Characterisation of size and direction of osteophyte in knee osteoarthritis: a radiographic study

OBJECTIVES

To examine the size and direction of osteophyte in knee osteoarthritis (OA) and to determine associations between osteophyte size and other radiographic features.

METHODS

Knee radiographs (standing extended anteroposterior and 30 degrees flexion skyline views) were examined from 204 patients referred to hospital with symptomatic knee OA (155 women, 49 men; mean age 70, range 34-91 years). A single observer assessed films for osteophyte size and direction at eight sites; narrowing in each compartment; varus/valgus angulation; patellofemoral subluxation; attrition; and chondrocalcinosis using a standard atlas, direct measurement, or visual assessment. For analysis, one OA knee was selected at random from each subject.

RESULTS

Osteophyte direction at the eight sites was divisible into five categories. At all sites, except for the lateral tibial plateau and the medial patella, osteophyte direction varied according to (a) the size of osteophyte and (b) the degree of local narrowing. At the medial femur, medial tibia, and lateral femur osteophyte direction changed from being predominantly horizontal to predominantly vertical with increasing size. The size of osteophyte correlated positively with the severity of local narrowing, except for the medial patellofemoral compartment where osteophyte size correlated positively with the severity of narrowing in the medial tibiofemoral compartment. Logistic regression analysis showed that osteophyte size was associated not only with local narrowing but also with local malalignment and bone attrition, and that chondrocalcinosis was positively associated with osteophyte size at multiple sites.

CONCLUSION

In patients referred to hospital with knee OA different patterns of osteophyte direction are discernible. Osteophyte size is associated with local compartmental narrowing but also local alignment and attrition. Chondrocalcinosis is associated with osteophytosis throughout the joint. These data suggest that both local biomechanical and constitutional factors influence the size and direction of osteophyte formation in knee OA.

Influence of elastic bandage on knee pain, proprioception, and postural sway in subjects with knee osteoarthritis

OBJECTIVES

To investigate whether a "standard" sized (that is, a size that would be prescribed by a physiotherapist) elastic bandage (S-bandage) around the knee of subjects with knee osteoarthritis (OA) would, in the short term (a) reduce pain, (b) improve knee joint proprioception, and (c) decrease sway in comparison with a looser (L-bandage).

METHODS

In a cross over, within-subject study, 68 subjects (49 women, 19 men; mean age 67.1, range 36-87) with symptomatic and radiographic knee OA were randomly assigned to either an S-bandage or an L-bandage. Two weeks later they were assigned to the opposite bandage size. Knee pain (10 cm visual analogue scale (VAS)), knee proprioception, and static postural sway were assessed for each bandage two weeks apart. During each visit assessments were performed at baseline, after 20 minutes of bandage application, and immediately after bandage removal.

RESULTS

The S-bandage did not have any effect on knee pain, proprioception, or postural sway. The L-bandage reduced knee pain significantly (pre-bandage application: median VAS 4.36, IQR 3.84 -4.90; after 20 minutes of bandage application: median VAS 3.80, IQR 3.3-4.3, p<0.001), improved static postural sway (pre-bandage: median sway 4.50, IQ range 3.5-6.4; bandage applied: median sway 4.45, IQ range 3.4-6.3, p=0.027), but had no significant influence on knee proprioception.

CONCLUSIONS

In subjects with knee OA application of an elastic bandage around the knee can reduce knee pain and improve static postural sway. This outcome depends on the size of applied bandage.

A nurse-delivered advice intervention can reduce chronic non-steroidal anti-inflammatory drug use in general practice: a randomized controlled trial

OBJECTIVE

To find out whether a nurse-delivered educational package can reduce chronic oral non-steroidal anti-inflammatory drug (NSAID) usage in general practice.

METHOD

A prospective randomized controlled trial with assessment of economic cost/benefits was carried out in five general practices in Nottinghamshire with computerized prescribing systems, representing a mix of rural/urban and fundholding/non-fundholding practices. Patients suffering from non-malignant, non-inflammatory musculoskeletal pain received repeat prescriptions for oral NSAIDs. Two hundred and twenty-two patients were randomized to a control group (simple advice regarding NSAID use) or an intervention group (asked to withdraw their NSAIDs and employ appropriate alternative drug and non-drug therapies). All advice was supported by patient literature and delivered by a nurse practitioner trained in musculoskeletal assessment. The primary outcome measure was change in NSAID use 6 months after the intervention. Secondary outcome measures were changes in health and quality of life (SF-36 and EQ-5D questionnaires) and drug, health service and patient costs.

RESULTS

An extra 28% of patients in the intervention group either stopped taking oral NSAIDs or reduced dosage by > or =50% at 6 months compared with controls. There was no detrimental effect on health and well-being. Oral NSAID prescription costs were significantly lowered in the intervention group but not in the control group. A non-significant increase in total drug prescription costs occurred in both groups.

CONCLUSIONS

Nurse-based intervention can reduce chronic NSAID usage and costs in primary care and would be cost-effective if maintained in the long term. This intervention package would be readily applicable in primary care.

The influence of crank rate on peak oxygen consumption during arm crank ergometry

The aim of this study was to assess the influence of three imposed crank rates on the attainment of peak oxygen consumption (VO2peak) and other physiological responses during incremental arm crank ergometry. Twenty physically active, although non-specifically trained, males volunteered for the study. They completed an exercise protocol using an electrically braked arm ergometer (Lode Angio, Groningen, Netherlands) at crank rates of 60, 70 and 80 rev x min(-1). The order of tests was randomized and they were separated by at least 2 days. Peak VO2 was significantly higher (P < 0.05) at 70 and 80 rev x min(-1) than at 60 rev x min(-1). Peak ventilation volume increased as a function of crank rate and was higher (P < 0.05) at 80 than at 60 rev x min(-1). Peak heart rate was higher (P < 0.05) at 70 and 80 rev x min(-1) than at 60 rev x min(-1). Furthermore, 70 and 80 rev x min(-1) resulted in an extended test time compared with 60 rev x min(-1). The greater physiological responses observed during the tests at the two faster crank rates might have been the result of a postponement of acute localized neuromuscular fatigue, allowing for more work to be completed. We recommend, therefore, that an imposed crank rate between 70 and 80 rev x min(-1) should be used to elicit VO2peak and other physiological responses in arm crank ergometry.

Rating of perceived exertion during high-intensity treadmill running

PURPOSE

The purpose of this investigation was 1) to evaluate the time course of the rating of perceived exertion (RPE; 6-20 Borg scale) during short-term, high-intensity, constant-load running (ST); and 2) to determine the reproducibility of RPE during ST.

METHODS

Fifteen well-trained males (VO2max = 58.0 +/- 4.6 mL x kg(-1) x min(-1), mean +/- SD) performed treadmill running (i.e., between 3 and 4 m.s-1 at 10.5% incline) to volitional exhaustion (Tlim) at an exercise intensity equivalent to 125% VO2max. A total of four RPE measurements were taken during each test, one every 30 s during the first 120 s of the exercise. The tests were repeated at the same time of day on three occasions within a 3-wk period.

RESULTS

Tlim for the three tests was 197.6 +/- 34.8 s. RPE was linearly related with exercise time (mean +/- SD for the three tests: RPE at 30 s = 10.8 +/- 2.2; RPE at 60 s = 12.6 +/- 1.8; RPE at 90 s = 14.5 +/- 1.7; RPE at 120 s = 16.0 +/- 1.9; RPE = 9.06 + (0.06 x time (s)); r = 0.71, SEE = 2.0, P < 0.01). Repeated ANOVA revealed no systematic bias between the three tests for RPE, and other measures of reliability were also favorable. These included intraclass correlation coefficients ranging from 0.78 to 0.87 and sample coefficients of variation of between 4.4% and 6.0%. The 95% limits of agreement ranged between 0.0 +/- 2.3 and 0.0 +/- 2.5.

CONCLUSION

ST RPE displays a positive linear response during the first 2 min. The measurement of ST RPE appears to be reliable and could thus add a new dimension to ST investigations.

Pharmacogenetics--legal, ethical and regulatory considerations

The overall objective of pharmacogenetics is to determine the genetic basis of variability in drug efficacy and safety, and to use this information to benefit the patient. Genetics can be used to develop drugs that are suitable for the majority of patients and to help identify those patients for whom a certain drug may not be the most appropriate. This review will cover some background to pharmacogenetics and various issues including confidentiality, data protection, coding of samples and genetic data, informed consent, and drug development guidelines. International, national and regional variation in the legal and regulatory basis for pharmacogenetics presents challenges for researchers attempting to increase scientific understanding in the field. Examples of national and international regulations and guidelines will be given. It is clear that pharmacogenetics today is a long way from the 'personalised medicine' advocated by some individuals in recent years. The aim of pharmacogenetic research should always be to make sure that patients have the best treatment available and that patients are not exposed to drugs to which they are genetically unable to respond. This vision must continue to inspire researchers and regulators who are working together to make it a widespread reality.

Evidence-based management of osteoarthritis: practical issues relating to the data

Osteoarthritis (OA) is a major cause of pain and disability in the elderly. The perspective of OA as a dynamic process triggered by diverse insults is increasingly accepted. Objectives of management are patient education, relief of pain, optimization of function and modification of the OA process. Management should be individualized and should take into account factors relating to the person as well as the OA joint. There is a reasonable evidence base for several key elements of management. Recent review of the research evidence shows a skewed distribution in favour of drugs, particularly NSAIDs, and important gaps in clinically relevant knowledge. The restricted generalizability of the research data could be improved by improvements in study design and methods of reporting. Current published guidelines on management of OA are critically reviewed and compared.

Lifestyle changes in the management of osteoarthritis

Lifestyle changes are gaining increasing recognition in the management of osteoarthritis. In most guidelines advice on exercise and weight reduction is now given priority over pharmacological therapies. In view of the face validity, safety and cost-effectiveness of such measures this would seem appropriate. This chapter discusses the role of exercise therapy, weight reduction and footwear. The emphasis is on evidence for effectiveness, comparison of techniques available and maintenance of adherence with each lifestyle change. Because most of our knowledge surrounds management of knee osteoarthritis, this is the focus of our discussion, with reference being made to other sites as appropriate.

Pancreatic fate of D-[3H] mannoheptulose

D-Mannoheptulose was recently postulated to be transported into cells by GLUT2. The validity of such an hypothesis was assessed by comparing the uptake of tritiated D-mannoheptulose by pancreatic islets versus pieces of pancreas and, in the latter case, by comparing results obtained in control rats versus animals injected with streptozotocin (STZ). The uptake of D-[3H] mannoheptulose by islets represents a time-related and temperature-sensitive process, inhibited by cytochalasin B and enhanced by D-glucose. The uptake of the tritiated heptose was much lower in pieces of pancreatic tissue and inhibited by D-glucose, at least in the STZ rats. Whether in pieces of pancreas exposed in vitro to D-[3H] mannoheptulose or after intravenous injection of the tritiated heptose, the radioactive content of the pancreatic tissue was lower in STZ rats than in control animals. This contrasted with an unaltered radioactive content of liver and muscle in the STZ rats, at least when treated with insulin. Suitably radiolabelled D-mannoheptulose or an analogue of the heptose could thus conceivably be used for quantification of the endocrine pancreatic mass.

Effect of alignment of the medial tibial plateau and x-ray beam on apparent progression of osteoarthritis in the standing anteroposterior knee radiograph

OBJECTIVE

Previous studies of knee osteoarthritis (OA) have yielded variable estimates of the rate of joint space narrowing (JSN) in the standing anteroposterior (AP) radiograph, due largely to longitudinal changes in the alignment of the medial tibial plateau (MTP) and x-ray beam. To characterize this bias, we examined serial radiographs of subjects with knee OA in population-based and clinical OA cohorts from 3 locations in the United States and the United Kingdom.

METHODS

Radiographic features of knee OA (e.g., osteophytosis, JSN) and MTP alignment in 428 OA knees were evaluated by consensus of 2 readers. Alignment was considered satisfactory if the anterior and posterior margins of the MTP were superimposed within 1 mm. Readers were blinded to subject identity, and films were read in random order. The minimum medial joint space width was also measured manually (standard error of repeated measurements 0.20 mm) in serial knee images.

RESULTS

Only 14% of serial radiographs exhibited alignment of the MTP in both images. In OA knees with satisfactory alignment in both images, the mean rate of JSN over 2-3 years (0.26 mm/year) was significantly larger (P = 0.004) than that in OA knees with misalignment in 1 or both radiographs and was 86% more rapid than the mean JSN in all OA knees. Moreover, the within-group standard deviation of JSN was significantly smaller among knees with reproduced alignment of the MTP than in knees in which misalignment occurred in 1 or both images (P = 0.006).

CONCLUSION

Poor standardization of knee positioning in serial standing AP radiographs in previous studies of OA progression has obscured the rate and variability of articular cartilage loss in subjects with knee OA. True JSN (i.e., JSN that is not attributable to longitudinal changes in the alignment of the MTP with the x-ray beam in serial radiographic examinations) may occur more rapidly, and with less between-subject variability, than that previously thought to be characteristic of knee OA.

Multiple choice question quiz: a valid test for needs assessment in CME in rheumatology and for self assessment

Drawing from experience in Switzerland, a test of 60 multiple choice questions covering the entire area of rheumatology was constructed and used at the international symposium of rheumatology, EULAR, Geneva 1998. It was introduced as a multiple choice question game, the language was English, and the level of acceptance was very high. Language posed only occasional problems. The reliability of the test for internal consistency was high (Cronbach alpha 0.852). One of the main target groups, the private practitioners, was the largest group of rheumatologists (nearly 50%). Evaluative statements of the participants indicate that it was a highly relevant test for rheumatology. This test is a valuable way for needs assessment in continuing medical education and for self assessment. Importantly, it has been shown that such a test can be conducted at an international level.

Oxidation of D-[U-(14)C] glucose and [1,12-(14)C] dodecanedioic acid by pancreatic islets from Goto-Kakizaki rats

In pancreatic islets from hereditarily diabetic GK rats, [1,12 -(14)C] dodecanedioic acid (5.0 mM) was oxidized at a rate representing about 5 % of that of D-[U - (14)C] glucose (8.3 mM). Dioic acid and hexose failed to exert any significant reciprocal effects on their respective oxidation. The production of (14)CO(2) from [1,12 -(14)C] dodecanedioic acid was proportional to its concentration in the 0.2 - 5.0 mM range. These results were essentially comparable to those obtained in islets from control rats. They extend, therefore, to GK rats the knowledge that dodecanedioic acid acts as a nutrient in pancreatic islet cells.

Static postural sway, proprioception, and maximal voluntary quadriceps contraction in patients with knee osteoarthritis and normal control subjects

OBJECTIVES

To investigate whether subjects with knee osteoarthritis (OA) have reduced static postural control, knee proprioceptive acuity, and maximal voluntary contraction (MVC) of the quadriceps compared with normal controls, and to determine possible independent predictors of static postural sway.

METHODS

77 subjects with symptomatic and radiographic knee OA (58 women, 19 men; mean age 63.4 years, range 36-82) and 63 controls with asymptomatic and clinically normal knees (45 women, 18 men; mean age 63 years, range 46-85) underwent assessment of static postural sway. 108 subjects (59 patients, 49 controls) also underwent assessment of knee proprioceptive activity and MVC (including calculation of quadriceps activation). In patients with knee OA knee pain, stiffness, and functional disability were assessed using the WOMAC Index. The height (m) and weight (kg) of all subjects was assessed.

RESULTS

Compared with controls, patients with knee OA were heavier (mean difference 15.3 kg, p<0.001), had increased postural lateral sway (controls: median 2.3, interquartile (IQ) range 1.8-2.9; patients: median 4.7, IQ range 1.9-4.7, p<0.001), reduced proprioceptive acuity (controls: mean 7.9, 95% CI 6.9 to 8.9; patients: mean 12.0, 95% CI 10.5 to 13.6, p<0.001), weaker quadriceps strength (controls: mean 22.5, 95% CI 19.9 to 24.6; patients: mean 14.7, 95% CI 12.5 to 16.9, p<0.001), and less percentage activation of quadriceps (controls: mean 87.4, 95% CI 80.7 to 94.2; patients: mean 66.0, 95% CI 58.8 to 73.2, p<0.001). The significant predictors of postural sway were knee pain and the ratio of MVC/body weight.

CONCLUSIONS

Compared with age and sex matched controls, subjects with symptomatic knee OA have quadriceps weakness, reduced knee proprioception, and increased postural sway. Pain and muscle strength may particularly influence postural sway. The interaction between physiological, structural, and functional abnormalities in knee OA deserves further study.

Glycogen accumulation in rat pancreatic islets: in vitro experiments

Under conditions of sustained hyperglycemia, glycogen accumulates in pancreatic islets, but not so in acinar pancreatic cells. Advantage conceivably could be taken from such a situation in the perspective of the noninvasive imaging of the endocrine pancreas. The present experiments aim, therefore, at characterizing the time course for glycogen accumulation in pancreatic islets cultured at a high concentration (30 mM) of D-glucose in the presence of tracer amounts of either D-[U-14C]glucose or 2-deoxy-2-[18F]fluoro-D-glucose. The 14C-labeled glycogen content of the cultured islets increased with time (150 min to 72 h), exceeded that found in acinar tumoral cells, and did not decrease over 60 min of incubation at 30 mM D-glucose in the absence of D-[U-14C]glucose. Glycogenolysis was observed, however, when the concentration of D-glucose was decreased to 2.8 mM and, in such a case, was further enhanced by forskolin and theophylline. Such a glycogenolysis coincided with the generation of 14CO2 from radioactive intracellular precursors and alteration of the B-cell secretory response to D-glucose. The radioactive glycogen content was higher in islets exposed to 2-deoxy-2-[18F]fluoro-D-glucose than D-[U-14C]glucose. Prior exposure of the islets to streptozotocin suppressed the accumulation of glycogen during their subsequent culture at high D-glucose concentration. These findings may help to define the experimental conditions optimal for the labeling and accumulation of islet glycogen in vivo.

Epidemiology and genetics of hand osteoarthritis

The aim of this session was to identify current issues and problems relating to risk factors for hand osteoarthritis (OA). The following important factors were discussed: Genetics, Age, Gender, Obesity, HRT (hormone replacement therapy), Physical activity/trauma.

Genetics of hand osteoarthritis

There is convincing epidemiological evidence for a strong hereditary component to hand osteoarthritis (OA). For example: (1) greater concordance for hand OA in monozygotic than in dizygotic twins, the estimated proportion of variance explained by genetic factors being as high as 0.59; and (2) a substantially increased risk of hand OA in first-degree relatives (siblings, parents, offspring) of subjects with hand OA. Such evidence clearly justifies a search for the genes involved. However, gene association studies in genetically complex polygenic conditions such as OA present many problems, including case definition, late age of phenotype expression and adjustment for other constitutional and environmental risk factors. Nevertheless, association studies of affected sibling pairs and nuclear families, using candidate gene and genome wide screening and transmission disequilibrium testing, suggest no association with candidates such as COL2A1 (responsible for some rare monogenic syndromes of premature generalized OA) but possible associations, currently not isolated, on chromosome 2q. Such ongoing work and subsequent gene-gene and gene-environment interaction studies are likely to give important, perhaps unexpected, insights into the pathogenesis of hand OA.

Pancreatic uptake of [2-(14)C]alloxan

The uptake of [2-(14)C]alloxan by the pancreatic gland was investigated in control and streptozotocin-induced diabetic (STZ) rats, using both in vitro and in vivo techniques. Whether after 10 to 60 min incubation of pieces of pancreas in the presence of [2-(14)C]alloxan or 60 min to 24 h after intravenous injection of [2-(14)C]alloxan to control and insulin-treated STZ rats, the radioactive content of the pancreas (dpm/mg wet weight) only represented, in the STZ rats, about two thirds of the reference value found in control animals. These findings indicate that insulin-producing islet B-cells participate to a sizeable extent to the overall uptake of [2-(14)C]- alloxan by the whole pancreatic gland, despite the fact that they account for no more than about one percent of the total pancreas mass. Hence, it should be possible to preferentially label the endocrine moiety of the pancreas, in the perspective of its imaging and quantification by a non-invasive procedure, by use of a suitable radiolabelled molecule selectively taken up by islet, as distinct from acinar, pancreatic cells.

The lipid phosphatase SHIP2 controls insulin sensitivity

Insulin is the primary hormone involved in glucose homeostasis, and impairment of insulin action and/or secretion has a critical role in the pathogenesis of diabetes mellitus. Type-II SH2-domain-containing inositol 5-phosphatase, or 'SHIP2', is a member of the inositol polyphosphate 5-phosphatase family. In vitro studies have shown that SHIP2, in response to stimulation by numerous growth factors and insulin, is closely linked to signalling events mediated by both phosphoinositide-3-OH kinase and Ras/mitogen-activated protein kinase. Here we report the generation of mice lacking the SHIP2 gene. Loss of SHIP2 leads to increased sensitivity to insulin, which is characterized by severe neonatal hypoglycaemia, deregulated expression of the genes involved in gluconeogenesis, and perinatal death. Adult mice that are heterozygous for the SHIP2 mutation have increased glucose tolerance and insulin sensitivity associated with an increased recruitment of the GLUT4 glucose transporter and increased glycogen synthesis in skeletal muscles. Our results show that SHIP2 is a potent negative regulator of insulin signalling and insulin sensitivity in vivo.

EULAR recommendations for the management of knee osteoarthritis: report of a task force of the Standing Committee for International Clinical Studies Including Therapeutic Trials (ESCISIT)

BACKGROUND

Osteoarthritis (OA) is the most common joint disease encountered throughout Europe. A task force for the EULAR Standing Committee for Clinical Trials met in 1998 to determine the methodological and logistical approach required for the development of evidence based guidelines for treatment of knee OA. The guidelines were restricted to cover all currently available treatments for knee OA diagnosed either clinically and/or radiographically affecting any compartment of the knee.

METHODS

The first stage was the selection of treatment modalities to be considered. The second stage comprised a search of the electronic databases Medline and Embase using a combination of subject headings and keywords. All European language publications in the form of systematic reviews, meta-analyses, randomised controlled trials, controlled trials, and observational studies were included. During stage three all the relevant studies were quality scored. The summary statistics for validated outcome measures, when available, were recorded and, where practical, the numbers needed to treat and the effect size for each treatment were calculated. In the fourth stage key clinical propositions were determined by expert consensus employing a Delphi approach. The final stage ranked these propositions according to the available evidence. A second set of propositions relating to a future research agenda was determined by expert consensus using a Delphi approach.

RESULTS

Over 2400 English language publications and 400 non-English language publications were identified. Seven hundred and forty four studies presented outcome data of the effects of specific treatments on knee OA. Quantitative analysis of treatment effect was possible in only 61 studies. Recommendations for the management of knee OA based on currently available data and expert opinion are presented. Proposals for a future research agenda are highlighted.

CONCLUSIONS

These are the first clinical guidelines on knee OA to combine an evidence based approach and a consensus approach across a wide range of treatment modalities. It is apparent that certain clinical propositions are supported by substantial research based evidence, while others are not. There is thus an urgent need for future well designed trials to consider key clinical questions.

Assessment of a genetic contribution to osteoarthritis of the hip: sibling study

OBJECTIVES

To study the influence of genetics on the development of hip osteoarthritis as determined by structural change on plain radiographs.

DESIGN

Sibling study.

SETTING

Nottinghamshire, England.

PARTICIPANTS

392 index participants with hip osteoarthritis of sufficient severity to warrant total hip replacement, 604 siblings of the index participants, and 1718 participants who had undergone intravenous urography.

MAIN OUTCOME MEASURE

Odds ratios for hip osteoarthritis in siblings.

RESULTS

The age adjusted odds ratios in siblings were 4.9 (95% confidence interval, 3.9 to 6.4) for probable hip osteoarthritis and 6.4 (4.5 to 9.1) for definite hip osteoarthritis. These values were not significantly altered by adjusting for other risk factors.

CONCLUSION

Siblings have a high risk of hip osteoarthritis as shown by structural changes on plain radiographs. One explanation is that hip osteoarthritis is under strong genetic influence.