected from among the many proven therapies to obtain the best results for the individual patient. © 2011 Elsevier Inc. Source

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