The Value of the Distal Radioulnar Joint Effusion in Diagnosing Triangular Fibrocartilage Complex Tears on Magnetic Resonance Imaging.

BACKGROUND: A retrospective study was conducted to evaluate the role of distal radioulnar joint (DRUJ) effusion in aiding the diagnostic accuracy of central triangular fibrocartilage complex (TFCC) tears on non-contrast MRI. METHODS: 89 consecutive patients who had undergone wrist arthroscopy for ulna sided wrist pain in our unit were identified and their preoperative imaging reviewed. Two consultant musculoskeletal Radiologists independently reported the presence or absence of a DRUJ effusion and or a TFCC tear. The inter-observer variability was calculated using weighted Kappa tests. Two by two tables were constructed to calculate the sensitivity and specificity of reported TFCC tear or DRUJ effusion on MRI in correctly diagnosing central TFCC tears identified at arthroscopy. RESULTS: Sensitivity of MRI to report a TFCC tear was 0.56 and specificity was 0.79. Sensitivity increased to 0.89 if either a DRUJ effusion or TFCC tear were seen on MRI. When observed together, the presence of both a DRUJ effusion and a TFCC tear seen on the imaging lead to a sensitivity of 0.74 and PPV of 82% when compared to findings at arthroscopy. In the absence of both DRUJ effusion and TFCC tear, the specificity of MRI increased to 0.92. Agreement by the radiologists on the presence of DRUJ effusion was substantial (k value 0.67) and TFCC tear was moderate (k value 0.58). CONCLUSION: The presence of DRUJ effusion on MRI can further improve sensitivity of MRI in diagnosing central TFCC tears. The sensitivity of detecting a central TFCC tear on MRI scan when both a DRUJ effusion and a TFCC tear were seen (0.74) is comparable to rates demonstrated on MRA meta-analysis results (0.78). Furthermore, considering the absence of both a DRUJ effusion and TFCC tear seen on MRI is useful in excluding the presence of a TFCC tear at arthroscopy.

Mitigating the effects of COVID-19 pandemic on controlling vascular risk factors among participants in a carotid stenosis trial.

INTRODUCTION: The COVID-19 pandemic has presented challenges to managing vascular risk factors with in-person follow-up of patients with asymptomatic carotid stenosis enrolled in the CREST2 trial. CREST2 is comparing intensive medical management alone versus intensive medical management plus revascularization with endarterectomy or stenting. We performed a study to evaluate the feasibility of a home-based program for testing blood pressure (BP) and low-density lipoprotein (LDL) in CREST2. METHODS: This study involved 45 patients at 10 sites in the CREST2 trial. The initial patients were identified by the Medical Management Core (MMC) as high-risk patients defined by stage 2 hypertension, LDL > 90 mg/dl, or both. If a patient at the site declined participation, another was substituted. All patients who agreed to participate were sent a BP monitoring device and a commercially available at-home lipid test kit that uses a self-performed finger-stick blood sample that was resulted to the patient. Training on the use of the equipment and obtaining the risk factor results was done by the study coordinator by telephone. RESULTS: Ten of the 130 currently active CREST2 sites participated, 8 in the LDL portion and 5 in the BP portion (3 sites did both). Twenty-six BP devices and 23 lipid tests were sent to patients. Of the 26 patients who obtained BP readings with the devices, 9 were out of the study target and adjustments in BP medications were made in 3. Of the 23 patients sent LDL tests, 13 were able to perform the test showing 7 were out of target, leading to adjustments in lipid medications in 4. CONCLUSION: This study established the feasibility of at-home monitoring of BP and LDL in a clinical trial and identified implementation challenges prior to widespread use in the trial. (ClinicalTrials.gov number NCT02089217).

Reversed palmaris longus muscle: a report of two cases.

The palmaris longus muscle is the most superficial muscle of the volar forearm which demonstrates significant anatomical variance. A reversed palmaris longus muscle is one such variant. Here we discuss two cases in which reversed palmaris longus was postulated as a cause of wrist discomfort.

Reducing health disparities through primary care reform: the New Zealand experiment.

New Zealand experiences significant health disparities related to both ethnicity and deprivation; the average life expectancy for Maori New Zealanders is 9 years less than for other New Zealanders. The government recently introduced a set of primary care reforms aimed at improving health and reducing disparities by reducing co-payments, moving from fee-for-service to capitation, promoting population health management and developing a not for profit infrastructure with community involvement to deliver primary care. Funding for primary care visits will increase by some 43% over 3 years. This paper reviews policy documents and enrollment and payment data for the first 15 months to assess the likely impact on health disparities. The policy has been successfully introduced; over half the New Zealand population (of four million) enrolled in new Primary Health Organizations within 15 months. Over 400,000 people (half of them in vulnerable groups) gained improved access to primary care subsidies in the first 15 months. The combined effect of new payment rules and the deprived nature of the minority populations was that the average per person payment to PHOs on behalf of Maori and Pacific enrollees was more than 70% greater than the per person amount for other ethnicities for the period. The policy is consistent with the principles of the Alma Alta Declaration. Barriers to successful implementation include the risk of middle class capture of the additional funding; the risk that co-payments are not low enough to improve access for the poor; PHO inexperience; and the small size of many PHOs. Transitional equity and efficiency issues with the use of aggregate population characteristics to target higher subsidies are being ameliorated by the introduction of low cost access based on age. A tension between the twin policy goals of low cost access for all, and very low cost access for the most vulnerable populations is identified as a continuing and unresolved policy issue.