Multiple sclerosis management during the COVID-19 pandemic

Background:

People with multiple sclerosis (MS) may be at higher risk for complications from the 2019 coronavirus (COVID-19) pandemic due to use of immunomodulatory disease modifying therapies (DMTs) and greater need for medical services.

Objectives:

To evaluate risk factors for COVID-19 susceptibility and describe the pandemic’s impact on healthcare delivery.

Methods:

Surveys sent to MS patients at Cleveland Clinic, Johns Hopkins, and Vall d’Hebron-Centre d’Esclerosi Múltiple de Catalunya in April and May 2020 collected information about comorbidities, DMTs, exposures, COVID-19 testing/outcomes, health behaviors, and disruptions to MS care.

Results:

There were 3028/10,816 responders. Suspected or confirmed COVID-19 cases were more likely to have a known COVID-19 contact (odds ratio (OR): 4.38; 95% confidence interval (CI): 1.04, 18.54). In multivariable-adjusted models, people who were younger, had to work on site, had a lower education level, and resided in socioeconomically disadvantaged areas were less likely to follow social distancing guidelines. 4.4% reported changes to therapy plans, primarily delays in infusions, and 15.5% a disruption to rehabilitative services.

Conclusion:

Younger people with lower socioeconomic status required to work on site may be at higher exposure risk and are potential targets for educational intervention and work restrictions to limit exposure. Providers should be mindful of potential infusion delays and MS care disruption.

Plasma Trimethylamine N-Oxide, a Gut Microbe-Generated Phosphatidylcholine Metabolite, Is Associated With Atherosclerotic Burden

BACKGROUND

Trimethylamine N-oxide (TMAO), a gut microbiota metabolite from dietary phosphatidylcholine, has mechanistic links to atherosclerotic coronary artery disease (CAD) pathogenesis and is associated with adverse outcomes.

OBJECTIVES

This study sought to examine the relationship between plasma TMAO levels and the complexity and burden of CAD and degree of subclinical myonecrosis.

METHODS

We studied 353 consecutive stable patients with evidence of atherosclerotic CAD detected by elective coronary angiography between 2012 and 2014. Their high-sensitivity cardiac troponin T (hs-cTnT) levels were measured. SYNTAX (Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery) scores and lesion characteristics were used to quantify atherosclerotic burden. Fasting plasma TMAO was measured by mass spectrometry.

RESULTS

In this prospective cohort study, the median TMAO level was 5.5 μM (interquartile range [IQR]: 3.4 to 9.8 μM), the median SYNTAX score was 11.0 (IQR: 4.0 to 18.5), and 289 (81.9%), 40 (11.3%), and 24 (6.8%) patients had low (0 to 22), intermediate (23 to 32), and high (≥33) SYNTAX scores, respectively. Plasma TMAO levels correlated (all p < 0.0001) with the SYNTAX score (r = 0.61), SYNTAX score II (r = 0.62), and hs-cTnT (r = 0.29). Adjusting for traditional risk factors, body mass index, medications, lesion characteristic, renal function, and high-sensitivity C-reactive protein, elevated TMAO levels remained independently associated with a higher SYNTAX score (odds ratio [OR]: 4.82; p < 0.0001), SYNTAX score II (OR: 1.88; p = 0.0001), but were not associated with subclinical myonecrosis (OR: 1.14; p = 0.3147). Elevated TMAO level was an independent predictor of the presence of diffuse lesions, even after adjustments for traditional risk factors and for hs-cTnT (OR: 2.05; 95% confidence interval: 1.45 to 2.90; p = 0.0001).

CONCLUSIONS

Fasting plasma TMAO levels are an independent predictor of a high atherosclerotic burden in patients with CAD.

Relation of Red Cell Distribution Width to Left Ventricular End-Diastolic Pressure and Mortality in Patients With and Without Heart Failure

Higher red cell distribution width (RDW) has been associated with poor prognosis in patients with heart failure (HF). RDW is also closely associated with iron deficiency. However, the mechanism underlying this association is unclear. The relation between left ventricular end-diastolic pressure (LVEDP) and RDW has not been studied, especially in those without HF. We examined the relation between LVEDP and RDW in 1,084 consecutive stable patients who underwent elective coronary angiography. We observed that 38% had high LVEDP (>16 mm Hg) and 29% had history of HF. The median RDW was 13.4%, which was higher with increasing LVEDP (p <0.0001) and significantly higher in patients with HF (p <0.0001). Baseline RDW were independently associated with high LVEDP even after multivariable logistic regression analysis (adjusted odds ratio [OR] per unit change 1.14, 95% confidence interval [CI] 1.0 to 1.29, p = 0.044). Interestingly, result were stronger in non-HF cohort (adjusted OR per unit change 1.37, 95% CI 1.13 to 1.67, p = 0.001). In addition, elevated (third vs first tertiles) RDW levels were independently a predictor of high LVEDP and were associated with a 4.8-fold increased 5-year mortality risk (adjusted hazard ratio 4.11, 95% CI 2.12 to 7.96, p <0.0001), even with the addition of B-type natriuretic peptide to the model (adjusted OR for LVEDP 2.25, 95% CI 1.0 to 5.05, p = 0.05; adjusted hazard ratio for mortality 3.79, 95% CI 1.033 to 13.89, p = 0.044, respectively). In conclusion, high RDW levels were observed in patients with or without HF and independently associated with high LVEDP and with mortality.

[Different forms of tuberculous hip arthritis (case study)]

Tuberculous hip arthritis ranks third in the classification of orthopedic tuberculosis, after tuberculosis of the spine and knee joint. It accounts for about 15 % of all orthopedic tuberculosis. The aim of this paper is to demonstrate the etiology, clinical presentation and forms of disease on the case reports of six patients. The scope of disease is wide - from a mild reversible synovial form, then fibrous or bone ankylosis, to severe destruction of the hip with subluxation or dislocation, pseudoarthrosis or chronic arthritis with a fistula. The wide diversity of clinical findings and difficulties is making diagnosis are often responsible for a late start of therapy. However, only an early and adequate treatment permits the prevention of irreversible damage to the hip joint or further complications. Key words: tuberculous hip arthritis.

[Our experience with total knee arthroplasty following tuberculous arthritis (1980-2005)]

PURPOSE OF THE STUDY

Orthopedic tuberculosis is number one in non-pulmonary forms of tuberculosis and, among these, knee joint tuberculosis ranks second after spinal tuberculosis. Arthritic lesions are currently treated by total knee arthroplasty (TKA).

MATERIAL

A group of 10 patients who, after having gone through tuberculous gonarthritis, underwent TKA was evaluated for the period from 1980 to 2005. It consisted of six women and four men, whose average age at the time of arthroplasty was 65 years.

METHODS

The most frequent indication for TKA after tuberculous gonarthritis was post-inflammatory arthritis (80 %); the other indication was fibrous ankylosis (20 %). No conversion of arthrodesis to total replacement was carried in our group. All patients underwent pre-operative microbiological tests including PCR, as well as histological examination. Pre- and post-operative prophylaxis included anti-tuberculous (AT) drugs (rifampicin and izoniazid) combined with a cephalosporin antibiotic. AT drugs were administered for 3 to 5 months after surgery in accordance with the results of laboratory tests.

RESULTS

In 1980 to 2005, ten patients after tuberculous gonarthrosis underwent TKA at our department. No complications were recorded. The average range of flexion was 0 to 90 degrees. None of the patients needed any walking aid, and all were able of full weight-bearing on the treated limb. There was no recurrent tuberculosis in this group.

DISCUSSION

Any implantation of an endoprosthesis in a post-inflammatory terrain is always difficult. Subjective evaluation by the patients was good. At long-term follow-up, clinical, radiographic and laboratory findings were within standards, which is in agreement with the results of other authors. The pre- and post-operative therapy with AT drugs and antibiotics was used in all patients.

CONCLUSIONS

Compared to arthrodesis, TKA brings about a significant improvement in the patient's mobility as well as a better quality of life. Before the patient is indicated for TKA, emphasis is placed on recording a thorough medical history, complete laboratory examination, radiography, CT scans, or magnetic resonance imaging, relevant orthopedic, internal and pulmonary examination including X-ray of the heart and lungs, as well as the assessment of the patient's somatic and psychical state with regard to the post-operative rehabilitation course.

[Resection hip arthroplasty--mid- and long-term results]

PURPOSE OF THE STUDY

The study deals with resection hip arthroplasty, which is currently one of the principal orthopedic surgery procedures.The aim of the study was to evaluate the mid- and long-term results of resection arthroplasty carried out for different indications and to ascertain effects of the extent of proximal femur resection on the functional outcome.

MATERIAL

In the period from 1979 to 2000, we carried out 159 resection hip arthroplasties for septic and aseptic loosening of total hip arthroplasty (THA), septic arthritis or osteomyelitis. Of these only the patients who underwent no THA implantation or reimplantation within 2 years of the operation were evaluated. We assessed 102 patients (71 women and 31 men) with 105 resection arthroplasties for the following indications: 14 cases of aseptic loosening of the THA, 72 cases of septic loosening and 19 cases of hip inflammation. The average follow-up was 70.8 months (range, 26 months to 20 years). The average age of the patients at the time of surgery was 62.5 years (29 to 86 years).

METHODS

We recorded the patient's subjective evaluation of the surgery outcome, shortening of the extremity, and the range of hip motion. Harris hip scores were used to assess the functional outcome. We also evaluated, and statistically analysed, the extent of resection of the proximal femur on X-ray images and its effect on the eventual shortening of the extremity; this was done on the basis of the Grauer classification system.

RESULTS

The average Harris hip score was 63.2 points (range, 47 to 88). None of the joints achieved excellent outcomes; 8.5 % were good, 22 % were satisfactory and 73 % were poor. On pain evaluation, 35 % of the patients were completely free from pain, 18 % reported mild pain not interfering with daily activities, 27 % experienced moderate pain responding to common analgetics and 11 % had severe pain necessary to be treated with strong analgetics. Persistent rest pain not responding to analgetics was in 9 % of the patients. The average shortening of the extremity for the whole group was 4.1 cm (range, 3.5- 7 cm): the average values for shortening in type I, type II and type II resections were 3.25 cm (3-5 cm), 4.1 cm (3-6 cm) and 5.3 cm (4.5/7 cm), respectively. The range of passive flexion was on average 81 degrees (range, 45-105 degrees ). Limping and a positive Trendelenburg's test were recorded in all patients and all also had to use walking aids. The outcome of surgery was evaluated as satisfactory by 35 % and as partially satisfactory by 43 % of the patients.

DISCUSSION

Resection arthroplasty is a reliable technique for pain reduction, but it results in a considerable alteration of hip function. Pain in the hip after surgery is bearable, as 80 % of our patients reported only mild or moderate pain alleviated by common analgetics, or complete absence of pain. This is in agreement with the results of Stoklasa (84 %) and Stedrý (79 %). However, the subjective evaluation of surgery by patients is different; Petty has reported 14 % of satisfied patients, while Ahlgren and Böhler described 100 % of satisfied patients. Hip stability and less shortening of the extremity are more important for patients' satisfaction than a certain mild degree of pain. The best subjective evaluation was reported by the patients who had resection at the femoral neck level and who also had the lowest average shortening of the extremity. But only 55 % of the satisfied or partially satisfied patients reported mild or no pain.

CONCLUSIONS

Resection arthroplasty is, in indicated cases, a reliable method which, in spite of certain drawbacks, produces good functional outcomes and makes the patients satisfied. It is, without doubt, an integral part of the current orthopedic surgery repertoire. We recommend a cautious approach to repeated attempts at THA reimplantation or to reconstruction procedures.

[Current views on diagnosis of osteoarticular tuberculosis]

This paper presents current methods used in the diagnosis of osteoarticular tuberculosis in the Czech Republic. It draws attention to difficulties and errors associated with the diagnosis of this disease. The aim of this study is to provide a comprehensive review of relevant diagnostic methods, from medical history to imaging techniques. A misdiagnosis and/or a late establishment of the diagnosis, which may result in inadequate primary therapy, prolong both the time needed for complete treatment and the duration of absenteeism. These may eventually have negative economic and social implications.

[Two-stage reimplantation using spacers--the method of choice in treatment of hip joint prosthesis-related infections. Comparison with methods used from 1979 to 1998]

PURPOSE OF THE STUDY

Several therapies are available for the treatment of deep infection in total hip arthroplasty but none is completely successful; there is no consensus on an optimal method. The aim of this study was to evaluate the treatment used in our institution and its outcomes over the last 20 years. In each method, the success of treatment was evaluated in terms of both infection control and restoration of function in the treated joint.

MATERIAL

A total of 172 patients with infected total hip replacements were treated at the First Orthopedic Clinic of the First Faculty of Medicine, Charles University, Prague, between 1979 and 1998. Our sample consisted of 132 patients, 92 men and 40 women. Resection arthroplasty was performed in 62 patients. Two-stage reimplantation was used in 64 patients. Two-stage reimplantation involving skeletal traction was applied in 35 and a block spacer was used in 29 patients. The remaining patients were treated by other techniques.

METHODS

The type of infection was classified according to the Coventry system. The outcome of surgery was assessed on the basis of the Tsukayma rating system, radiographic findings and the Harris hip score.

RESULTS

The average follow-up time from the definitive operation was 70.8 months. In the patients who had resection arthroplasty only, the cure rate of infection was 91.9%. However, an increase in the Harris hip score, as compared with the condition before surgery, was low (9.7 points). In the patients treated by the two-stage reimplantation without a spacer but with skeletal traction, the cure rate of infection was 94.3% and the Harris score increased by 20 points. The patients who were treated by two-stage reimplantation with a spacer showed an infection cure rate of 96.5% and an increase in the Harris score by 29 points. This increase was higher by 9 points in comparison with the patients who had reimplantation without the use of a spacer. An even greater difference (28.2 points) was found when the outcomes of this technique were compared with those of resection arthroplasty. The incidence of spacer dislocation in 21% of the cases was an unexpected finding.

DISCUSSION

No great differences in outcome in terms of infection cure rate were found among the methods used, i.e., two-stage reimplantation facilitated a better function for the hip joint than Girdlestone's operation. The use of a spacer in two-stage reimplantation ensured a greater comfort for the patient during treatment and gave better results in terms of joint function than treatment without a spacer. The use of a cemented spacer is an optimal method that not only ensures the stability of a limb during the period necessary for infection control but also provides conditions for the prospective implantation of a new prosthesis. The spacer also permits delivery of high-dose local antibiotics released from the cement as well as makes space for a long-term application of antibiotic-containing lavage.

CONCLUSIONS

The rate of success in the treatment of an infected hip arthroplasty and the possibility of preserving the implant and thus enabling the patient to move comfortably are currently high. The prerequisite is early diagnosis and a radical surgical approach that involves the use of a method leading to the most effective eradication of infection and the maintenance of a good function for the joint. The reimplantation of a new prosthesis, after removal of the previous one and debridement of all infected tissue and material, combined with a targeted antibiotic therapy, is the method of choice for both the patient and the surgeon.

[An interesting case of actinomycotic affection of the lower limb.]

The authors deal with a rare case of a 14-year actinomycotic affection of the left lower limb in at present 39 years old female patient. They point out the difficulty and mistakes in the diagnosis of the mentioned disease. During the 14 years the patient was hospitalized, examined and treated at approximately 6-7 clinics all over the republic with different conclusions within the differential diagnosis. It is a fact that the history of the patient was underestimated, not all possibilities of the examination within differential diagnosis were used and at one clinic the histological finding got even lost, the examination was not repeated and the treatment focussed only on the incipient symptoms of the disease. Therefore in the first stage of the disease the diagnostic conclusion was synovialitis of the left ankle, in the following years the tuberculous etiology was suspected and finally the disease was diagnosed as a juvenile rheumatoid progressive ostearthritis with negative rheumatotests. Proper diagnosis was determined only after 13 years (bacteriological tests revealed actinomycotic particles on the dorsum of the left foot, chronic liver lesion and incomplete nephrotic syndrome were diagnosed. However, it has to be taken into account that in the 14-year course of the disease there were several-year periods without subjective complaints and with a complete normalization of the clinical condition. As stated in the discussion it is a rare case of the disease, we have not found in the available literature any similar case study of actinomycotic affection. Key words: actinomycosis of the musculoskeletal apparatus.

Tris(dichloropropyl)phosphate, a mutagenic flame retardant: frequent cocurrence in human seminal plasma

Negative-chemical-ionization mass spectral screening of extracts of human seminal plasma has revealed a presence of a Cl7 ion cluster at a mass-to-charge ratio (m/z) of 463 in a significant number of the samples examined (34 out of 123). Experiments with different gases used to generate the negative-chemical-ionization plasma indicated that the ion at m/z 463 was a chloride adduca of a Cl6 molecule with a mass of 428 daltons. Negative-chemical-ionization mass measurement with ions from the iodoform mass spectrum used as reference peaks gave a mass of 427.882 daltons; C9H15PCl6 has a molecular weight of 427.883. Extraction of polyurethane foam with toluene produced an extract that consistently gave a negative-chemical-ionization spectrum containing an intense Cl7ion at m/z463. The component producing ion was isolated, and its proton nuclear magnetic resonance spectrum confirmed that it was tris (1,3-dichloro-2-propyl)phosphate, a mutagenic flame retardant. The negative-chemical-ionization screening evidence suggests that this flame retardant or its isomer tris(2,3-dichloro-l-propyl)phosphate, or both, are absorbved into the body from formulations in which they are used as flame retardants. Remedial action seems indicated to reduce human exposure to these compunds.