Comparison of T2 Weighted, Fat-Suppressed T2 Weighted, and Three-Dimensional (3D) Fast Imaging Employing Steady-State Acquisition (FIESTA-C) Sequences in the Temporomandibular Joint (TMJ) Evaluation

Aim. Osteonecrosis can affect the mandibular condyle, and bone marrow edema may be a precursor in osteonecrosis development in temporomandibular disorder (TMD) patients. Early detection of bone marrow changes is crucial for occurring osteonecrosis. The purpose of this study was to compare the diagnostic value of fast spin-echo T2 weighted (FSE-T2W), fat-suppressed T2W (FS-T2W), and three-dimensional (3D) fast imaging employing steady-state acquisition (FIESTA-C) MR sequences for early detection of bone marrow changes as well as TMJ soft tissue alterations. Methods. A total of 60 joints with TMD were included in this study using a 1.5T MR machine (Signa HDxt, GE, Milwaukee, USA) using a dual surface TMJ coil. Qualitatively, the images were interpreted by two observers for disk configuration, disk position, joint fluid, and bone marrow changes. Quantitatively, signal intensity ratios (SIR) in the TMJ condyle, retrodiscal tissue, disk, and muscle were also measured using all tested sequences. Kappa coefficients were calculated to assess both intra- and interobserver agreements for each image set. The SIR of each sequence was compared using a one-way ANOVA Bonferroni-Dunn test. Results. Overall intraobserver kappa coefficients ranged between 0.35 and 0.88 for joint fluid and between 0.22 and 0.82 for bone marrow changes diagnosis, suggesting high intraobserver agreement for FS-T2W and 3D FIESTA-C sequences than FSE T2W sequence ( p < 0.05 ). 3D FIESTA-C showed higher agreement values for disk configuration and position detection than other sequences. Conclusions. 3D FIESTA-C sequences can be used and incorporated into routine MRI protocols for obtaining high-resolution TMJ MR images due to the short acquisition time and 3D nature of the sequence. Additional studies should be done for dynamic TMJ imaging with this sequence.

Modification of cognitive behavior therapy to improve the skill of elderly with osteoarthritis

One of the characteristics of physical changes in the elderly involves a decrease in the musculoskeletal system, such as the depletion of the synovial joint fluid which has an impact on the pain felt in joints. This condition can cause a disruption of the quality of life for the elderly and results in increases in the family burden. The purpose of cognitive-behavioral therapy in nurse care planning is to provide an overview of the implementation of family care nursing, community care health nursing, and management of health services by community health nurses to the elderly with osteoarthritis. The innovation and development of this senior citizen community program, initially named Lansia SMART (SMART Elderly), consists of six sessions, including psychoeducation sessions, cognitive restructuring sessions, pain management sessions with progressive muscle relaxation, activity scheduling sessions, problem-solving sessions, and tutorial sessions for the Lansia SMART (SMART Elderly) group with the Android application. The final maintaining challenging stage of these services involved 59 elderly participants. Data analysis used paired T-tests. The results of this innovation showed significant differences in the behavior of the elderly participants after the implementation of the SMART Elderly program (p < 0.05). The SMART Elderly program was effective to improve the elderly participants’ behavior. Nurses can use cognitive behavioral therapy to improve the process of self-management of osteoarthritis among their clients.

Effectiveness and safety of acupotomy for knee osteoarthritis: study protocol for a randomized controlled trial

Background Knee osteoarthritis (KOA) is one of the most common musculoskeletal disorders. Acupotomy may be effective for KOA, but the evidence is limited. This trial aims to determine the effectiveness and safety of acupotomy for KOA. Methods/design This is a parallel-group, assessor-blinded randomized controlled trial. Two hundred patients with KOA will be recruited and randomly assigned to two groups (group A or group D) in a 1:1 ratio. Patients in group A will receive acupotomy and topical diclofenac diethylamine for 4 weeks, while patients in group D will receive topical diclofenac diethylamine alone for 4 weeks. The primary outcome will be the response rate—the proportion of patients who achieve the minimal clinically important improvement in pain and function at week 4 compared with baseline. Secondary outcomes will include pain, function, quality of life, the use of rescue medicine (loxoprofen sodium), and adverse events at weeks 4, 8, and 24 after randomization. Besides, joint fluid and serum will be collected to assess the level of inflammatory cytokines, like TNF-α, IL-1β, and MMP-3. Discussion This study will contribute to a better understanding of the effectiveness and safety of acupotomy in combination with topical nonsteroidal anti-inflammatory drugs. If the hypothesis is confirmed, acupotomy may be recommended as adjunctive therapy for patients with KOA. Results of the study will be of great importance for the guidelines of clinical therapy. Trial registration Chinese Clinical Trial Registry ChiCTR2100043005 Registered on 4 February 2021.

Aging and interferon gamma response drive the phenotype of neutrophils in the inflamed joint

Objectives: Neutrophils are typically the most abundant leukocyte in arthritic synovial fluid. We sought to understand changes that occur in neutrophils as they migrate from blood to joint. Methods: We performed RNA sequencing of neutrophils from healthy human blood, arthritic blood, and arthritic synovial fluid, comparing transcriptional signatures with those from murine K/BxN serum transfer arthritis. We employed mass cytometry to quantify protein expression and sought to reproduce the synovial fluid phenotype ex vivo in cultured healthy blood neutrophils. Results: Blood neutrophils from healthy donors and patients with active arthritis exhibited largely similar transcriptional signatures. By contrast, synovial fluid neutrophils exhibited more than 1,600 differentially expressed genes. Gene signatures identified a prominent response to interferon gamma (IFNγ), as well as to tumor necrosis factor, interleukin 6, and hypoxia, in both humans and mice. Mass cytometry also found healthy and arthritic donor blood neutrophils largely indistinguishable but revealed a range of neutrophil phenotypes in synovial fluid defined by downregulation of CXCR1 and upregulation of FcγRI, HLA-DR, PD-L1, ICAM-1 and CXCR4. Reproduction of key elements of this signature in cultured blood neutrophils required both IFNγ and prolonged culture. Conclusions: Circulating neutrophils from arthritis patients resemble those from healthy controls, but joint fluid cells exhibit a network of changes, conserved across species, that implicate IFNγ response and aging as complementary drivers of the synovial neutrophil phenotype.

Perforated flexible catheters improve joint fluid aspiration in shoulder cadavers

A fluoroscopically controlled anterior approach in supine position is often used for arthrocentesis of the shoulder, but can lead to a high rate of dry aspirations. The aim of this study was to compare the aspiration performance of rigid needles and flexible catheters used with this approach. We hypothesized that a flexible catheter can significantly improve the amount of the obtained fluid. The glenohumeral joint of ten human cadaveric shoulder specimens were sequentially filled with 5, 10, 20 and 30 mL of contrast agent. For each volume the maximum aspirated amount of contrast agent with 4 different aspiration devices (20 gauge needle, 16 gauge needle, 16 gauge flexible catheter and 16 gauge perforated flexible catheter) were compared. All aspirations were done in supine cadaver position from anterior under fluoroscopic control. The aspirated amount of fluid was significantly higher using the 16 gauge perforated flexible catheter (p = 0.002–0.028) compared with all other devices when 5, 10 and 20 mL of contrast agent were in the joint. This perforated flexible catheter aspirated 80–96% of the available fluid while the standard 20 gauge needle aspirated 40–60%. Using a 16 gauge perforated flexible catheter in a supine anterior arthrocentesis technique results in aspiration of most of the fluid in human cadaveric shoulder specimens, while standard needles aspirate only about 50% of it. This can be clinically relevant when there is very little synovial fluid available and might reduce the number of insufficient aspirations.

1157. Determining the Clinical Utility of 16S rRNA in the Management of Pediatric Infections

Background Conventional culture remains the gold standard to facilitate a targeted antimicrobial regimen in the treatment of bacterial infections. However, certain pediatric infections are caused by fastidious organisms and treatment with antibiotics prior to specimen collection may hamper growth of pathogens in routine culture. The use of 16S rRNA in culture negative infections has improved identification of bacterial pathogens in select scenarios. However, the specific impact of 16S rRNA on clinical decision making, especially in pediatric infections, is not well-defined. This study aims to elucidate the utility of 16S rRNA on clinical management of pediatric infections. Methods A retrospective analysis was done on different clinical specimens which had 16S rRNA performed from August 2016 – March 2020 in our institution. Detailed chart review was performed to determine how the 16S rRNA result impacted clinical decision making. Clinical utility was defined as change in patient’s overall antimicrobial regimen, pathogen confirmation, and treatment duration. Results Seventy-four samples from 71 pediatric patients were included in the analysis: 32 (43%) were fluid specimens and 42 (57%) were tissue specimens. Significant clinical utility was identified in 30 (40.5%) of 74 clinical samples (p &lt; 0.0001). Of all specimens, pulmonary samples yielded the most clinical utility (n=9, 30%) followed equally by joint fluid (n=6, 20%) and bone (n=6, 20%). There was no significant difference in clinical utility between fluid and tissue specimens (p= 0.346). In 64 patients whose antimicrobial spectrum coverage was analyzed, patients with broad spectrum coverage was decreased from 48 to 21 and narrow spectrum coverage increased from 16 to 43 using 16S rRNA result, though not significant (p= 0.4111). Of all patients included in the analysis, the median number of antibiotics used before 16S rRNA result, 2, was significantly decreased to 1 (p &lt; 0.0001). Conclusion 16S rRNA has a significant impact in terms of decreasing number of antibiotics used in treatment of pediatric infections. Pulmonary specimens have the highest clinical utility among all samples. Additional cost benefit analysis needs to be completed to further determine clinical benefit. Disclosures All Authors: No reported disclosures

1031. Utility of Broad-Range Polymerase Chain Reaction Sequencing for Infectious Diseases Clinical Decision Making: A Pediatric Center Experience

Background Broad-range polymerase chain reaction (PCR) sequencing is a promising tool for diagnosis of infectious conditions when traditional microbiologic strategies fail to identify a pathogen. Data on the optimal clinical scenarios in which to use this tool are limited. Methods We assessed the rate of organism identification from broad-range PCR testing sent from our quaternary care children’s hospital between March 2017 and June 2020. We completed a retrospective chart review to evaluate patients’ baseline demographic and clinical features as well as clinical significance of results (defined as influencing antimicrobial management) by specimen type. Results Among 184 total samples, 111 (60%) were obtained from immunocompromised patients. The median age of patients at the time of sample collection was 11.4 years (IQR 6.5-16.0). 128/181 (71%) samples were from patients known to be on ≥ 1 antimicrobial, including prophylaxis, in the 24 hours prior to sample collection. 52/184 (28%) patients ultimately had an infectious disease diagnosed by another testing modality. The most common PCR sample types were bronchoalveolar lavage (BAL) fluid (35), lung tissue (20), and bone (14). An organism was identified from 41 (22%) samples, but positive results for only 8 samples (4%) led to a change in antimicrobial management: addition of agents in 4 cases, cessation of agents in 2, and transition from one agent to another in 2. Negative results for 3 (2%) samples led to discontinuation of antimicrobials. Organisms were identified from 11 (31%) BAL samples, of which only 2 (6%) were judged to be clinically significant. No results from lung tissue, CSF (11), skin biopsies (6), or joint fluid (4) affected antimicrobial management. Conclusion We found that only 6% of broad-range PCR results influenced antimicrobial management in a diverse pediatric cohort. Our findings suggest that many positive results, especially in BAL fluid, do not lead to changes in antimicrobial management. Additional work is necessary to characterize the ideal clinical scenarios in which broad-range PCR should be used as over a quarter of patients had a causative infectious disease identified by another modality. Disclosures All Authors: No reported disclosures

241. A Comparison of Staphylococcal and Streptococcal Septic Arthritis with Lyme Arthritis

Background Septic arthritis is considered the most important differential diagnosis in suspected Lyme arthritis. The present study sheds light on the most frequent misdiagnoses in Lyme arthritis cases and clues for differentiation from Staphylococcal and Streptococcal septic arthritis. Methods We studied patients with positive joint fluid cultures with Staphylococcus aureus (SA) and streptococci and Lyme polymerase chain reaction (PCR) positive joint fluid in 9 hospitals in Eastern Pennsylvania and 1 in Warren county, New Jersey over a 3 year period. Results One hundred and thirty four out of 7000 SA and 21 out of 1321 streptococcal isolates were from joint fluid. Twenty nine had Lyme arthritis, ages 5-74 ( 24 males,5 females). Twelve out of 29 were ages 10-18 with 20/29 under age 40. Predominant joint affected was a single knee 27/29. All had pain with or without swelling and little erythema. Two had fever. One reported a tick bite. None had other manifestations of Lyme disease. The diagnosis at the initial visit was sprain or sports injury in 5, osteoarthritis in 5, inflammatory arthritis or gout in 2 each, i septic arthritis, 1 viral syndrome and 1 ruptured Baker's cyst. Joint fluid count range was 3500-77,360 with only 3 over 50,000. White blood cell count (wbc) range was 3200-14,580. SA arthritis involved knee in 66 (49.3%), hip 31(23.9%), elbow 19 (14.2%), shoulder 14 (10.4%) with 2 wrist, 1 ankle and 1 sterno-clavicular joint. Fifty seven had a history of joint surgery. Eighty six were male and 48 female. age range 14-95 with a median age 65. Synovial fluid cell count was 335-470,000 and wbc 5,200-28,410 . Streptococcal septic arthritis ( 13 male 8 female) involved the knee in 17/21 with one each of hip, elbow, shoulder. The ages were 36-86 with 15/21 over age 60. Synovial fluid count was15,242-641,425 . Wbc count 11,140-25,080 .Nine out 21 had prior joint surgery. Conclusion Lyme arthritis patients were younger, mostly involving 1 knee, majority male without other manifestations of Lyme disease. Highest synovial fluid count was 77,360 and highest wbc count 14,580. Most frequent misdiagnoses were sports injury/sprain or osteoarthritis. SA and Streptococcal arthritis were mostly in elderly, with higher joint fluid cell and wbc counts. Only 1/29 Lyme arthritis was initially misdiagnosed septic arthritis. Disclosures All Authors: No reported disclosures

Monoarticular Crystal Arthropathy of the Knee: Tophaceous Gout

Tophaceous gout is a crystal arthropathy and a disorder of purine metabolism characterized by monosodium urate crystal deposition. A case of tophaceous gout of the knee joint in a 30-year-old female is reported, and the imaging appearances on high-resolution ultrasonography are described. The patient presented with complaints of insidious onset painless swelling of the left knee joint with limitation of range of movement for 1 week. The aspirated joint fluid demonstrated needle-like monosodium urate crystals showing strong negative birefringence consistent with a diagnosis of tophaceous gout. Targeted urate-lowering treatment included oral nonsteroidal anti-inflammatory drugs and oral colchicine. Prophylactic treatment for gout flare-ups included initiation of allopurinol at 300 mg/day along with modification of the dietary regimen including limited consumption of red meat and increased consumption of low-fat dairy products. Symptomatic improvement with reduced pain and swelling of the knee joint was noted at 10 days after treatment. Subsequently, at 3-month follow-up, the patient was disease free with no signs of recurrence and serum uric acid levels at 3.7 mg/dL. In spite of a wide range of therapeutic options available for the management of tophaceous gout, suboptimal management of gout is prevalent till date in both developing and developed nations across the world.

Inflammatory arthritis complicating galactosialidosis: a case report

Background Galactosialidosis (GS) is a rare inherited lysosomal storage disorder (LSD) which is characterized by a defect in the lysosomal glycoprotein catabolism. We report, for the first time, the case of a child affected by GS presenting with recurrent episodes of extensive joint inflammation in both knee joints. The aim of this case-report is to describe the clinical presentation as well as the laboratory, radiologic and microscopic features of this unique presentation of GS. Furthermore, we explore inflammatory mechanisms potentially responsible for the origination of the arthritic joint pathology observed in our patient. Case presentation We describe the rare case of a 12-year-old boy diagnosed with GS (late infantile form) who presented with multiple episodes of inflammatory arthritis involving both knees; no other joints were suspected for joint inflammation. Laboratory results did not indicate an autoimmune disorder. Synovial fluid tested negative for any bacterial infection and ruled out a malignancy and crystal-induced arthritis. Microscopic examination of the synovial tissue revealed numerous foamy macrophages with extensive vacuolization, consistent with the previous diagnosis of GS. Treatment consisted of aspiration of excessive joint fluid and subsequent intra-articular injection of triamcinolonhexacetonide with excellent but transient result. Given the evidence of storage products within macrophages of the inflamed synovial tissue and the absence of other etiological clues, GS itself was considered as the primary cause for the relapsing inflammatory joint pathology. According to the restricted data on articular manifestations in GS, to date, GS cannot be linked directly to joint inflammation. Nevertheless, in several other LSDs, the accumulation of storage material has been associated with numerous osteoimmunological changes that might play a role in the pathophysiology of arthritic processes. Conclusions We hypothesize that the articular build-up of GS storage products triggered systemic as well as local inflammatory processes, resulting in the extensive inflammatory joint pathology as observed in our patient. Future identification of other patients with GS is required to corroborate the existence of an arthritic clinical phenotype of GS and to assess the underlying pathophysiology.