Frequency of Knee Pain and Risk Factors and Its Impact on Functional Impairment: A Cross-Sectional Study from Saudi Arabia

BACKGROUND

Adolescents frequently self-report pain, according to epidemiological research. The knee is one of the sites wherein pain is most commonly reported. Musculoskeletal disorders play a significant role in the prolonged disability experienced by individuals, leading to substantial global personal, societal, and economic burdens. Patellofemoral pain (PFP) is a clinical knee pain commonly affecting adolescents. This study aimed to estimate the frequency of knee pain in Saudi adolescents.

METHODS

This cross-sectional survey was conducted from June to November 2022 and included 676 adolescents aged 10 to 18 years. The participants were questioned regarding their demographics, school habits, and the impact of these factors on back pain, musculoskeletal pain in the past 12 months, as well as quality-of-life scale and knee pain symptoms. The data were analyzed using descriptive statistics, with frequencies and percentages presented for categorical variables. Analysis of variance (ANOVA) was performed to compare means between groups, while the chi-squared test was used to compare categorical variables. Statistical significance was set at p < 0.05.

RESULTS

A total of 676 adolescents participated in the study, with 57.5% females and 42.5% males. Among the participants, 68.8% were aged between 15 and 18 years. The prevalence of knee pain was notably higher among females (26%) compared to males (19.2%). Age and BMI were identified as significant predictors of knee pain. A significant association was also found between BMI classification and knee stiffness (p-value = 0.008). Furthermore, a significant difference was observed between adolescents who engaged in physical activities during leisure time and those who experienced difficulty bending (p-value = 0.03).

CONCLUSIONS

Our study highlights a high prevalence of knee pain among Saudi adolescents, emphasizing the need for increased awareness about its risk factors. Preventive measures, including conservative approaches and lifestyle/activity modifications, can effectively mitigate adolescent knee pain.

Correction: Comparison of the Effects of Regular Periods of Immobilization and Prolonged Immobilization on Hand Function Post Distal Radial Fracture

[This corrects the article DOI: 10.7759/cureus.30986.].

Correction: Hidden Blood Loss in Transforaminal Lumbar Interbody Fusion: An Analysis of Underlying Factors

[This corrects the article DOI: 10.7759/cureus.35126.].

Hidden Blood Loss in Transforaminal Lumbar Interbody Fusion: An Analysis of Underlying Factors

Background In the management of lumbar spine diseases, various techniques have been described for minimizing intraoperative blood loss. Soft tissue extravasation and hemolysis have been referred to as hidden blood loss (HBL). By acknowledging HBL and accounting for it in our postoperative care, strategies of fluid infusion and blood transfusion may be altered. Our study aims to estimate HBL in transforaminal lumbar interbody fusion (TLIF) surgeries and to analyze associated factors. Methods This is a retrospective cohort study. Records of patients who underwent TLIF between January 2016 and December 2020 were reviewed. Patients with both minimally invasive (MIS) and open TLIF were included. Patients with infection, tumors, or fractures being the indication for surgery were excluded. Moreover, patients with known blood-related diseases, aged younger than 18 years, patients requiring blood transfusion, or patients with estimated intra-operative blood loss greater than 1.5 L were excluded. HBL was calculated according to the formulae depending on patients' weight, height, and hematocrit. Statistical analyses were performed to determine associations between HBL and other factors. Results A total of 95 patients were included. The mean estimated blood loss (EBL) was 231 mL, whereas the mean HBL was 265 mL, and the mean total blood loss is 629.7 ml with HBL accounting for 42% of it. Significant associated factors with HBL were the type of surgery, patient's total blood volume, preoperative hemoglobin and hematocrit, and decrease in hemoglobin and hematocrit. Conclusion Significant HBL may occur after TLIF, which was shown to be more than EBL. Although MIS had less EBL, it was associated with more HBL. Patients' preoperative hemoglobin and hematocrit, and a decrease in them, have been shown to be associated with HBL. All these factors should be considered for postoperative management of blood loss.

Comparison of the Effects of Regular Periods of Immobilization and Prolonged Immobilization on Hand Function Post Distal Radial Fracture

Introduction Distal radius fracture (DRF) is one of the most common orthopedic cases managed in the emergency room. DRF treatment is either non-operative or operative. Regardless of the treatment methodology, a period of immobilization of 4-6 weeks is required. Purpose The study aims to evaluate hand function for patients who sustained DRF with different immobilization periods in King Abdul-Aziz Medical City, National Guard Hospital - Jeddah (NGHA) from December 2016 until December 2019. Materials and methods This is a retrospective cohort study where we collected data of DRF patients managed in NGHA. Data was collected directly from NGHA medical records (December 2016-December 2019). A total of 44 patients met the inclusion criteria. Patients were divided into two groups; a group that was immobilized as per protocol (six weeks) and a group that deviated from protocol and immobilization exceeded six weeks. A data collection sheet included the patient's demographics, history, fracture description, management method, and hand function measurements. Results Of the 44 participants, 24 (54%) deviated from protocol; the remaining 20 (46%) were immobilized as per protocol. The prolonged immobilization group had limitations in hand function, restriction in extension (P-value = 0.641), and a decrease in grip strength (P-value = 0.291) compared to the per-protocol group. Flexion and radial deviation were affected similarly in both groups. Conclusion Although the results were not significant, immobilization for more than six weeks is associated with decreased hand function, range of motion (ROM), grip strength, and higher pain scores based on occupational therapy (OT) measurements.

Rapid Deterioration of a Cervical Tuberculosis Disease in a Young Immunocompetent Patient: A Case Report

Any organ system is prone to extrapulmonary tuberculosis (EPTB) development, including the spine. Spinal TB is a rare involvement, although considered one of the most dangerous forms of skeletal TB (STB).

A 31-year-old man, who is a healthcare worker, presented to the outpatient Orthopedic Spine clinic at King Abdulaziz Medical City-Ministry of National Guard Health Affairs (KAMC-MNGHA) Jeddah, Saudi Arabia, with a complaint of axial neck and upper back pain whose condition deteriorated quickly, necessitating urgent admission for surgical treatment in the form of cervical spine decompression and fusion, in addition to the anti-tuberculosis drug (ATD) scheme.

Cervical TB is a rare spinal disease that supposedly has a slow, insidious progression. The main presenting symptoms of which are axial and/or radicular pain, with a possible neurological deficit(s). In this particular case, the rapid progression of the disease necessitated rapid action.

In spite of what is known about spine TB and its slow progression, the case presented here was beyond our expectations. Treatment planning and urgency should not rely on the known natural history of the disease but rather be tailored to each case individually. This delineates the importance of reporting the quick, unexpected deterioration of our patient’s condition.

A274 EARLY SINGLE-OPERATOR CHOLANGIOSCOPY ASSISTED ELECTROHYDRAULIC LITHOTRIPSY (SOC-EHL) IN THE MANAGEMENT OF DIFFICULT BILIARY STONES IS COST-EFFECTIVE WHEN COMPARED TO A DELAYED STEP-UP APPROACH TO LATER SOC-EHL

Background

Single-operator cholangioscopy assisted electrohydraulic lithotripsy is the standard of care for difficult common bile duct (CBD) stones with failed clearance using standard ERCP. This technology is expensive and optimal timing of its use in terms of cost-effectiveness in the management algorithm of patients with difficult CBD stones remains unclear

Aims

To determine the cost-effective timing of SOC-EHL utilization in the management of difficult CBD stones

Methods

A decision model was developed assessing 4 strategies and progressively delayed introduction of SOC-EHL in relation to ERCP over 6-months. Difficult stones were defined as having failed CBD clearance via standard ERCP. Probability estimates for each health state were obtained from a literature systematic review. For each strategy, outpatients undergoing ERCP underwent different timings of SOC-EHL introduction from the first to the fourth ERCP and were followed for subsequent need for re-intervention, adverse events, need for surgery, and/or successful endoscopic CBD clearance. The unit of effectiveness was complete CBD clearance without need for surgery. Deterministic sensitivity analyses were performed varying all 50 model variables across ranges spanning 30% of their respective values. Costs are in 2018US$ based on US data.

Results

Performing SOC-EHL immediately during the first ERCP is the least expensive approach when compared to delaying SOC-EHL. This strategy costs $15,528 on average per patient with CBD clearance avoiding surgery and can save between $260 to $720 compared to the 3 other strategies, which introduce SOC-EHL during the second to the fourth ERCP. Effectiveness is clinically comparable between the four strategies ranging from 97–99%. Deterministic sensitivity analysis shows changes in the results when the ERCP complication rate (baseline probability of 6%) decreases to 4.5%, when the SOC-EHL (baseline costs of $2,450) costs more than $2,670, or when the ERCP facility fees (baseline costs of $4,292) are less than $3,425. In all 3 scenarios, delaying the first SOC-EHL use to the fourth procedural attempt becomes the dominant strategy. Variations of the other 47 variables did not alter results.

Conclusions

Although SOC-EHL is expensive, this analysis demonstrates that among patients who have failed a prior attempt at stone extraction, utilization of SOC-EHL at the next (first subsequent) ERCP is less costly when compared to its delayed introduction. However, postponing the use of SOC-EHL to the fourth ERCP could be identified as the most cost-effective strategy when facility fees or ERCP complications rates are below certain thresholds, or when the costs of SOC-EHL extend beyond a defined threshold.

Funding Agencies

None

Scoliosis Associated with Lumbar Spondylolisthesis: Spontaneous Resolution and Seven-Year Follow-Up

Scoliosis is defined as a structural deformity of the spine in all three dimensions and diagnosed if the Cobb angle is ≥10 degrees. Scoliosis is frequently associated with symptomatic spondylolisthesis, with an incidence ranging from 15% to 48%. The present report describes a patient with scoliosis associated with grade IV lumbar dysplastic spondylolisthesis who experienced the spontaneous correction of scoliosis after spondylolisthesis correction and fixation. The patient was a 12-year-old girl premenarche with an eight-month history of progressively increasing scoliosis, including back pain, left side leg pain, spinal deformity, and abnormal gait. She had been treated with a brace at the referring hospital but without significant improvement. Anteroposterior radiographs showed a long section of the spine, from T2 to L2, curving about 28.8 degrees to her right side, without evident pedicle rotation. Lateral radiographs revealed L5/S1 dysplastic type spondylolisthesis with >75% slippage (Meyerding Grade IV), a dome-shaped sacrum, and a flat back with butterfly sign. Correction of her spondylolisthesis by segmental instrumentation and interbody fusion of L5 and S1 resulted in almost complete resolution of her pain and scoliosis, with the outcome remaining stable seven years after surgery. These findings indicate that patients with scoliosis caused by spondylolisthesis may require only surgery for the latter condition, avoiding unnecessary surgery for scoliosis. 

Pedicle screw insertion in the thoracolumbar spine: comparison of 4 guidance techniques in the intact cadaveric spine

Object

Pedicle screw fixation is a mainstay of thoracolumbar stabilization. Screw insertion using anatomical landmarks and fluoroscopy is common but can be technically challenging and generally involves substantial exposure to ionizing radiation. Computerized navigation has been reported to improve accuracy but is expensive and complex. The authors undertook this study to evaluate these 3 methods in comparison with a fourth technique using standard cervical distractor screws to mark the entry point and trajectory.

Methods

Four cadaveric human spines were used for this study. After an initial CT scan, 34 pedicle screws were inserted in each intact spine from T-1 to L-5 using the following 4 screw insertion guidance techniques (1 technique per specimen): use of anatomical landmarks, use of cervical distractor screws and spot fluoroscopy, fluoroscopy-based navigation, and fluoroscopy- and CT-based navigation (using merged imaging data). Postprocedural CT and anatomical dissection were then performed to evaluate screw position for site and degree of breach.

Results

The cervical distractor screw method had a breach rate of 5.9% versus 29.4%, 32.4%, and 20.6% for use of anatomical landmarks, fluoroscopic navigation, and fluoroscopic-CT navigation, respectively (p < 0.05). There is also a significant association between degree of medial and distal breach and the method of screw insertion (p < 0.05).

Conclusions

Cervical distractor screws as pedicle markers offer favorable insertion accuracy and reduction of radiation exposure compared with the other 3 methods used in clinical practice.

Endoscopic ultrasound-guided fine-needle aspiration with or without flow cytometry for the diagnosis of primary pancreatic lymphoma - a case series

The role of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) with flow cytometry for the diagnosis of primary pancreatic lymphoma (PPL) has not been previously described. Our aims were to describe the EUS features of PPL and the role of EUS-FNA with and without flow cytometry in the diagnosis of 16 patients. When EUS-FNA with flow cytometry was compared with EUS-FNA without flow cytometry, the sensitivities for diagnosing non-Hodgkin's lymphoma were 84.6 % versus 30.8 %, respectively ( P = 0.01). EUS-FNA with flow cytometry is a valuable tool to diagnose PPL. Flow cytometry analysis complements traditional assessment by standard cytology.

Identifying exposure targets for treatment of staphylococcal pneumonia with ceftobiprole

Ceftobiprole is a cephalosporin with potent activity against methicillin (meticillin)-resistant Staphylococcus aureus (MRSA). In order to treat patients with severe staphylococcal pneumonia, it is important to understand the drug exposure required to mediate the killing of multiple log(10) cells in a preclinical-infection model. We measured drug exposure in terms of the percentage of penetration of the drug into epithelial lining fluid (ELF) and in terms of the time for which the drug concentration was above the MIC (time>MIC) in plasma and ELF. In a murine model of staphylococcal pneumonia, we demonstrated that ceftobiprole penetrated into ELF from the plasma at a median level of nearly 69% (25th to 75th percentile range, 25 to 187%), as indexed to the ratio of values for the area under the concentration-time curve in ELF and plasma. The total-drug times>MIC in ELF that were required to kill 1 log(10) and 2 log(10) CFU/g of lung tissue were 15% and 25% of the dosing interval. We also examined the penetration of ELF by ceftobiprole in volunteers, demonstrating mean and median penetration percentages of 25.5% and 15.3%, respectively (25th to 75th percentile range, 8 to 30%). Attainment rates were calculated for kill targets of 1 log(10) and 2 log(10) CFU/g, taken from the murine model, but using the volunteer ceftobiprole ELF penetration data. The standard dose for ceftobiprole is 0.5 g every 8 h as a 2-h infusion. The attainment rates remained above 90% for 1-log(10) and 2-log(10) CFU/g kill targets at MICs of 1 and 0.5 mg/liter, respectively. Taking the expectation over the distribution of ceftobiprole MICs for 4,958 MRSA isolates showed an overall target attainment of 85.6% for a 1-log(10) CFU/g kill and 79.7% for a 2-log(10) CFU/g kill. It is important to derive exposure targets in preclinical-infection models of the infection site so that these targets can be explored in clinical trials in order to optimize the probability of a good clinical outcome.

A trial of levofloxacin 750 mg once daily for 5 days versus ciprofloxacin 400 mg and/or 500 mg twice daily for 10 days in the treatment of acute pyelonephritis

OBJECTIVE

A double-blind, noninferiority trial was conducted to establish the safety and efficacy of a once-daily, 5-day course of levofloxacin 750 mg compared to a twice-daily, 10-day course of ciprofloxacin in complicated urinary tract infections (cUTI) and acute pyelonephritis (AP). This report focuses on subjects with AP.

RESEARCH DESIGN AND METHODS

Adult male and female subjects with clinical signs and symptoms of AP and laboratory confirmation of their diagnosis were randomized to receive one dose of levofloxacin 750 mg once daily intravenously (i.v.) or orally and one dose of placebo for 5 days, followed by placebo; or ciprofloxacin 400 mg i.v. and/or 500 mg orally twice daily for 10 days.

MAIN OUTCOME MEASURES

The primary, prospectively defined end point was microbiologic eradication at post-therapy (study days 15-22). Secondary outcomes included clinical response and safety and tolerability.

RESULTS

In the modified intent-to-treat (mITT) population (levofloxacin 94, ciprofloxacin 98), 83% of levofloxacin-treated and 79.6% of ciprofloxacin-treated subjects achieved microbiological eradication (difference -3.4, 95% CI -14.4%, 7.6%). In the microbiologically evaluable (ME) population (levofloxacin 80, ciprofloxacin 76), 92.5% of levofloxacin-treated vs. 93.4% of ciprofloxacin-treated subjects (difference -0.9, 95% CI -7.1%, 8.9%) achieved microbiologic eradication. Clinical success was achieved in 86.2% vs. 80.6% (mITT) and in 92.5% vs. 89.5% (ME) of levofloxacin-treated and ciprofloxacin-treated subjects, respectively. Escherichia coli was the most commonly isolated uropathogen. Few (2.1%) of the pathogens were fluoroquinolone-resistant. Adverse events (AEs) were similar to those seen previously with both agents. Potential limitations are that this analysis is based on a subset of subjects from a larger study and, because of different durations of therapy, the results may be biased against levofloxacin.

CONCLUSIONS

High-dose, short-course therapy with levofloxacin in subjects with AP is at least as effective as standard 10-day therapy with ciprofloxacin.

Study entry microbiology in patients with acute bacterial exacerbation of chronic bronchitis in a clinical trial stratifying by disease severity

OBJECTIVE

To examine study entry microbiology in patients stratified by disease severity in a clinical trial in acute bacterial exacerbation of chronic bronchitis (ABECB).

METHODS

Patients were assigned to differing antibiotic therapies based on stratification by disease severity using parameters including forced expiratory volume in 1 second (FEV(1)) as a percentage of predicted value, number of exacerbations during the previous 12 months, and defined co-morbidities. All patients were required to have sputum Gram stain and culture at study entry.

RESULTS

There was no statistically significant difference in overall microbiology between patients with less severe and more severe clinical presentations. Typical ABECB pathogens (Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis) were found in 46.2% (147/318) of patients with less severe presentations and 41.9% (143/341) of patients with more severe presentations. Gram-negative organisms and Staphylococcus aureus were also found in both groups. Pneumococcal susceptibilities to the three antibiotics utilized in the trial revealed marked resistance to azithromycin. Limitations of this analysis include that the clinical trial was designed to examine clinical outcomes rather than microbiology, and that we do not correlate study entry microbiology with clinical outcomes.

CONCLUSIONS

Stratification of patients by disease severity did not reveal a statistically significant difference in overall microbiological profile. Gram-negative organisms and S. aureus were recovered even from patients with less severe clinical presentations. Pneumococcal resistance varied with the agent tested. These findings may have implications for the selection of appropriate antibiotic therapy.

A trial of high-dose, short-course levofloxacin for the treatment of acute bacterial sinusitis

OBJECTIVE

Compare two dosage strengths of levofloxacin in the treatment of acute bacterial sinusitis.

STUDY DESIGN AND SETTING

Multicenter clinical trial comparing levofloxacin 750 mg for 5 days vs levofloxacin 500 mg for 10 days.

RESULTS

Sinus fluid samples were obtained by antral puncture (59.2%) or by sinus endoscopy (40.8%). Among microbiologically evaluable patients, 91.4% (139/152) of patients receiving levofloxacin 750 mg achieved clinical success vs 88.6% (132/149) of patients receiving levofloxacin 500 mg (95% CI -10.0, 4.2). Clinical success rates by pathogen were above 90% in both treatment groups for the 3 typical pathogens of acute sinusitis: Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. The safety profile of the 2 dosage strengths was similar.

CONCLUSION

Levofloxacin 750 mg for 5 days is noninferior to levofloxacin 500 mg for 10 days.

SIGNIFICANCE

Levofloxacin 750 mg for 5 days represents a safe and effective treatment regimen for acute bacterial sinusitis.

EBM RATING

A-1b.

Efficacy and tolerability of a new formulation of sodium phosphate tablets (INKP-101), and a reduced sodium phosphate dose, in colon cleansing: a single-center open-label pilot trial

BACKGROUND

The tablet form of sodium phosphate for bowel preparation for colonoscopy contains microcrystalline cellulose. This inactive ingredient produces a residue that obscures mucosal visualization and is time-consuming to remove during colonoscopy.

AIM

To perform an open-label study of efficacy and tolerability of a modified formulation with microcrystalline cellulose reduced by 50% (code named INKP-101) and a lower total dose of sodium phosphate.

METHODS

Patients scheduled for colonoscopy self-administered 28 INKP-101 tablets (42 g sodium phosphate). Colon cleansing efficacy was evaluated using a standard 4-point scoring system and the amount of microcrystalline cellulose present and time spent removing it using an 8-point scale.

RESULTS

A total of 31 patients were screened and enrolled. Thirty patients had a colonoscopy and were evaluated for colon cleansing efficacy. Overall colon cleansing was rated as excellent and good in 90% and 10% of patients respectively. About 77% of patients had microcrystalline cellulose scores of 2 or 3 (corresponding to <1 or 1-2 min spent removing microcrystalline cellulose, respectively). The drug was well-tolerated and adverse events were generally benign.

CONCLUSION

A new formulation of sodium phosphate with reduced microcrystalline cellulose and a lower total dose of sodium phosphate was effective for colonoscopy and well-tolerated.