Monday Weekly Update

Is In-person and remote physical therapy are equally effective for Chronic Knee Pain? Remote therapy might be more convenient without sacrificing improvements in pain and function. Like telemedicine, telerehabilitation (remotely delivered physical therapy) became more popular during the COVID-19 pandemic and allowed many patients to continue their rehabilitation despite quarantines and lockdowns. Telerehabilitation could have a continuing role in improving patient access to care, but the relative effectiveness of remote and in-person rehabilitation has not been studied in rigorous clinical trials. In a noninferiority trial, researchers in Australia randomized 394 adults with chronic knee pain (consistent with osteoarthritis) to [...]

What is the likelihood of the overdiagnosis of breast cancer in women older than 70 years after screening? Overdiagnosis — the identification of, in this case, breast cancer, that would not have caused symptoms in a person's lifetime — seems to increase with age. In this study, the overdiagnosis rate was 31% for women ages 70 to 74 years. The rate of overdiagnosis increased with age: 47% for women 75 to 84 years and 51% for women who were screened and found to be positive over age 85. Richman IB, Long JB, Soulos PR, Wang SY, Gross CP. Estimating [...]

Denosumab use is not restricted to individuals with osteoporosis who have advanced kidney disease. However, concerns remain regarding the risk of severe hypocalcemia in such patients. In a cohort study of 2804 female patients (aged ≥65 years) with osteoporosis and undergoing dialysis, severe hypocalcemia (serum calcium <7.5 mg/dL [1.9 mmol/L] or hypocalcemia requiring emergency care) occurred in a higher proportion of patients who initiated denosumab compared with those who initiated an oral bisphosphonate (12-week weighted cumulative incidence 41.1 versus 2 percent, respectively) [1]. Denosumab also was associated with a higher incidence of very severe hypocalcemia (serum calcium <6.5 mg/dL [...]

Does the monoclonal antibody sarilumab facilitate the tapering of glucocorticoid therapy in patients with polymyalgia rheumatica? Giving patients with PMR sarilumab twice monthly for 1 year allows an accelerated tapering regimen that greatly reduces the cumulative steroid dose and increases the likelihood of remission (which was low in both groups). Neutropenia, diarrhea, and arthralgia were common adverse effects. The annual drug cost is estimated to be $18,400. The cost per additional sustained response is more than $90,000, and it is unclear what the value is of the lower cumulative dose of prednisone. Spiera RF, Unizony S, Warrington KJ, et [...]

Are patients with nonerosive gastroesophageal disease at an increased risk of esophageal cancer as compared with the average population? We can reassure our patients (and ourselves) that nonerosive GERD does not increase the likelihood of esophageal cancer. Erosive GERD, however, is associated with a doubled — but still low — risk of developing cancer, with the likelihood increasing over time. Holmberg D, Santoni G, von Euler-Chelpin M, et al Non-erosive gastro-oesophageal reflux disease and incidence of oesophageal adenocarcinoma in three Nordic countries: Population based cohort study. BMJ 2023 Sep 13;382:e076017.

How long do symptoms last after successful treatment of lower limb cellulitis? Despite successful treatment of lower limb cellulitis, signs and symptoms of inflammation can still be present 10 days after treatment begins. These remnants do not indicate that treatment was ineffective. Williams OM, Hamilton F, Brindle R. The natural history of antibiotic-treated lower limb cellulitis: analysis of data extracted from a multicenter clinical trial. Open Forum Infect Dis 2023;10(10):ofad488.

Is twice-daily low-dose aspirin noninferior to a low-molecular-weight heparin for thromboprophylaxis after an extremity, acetabular, or pelvic fracture? Aspirin is noninferior to enoxaparin for thromboprophylaxis following inpatient treatment of a fracture. It is, of course, much cheaper, more convenient, and preferred by patients. The challenge will be convincing orthopedic surgeons that, in this case, "less is more." Major Extremity Trauma Research Consortium (METRC); O'Toole RV, Stein DM, et al. Aspirin or low-molecular-weight heparin for thromboprophylaxis after a fracture. N Engl J Med 2023;388(3):203-213.

How long do ankle arthroplasties last? Using national registry data linked to the national healthcare database, 90% of ankle arthroplasties last 5 years. 2b Jennison T, Ukoumunne O, Lamb S, Sharpe I, Goldberg AJ. How long do ankle arthroplasties last? Bone Joint J 2023;105-B(3):301-306.

In adults with prediabetes, can vitamin D supplementation decrease their likelihood of developing type 2 diabetes over several years? Vitamin D supplementation, over a median of 3 years, slightly reduces the diagnoses of diabetes in older people at risk of developing type 2 diabetes (NNT = 18 - 115). The benefit is greater in patients who achieve higher serum levels of vitamin D. Myhrvold SB, Brouwer EF, Andresen TKM, et al. Nonoperative or surgical treatment of acute Achilles’ tendon rupture. N Engl Med J 2022;386(15):1409-1420.

Is open repair or minimally invasive surgery better than nonoperative management for adults with acute Achilles tendon rupture? There is no clear benefit to surgery over nonoperative management for adults with acute Achilles tendon rupture. Symptomatic improvement is the same, and surgery trades more nerve injuries for a lower risk of re-rupture. Myhrvold SB, Brouwer EF, Andresen TKM, et al. Nonoperative or surgical treatment of acute Achilles’ tendon rupture. N Engl Med J 2022;386(15):1409-1420.