Relationship of relaxin hormone and thumb carpometacarpal joint arthritis.

BACKGROUND: The female predominance in thumb carpometacarpal (CMC) joint arthritis has led to speculation that reproductive hormones or hypermobility are responsible. Evidence shows that patients with pathologic laxity have a higher rate of thumb CMC arthritis. Relaxin hormone increases laxity in the pelvic ligaments through upregulation of matrix metalloproteases (MMPs). It is thus a hormone of interest in the development of thumb CMC arthritis. QUESTIONS/PURPOSES: Our goals were to identify demographic and hormonal factors associated with joint laxity in patients with CMC arthritis and to evaluate the relationship among serum relaxin, relaxin receptors, and MMPs in the anterior oblique ligament (AOL) of the thumb. We hypothesized that serum relaxin was correlated with joint laxity as well as with relaxin receptors and MMPs in the AOL. METHODS: Forty-nine patients undergoing thumb CMC arthroplasty underwent laxity examination, blood draw, and AOL sampling. Ligaments were analyzed for relaxin receptor and MMPs 1 and 3 using quantitative reverse-transcriptase polymerase chain reaction. RESULTS: Women demonstrated more joint laxity than men (p < 0.001). RNA analysis confirmed relaxin receptors in the AOL as well as MMPs 1 and 3. There was a significant correlation between serum relaxin and MMP-1 (p = 0.04). Detectable serum relaxin was negatively correlated with relaxin receptors in the AOL (p = 0.02). CONCLUSIONS: Further studies are needed to evaluate the role of laxity and sex hormones in thumb CMC arthritis. CLINICAL RELEVANCE: Relaxin hormone may play a role in the development of arthritis at the thumb CMC joint. LEVEL OF EVIDENCE: Level I, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.

Histomorphologic changes of the long head of the biceps tendon in common shoulder pathologies.

PURPOSE: To assess molecular and histologic differences between the proximal (intra-articular) and distal (extra-articular) portions of the long head of the biceps (LHB) tendon in 3 different disease states (biceps instability, tendinosis, and degenerative joint disease [DJD]) compared with a healthy tendon (fresh frozen). METHODS: We used 32 LHB tendons of patients undergoing tenodesis (mean age, 54.7 ± 10.1 years) and 9 harvested tissue donors. Tendons were divided according to 4 diagnostic groups: (1) biceps instability, (2) tendinosis, (3) DJD, and (4) normal control. After sectioning, tendons were fixed in formalin and stained with H&E and alcian blue for histologic analysis. Measurements of collagen organization by use of polarized light microscopy was then performed, and protein expression for type I and type III collagen, tenascin C, and decorin was determined. RESULTS: There were no statistical differences found for protein expression of type I or type III collagen, tenascin C, or decorin. The proximal and distal regions of the tendons had statistically significant differences in alcian blue staining, with the proximal portion containing a higher amount of proteoglycan (instability, P = .001; tendinosis, P = .005; DJD, P = .008; control, P = .011). When compared with the nonpathologic control tendons, a significant increase in alcian blue staining for the proximal region was seen in all 3 groups. Total polarized light analysis showed that the distal tendon had a significantly higher intensity (organization) compared with the proximal tendon (P < .001); this was also seen in all of the diagnostic groups (instability, P = .010; tendinosis, P = .013; DJD, P = .07; control, P = .028). CONCLUSIONS: This study showed a greater degree of degeneration of the proximal (intra-articular) regions of the LHB tendon when compared with the distal regions in all pathologic groups. However, no major differences at the cellular level were found among groups. CLINICAL RELEVANCE: The pathomechanisms of the various forms of known LHB diagnoses are not yet fully understood and basic science studies may help in understanding their etiology and therefore optimizing treatment options.

Relationship of serum relaxin to generalized and trapezial-metacarpal joint laxity.

PURPOSE: The reproductive hormone relaxin acts to loosen pelvic ligaments in preparation for childbirth and is thought to be a mediator of joint laxity. The purpose of this study was to evaluate the correlation of serum relaxin with radiographic laxity at the trapezial-metacarpal joint and with generalized joint laxity. METHODS: We enrolled 289 healthy subjects prospectively. Participants completed a demographic questionnaire and were examined for generalized joint hypermobility using the Beighton-Horan scale. Stress radiographs of the trapezial-metacarpal joint were obtained in 163 subjects (56%). Blood samples were collected, and serum relaxin was measured for 287 subjects using enzyme-linked immunosorbent assay for human relaxin-2. RESULTS: The mean serum relaxin level among all subjects was 1.84 pg/mL (range, 0-45.25 pg/mL). Relaxin was not detectable in 166 of 287 samples, whereas the mean serum relaxin level among the 121 subjects with a detectable relaxin level (of 287 total relaxin samples) was 4.37 pg/mL (range, 0.46-45.25 pg/mL). Mean trapezial-metacarpal subluxation ratio scores were higher among those with a detectable relaxin level compared to those without a detectable relaxin level (0.34 vs 0.30 pg/mL). The average Beighton-Horan laxity score was 1.8 (range, 0-9). There was no correlation between generalized joint laxity measures and serum relaxin levels. CONCLUSIONS: In a large volunteer population, we demonstrated a relationship between circulating relaxin and trapezial-metacarpal joint laxity. However, we were unable to show a direct link between serum relaxin and generalized joint laxity. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

Current trends in nonoperative and operative treatment of trapeziometacarpal osteoarthritis: a survey of US hand surgeons.

PURPOSE: Multiple procedures have been described for trapeziometacarpal (TM) osteoarthritis with varying levels of evidence support. The purpose of this study was to evaluate current trends in the treatment of TM arthritis by surveying active members of the American Society for Surgery of the Hand. METHODS: We sent an online questionnaire to the e-mail addresses of 2,326 active members of the American Society for Surgery of the Hand, consisting of 5 treatment and 2 demographic questions. Surgeons were contacted twice by e-mail and provided with a link to a de-identified online survey. We performed statistical analysis of correlations between demographics and treatment preferences using chi-square testing. RESULTS: We received responses from 1,156 out of 2,326 hand surgeons, a response rate of 50%. The vast majority of surgeons use corticosteroid injections for TM arthritis, and 719 out of 1,156 perform trapeziectomy with ligament reconstruction and tendon interposition (LRTI) for common Eaton stage III arthritis. For scaphotrapeziotrapezoid (STT) arthritis, approximately half of respondents also perform trapeziectomy/LRTI, followed by STT fusion. For a younger woman with minimal radiographic change and pain, 535 out of 1,142 surgeon respondents would advocate continued conservative treatment, whereas the remainder chose Eaton ligament reconstruction, arthroscopy, and metacarpal osteotomy. CONCLUSIONS: This survey study presents the current opinions of a group of hand surgeons who responded to an online questionnaire regarding treatment of TM arthritis. The results show that trapeziectomy/LRTI is the treatment of choice by most respondents. The use of trapeziectomy/LRTI in the treatment of STT arthritis has not been studied in depth, but this procedure was chosen by half the respondents. The process of choosing treatment strategies is a question for future study. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

Asthma guideline use by pediatricians in private practices and asthma morbidity.

OBJECTIVE: We sought to examine whether pediatric clinicians in private, non-health maintenance organization practices could implement the national asthma guidelines and whether, when implemented, these guidelines would decrease medical services utilization and improve asthma care for children. METHODS: A trial of a disease management program (Easy Breathing II) involving 20 private pediatric practices in the greater Hartford, Connecticut area was conducted between January 1, 2001, and December 31, 2003. Demographic data on participating practitioners and patients were obtained from questionnaires. Medical services utilization data from claims were obtained from ConnectiCare, a regional managed care organization. RESULTS: Of the 16750 children enrolled in Easy Breathing II, 2458 were enrolled in ConnectiCare and 490 had asthma. Inhaled corticosteroid use increased in the community overall during the study period. After enrollment in Easy Breathing II, with adjustment for age, gender, ethnicity, asthma severity, season, and calendar year, children with persistent asthma experienced an additional 47% increase in inhaled corticosteroid use, a 56% reduction in outpatient visits, and a 91% decrease in emergency department visits for treatment of asthma. Adherence to national asthma guidelines for prescribing inhaled corticosteroids was 95%. Seventeen of the 20 practices are still using Easy Breathing, 5 years after program implementation. CONCLUSIONS: Pediatric primary care clinicians in private practice settings can implement an asthma management program patterned after the national asthma guidelines. When implemented, this program is successful in reducing medical services utilization for children with asthma. Just as differences in patterns of medical services utilization exist in private practices, compared with urban clinics, the impact of disease management on medical services utilization differs in private practices, compared with urban clinics.

Improving glycemic control: the case for self-monitoring blood glucose levels.

Diabetes can be potentially identified, monitored, treated, and prevented more easily now than at any other time in history. Yet, the prevalence of diabetes continues to grow and the complications associated with it continue to afflict millions of Americans. Glycemic control, or the maintenance of appropriate levels of blood sugar, measured through the self-monitoring of blood glucose or a glycated hemoglobin test, represents the best opportunity for persons with diabetes to prevent complications by helping them understand the effect of their lifestyle choices and medications on their health. Despite the numerous advantages of glycemic control, a number of barriers prevent individuals from monitoring their blood sugar concentrations and achieving the health benefits that come with the proper understanding of their condition.

Improving asthma treatment in a managed care population.

OBJECTIVE: To identify and educate members of ConnectiCare, Inc & Affiliates, a regional managed care organization, who were not using asthma medications as recommended by the National Heart, Lung, and Blood Institute, by means of a nurse-administered 6-month telephonic case management intervention called the Asthma Treatment Awareness Project. STUDY DESIGN: A randomized controlled design was used to evaluate intervention and control groups. Self-selected members who opted in, opted out, or did not respond to an invitation to participate were included in the analysis. METHODS: Changes in asthma medication use, physician office visits, emergency department visits, hospitalizations, and quality of life were measured. A change in asthma medication use was measured using an asthma medication index ranging from 0 to 1.00, with a higher score indicating a better prescribing pattern. RESULTS: There was significant improvement in asthma medication use for all groups, but the asthma medication index increase of 0.176 for the intervention group was nearly 2 times the 0.091 increase for the control group. This difference remained significant (P = .04) after using analysis of variance to control for age and the preintervention asthma medication index. There was also a significant increase in overall quality of life for the intervention group (P = .04) but not for the control group. CONCLUSION: Individualized telephonic case management from a specially trained registered nurse may be effective in improving asthma medication use and quality of life in subjects that do not use asthma medications according to National Heart, Lung, and Blood Institute guidelines.

Barriers to A1C testing among a managed care population.

PURPOSE: The purpose of this study is to explore reasons adults with diabetes do not receive at least 2 A1C tests per year as recommended by the American Diabetes Association (ADA). METHODS: ConnectiCare, a regional managed care company based in Farmington, Connecticut, identified adult members with diabetes who did not have a medical claim for an A1C laboratory test from their physician. A questionnaire was sent to 740 randomly selected members asking them to report the number of A1C tests they received in the past 12 months and reasons for not receiving the number of tests recommended by the ADA. After sending an automated telephone reminder to nonrespondents, a 26% (n = 192) response rate was achieved. RESULTS: Thirty-three percent of respondents (n = 63) reported having diabetes and receiving fewer than 2 A1C tests in the past year. Respondents were equally divided between men and women, with a mean age of 58 years. The primary reasons given for not obtaining at least 2 A1C tests as recommended by the ADA were that respondents were unaware that the test is recommended (49%), not informed of the need for the test by their physician (38%), never heard of the A1C test (33%), and not seen regularly by their physician (19%). CONCLUSIONS: Diabetes self-management education remains an important means of encouraging adherence to important ADA recommendations such as regular A1C testing. Barriers to A1C testing can be addressed in multiple settings, including individual and group education, disease management programs, and physician education.

Using case management to increase antiinflammatory medication use among a managed care population with asthma.

The National Heart, Lung, and Blood Institute (NHLBI) recommends the regular use of antiinflammatory medications to achieve and maintain control of persistent asthma, while recommending that quick-relief beta2-agonist medications should be used to treat acute symptoms and exacerbations. Despite these suggestions, the overuse of short-acting quick-relief medications and underuse of long-acting antiinflammatory medications persists. ConnectiCare, Inc., a regional managed care company, used pharmacy claims data to identify members who had been dispensed a total of three or more beta2-agonist prescriptions for three consecutive months in a 12-month period. These members had also not been prescribed an inhaled corticosteroid, cromolyn sodium, or nedocromil during the same three consecutive months. An intensive case management intervention was developed that included multiple contacts from a nurse case manager to provide education and information about asthma control and the guidelines. Twenty-eight percent (n = 40) were purposively chosen to receive the intensive multiple-contact intervention and the remainder received a standard, single-contact intervention. After adjusting for the effects of age, gender, and pre-intervention medication use, ConnectiCare members who received the intensive intervention were 4.3 times more likely to increase the number of antiinflammatory medication prescriptions dispensed that those who received a standard intervention (p < 0.001). This study suggests that the use of intensive case management for persons identified as inappropriate users of asthma medication may result in medication changes that achieve the long-term control of asthma.