Manual therapy for osteoarthritis of the hip or knee - a systematic review

The aim of this systematic review was to determine if manual therapy improves pain and/or physical function in people with hip or knee OA. Eight databases were searched for randomised controlled trials (RCTs). Data were extracted and risk of bias assessed by independent reviewers. Four RCTs were eligible for inclusion (280 subjects), three of which studied people with knee OA and one studied those with hip OA. One study compared manual therapy to no treatment, one compared to placebo intervention, whilst two compared to alternative interventions. Meta-analysis was not possible due to clinical heterogeneity of the studies. One study had a low risk of bias and three had high risk of bias. All studies reported short-term effects, and long-term effects were measured in one study. There is silver level evidence that manual therapy is more effective than exercise for those with hip OA in the short and long-term. Due to the small number of RCTs and patients, this evidence could be considered to be inconclusive regarding the benefit of manual therapy on pain and function for knee or hip OA.

Widespread divergence between incipient Anopheles gambiae species revealed by whole genome sequences

The Afrotropical mosquito Anopheles gambiae sensu stricto, a major vector of malaria, is currently undergoing speciation into the M and S molecular forms. These forms have diverged in larval ecology and reproductive behavior through unknown genetic mechanisms, despite considerable levels of hybridization. Previous genome-wide scans using gene-based microarrays uncovered divergence between M and S that was largely confined to gene-poor pericentromeric regions, prompting a speciation-with-ongoing-gene-flow model that implicated only about 3% of the genome near centromeres in the speciation process. Here, based on the complete M and S genome sequences, we report widespread and heterogeneous genomic divergence inconsistent with appreciable levels of interform gene flow, suggesting a more advanced speciation process and greater challenges to identify genes critical to initiating that process.

The effectiveness of interventions in the management of patients with primary frozen shoulder

There are many types of treatment used to manage the frozen shoulder, but there is no consensus on how best to manage patients with this painful and debilitating condition. We conducted a review of the evidence of the effectiveness of interventions used to manage primary frozen shoulder using the Cochrane Database of Systematic Reviews, the Database of Abstracts of Reviews of Effects, the Physiotherapy Evidence Database, MEDLINE and EMBASE without language or date restrictions up to April 2009. Two authors independently applied selection criteria and assessed the quality of systematic reviews using the Assessment of Multiple Systematic Reviews (AMSTAR) tool. Data were synthesised narratively, with emphasis placed on assessing the quality of evidence. In total, 758 titles and abstracts were identified and screened, which resulted in the inclusion of 11 systematic reviews. Although these met most of the AMSTAR quality criteria, there was insufficient evidence to draw firm conclusions about the effectiveness of treatments commonly used to manage a frozen shoulder. This was mostly due to poor methodological quality and small sample size in primary studies included in the reviews. We found no reviews evaluating surgical interventions. More rigorous randomised trials are needed to evaluate the treatments used for frozen shoulder.

THE REACTIONS OF HALICYSTIS AND OF VALONIA TO INJECTIONS OF CERTAIN PROTEINS

It is shown (1) that Valonia and Halicystis cells exhibit varying degrees of tolerance to injections of animal peptone, animal proteose, crystallized egg albumen, and diphtheria toxin; (2) that Valonia cells display decreased tolerance to egg albumen in increasing dosages, although Halicystis is completely tolerant of the highest dosage used; (3) that the mortality curves of Valonia injected with egg albumen and of both Valonia and Halicystis injected with diphtheria toxin show the delayed effect characteristic of laboratory mammals when treated similarly; (4) that Valonia cells injected twice with egg albumen exhibit no change in susceptibility to its effects; and (5) that neither species of algae gives evidence of having formed antibodies against the antigens used.

REACTIONS OF VALONIA AND OF HALICYSTIS TO COLLOIDS

From the results of these tests it is clear that both Halicystis and Valonia have a high degree of tolerance for animal peptone, and a very high degree of tolerance for animal proteose and for egg albumen. The products of bacterial growths fostered by these proteins have a deleterious effect upon both species of algae; but, if it were possible to prevent bacterial growth entirely and at the same time supply proper food, it is probable that Halicystis and Valonia would show normal growth indefinitely in the presence of these three colloids. This is not true where exposure is made to yeast nucleic acid dissolved in sea water containing 0.00093 gm. per cc. of NaOH. Valonia is markedly less tolerant of this medium (perhaps of NaOH rather than the colloid used) than Halicystis. Such differential effects, however, reach a high point in the case of the solutions of diphtheria toxin and of edestin. Halicystis has a very high tolerance for diphtheria toxin, and Valonia a very low tolerance. In the case of edestin, the relationship is reversed. Here Halicystis has a very low tolerance, and Valonia a very high tolerance. In fact, it may be said that diphtheria toxin has no appreciable effect upon Halicystis, and edestin a very slight effect upon Valonia; while diphtheria toxin is extremely toxic to Valonia, and edestin is extremely toxic to Halicystis. We can offer no suggestions, at present, as to the way in which these effects are produced. It is probable that the very thin protoplasmic layer of these species, which is certainly no thicker than 8µ, is sufficient to obstruct the passage of proteins having large molecules, like egg albumen, with a degree of efficiency that is extraordinary. In the tests we have reported, areas of from 20 sq. cm. to 40 sq. cm. have been submitted to the action of a relatively high concentration of egg albumen for several days without permitting the passage of sufficient amounts to give definable tests either with Spiegler's or with Tanret's method,— presumably less than 1 part in 250,000. In the tests of the proteins having much smaller molecules (though the size may not be the explanation), there is some probability that the membranes exhibit a little permeability. The peptone and the proteose of animal origin, or biuret-positive substances derived from them, apparently pass the protoplasmic membranes occasionally in quantities sufficient to give biuret tests. The most probable case of protein passage, however, was that of the proteose of the scarlet runner bean, where specific detection of less than 1 part per 80,000 was possible. In this instance the proteose appeared to pass membranes that were healthy and were functioning normally. But since the cells of the algae had to be destroyed in making the tests, one cannot maintain this point. All one can say is that protein passage was indicated in carefully examined cells of both species, where no breaks in the protoplasmic membrane were discernible, and where samples of the treated cells behaved normally after treatment.

Solvent–detergent plasma as replacement therapy in a pregnant patient with factor V deficiency

This case illustrates the successful treatment of factor V deficiency in pregnancy using solvent-detergent plasma.

Long-term activation of the pro-coagulant response after neoadjuvant chemoradiation and major cancer surgery

Background:

The association between cancer, major surgery and venous thromboembolism (VTE) is well established. Multimodal therapy is increasingly being used as standard treatment for localised gastrointestinal cancer. The aim of this study was to examine the markers of pro-coagulation response and VTE risk in an exemplar multimodal model of pre-operative combination chemotherapy and radiation therapy, followed by complex cancer surgery.

Methods:

Consecutive patients (n=36) with localised oesophageal cancer were studied at baseline after the first and second cycles of chemoradiation, and on post-operative days 1–28, and at 3, 6 and 9 months. Factors regulating the pro- and anti-coagulant response, as well as pro-inflammatory markers including NFκB activation in peripheral blood mononuclear cells, were examined. All patients received enoxaparin 40 mg s.c. postoperatively up to discharge, and underwent pulmonary CT-pulmonary angiography and venography on day 10 postoperatively.

Results:

Four (11%) non-fatal thromboembolic events were documented, all after hospital discharge. Neoadjuvant therapy before surgery activated factor VIII (FVIII) and pro-inflammatory NFκB, and increased D-dimers, pro-thrombin fragment 1+2 (F1+2) and the thrombin-anti-thrombin complex (TAT). Surgery significantly (P<0.05) increased pro-thrombin time (PT), activated partial thromboplastin time, fibrinogen, D-dimers, TAT, F1+2 and FVIII up to 6 months.

Conclusion:

These data highlight the linked pro-coagulant and immunoinflammatory pathways in the multimodal management of oesophageal cancer, and suggest that the duration of current standard thromboprophylaxis regimens warrants further study.

Reporting disease activity in clinical trials of patients with rheumatoid arthritis: EULAR/ACR collaborative recommendations

OBJECTIVE

To make recommendations on how to report disease activity in clinical trials of rheumatoid arthritis (RA) endorsed by the European League Against Rheumatism (EULAR) and the American College of Rheumatology (ACR).

METHODS

The project followed the EULAR standardised operating procedures, which use a three-step approach: (1) expert-based definition of relevant research questions (November 2006); (2) systematic literature search (November 2006 to May 2007); and (3) expert consensus on recommendations based on the literature search results (May 2007). In addition, since this is the first joint EULAR/ACR publication on recommendations, an extra step included a meeting with an ACR panel to approve the recommendations elaborated by the expert group (August 2007).

RESULTS

Eleven relevant questions were identified for the literature search. Based on the evidence from the literature the expert panel recommended that each trial should report the following items: (1) disease activity response and disease activity states; (2) appropriate descriptive statistics of the baseline, the endpoints and change of the single variables included in the core set; (3) baseline disease activity levels (in general); (4) the percentage of patients achieving a low disease activity state and remission; (5) time to onset of the primary outcome; (6) sustainability of the primary outcome; (7) fatigue.

CONCLUSIONS

These recommendations endorsed by EULAR and ACR will help harmonise the presentations of results from clinical trials. Adherence to these recommendations will provide the readership of clinical trials with more details of important outcomes, while the higher level of homogeneity may facilitate the comparison of outcomes across different trials and pooling of trial results, such as in meta-analyses.

The genome of the simian and human malaria parasite Plasmodium knowlesi

Plasmodium knowlesi is an intracellular malaria parasite whose natural vertebrate host is Macaca fascicularis (the 'kra' monkey); however, it is now increasingly recognized as a significant cause of human malaria, particularly in southeast Asia. Plasmodium knowlesi was the first malaria parasite species in which antigenic variation was demonstrated, and it has a close phylogenetic relationship to Plasmodium vivax, the second most important species of human malaria parasite (reviewed in ref. 4). Despite their relatedness, there are important phenotypic differences between them, such as host blood cell preference, absence of a dormant liver stage or 'hypnozoite' in P. knowlesi, and length of the asexual cycle (reviewed in ref. 4). Here we present an analysis of the P. knowlesi (H strain, Pk1(A+) clone) nuclear genome sequence. This is the first monkey malaria parasite genome to be described, and it provides an opportunity for comparison with the recently completed P. vivax genome and other sequenced Plasmodium genomes. In contrast to other Plasmodium genomes, putative variant antigen families are dispersed throughout the genome and are associated with intrachromosomal telomere repeats. One of these families, the KIRs, contains sequences that collectively match over one-half of the host CD99 extracellular domain, which may represent an unusual form of molecular mimicry.

Activated protein C resistance, factor V Leiden and assessment of thrombotic risk

Venous thromboembolism comprises deep vein thrombosis (DVT) and pulmonary embolism (PE). Acute venous thromboembolism (VTE) is a serious and potentially fatal disorder which often complicates the course of hospitalized patients, but also affects ambulatory and otherwise healthy people. The annual incidence of venous thromboembolism is 1 to 2 cases per 1000 person and the risk of the disorder rises exponentially with age, from an annual rate of less than 5 per 100,000 children to greater than 400 per 100,000 adults older than 80 years.

High-dose cyclophosphamide without stem cell rescue in scleroderma

OBJECTIVE

To investigate the safety and tolerability of high-dose cyclophosphamide without stem cell rescue in scleroderma.

METHODS

An open-label, single-site, uncontrolled study design entered patients with active diffuse cutaneous scleroderma. Patients were treated with cyclophosphamide (50 mg/kg) intravenously daily for 4 consecutive days (total 200 mg/kg) followed by granulocyte colony-stimulating factor (5 microg/kg/day). The primary clinical efficacy end point was the modified Rodnan skin score (mRSS). Secondary end points included the Health Assessment Questionnaire-Disability Index (HAQ-DI), physician global assessment (PGA) and pulmonary function tests.

RESULTS

Six patients (4 men, 2 women) aged 19-60 years were entered into the study. One patients died early in the protocol, thus five patients had follow-up data. The percentage reduction of the mRSS in these five evaluable patients within 1 month of treatment was 60%, 55%, 41%, 31% and 0%. The patient with no decline in skin score at 1 month showed a decrease in skin score from 41 to 26 by the 3-month visit, a 37% improvement. Three patients sustained the improvement after treatment for 24, 12 and 12 months. Two patients relapsed at 12 and 6 months after treatment. The PGA and HAQ-DI scores improved in five of the six patients by 72% and 79% respectively at 3 months. The only serious adverse event was a death that occurred owing to infection after neutrophil count recovery.

CONCLUSIONS

High-dose cyclophosphamide without stem cell rescue can lead to a clinically significant improvement in skin score and measures of disease severity in patients with diffuse cutaneous scleroderma.