Minna J. Kohler

Adverse effects of topical nonsteroidal antiinflammatory drugs in older adults with osteoarthritis: A systematic literature review

Objective. To systematically review the literature on reported adverse effects (AE) associated with use of topical nonsteroidal antiinflammatory drugs (NSAID) in older adults with osteoarthritis (OA). Methods. A systematic search of Medline (1950 to November 2009), Scopus, Embase, Web of Science, Cochrane databases, Dissertation and American College of Rheumatology meeting abstracts was performed to identify original randomized controlled trials, case reports, observational studies, editorials, or dissertations reporting AE from topical NSAID in older adults with OA. Information was sought on study and participant characteristics, detailed recording of application site, and systemic AE as well as withdrawals due to AE. Results. The initial search yielded 953 articles of which 19 met eligibility criteria. Subjects receiving topical NSAID reported up to 39.3% application site AE, and up to 17.5% systemic AE. Five cases of warfarin potentiation with topical agents were reported, 1 resulting in gastrointestinal bleeding. In formal trials, the withdrawal rate from AE ranged from 0 to 21% in the topical agents, 0 to 25% in the oral NSAID, and 0 to 16% in the placebo group. Conclusion. Although topical NSAID are safer than oral NSAID (fewer severe gastrointestinal AE), a substantial proportion of older adults report systemic AE with topical agents. The withdrawal rate due to AE with topical agents is comparable to that of oral NSAID. Given the safety profile and withdrawal rates described in this study, further data are needed to determine the incremental benefits of topical NSAID compared to other treatment modalities in older adults with OA.

Measuring Pain Impact Versus Pain Severity Using a Numeric Rating Scale

BackgroundRoutine assessments of pain using an intensity numeric rating scale (NRS) have improved documentation, but have not improved clinical outcomes. This may be, in part, due to the failure of the NRS to adequately predict patients’ preferences for additional treatment.ObjectiveTo examine whether patients’ illness perceptions have a stronger association with patient treatment preferences than the pain intensity NRS.DesignSingle face-to-face interview.ParticipantsOutpatients with chronic, noncancer, musculoskeletal pain.Main MeasuresExperience of pain was measured using 18 illness perception items. Factor analysis of these items found that five factors accounted for 67.1% of the variance; 38% of the variance was accounted for by a single factor labeled “pain impact.” Generalized linear models were used to examine how NRS scores and physical function compare with pain impact in predicting preferences for highly effective/high-risk treatment.Key ResultsTwo hundred forty-nine subjects agreed to participate. Neither NRS nor functioning predicted patient preference (NRS: χ2 = 1.92, df = 1, p = 0.16, physical functioning: χ2 = 2.48, df = 1, p = 0.11). In contrast, pain impact was significantly associated with the preference for a riskier/more effective treatment after adjusting for age, comorbidity, efficacy of current medications and numeracy (χ2 = 4.40, df = 1, p = 0.04).ConclusionsTools that measure the impact of pain may be a more valuable screening instrument than the NRS. Further research is now needed to determine if measuring the impact of pain in clinical practice is more effective at triggering appropriate management than more restricted measures of pain such as the NRS.

Pilot Point-of-Care Ultrasound Curriculum at Harvard Medical School: Early Experience

Introduction Point-of-care ultrasound (POCUS) is expanding across all medical specialties. As the benefits of US technology are becoming apparent, efforts to integrate US into pre-clinical medical education are growing. Our objective was to describe our process of integrating POCUS as an educational tool into the medical school curriculum and how such efforts are perceived by students. Methods This was a pilot study to introduce ultrasonography into the Harvard Medical School curriculum to first- and second-year medical students. Didactic and hands-on sessions were introduced to first-year students during gross anatomy and to second-year students in the physical exam course. Student-perceived attitudes, understanding, and knowledge of US, and its applications to learning the physical exam, were measured by a post-assessment survey. Results All first-year anatomy students (n=176) participated in small group hands-on US sessions. In the second-year physical diagnosis course, 38 students participated in four sessions. All students (91%) agreed or strongly agreed that additional US teaching should be incorporated throughout the four-year medical school curriculum. Conclusion POCUS can effectively be integrated into the existing medical school curriculum by using didactic and small group hands-on sessions. Medical students perceived US training as valuable in understanding human anatomy and in learning physical exam skills. This innovative program demonstrates US as an additional learning modality. Future goals include expanding on this work to incorporate US education into all four years of medical school.

Resident-Perceived Benefit of a Diagnostic and Interventional Musculoskeletal Ultrasound Curriculum: A Multifaceted Approach Using Independent Study, Peer Teaching, and Interdisciplinary Collaboration.

ABSTRACTMusculoskeletal ultrasound (MSUS) training is now a required component of physiatry residency, but formal curriculum guidelines are not yet required or established. The authors’ objective was to assess the educational value of a collaborative residency MSUS training program. The authors designed a structured MSUS training curriculum for residents based on the authors’ experience and previous literature. Twenty-five residents participated in this MSUS curriculum designed by faculty and chief residents. Resident volunteers were trained by the faculty as “table trainers” who taught their peers in small groups. Hands-on MSUS training sessions were led by a Physical Medicine and Rehabilitation faculty MSUS expert. A Likert scale–formatted questionnaire assessed resident-perceived value of the curriculum. Response rate was 96% (22 of 23). Self-reported MSUS knowledge comparing precurriculum and postcurriculum implementation resulted in significant improvement (P = 0.001). Peer teaching was highly valued, with 86% of residents rating it “very” or “extremely” beneficial (mean [SD] score, 3.9 [1.1]). Self-guided learning, by supplemental scanning and reading, was rated “beneficial” or “very beneficial” by 73% of residents (3.0 [0.7]). The authors’ successful pilot program may serve as a teaching model for other residency programs.

The Use of Ultrasound in Palliative Care and Hospice

Palliative care aims to reduce symptom burden and enhance quality of life for those with terminal disease. Ultrasound has become an increasingly popular diagnostic and therapeutic modality due to its low cost, ease of portability, safety, and good patient acceptance. A review of the literature to date shows that as a diagnostic tool, as a therapeutic modality, and as a tool to accurately guide palliative procedures, ultrasound can have many roles in palliative care and hospice. Based on our clinical experience, musculoskeletal ultrasound can be of benefit to patients with terminal disease. Examples include adhesive capsulitis in advanced neurologic disease and chronic osteomyelitis in a patient with metastatic colon cancer. Ideally, further studies investigating the use of ultrasound in the palliative care population will be conducted in the future to enhance the availability of diagnostic and therapeutic capabilities of this particular modality.

MicroRNA Expression Shows Inflammatory Dysregulation and Tumor-Like Proliferative Responses in Joints of Patients With Postinfectious Lyme Arthritis.

Lyme arthritis (LA) is caused by infection with Borrelia burgdorferi and usually resolves following spirochetal killing with antibiotics. However, in some patients, arthritis persists after antibiotic therapy. To provide insights into underlying pathogenic processes associated with antibiotic‐refractory LA (postinfectious LA), we analyzed differences in microRNA (miRNA) expression between LA patients with active infection and those with postinfectious LA.

Point-of-care ultrasonography in the diagnosis and management of superficial peroneal nerve entrapment: case series.

Superficial peroneal nerve (SPN) entrapment at the crural fascia is a rare but perhaps underdiagnosed entity. Over the past few years, advances in ultrasound technology have allowed point-of-care ultrasound to accurately visualize peripheral nerves in the lower extremity, and may be the imaging modality of choice for peripheral nerves due to its higher resolution and ability to track the course of the nerve, even when compared to MRI. To our knowledge, there have been no reports of utilizing dynamic ultrasound imaging with realtime clinical correlation to identify SPN entrapment. We present 2 cases of SPN entrapment which were successfully diagnosed and treated by point-of-care ultrasonography. SPN entrapment was first reported by Henry in 1945. He called it “mononeuralgia in the superficial peroneal nerve.” There have been few cases reported since its discovery. Among the elusive nerve entrapment syndromes of the lower extremity, SPN entrapment is a difficult diagnosis. First, it is a rare occurrence with early studies citing only 3.5% of cases of lower leg pain due to SPN entrapment. Classically, this diagnosis has been based on the physical exam producing sensory abnormalities over the lateral leg and dorsal foot, especially after exercise provocation. Electrophysiology studies and MRI are typically ordered in an attempt to confirm the diagnosis, but these studies can often be normal despite symptoms. The diagnosis of SPN entrapment almost always comes after a workup for chronic lateral exertional compartment syndrome as these 2 entities may present with an identical clinical history and physical exam.

Musculoskeletal Ultrasound Instruction in Adult Rheumatology Fellowship Programs

Musculoskeletal ultrasound (MSUS) in rheumatology in the US has advanced by way of promotion of certifications and standards of use and inclusion of core fellowship curriculum. In order to inform endeavors for curricular integration, the objectives of the present study were to assess current program needs for curricular incorporation and the teaching methods that are being employed.

Poster 309: Point-of-Care Ultrasonography Assists with the Diagnosis and Management of Compression Neuropathy of the Common Peroneal Nerve after Total Knee Arthroplasty: A Case Report

Disclosures: Andrew Joyce: I Have No Relevant Financial Relationships To Disclose Case/Program Description: A 73-year-old woman presented with right lateral knee pain, paresthesias, and numbness along the lateral knee 10 years after total knee arthroplasty (TKA). Physical examination demonstrated sensory deficits along the lateral knee and weakness of the extensor hallucis longus and ankle dorsiflexors. Setting: Outpatient Musculoskeletal Clinic Results: Radiographs demonstrated intact hardware. Electrodiagnostics confirmed peroneal neuropathy at the knee. Magnetic resonance imaging (MRI) of the knee demonstrated small lateral osteophytes near the peroneal nerve, but no source of compression. Point-of-care ultrasonography (POCUS) localized nerve compression to an area of hypoechoic tissue thickening with calcifications adjacent to the right peroneal nerve at the point of maximal tenderness. Discussion: Delayed presentation of peroneal neuropathy after total knee arthroplasty is uncommon. Ultrasonography has higher resolution than MRI and can identify compression neuropathies. This case highlights how POCUS was able to identify scar tissue contributing to nerve compression. POCUS demonstrated nerve edema with surrounding soft tissue thickening near the level of the fibular head, which is a common point of compression per the surgical literature. Dynamic ultrasound confirmed soft tissue causing nerve compression, clinically correlating with patient’s symptoms and tenderness on physical examination. Ability to localize the compression site allows for ultrasound-guided intervention or focused physical therapy in an effort to avoid surgical release. Ultrasound-guided hydrodissection and steroid injection were offered, but patient preferred to obtain soft tissue mobilization therapy. Conclusions: Soft tissue abnormalities may contribute to peroneal neuropathy after TKA. POCUS can identify nerve edema; dynamic ultrasound can confirm soft tissue impingement and offer therapeutic guided procedures for nerve entrapment. Level of Evidence: Level V

Case 32-2017. A 64-Year-Old Man with Dyspnea, Wheezing, Headache, Cough, and Night Sweats.

A 64-year-old man presented with headache, dyspnea, wheezing, cough, and night sweats. He had eosinophilia, sinusitis on CT, and abnormal results on pulmonary-function tests, including an elevated fraction of exhaled nitric oxide. Diagnostic tests were performed.