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Zhou D, Xia X, Ling J, Liu C. Regulating spleen and stomach can improve bone and joint function of knee osteoarthritis patients complicated with osteoporosis. Am J Transl Res 2023; 15:5769-5777. [PMID: 37854227 PMCID: PMC10579020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Accepted: 07/14/2023] [Indexed: 10/20/2023]
Abstract
OBJECTIVE This study was designed to determine the influences of spleen and stomach conditioning treatment in Traditional Chinese Medicine (TCM) on patients with both knee osteoarthritis (KOA) and osteoporosis (OP). METHODS The medical records of 108 patients with both KOA and OP treated in Wuhan No. 1 Hospital between February 2020 and December 2021 were retrospectively studied. Among them, 58 patients treated with western medicine alone were assigned to a control group, and 50 patients who received spleen and stomach conditioning treatment in TCM based on western medicine treatment were assigned to an observation group. The efficacy on the two groups was compared. The joint function, pain, inflammatory factors and bone turnover markers in the two groups before and after treatment were analyzed, as well as the incidence of adverse reactions after treatment. The prognosis of the patients at 12 months after treatment was counted, and the influencing factors of poor prognosis were analyzed by multivariate analysis. RESULTS The observation group showed a notably higher total effective rate than the control group (P<0.05). After treatment, the observation group had notably higher Lysholm score, but notably lower Western Ontario and McMaster University Osteoarthritis Index (WOMAC) and visual analogue scale (VAS) scores than the control group (all P<0.05). After treatment, the bone turnover markers (beta collagen degradation products (β-CTx) and procollagen type I amino-terminal propeptide (P1NP)) in both groups decreased notably (P<0.05), with notably lower levels of them in the observation group than those in the control group (both P<0.05). Additionally, after the treatment, the inflammatory indexes (interleukin-1β (IL-1β), interleukin-6 (IL-6), and tumor necrosis factor-α (TNF-α)) in both groups decreased notably (all P<0.05), with notably lower levels of them in the observation group than those in the control group (all P<0.05). Moreover, the observation group presented a notably lower incidence of adverse reactions than the control group (P<0.05). The rate of poor prognosis in the observation group was notably lower than that in the control group. According to multiple logistic regression analysis, older age, higher BMI, higher Kellgren-Lawrence grading based on X-ray and history of bone fracture were independent risk factors for poor prognosis, and spleen and stomach conditioning treatment was an independent protective factor. CONCLUSION Additional TCM spleen and stomach conditioning treatment can substantially improve the efficacy in patients with both KOA and OP by adjusting the inflammatory factors and bone turnover markers of patients, improving their joint function, alleviating their pain, and strongly preventing adverse reactions, so it is of great clinical application value.
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Affiliation(s)
- Dun Zhou
- Department of Traditional Chinese Medicine, Wuhan No. 1 HospitalWuhan, Hubei, China
| | - Xue Xia
- Department of Traditional Chinese Medicine, Wuhan No. 1 HospitalWuhan, Hubei, China
| | - Jiayan Ling
- Department of Traditional Chinese Medicine, Wuhan No. 1 HospitalWuhan, Hubei, China
| | - Chong Liu
- Hubei University of Chinese MedicineWuhan, Hubei, China
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Herrero-Manley L, Alabajos-Cea A, Suso-Martí L, Cuenca-Martínez F, Calatayud J, Casaña J, Viosca-Herrero E, Vázquez-Arce I, Ferrer-Sargues FJ, Blanco-Díaz M. Serum lipid biomarkers and inflammatory cytokines associated with onset and clinical status of patients with early knee osteoarthritis. Front Nutr 2023; 10:1126796. [PMID: 37006936 PMCID: PMC10050464 DOI: 10.3389/fnut.2023.1126796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Accepted: 02/24/2023] [Indexed: 03/17/2023] Open
Abstract
IntroductionOsteoarthritis (OA) is a common joint condition and one of the greatest causes of disability worldwide. The role of serum lipid and inflammatory biomarkers in the origin and development of the disease is not clear, although it could have important implications for diagnosis and treatment. The primary aim of this study was to evaluate differences of serum lipid and inflammatory biomarkers with knee EOA in comparison with matched controls, in order to determine the role of these factors in the origin of EOA.MethodsFor this proposal, a cross-sectional study with a non-randomized sample was performed. 48 subjects with early osteoarthritis (EOA) and 48 matched controls were selected and serum lipid levels (total cholesterol, LDL, HDL) and inflammatory biomarkers C-reactive protein (CRP), uric acid (UA) were analyzed. In addition, clinical (pain, disability) and functional (gait speed, sit-to-stand) variables were measured to establish their relationship to serum lipid levels and inflammatory biomarkers.ResultsPatients with EOA showed higher levels of total cholesterol LDL, UA, and CRP. Higher levels of total cholesterol, LDL and CRP were correlated with higher levels of pain intensity and higher disability (p < 0.05). In addition, UA and CRP were inversely correlated with gait speed and sit-to-stand tests (r = −0.038 to −0.5, p < 0.05).ConclusionThese results highlight the relevance of metabolic and proinflammatory aspects in the early stages of knee OA and could be key to developing early diagnoses to prevent the onset and development of the disease.
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Affiliation(s)
- Luz Herrero-Manley
- Servicio de Medicina Física y Rehabilitación, Hospital La Fe, Valencia, Spain
| | - Ana Alabajos-Cea
- Servicio de Medicina Física y Rehabilitación, Hospital La Fe, Valencia, Spain
- Grupo de Investigación en Medicina Física y Rehabilitación, Instituto de Investigación Sanitaria La Fe (IISLAFE), Valencia, Spain
| | - Luis Suso-Martí
- Exercise Intervention for Health Research Group (EXINH-RG), Department of Physiotherapy, University of Valencia, Valencia, Spain
| | | | - Joaquín Calatayud
- Exercise Intervention for Health Research Group (EXINH-RG), Department of Physiotherapy, University of Valencia, Valencia, Spain
- *Correspondence: Joaquín Calatayud,
| | - José Casaña
- Exercise Intervention for Health Research Group (EXINH-RG), Department of Physiotherapy, University of Valencia, Valencia, Spain
| | | | - Isabel Vázquez-Arce
- Servicio de Medicina Física y Rehabilitación, Hospital La Fe, Valencia, Spain
| | | | - María Blanco-Díaz
- Department of Surgery and Medical Surgical Specialties, Faculty of Medicine and Health Sciences, University of Oviedo, Oviedo, Spain
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Alabajos-Cea A, Herrero-Manley L, Suso-Martí L, Sempere-Rubio N, Cuenca-Martínez F, Muñoz-Alarcos V, Pérez-Barquero JA, Viosca-Herrero E, Vázquez-Arce I. Screening Clinical Changes for the Diagnosis of Early Knee Osteoarthritis: A Cross-Sectional Observational Study. Diagnostics (Basel) 2022; 12:diagnostics12112631. [PMID: 36359475 PMCID: PMC9689265 DOI: 10.3390/diagnostics12112631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 10/24/2022] [Accepted: 10/27/2022] [Indexed: 11/16/2022] Open
Abstract
Background: The main objective was to evaluate differences in the clinical, motor, or functional variables in patients with Early Osteoarthritis (EOA) and individuals at risk of developing osteoarthritis (OA). Methods: A cross-sectional study was performed. All the participants were divided into two groups: EOA patients and healthy subjects (HS) at risk of developing OA. The main outcomes were clinical tests, such as those of knee morphology, instability, or proprioception; motor and functional variables, such as knee strength, range of motion, walking speed, and the sit-to-stand test; pain and disability, assessed through the Western Ontario McMaster Universities Osteoarthritis Index (WOMAC) and Knee injury and Osteoarthritis Outcome Score (KOOS) scales; and knee alignment and leg length inequality, assessed via X-ray images. Results: A total of 97 participants were included (54 EOA and 43 HS). Patients with EOA showed a greater presence of knee pain (p < 0.01). In addition, more EOA patients showed instability both in the left (p < 0.01) and right legs (p < 0.05). Regarding the knee alignment variable, significant differences were found (p < 0.04), with more patients with EOA diagnosed as possessing a varus alignment. In addition, EOA patients showed lower knee strength, since statistically significant differences were found regarding flexion and extension strength in the left leg (Mean Difference (MD): 12.92; p = 0.03; d = −0.46 and MD:7.81; p = 0.04; d = −0.39). Differences were found for the sit-to-stand test scores, showing lower results for the EOA group (MD: −1.91; p < 0.01; d = 0.54). Conclusions: The results of this research show statistically significant differences between patients with EOA and HS at risk of developing OA with respect to pain, disability, instability, knee strength, and the sit-to-stand test. Our results suggest that the evaluation of clinical, motor, and functional features could contribute to an early management of knee OA.
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Affiliation(s)
- Ana Alabajos-Cea
- Servicio de Medicina Física y Rehabilitación, Hospital La Fe, 46026 Valencia, Spain
| | - Luz Herrero-Manley
- Servicio de Medicina Física y Rehabilitación, Hospital La Fe, 46026 Valencia, Spain
| | - Luis Suso-Martí
- Exercise Intervention for Health Research Group (EXINH-RG), Department of Physiotherapy, University of Valencia, 46010 Valencia, Spain
- Correspondence: (L.S.-M.); (F.C.-M.); Tel.: +34-963-983-855
| | - Núria Sempere-Rubio
- UBIC, Department of Physiotherapy, Faculty of Physiotherapy, Universitat de Valencia, 46010 Valencia, Spain
| | - Ferran Cuenca-Martínez
- Exercise Intervention for Health Research Group (EXINH-RG), Department of Physiotherapy, University of Valencia, 46010 Valencia, Spain
- Correspondence: (L.S.-M.); (F.C.-M.); Tel.: +34-963-983-855
| | - Vicente Muñoz-Alarcos
- Exercise Intervention for Health Research Group (EXINH-RG), Department of Physiotherapy, University of Valencia, 46010 Valencia, Spain
| | | | | | - Isabel Vázquez-Arce
- Servicio de Medicina Física y Rehabilitación, Hospital La Fe, 46026 Valencia, Spain
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Adiguzel L, Kilic D. An investigation of the relationship between the functional status of the individuals with knee osteoarthritis and their quality of life. Niger J Clin Pract 2022; 25:576-581. [PMID: 35593598 DOI: 10.4103/njcp.njcp_1370_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Background Knee osteoarthritis, a chronic and degenerative joint disease, is more common among the growing elderly population. With the increasing life expectancy and obesity, the significance of knee osteoarthritis for public health has become more evident. Aim This study was carried out to investigate the relationship between the functional status of individuals with knee osteoarthritis and their quality of life. Patients and Methods The population of the study consisted of individuals with 1-4 s level of knee osteoarthritis diagnosed over the age of 50 who attended the physical therapy and rehabilitation polyclinic at Atatürk University hospital. The study was carried out with 129 individuals with knee osteoarthritis without sample selection. The data were collected using a demographic questionnaire and The Knee Injury and Osteoarthritis Outcome Score (KOOS) and analyzed with SPSS 22.00 statistical package program using frequency, percentage, t-test, Mann-Whitney U test, Kruskal-Wallis H test, and Dunnett T3 post hoc test. Results According to the results, the KOOS Function and Daily Life scores showing the functional status of the participants were 46.61 ± 16.17. The Function and Sports/Leisure Activities subscale scores were 29.49 ± 23.73, and the mean scores of the Quality of Life subscale were 34.15 ± 18.11. A positive significant relationship was determined between the functional status and the quality of life in the individuals. Conclusions As the functional status of individuals improves, the quality of life increases too.
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Affiliation(s)
- L Adiguzel
- Department of Public Health Nursing, Karadeniz Technical University, Turkey
| | - D Kilic
- Department of Public Health Nursing, Atatürk University, Turkey
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Restuccia R, Ruggieri D, Magaudda L, Talotta R. The preventive and therapeutic role of physical activity in knee osteoarthritis. Reumatismo 2022; 74. [PMID: 35506320 DOI: 10.4081/reumatismo.2022.1466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 02/18/2022] [Indexed: 11/22/2022] Open
Abstract
The aim of this narrative review is to discuss the results of studies investigating the role of physical activity in knee osteoarthritis (OA). We also formulated two evidence-based exercise programs that could be prescribed to patients with symptomatic knee OA or after joint replacement. The PubMed and Google Scholar databases were searched for articles related to knee OA and physical activity. A total of 86 papers written in English and published from 1957 to 2021 were selected. Adapted physical activity, even at high intensity, does not appear to trigger or exacerbate knee OA; on the contrary, it may prevent obesity or lower limb muscle weakness, both of which are considered predisposing factors for the disease. In patients already diagnosed with knee OA, scientific evidence suggests that both land-based and aquatic activities combining aerobics, strength, and endurance programs are safe and effective. Physical interventions tailored to the patient may also accelerate recovery time after knee arthroplasty. Knee OA is a painful and disabling rheumatic disease that is very common in the elderly population. Pharmacotherapy has a modest effect in controlling disease progression, possibly due to the still limited understanding of OA pathogenesis. Non-pharmacologic interventions, including dietary and lifestyle changes and physical activity, may be more effective and safer than drugs in preventing or treating knee OA.
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Affiliation(s)
- R Restuccia
- Postgraduate School of Sports and Physical Exercise Medicine, BIOMORF Department, University of Messina.
| | - D Ruggieri
- Degree Course of Theory and Methods of Preventive and Adapted Physical Activities, BIOMORF Department, University of Messina.
| | - L Magaudda
- Postgraduate School of Sports and Physical Exercise Medicine, BIOMORF Department, University of Messina, Italy; Degree Course of Theory and Methods of Preventive and Adapted Physical Activities, BIOMORF Department, University of Messina.
| | - R Talotta
- Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Messina.
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Alabajos-Cea A, Herrero-Manley L, Suso-Martí L, Viosca-Herrero E, Cuenca-Martínez F, Varangot-Reille C, Blanco-Díaz M, Calatayud J, Casaña J. The Role of Vitamin D in Early Knee Osteoarthritis and Its Relationship with Their Physical and Psychological Status. Nutrients 2021; 13:nu13114035. [PMID: 34836290 PMCID: PMC8622912 DOI: 10.3390/nu13114035] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 09/20/2021] [Accepted: 09/25/2021] [Indexed: 12/17/2022] Open
Abstract
Osteoarthritis (OA) is a common joint condition and one of the greatest causes of disability worldwide. The role of vitamin D in the origin and development of the disease is not clear, although it could have important implications for diagnosis and treatment. For this proposal, a cross-sectional study with a non-probabilistic sample was performed. In total, 48 with early osteoarthritis (EOA) and 48 matched controls were selected, and serum 25(OH)D and parathyroid hormone (PTH) levels were analyzed. In addition, physical and psychological variables were measured to establish their relationship with vitamin D levels. Patients with EOA showed lower levels (22.3 ± 7.3 ng/mL) in comparison to matched controls (29.31 ± 9.2 ng/mL). A statistically significant higher number (Chi-squared = 8.525; p = 0.004) of patients with EOA had deficiency levels (<20 ng/mL) compared to the control group. Patients with lower vitamin D levels showed higher levels of pain intensity, disability, and anxiety, as well as poorer values for sit-to-stand, walking speed, and social participation. Correlation analysis showed a relationship between serum 25(OH)D, PTH and pain intensity, and social participation. These results highlight the relevance of vitamin D in the early diagnosis and prevention of EOA.
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Affiliation(s)
- Ana Alabajos-Cea
- Servicio de Medicina Física y Rehabilitación, Hospital La Fe, 46026 Valencia, Spain; (A.A.-C.); (L.H.-M.); (E.V.-H.)
- Grupo de Investigación en Medicina Física y Rehabilitación, Instituto de Investigación Sanitaria La Fe (IISLAFE), 46026 Valencia, Spain
| | - Luz Herrero-Manley
- Servicio de Medicina Física y Rehabilitación, Hospital La Fe, 46026 Valencia, Spain; (A.A.-C.); (L.H.-M.); (E.V.-H.)
| | - Luis Suso-Martí
- Exercise Intervention for Health Research Group (EXINH-RG), Department of Physiotherapy, University of Valencia, 46026 Valencia, Spain; (F.C.-M.); (C.V.-R.); (J.C.); (J.C.)
- Correspondence:
| | - Enrique Viosca-Herrero
- Servicio de Medicina Física y Rehabilitación, Hospital La Fe, 46026 Valencia, Spain; (A.A.-C.); (L.H.-M.); (E.V.-H.)
- Grupo de Investigación en Medicina Física y Rehabilitación, Instituto de Investigación Sanitaria La Fe (IISLAFE), 46026 Valencia, Spain
| | - Ferran Cuenca-Martínez
- Exercise Intervention for Health Research Group (EXINH-RG), Department of Physiotherapy, University of Valencia, 46026 Valencia, Spain; (F.C.-M.); (C.V.-R.); (J.C.); (J.C.)
| | - Clovis Varangot-Reille
- Exercise Intervention for Health Research Group (EXINH-RG), Department of Physiotherapy, University of Valencia, 46026 Valencia, Spain; (F.C.-M.); (C.V.-R.); (J.C.); (J.C.)
| | - María Blanco-Díaz
- Surgery and Medical Surgical Specialities Department, Faculty of Medicine and Health Sciences, University of Oviedo, 33006 Oviedo, Spain;
| | - Joaquín Calatayud
- Exercise Intervention for Health Research Group (EXINH-RG), Department of Physiotherapy, University of Valencia, 46026 Valencia, Spain; (F.C.-M.); (C.V.-R.); (J.C.); (J.C.)
| | - José Casaña
- Exercise Intervention for Health Research Group (EXINH-RG), Department of Physiotherapy, University of Valencia, 46026 Valencia, Spain; (F.C.-M.); (C.V.-R.); (J.C.); (J.C.)
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Editorial Commentary: More Clinical Trials Should Focus on Primary Prevention of Osteoarthritis: Disruptive Thinkers Are Required. Arthroscopy 2021; 37:2640-2641. [PMID: 34353566 DOI: 10.1016/j.arthro.2021.05.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 05/06/2021] [Indexed: 02/02/2023]
Abstract
With increasing life expectancy and an increased prevalence of osteoarthritis, the total number of individuals with symptomatic degenerative arthritis will most likely increase considerably. The current focus of nonoperative treatment is on weight loss, exercise, muscle strengthening, physical therapy, nonsteroidal anti-inflammatory drugs, intra-articular injection therapies with corticosteroids, hyaluronic acid, or platelet-rich plasma, and lately, disease-modifying drugs. Obviously, prevention is better than cure, but only 5% of all studies registered on ClinicalTrials.gov in the United States are intending to develop strategies for prevention. The overall majority of included studies (89%) will target symptom resolution, and 6% will investigate disease-modifying drugs.
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Black JE, Kueper JK, Terry AL, Lizotte DJ. Development of a prognostic prediction model to estimate the risk of multiple chronic diseases: constructing a copula-based model using Canadian primary care electronic medical record data. Int J Popul Data Sci 2021; 6:1395. [PMID: 34007897 PMCID: PMC8112224 DOI: 10.23889/ijpds.v5i1.1395] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Introduction The ability to estimate risk of multimorbidity will provide valuable information to patients and primary care practitioners in their preventative efforts. Current methods for prognostic prediction modelling are insufficient for the estimation of risk for multiple outcomes, as they do not properly capture the dependence that exists between outcomes. Objectives We developed a multivariate prognostic prediction model for the 5-year risk of diabetes, hypertension, and osteoarthritis that quantifies and accounts for the dependence between each disease using a copula-based model. Methods We used data from the Canadian Primary Care Sentinel Surveillance Network (CPCSSN) from 2009 onwards, a collection of electronic medical records submitted by participating primary care practitioners across Canada. We identified patients 18 years and older without all three outcome diseases and observed any incident diabetes, osteoarthritis, or hypertension within 5-years, resulting in a large retrospective cohort for model development and internal validation (n=425,228). First, we quantified the dependence between outcomes using unadjusted and adjusted Ø coefficients. We then estimated a copula-based model to quantify the non-linear dependence between outcomes that can be used to derive risk estimates for each outcome, accounting for the observed dependence. Copula-based models are defined by univariate models for each outcome and a dependence function, specified by the parameter θ. Logistic regression was used for the univariate models and the Frank copula was selected as the dependence function. Results All outcome pairs demonstrated statistically significant dependence that was reduced after adjusting for covariates. The copula-based model yielded statistically significant θ parameters in agreement with the adjusted and unadjusted Ø coefficients. Our copula-based model can effectively be used to estimate trivariate probabilities. Discussion Quantitative estimates of multimorbidity risk inform discussions between patients and their primary care practitioners around prevention in an effort to reduce the incidence of multimorbidity.
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Affiliation(s)
- Jason E Black
- Department of Epidemiology & Biostatistics, Western University, 1151 Richmond Street London, Ontario, Canada, N6A 3K7
| | - Jacqueline K Kueper
- Department of Computer Science, Department of Epidemiology & Biostatistics, Western University, 1151 Richmond Street London, Ontario, Canada, N6A 3K7
| | - Amanda L Terry
- Department of Family Medicine, Department of Epidemiology & Biostatistics, Western University, 1151 Richmond Street London, Ontario, Canada, N6A 3K7
| | - Daniel J Lizotte
- Department of Computer Science, Department of Epidemiology & Biostatistics, Western University, 1151 Richmond Street London, Ontario, Canada, N6A 3K7
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Black JE, Terry AL, Lizotte DJ. Development and evaluation of an osteoarthritis risk model for integration into primary care health information technology. Int J Med Inform 2020; 141:104160. [PMID: 32593009 DOI: 10.1016/j.ijmedinf.2020.104160] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Revised: 02/28/2020] [Accepted: 04/24/2020] [Indexed: 11/15/2022]
Abstract
BACKGROUND We developed and evaluated a prognostic prediction model that estimates osteoarthritis risk for use by patients and practitioners that is designed to be appropriate for integration into primary care health information technology systems. Osteoarthritis, a joint disorder characterized by pain and stiffness, causes significant morbidity among older Canadians. Because our prognostic prediction model for osteoarthritis risk uses data that are readily available in primary care settings, it supports targeting of interventions delivered as part of clinical practice that are aimed at risk reduction. METHODS We used the CPCSSN (Canadian Primary Sentinel Surveillance Network) database, which contains aggregated electronic health information from a cohort of primary care practices, to develop and evaluate a prognostic prediction model to estimate 5-year osteoarthritis risk, addressing contextual challenges of data availability and missingness. We constructed a retrospective cohort of 383,117 eligible primary care patients who were included in the cohort if they had an encounter with their primary care practitioner between 1 January 2009 and 31 December 2010. Patients were excluded if they had a diagnosis of osteoarthritis prior to their first visit in this time period. Incident cases of osteoarthritis were observed. The model was constructed to predict incident osteoarthritis based on age, sex, BMI, previous leg injury, and osteoporosis. Evaluation of the model used internal 10-fold cross-validation; we argue that internal validation is particularly appropriate for a model that is to be integrated into the same context from which the data were derived. RESULTS The resulting prediction model for 5-year risk of osteoarthritis diagnosis demonstrated state-of-the-art discrimination (estimated AUROC 0.84) and good calibration (assessed visually.) The model relies only on information that is readily available in Canadian primary care settings, and hence is appropriate for integration into Canadian primary care health information technology. CONCLUSIONS If the contextual challenges arising when using primary care electronic medical record data are appropriately addressed, highly discriminative models for osteoarthritis risk may be constructed using only data commonly available in primary care. Because the models are constructed from data in the same setting where the model is to be applied, internal validation provides strong evidence that the resulting model will perform well in its intended application.
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Affiliation(s)
- Jason E Black
- Graduate Program in Epidemiology & Biostatistics, Western University, 1151 Richmond Street, London, Ontario, N6A 5C1, Canada.
| | - Amanda L Terry
- Department of Family Medicine, Department of Epidemiology & Biostatistics, Schulich Interfaculty Program in Public Health, Western University, 1151 Richmond Street, London, Ontario, N6A 3K7, Canada.
| | - Daniel J Lizotte
- Department of Computer Science, Department of Epidemiology & Biostatistics, Schulich Interfaculty Program in Public Health, Department of Statistical and Actuarial Sciences, 1151 Richmond Street, Western University, London, Ontario, N6A 3K7, Canada.
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Long H, Zeng X, Liu Q, Wang H, Vos T, Hou Y, Lin C, Qiu Y, Wang K, Xing D, Zhang Y, Zhou M, Lin J. Burden of osteoarthritis in China, 1990-2017: findings from the Global Burden of Disease Study 2017. THE LANCET. RHEUMATOLOGY 2020; 2:e164-e172. [PMID: 38263654 DOI: 10.1016/s2665-9913(19)30145-6] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Revised: 12/09/2019] [Accepted: 12/12/2019] [Indexed: 12/27/2022]
Abstract
BACKGROUND China has seen a remarkable epidemiological and demographic transition during the past three decades. We aimed to describe the prevalence of osteoarthritis as well as years lived with disability (YLDs) due to osteoarthritis in China, according to age, sex, and geographical location, from 1990 to 2017. METHODS Data were obtained from systematic reviews of symptomatic osteoarthritis of the knee and hip in the Global Burden of Diseases, Injuries, and Risk Factors Study 2017 (GBD 2017). Three categories of sequelae (mild, moderate, and severe) of osteoarthritis were defined to indicate the degrees of severity and functional loss associated with the condition. A Bayesian meta-regression tool was applied to estimate the prevalence of osteoarthritis and the distribution of its severity. YLDs were calculated by multiplying the prevalence of osteoarthritis sequelae by their corresponding disability weights. All data were analysed by age-sex-province-year groups in China. FINDINGS Around 26·1 million individuals in China had osteoarthritis in 1990, and this number rose to 61·2 million in 2017. The age-standardised prevalence of osteoarthritis increased from 2·9% (95% uncertainty interval 2·5-3·3) in 1990 to 3·1% (2·7-3·4) in 2017. The total YLDs due to osteoarthritis increased from 0·84 million (0·42-1·69) in 1990 to 1·97 million (0·98-3·94) in 2017, while the age-standardised YLD rate increased from 92·5 (45·7-185·6) per 100 000 people to 98·8 (49·4-197·6) per 100 000. Osteoarthritis prevalence and YLDs were higher in females than in males, and YLD rate increased with age. Osteoarthritis was the 24th most common cause of YLDs in China in 2017, accounting for 1·08% (0·64-2·02) of all YLDs. INTERPRETATION Osteoarthritis is prevalent in China. Between 1990 and 2017, disease burden increased and varied greatly according to geographical location. Appropriate prevention and treatment strategies, predominantly those targeted at women, older people, and underdeveloped areas, must be developed to reduce the burden of the disease. FUNDING National Natural Science Foundation of China, China National Key Research and Development Programme.
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Affiliation(s)
- Huibin Long
- Arthritis Clinic and Research Center, Peking University People's Hospital, Beijing, China
| | - Xinying Zeng
- National Center for Chronic and Noncommunicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Qiang Liu
- Arthritis Clinic and Research Center, Peking University People's Hospital, Beijing, China
| | - Haidong Wang
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Theo Vos
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Yunfei Hou
- Arthritis Clinic and Research Center, Peking University People's Hospital, Beijing, China
| | - Chutong Lin
- Arthritis Clinic and Research Center, Peking University People's Hospital, Beijing, China
| | - Yudian Qiu
- Arthritis Clinic and Research Center, Peking University People's Hospital, Beijing, China
| | - Kai Wang
- Arthritis Clinic and Research Center, Peking University People's Hospital, Beijing, China
| | - Dan Xing
- Arthritis Clinic and Research Center, Peking University People's Hospital, Beijing, China
| | - Yuqing Zhang
- Section of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Maigeng Zhou
- National Center for Chronic and Noncommunicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China.
| | - Jianhao Lin
- Arthritis Clinic and Research Center, Peking University People's Hospital, Beijing, China.
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de Windt TS, Niemansburg SL, Vonk LA, van Delden JM, Roes KCB, Dhert WJA, Saris DBF, Bredenoord AL. Ethics in musculoskeletal regenerative medicine; guidance in choosing the appropriate comparator in clinical trials. Osteoarthritis Cartilage 2019; 27:34-40. [PMID: 30243948 DOI: 10.1016/j.joca.2018.08.022] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Revised: 05/30/2018] [Accepted: 08/07/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND Regenerative Medicine (RM) techniques aimed at the musculoskeletal system are increasingly translated to clinical trials and patient care. This revolutionary era in science raises novel ethical challenges. One of these challenges concerns the appropriate choice of the comparator in (randomized controlled) trials, including the ethically contentious use of sham procedures. To date, only general guidelines regarding the choice of the comparator exist. OBJECTIVE To provide specific guidelines for clinical trial comparator choice in musculoskeletal RM. METHODS In this manuscript, we discuss the ethics of comparator selection in RM trials. First, we make a classification of RM interventions according to different health states from disease prevention, return to normal health, postponing RM treatment, supplementing RM treatment, substituting RM treatment, improving RM outcome, and slowing progression. Subsequently, per objective, the accompanying ethical points to consider are evaluated with support from the available literature. RESULTS a sham procedure is demonstrated to be an ethically acceptable comparator in RM trials with certain objectives, but less appropriate for musculoskeletal RM interventions that aim at preventing disease or substituting a surgical treatment. The latter may be compared to 'standard of care'. CONCLUSION From a scientific perspective, choosing the correct comparator based on ethical guidelines is a step forward in the success of musculoskeletal RM.
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Affiliation(s)
- T S de Windt
- Department of Orthopaedics, University Medical Center, University Utrecht, The Netherlands.
| | - S L Niemansburg
- Medical Humanities, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - L A Vonk
- Department of Orthopaedics, University Medical Center, University Utrecht, The Netherlands.
| | - J M van Delden
- Medical Humanities, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - K C B Roes
- Biostatistics and Research Support, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - W J A Dhert
- Faculty of Veterinary Medicine, Utrecht University, Utrecht, The Netherlands.
| | - D B F Saris
- Department of Orthopaedics, University Medical Center, University Utrecht, The Netherlands; MIRA Institute for Biomedical Technology and Technical Medicine, University of Twente, Enschede, The Netherlands; Department of Orthopedics, Mayo Clinic, Rochester, MN, USA.
| | - A L Bredenoord
- Medical Humanities, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands.
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Lo GH, Song J, McAlindon TE, Hawker GA, Driban JB, Price LL, Eaton CB, Hochberg MC, Jackson RD, Kwoh CK, Nevitt MC, Dunlop DD. Validation of a new symptom outcome for knee osteoarthritis: the Ambulation Adjusted Score for Knee pain. Clin Rheumatol 2018; 38:851-858. [PMID: 30417223 DOI: 10.1007/s10067-018-4352-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Revised: 10/10/2018] [Accepted: 10/24/2018] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Validation of a symptom measure for early knee OA may help identify new treatments and modifiable risk factors. Symptom measures that consider pain in the context of activity level may provide better discrimination than pain alone. Therefore, we aimed to compare sensitivity to change for radiographic progression between Ambulation Adjusted Score for Knee pain (AASK), which accounts for self-reported ambulation, and Western Ontario McMaster Osteoarthritis (WOMAC) knee pain score. DESIGN Participants were assessed annually up to 48 months using WOMAC, Physical Activity Scale for the Elderly (PASE) ambulation, and knee radiographs. AASK was defined as ((WOMAC pain) + 1)/((average daily hours of walking) + 1). Radiographs were scored for Kellgren-Lawrence (KL) grade. Linear regression, stratified by OA status, evaluated relationships between changes in AASK and WOMAC pain and KL grade over time. RESULTS For 4191 people (8030 knees), the mean age was 61.2 (+ 9.2) years old and BMI was 28.6 (+ 4.8) kg/m2; 58% female. Over 40% of knees had WOMAC pain scores of 0; by design, no knees had AASK scores of 0. Annual changes in AASK were more sensitive to changes in KL than changes in WOMAC in those without baseline OA (0.20 and 0.16 change per unit KL change, p = 0.005 and 0.070 respectively), but performed similarly in knees with OA. CONCLUSION AASK is simple to assess using existing validated questionnaires. AASK performs well in individuals with and without OA and should be considered in clinical trials and observational studies of early knee OA.
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Affiliation(s)
- Grace H Lo
- Department of Medicine, Baylor College of Medicine, 1 Baylor Plaza, BCM-285, Houston, TX, 77030, USA. .,Medical Care Line and Research Care Line, Houston VA HSR&D Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Medical Center, Houston, TX, USA.
| | - Jing Song
- Center for Healthcare Studies, Institute for Public Health and Medicine, Northwestern Feinberg School of Medicine, Chicago, IL, USA
| | | | - Gillian A Hawker
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | | | - Lori Lyn Price
- The Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, and Tufts Clinical and Translational Science Institute, Tufts University, Boston, MA, USA
| | - Charles B Eaton
- Department of Family Medicine and Epidemiology, Warren Alpert Medical School of Brown University, Providence, RI and Department of Epidemiology, School of Public Health of Brown University, Providence, RI, USA
| | - Marc C Hochberg
- Departments of Medicine and Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Rebecca D Jackson
- Division of Endocrinology, Diabetes and Metabolism, The Ohio State University, Columbus, OH, USA
| | - C Kent Kwoh
- University of Arizona Arthritis Center, University of Arizona, Tucson, AZ, USA
| | - Michael C Nevitt
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA, USA
| | - Dorothy D Dunlop
- Center for Healthcare Studies, Institute for Public Health and Medicine, Northwestern Feinberg School of Medicine, Chicago, IL, USA
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Runhaar J, Zhang Y. Can we prevent OA? Epidemiology and public health insights and implications. Rheumatology (Oxford) 2018; 57:iv3-iv9. [PMID: 29506178 DOI: 10.1093/rheumatology/key014] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Indexed: 11/14/2022] Open
Abstract
This narrative review discusses the potential of prevention of OA in different stages of the disease. The theoretical background for primary prevention (i.e. prevention of occurrence of definite structural or clinical OA in subjects free of the disease) and secondary prevention (i.e. prevention of progression of the disease in subjects with pre-clinical pathological changes to the joint) is provided and evidence for effective strategies is discussed. Since direct evidence for the prevention of OA development and progression is scarce, indirect evidence enhancing our current knowledge on the potential of OA prevention is additionally discussed. Also, implications of preventive strategies for study design and public health are considered. Prevention of OA has great potential, but as deliberated in the current review, there are still large gaps in our current knowledge and the implications of preventive strategies for the development and progression of OA require consideration.
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Affiliation(s)
- Jos Runhaar
- Department on General Practice, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Yuqing Zhang
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Harvard Medical School, Cambridge, MA, USA
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Oliveira MZ, Albano MB, Stirma GA, Namba MM, Vidigal L, Cunha LAMD. Intra-articular viscosupplementation of hyaluronic acids in an experimental osteoarthritis model. Rev Bras Ortop 2018; 53:293-299. [PMID: 29892579 PMCID: PMC5993877 DOI: 10.1016/j.rboe.2018.03.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Accepted: 04/06/2017] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE To analyze, from the immunohistochemical perspective, the effects of hyaluronic acid of different molecular weights in an experimental model of osteoarthritis in rabbits. METHODS Forty-four male California rabbits were randomly assigned to three different groups (PR, S, and P) and submitted to the resection of the anterior cruciate ligament of the right knee. Three weeks after the surgical procedure, three intra-articular weekly injections were carried out with low-molecular-weight native hyaluronic acid (Hyalgan®) to PR group, high molecular weight branched chain hyaluronic acid (Synvisc®) to group S, and saline solution 0.9% to group P. All animals were sacrificed 12 weeks after the surgical procedure, and the tibial plateaus of the infiltrated knees were then dissected. Histological sections of cartilage from the tibial plateau support areas were stained with immunohistochemical markers in order to investigate the amount of metalloproteases (MMPs 3 and 13) and their inhibitors (TIMPs 1 and 3). The staining intensity was quantified on a Zeiss Imager.Z2 Metasystems microscope and analyzed by Metafer4 Msearch software. RESULTS The chondroprotective effect of the hyaluronic acids used in the study was demonstrated when compared to the control group. However, the comparison between them presented no significant statistical difference regarding chondroprotection. CONCLUSION The injection of saline solution demonstrated signs of OA development, while adding native hyaluronic acid of low molecular weight (Hyalgan®) and hyaluronic acid of high molecular weight (Synvisc®) protected the articular cartilage in this model of OA.
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Affiliation(s)
- Marcello Zaia Oliveira
- Departamento de Ortopedia e Traumatologia, Universidade Federal do Paraná (UFPR), Curitiba, PR, Brazil
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Oliveira MZ, Albano MB, Stirma GA, Namba MM, Vidigal L, Cunha LAMD. Viscossuplementação intra‐articular de ácidos hialurônicos em modelo experimental de osteoartrite. Rev Bras Ortop 2018. [DOI: 10.1016/j.rbo.2017.04.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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de Vos BC, Landsmeer MLA, van Middelkoop M, Oei EHG, Krul M, Bierma-Zeinstra SMA, Runhaar J. Long-term effects of a lifestyle intervention and oral glucosamine sulphate in primary care on incident knee OA in overweight women. Rheumatology (Oxford) 2017; 56:1326-1334. [DOI: 10.1093/rheumatology/kex145] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Indexed: 11/12/2022] Open
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Qu H, Li J, Wu LD, Chen WP. Trichostatin A increases the TIMP-1/MMP ratio to protect against osteoarthritis in an animal model of the disease. Mol Med Rep 2016; 14:2423-30. [PMID: 27431944 PMCID: PMC4991690 DOI: 10.3892/mmr.2016.5523] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2015] [Accepted: 06/07/2016] [Indexed: 01/02/2023] Open
Abstract
The histone deacetylase inhibitor trichostatin A (TSA) has been demonstrated to alleviate certain symptoms associated with osteoarthritis (OA). However, the exact mechanisms underlying this protective effect remain to be elucidated. The present study therefore examined the effects of TSA on the expression levels of interleukin-1β (IL-1β)-induced matrix metalloproteinases (MMPs) and tissue inhibitor of metalloproteinases-1 (TIMP-1) in vitro and in vivo. In vitro, reverse transcription-quantitative polymerase chain reaction was performed to investigate alterations in mRNA expression levels in TSA-treated chondrocytes in the presence or absence of IL-1β; in addition, protein expression and acetylation levels were assessed by western blotting. In vivo, TSA was administered to rats by intra-articular injection, following which the mRNA and protein expression levels were analyzed. In addition, macroscopic and histological observations were conducted. Chondrocytes treated with IL-1β demonstrated increased mRNA and protein expression levels of MMP-1, MMP-3 and MMP-13, and decreased expression levels of TIMP-1 mRNA and protein; these alterations were significantly attenuated by TSA treatment. In addition, increased MMPs and decreased TIMP-1 expression levels were observed in vivo in the OA rat model. TSA treatment demonstrated in vivo efficacy through the attenuation of various OA-associated molecular and physiological changes. Taken together, the results of the present study suggest that TSA has potential therapeutic value for the treatment of OA.
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Affiliation(s)
- Hao Qu
- Department of Orthopedic Surgery, The Second Affiliated Hospital of Zhejiang University Medical College, Hangzhou, Zhejiang 310009, P.R. China
| | - Jin Li
- Department of Orthopedic Surgery, The Second Affiliated Hospital of Zhejiang University Medical College, Hangzhou, Zhejiang 310009, P.R. China
| | - Li-Dong Wu
- Department of Orthopedic Surgery, The Second Affiliated Hospital of Zhejiang University Medical College, Hangzhou, Zhejiang 310009, P.R. China
| | - Wei-Ping Chen
- Department of Orthopedic Surgery, The Second Affiliated Hospital of Zhejiang University Medical College, Hangzhou, Zhejiang 310009, P.R. China
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Landsmeer MLA, Runhaar J, van der Plas P, van Middelkoop M, Vroegindeweij D, Koes B, Bindels PJE, Oei EHG, Bierma-Zeinstra SMA. Reducing progression of knee OA features assessed by MRI in overweight and obese women: secondary outcomes of a preventive RCT. Osteoarthritis Cartilage 2016; 24:982-90. [PMID: 26748391 DOI: 10.1016/j.joca.2015.12.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2015] [Revised: 12/17/2015] [Accepted: 12/23/2015] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To evaluate the preventive effects of a randomized controlled trial on progression of Magnetic Resonance Imaging (MRI) features of knee osteoarthritis (OA) in overweight and obese women. DESIGN In a 2 × 2 factorial design, 2.5 years effects of a diet and exercise program and of glucosamine sulphate (double-blind, placebo-controlled) were evaluated in 407 middle-aged women with body mass index (BMI) ≥ 27 kg/m(2) without clinical signs of knee OA at baseline (ISRCTN 42823086). MRIs were scored with the MRI Osteoarthritis Knee Score (MOAKS). Progression was defined for bone marrow lesions (BMLs), cartilage defects, osteophytes, meniscal abnormalities and meniscal extrusion. Analyses on knee level were performed over the four intervention groups using adjusted Generalized Estimating Equations (GEE). RESULTS 687 knees of 347 women with mean age 55.7 years (±3.2 SD) and mean BMI 32.3 kg/m(2) (±4.2 SD) were analyzed. Baseline prevalence was 64% for BMLs, 70% for cartilage defects, 24% for osteophytes, 66% for meniscal abnormalities and 52% for meniscal extrusions. The diet and exercise program + placebo intervention showed significantly less progression of meniscal extrusion compared to placebo only (12% vs 22%, OR 0.50, 95% CI [0.27-0.92]). The interventions did not result in significant differences on other OA MRI features. CONCLUSIONS In subjects at high risk for future knee OA development, a diet and exercise program, glucosamine sulphate and their combination showed small and mainly non-significant effects on the progression of OA MRI features. Only progression of meniscal extrusion was significantly diminished by the diet and exercise program.
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Affiliation(s)
- M L A Landsmeer
- Department of General Practice, Erasmus MC, University Medical Center Rotterdam, The Netherlands.
| | - J Runhaar
- Department of General Practice, Erasmus MC, University Medical Center Rotterdam, The Netherlands.
| | - P van der Plas
- Department of Radiology, Maasstad Hospital, Rotterdam, The Netherlands.
| | - M van Middelkoop
- Department of General Practice, Erasmus MC, University Medical Center Rotterdam, The Netherlands.
| | - D Vroegindeweij
- Department of Radiology, Maasstad Hospital, Rotterdam, The Netherlands.
| | - B Koes
- Department of General Practice, Erasmus MC, University Medical Center Rotterdam, The Netherlands.
| | - P J E Bindels
- Department of General Practice, Erasmus MC, University Medical Center Rotterdam, The Netherlands.
| | - E H G Oei
- Department of Radiology, Erasmus MC, University Medical Center Rotterdam, The Netherlands.
| | - S M A Bierma-Zeinstra
- Department of General Practice, Erasmus MC, University Medical Center Rotterdam, The Netherlands; Department of Orthopaedics, Erasmus MC, University Medical Center Rotterdam, The Netherlands.
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Cuzdan Coskun N, Ay S, Evcik FD, Oztuna D. Adiponectin: is it a biomarker for assessing the disease severity in knee osteoarthritis patients? Int J Rheum Dis 2015; 20:1942-1949. [PMID: 26544540 DOI: 10.1111/1756-185x.12790] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
AIM The results of previous studies regarding the role of adiponectin in the pathogenesis of osteoarthritis (OA) are controversial. The aim of this study is to investigate the relation of plasma adiponectin levels with clinical and radiological disease severity in knee OA patients. METHOD Sixty patients with knee OA and 25 healthy controls were included in the study. Patients were divided into two subgroups: lean (Group 1, n = 30) and obese (Group 2, n = 30). Healthy controls were accepted as Group 3 (n = 25). Pain intensity was measured with a visual analogue scale (VAS), functional disability with Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and Quality of Life (QoL) with Short Form-36 (SF-36). Also all patients were radiologically evaluated and graded according to Kellgren-Lawrence (KL) scale. Plasma concentrations of adiponectin levels were measured by enzyme-linked immune-sorbent assay (ELISA). RESULTS Serum adiponectin levels were higher in OA patient subgroups than those in the control group but the difference did not reach a significant level after adjustments for age, gender and body mass index (P = 0.078). There was a positive correlation between adiponectin concentration and KL grading scores. Additionally, there was a positive correlation between adiponectin levels and clinical variables (VAS and WOMAC total scores) in patient subgroups (r = 0.326 P = 0.012, r = 0.583 P < 0.001, respectively). SF-36 scores were inversely associated with adiponectin levels. CONCLUSION Plasma adiponectin concentrations were associated with both clinical and radiological disease severity in knee OA patients. Thus, adiponectin hormone might be a potential clinically useful biomarker while assessing disease severity in the future.
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Affiliation(s)
- Nihan Cuzdan Coskun
- Department of Physical Medicine and Rehabilitation, Division of Rheumatology, Cukurova University School of Medicine, Adana, Turkey
| | - Saime Ay
- Department of Physical Medicine and Rehabilitation, Ufuk University School of Medicine, Ankara, Turkey
| | - Fatma Deniz Evcik
- Haymana Vocational School, Department of Therapy and Rehabilitation, Ankara University, Ankara, Turkey
| | - Derya Oztuna
- Department of Biostatistics, Ankara University School of Medicine, Ankara, Turkey
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Association of urinary biomarker COLL2-1NO₂ with incident clinical and radiographic knee OA in overweight and obese women. Osteoarthritis Cartilage 2015; 23:1398-404. [PMID: 25891749 DOI: 10.1016/j.joca.2015.04.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2014] [Revised: 03/24/2015] [Accepted: 04/08/2015] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To investigate the association between urinary biomarker Coll2-1NO2 (uColl2-1NO2) and incident knee OA after 2.5 years follow-up in middle-aged overweight and obese women at high risk for knee osteoarthritis (OA). DESIGN Data were used from PROOF, a randomized controlled trial with 2.5 years follow-up evaluating the preventive effects of a diet and exercise program and oral glucosamine sulphate (double blind and placebo controlled), on development of incident knee OA in women with body mass index ≥ 27 kg/m(2) without signs of knee OA at baseline. Baseline and 2.5 years uColl2-1NO2 concentrations were assessed with enzyme-linked immunosorbent assay (ELISA). Primary outcome measure was incidence of knee OA in one or both knees, defined as incidence of either Kellgren & Lawrence grade ≥2, joint space narrowing of ≥1.0 mm or knee OA according to the combined clinical and radiographic ACR-criteria. We used binary logistic regression for the association analyses. RESULTS 254 women were available for analyses. At 2.5 years follow-up, incident knee OA was present in 72 of 254 women (28.3%). An inversed association was found between baseline uColl2-1NO2 and incident knee OA at 2.5 years (OR 0.74, 95% CI 0.55-0.99). The concentration at 2.5 years and the change in concentration over 2.5 years did not show significant associations with the outcome. CONCLUSIONS In overweight and obese middle-aged women, not higher but lower baseline uColl2-1NO2 concentration was significantly associated with an increased risk for incident knee OA. This interesting but counterintuitive outcome makes further validation of this biomarker warranted.
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Runhaar J, van Middelkoop M, Reijman M, Willemsen S, Oei EH, Vroegindeweij D, van Osch G, Koes B, Bierma-Zeinstra SMA. Prevention of knee osteoarthritis in overweight females: the first preventive randomized controlled trial in osteoarthritis. Am J Med 2015; 128:888-895.e4. [PMID: 25818496 DOI: 10.1016/j.amjmed.2015.03.006] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2014] [Revised: 03/11/2015] [Accepted: 03/11/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND With accumulating knowledge on osteoarthritis development, the next step is to focus on possibilities for primary prevention. METHODS In a 2 × 2 factorial design, the effects of a diet-and-exercise program and of oral glucosamine sulfate (double blind and placebo-controlled) on the incidence of knee osteoarthritis were evaluated in a high-risk group of 407 middle-aged women with a body mass index ≥ 27 kg/m(2) without clinical signs of knee osteoarthritis at baseline (ISRCTN 42823086). Primary outcome was the incidence of knee osteoarthritis, defined as Kellgren & Lawrence grade ≥ 2, joint space narrowing of ≥ 1.0 mm, or clinical knee osteoarthritis (clinical and radiographic American College of Rheumatology criteria) after 2.5 years. RESULTS After 2.5 years, only 10% of all subjects were lost to follow-up, and 17% of all knees showed incident knee osteoarthritis. Accounting for the significant interaction between the interventions, no significant main effect of either intervention was found. Independently, both interventions alone showed indications of reduced knee osteoarthritis incidence (odds ratio [OR] 0.69; 95% CI, 0.39-1.21 for the diet-and-exercise program and OR 0.60; 95% CI, 0.31-1.12 for the glucosamine intervention). These effects were neutralized in subjects receiving both interventions (OR 0.97; 95% CI, 0.55-1.71). CONCLUSIONS No significant main effects of the diet-and-exercise program and of glucosamine sulfate were found on incident knee osteoarthritis. Nevertheless, this trial provides valuable insights for future trial design for preventive osteoarthritis studies.
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Affiliation(s)
- Jos Runhaar
- Department of General Practice, Erasmus MC University Medical Center, Rotterdam, The Netherlands.
| | - Marienke van Middelkoop
- Department of General Practice, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Max Reijman
- Department of Orthopaedics, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Sten Willemsen
- Department of Biostatistics, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Edwin H Oei
- Department of Radiology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | | | - Gerjo van Osch
- Department of Orthopaedics, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Bart Koes
- Department of General Practice, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Sita M A Bierma-Zeinstra
- Department of General Practice, Erasmus MC University Medical Center, Rotterdam, The Netherlands; Department of Orthopaedics, Erasmus MC University Medical Center, Rotterdam, The Netherlands
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Li J, Zhou XD, Yang KH, Fan TD, Chen WP, Jiang LF, Bao JP, Wu LD, Xiong Y. Hinokitiol reduces matrix metalloproteinase expression by inhibiting Wnt/β-Catenin signaling in vitro and in vivo. Int Immunopharmacol 2014; 23:85-91. [DOI: 10.1016/j.intimp.2014.08.012] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2014] [Revised: 08/07/2014] [Accepted: 08/13/2014] [Indexed: 01/03/2023]
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Coelho CDF, Leal-Junior ECP, Biasotto-Gonzalez DA, Bley AS, de Carvalho PDTDC, Politti F, Gonzalez TDO, de Oliveira AR, Frigero M, Garcia MBS, Dibai-Filho AV, Gomes CAFDP. Effectiveness of phototherapy incorporated into an exercise program for osteoarthritis of the knee: study protocol for a randomized controlled trial. Trials 2014; 15:221. [PMID: 24919587 PMCID: PMC4229877 DOI: 10.1186/1745-6215-15-221] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2014] [Accepted: 05/29/2014] [Indexed: 01/09/2023] Open
Abstract
Background Osteoarthritis is a chronic disease with a multifactor etiology involving changes in bone alignment, cartilage, and other structures necessary to joint stability. There is a need to investigate therapeutic resources that combine different wavelengths as well as different light sources (low-level laser therapy and light-emitting diode therapy) in the same apparatus for the treatment of osteoarthritis. The aim of the proposed study is to analyze the effect of the incorporation of phototherapy into a therapeutic exercise program for individuals with osteoarthritis of the knee. Methods/Design A double-blind, controlled, randomized clinical trial will be conducted involving patients with osteoarthritis of the knee. Evaluations will be performed using functional questionnaires before and after the treatment protocols, in a reserved room with only the evaluator and participant present, and no time constraints placed on the answers or evaluations. The following functional tests will also be performed: stabilometry (balance assessment), dynamometry (muscle strength of gluteus medius and quadriceps), algometry (pain threshold), fleximeter (range of motion), timed up-and-go test (functional mobility), and the functional reach test. The participants will then be allocated to three groups through a randomization process using opaque envelopes: exercise program, exercise program + phototherapy, or exercise program + placebo phototherapy, all of which will last for eight weeks. Discussion The purpose of this randomized clinical trial is to analyze the effect of the incorporation of phototherapy into a therapeutic exercise program for osteoarthritis of the knee. The study will support the practice based on evidence to the use of phototherapy in individuals with a diagnosis of osteoarthritis of the knee. Data will be published after the study is completed. Trial registration The protocol for this study has been submitted to Clinical Trials, registration number NCT02102347, on 29 March 2014.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | - Cid André Fidelis de Paula Gomes
- Postgraduate Program in Biophotonics Applied to Health Sciences, Universidade Nove de Julho (UNINOVE), Av, Dr, Adolfo Pinto,109, Água Branca, 05001-100 São Paulo, SP, Brazil.
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Karlsen TA, Jakobsen RB, Mikkelsen TS, Brinchmann JE. microRNA-140 targets RALA and regulates chondrogenic differentiation of human mesenchymal stem cells by translational enhancement of SOX9 and ACAN. Stem Cells Dev 2014; 23:290-304. [PMID: 24063364 DOI: 10.1089/scd.2013.0209] [Citation(s) in RCA: 94] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Lesions of articular cartilage do not heal spontaneously. One treatment strategy would be to make cartilage in the laboratory by directed chondrogenic differentiation of mesenchymal stem cells (MSCs). To promote our understanding of the molecular control of chondrogenesis, we have compared the changes in microRNAs (miRNAs) during in vitro chondrogenesis of MSCs with those observed in uncultured and dedifferentiated articular chondrocytes (ACs). Several miRNAs showed a reciprocal relationship during the differentiation of MSCs and dedifferentiation of ACs. miR-140-5p and miR-140-3p changed the most during in vitro chondrogenesis, they were the miRNAs most highly expressed in tissue-engineered chondrocytes, and they were also among the miRNAs most highly expressed in uncultured ACs. There was a 57% overlap for the 100 most highly expressed miRNAs in differentiated MSCs and uncultured ACs, but for other miRNAs, the expression pattern was quite different. We transiently and stably inhibited and overexpressed miR-140-5p and miR-140-3p in differentiating MSCs and dedifferentiating ACs, respectively, to describe global effects and identify and validate new targets. Surprisingly, SOX9 and aggrecan proteins were found to be downregulated in anti-miR-140 transduced differentiating MSCs despite unchanged mRNA levels. This suggests that miR-140 stimulates in vitro chondrogenesis by the upregulation of these molecules at the protein level. RALA, a small GTPase, was identified as a miR-140 target and knockdown experiments showed that RALA regulated SOX9 at the protein level. These observations shed new light on the effect of miR-140 for chondrogenesis in vitro and in vivo.
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Affiliation(s)
- Tommy A Karlsen
- 1 Norwegian Center for Stem Cell Research, Oslo University Hospital , Rikshospitalet, Oslo, Norway
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Abstract
Osteoarthritis (OA) is the most common form of arthritis in the United States and is a leading cause of disability. It is typically defined in epidemiologic studies by radiographic findings and consideration of symptoms. Its incidence and prevalence are rising, likely related to the aging of the population and increasing obesity. Risk factors for OA include numerous person-level factors, such as age, sex, obesity, and genetics, as well as joint-specific factors that are likely reflective of abnormal loading of the joints. In studying OA, several methodologic challenges exist that can hamper our ability to identify pertinent relationships.
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Affiliation(s)
- Tuhina Neogi
- Sections of Clinical Epidemiology Research, Training Unit and Rheumatology, Boston University School of Medicine, Boston, MA 02118, USA.
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Gkretsi V, Papanikolaou V, Dubos S, Papathanasiou I, Giotopoulou N, Valiakou V, Wu C, Malizos KN, Tsezou A. Migfilin's elimination from osteoarthritic chondrocytes further promotes the osteoarthritic phenotype via β-catenin upregulation. Biochem Biophys Res Commun 2012; 430:494-9. [PMID: 23237804 DOI: 10.1016/j.bbrc.2012.12.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2012] [Accepted: 12/04/2012] [Indexed: 01/18/2023]
Abstract
Osteoarthritis (OA) is a debilitating disease of the joints characterized by cartilage degradation but to date there is no available pharmacological treatment to inhibit disease progression neither is there any available biomarker to predict its development. In the present study, we examined the expression level and possible involvement of novel cell-ECM adhesion-related molecules such as Iintegrin Linked Kinase (ILK), PINCH, parvin, Mig-2 and Migfilin in OA pathogenesis using primary human articular chondrocytes from healthy individuals and OA patients. Our findings show that only ILK and Migfilin were upregulated in OA compared to the normal chondrocytes. Interestingly, Migfilin silencing in OA chondrocytes rather exacerbated than ameliorated the osteoarthritic phenotype, as it resulted in even higher levels of catabolic and hypertrophic markers while at the same time induced reduction in ECM molecules such as aggrecan. Furthermore, we also provide a link between Migfilin and β-catenin activation in OA chondrocytes, showing Migfilin to be inversely correlated with β-catenin. Thus, the present study emphasizes for the first time to our knowledge the role of Migfilin in OA and highlights the importance of cell-ECM adhesion proteins in OA pathogenesis.
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Affiliation(s)
- Vasiliki Gkretsi
- Center for Research and Technology-Thessaly (CE.RE.TE.TH), Department of Biomedical Research and Technology, Larissa 41222, Greece.
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Suri P, Morgenroth DC, Hunter DJ. Epidemiology of osteoarthritis and associated comorbidities. PM R 2012; 4:S10-9. [PMID: 22632687 DOI: 10.1016/j.pmrj.2012.01.007] [Citation(s) in RCA: 138] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2012] [Accepted: 01/19/2012] [Indexed: 12/14/2022]
Abstract
Osteoarthritis (OA) is the most common cause of walking-related disability among older adults in the United States, and the prevalence and incidence of OA are increasing rapidly. Systemic and local risk factors for knee OA have been identified, and obesity and joint injury appear to be the strongest risk factors that are both modifiable and have the potential for substantial impact on a population level. The risk factors for functional decline and disability in persons with symptomatic OA have been examined in relatively few studies. The course of functional decline in persons with symptomatic OA on a population level is generally one of stable to slowly deteriorating function, but on an individual level, many patients maintain function or improve during the first 3 years of follow-up. Obesity stands out as one of few modifiable risk factors of OA that also is a potentially modifiable predictor of functional decline. Physical activity also appears to have a substantial protective impact on future OA-related disability. Further epidemiologic studies and randomized controlled trials are needed to prioritize prevention through targeting these modifiable risk factors for OA and related disability.
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Affiliation(s)
- Pradeep Suri
- Division of PM&R, VA Boston Healthcare System-JP Campus, 150 S Huntington Ave, Boston, MA 02130, USA.
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Guermazi A, Niu J, Hayashi D, Roemer FW, Englund M, Neogi T, Aliabadi P, McLennan CE, Felson DT. Prevalence of abnormalities in knees detected by MRI in adults without knee osteoarthritis: population based observational study (Framingham Osteoarthritis Study). BMJ 2012; 345:e5339. [PMID: 22932918 PMCID: PMC3430365 DOI: 10.1136/bmj.e5339] [Citation(s) in RCA: 317] [Impact Index Per Article: 26.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
OBJECTIVE To examine use of magnetic resonance imaging (MRI) of knees with no radiographic evidence of osteoarthritis to determine the prevalence of structural lesions associated with osteoarthritis and their relation to age, sex, and obesity. DESIGN Population based observational study. SETTING Community cohort in Framingham, MA, United States (Framingham osteoarthritis study). PARTICIPANTS 710 people aged >50 who had no radiographic evidence of knee osteoarthritis (Kellgren-Lawrence grade 0) and who underwent MRI of the knee. MAIN OUTCOME MEASURES Prevalence of MRI findings that are suggestive of knee osteoarthritis (osteophytes, cartilage damage, bone marrow lesions, subchondral cysts, meniscal lesions, synovitis, attrition, and ligamentous lesions) in all participants and after stratification by age, sex, body mass index (BMI), and the presence or absence of knee pain. Pain was assessed by three different questions and also by WOMAC questionnaire. RESULTS Of the 710 participants, 393 (55%) were women, 660 (93%) were white, and 206 (29%) had knee pain in the past month. The mean age was 62.3 years and mean BMI was 27.9. Prevalence of "any abnormality" was 89% (631/710) overall. Osteophytes were the most common abnormality among all participants (74%, 524/710), followed by cartilage damage (69%, 492/710) and bone marrow lesions (52%, 371/710). The higher the age, the higher the prevalence of all types of abnormalities detectable by MRI. There were no significant differences in the prevalence of any of the features between BMI groups. The prevalence of at least one type of pathology ("any abnormality") was high in both painful (90-97%, depending on pain definition) and painless (86-88%) knees. CONCLUSIONS MRI shows lesions in the tibiofemoral joint in most middle aged and elderly people in whom knee radiographs do not show any features of osteoarthritis, regardless of pain.
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Affiliation(s)
- Ali Guermazi
- Department of Radiology, Boston University School of Medicine, FGH Building, 820 Harrison Avenue, Boston, MA 02118, USA.
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Tan AL, McGonagle D. Hand enthesophytes and knee enthesopathy: is osteoarthritis related to a systemic enthesopathy? J Rheumatol 2012; 39:1481; author reply 1481. [PMID: 22753800 DOI: 10.3899/jrheum.120332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
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Madry H, Luyten FP, Facchini A. Biological aspects of early osteoarthritis. Knee Surg Sports Traumatol Arthrosc 2012; 20:407-22. [PMID: 22009557 DOI: 10.1007/s00167-011-1705-8] [Citation(s) in RCA: 149] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2011] [Accepted: 10/04/2011] [Indexed: 01/15/2023]
Abstract
PURPOSE Early OA primarily affects articular cartilage and involves the entire joint, including the subchondral bone, synovial membrane, menisci and periarticular structures. The aim of this review is to highlight the molecular basis and histopathological features of early OA. METHODS Selective review of literature. RESULTS Risk factors for developing early OA include, but are not limited to, a genetic predisposition, mechanical factors such as axial malalignment, and aging. In early OA, the articular cartilage surface is progressively becoming discontinuous, showing fibrillation and vertical fissures that extend not deeper than into the mid-zone of the articular cartilage, reflective of OARSI grades 1.0-3.0. Early changes in the subchondral bone comprise a progressive increase in subchondral plate and subarticular spongiosa thickness. Early OA affects not only the articular cartilage and the subchondral bone but also other structures of the joint, such as the menisci, the synovial membrane, the joint capsule, ligaments, muscles and the infrapatellar fat pad. Genetic markers or marker combinations may become useful in the future to identify early OA and patients at risk. CONCLUSION The high socioeconomic impact of OA suggests that a better insight into the mechanisms of early OA may be a key to develop more targeted reconstructive therapies at this first stage of the disease. LEVEL OF EVIDENCE Systematic review, Level II.
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Affiliation(s)
- Henning Madry
- Experimental Orthopaedics and Osteoarthritis Research, Saarland University, Kirrbergerstrasse, Building 37, 66421, Homburg, Germany.
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Abstract
Obesity has become an epidemic in American healthcare. Comorbidities such as diabetes and cardiac disease increase the mortality and morbidity for these patients. Obesity-related pain conditions can limit the patient's efforts at increasing activity and limit quality of life. This article will offer information on these conditions and treatment options.
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Affiliation(s)
- Yvonne D'Arcy
- Suburban Hospital-Johns Hopkins Medicine, Bethesda, MD, USA
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Papavasiliou KA, Kenanidis EI, Potoupnis ME, Kapetanou A, Sayegh FE. Participation in athletic activities may be associated with later development of hip and knee osteoarthritis. PHYSICIAN SPORTSMED 2011; 39:51-9. [PMID: 22293768 DOI: 10.3810/psm.2011.11.1939] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Participation in physical activity and recreational sports is critical for maintaining overall health; athletic activities and reduction in the incidence of several "lifestyle" diseases seem to have a dose-dependent relationship. Also, quality of life is enhanced in people who are active and regularly participate in sports. However, sports-related joint loading and strenuous occupational loading have been shown to increase the risk of osteoarthritis (OA), which seems to have a multifactorial etiology. This article reviews the literature on known connections between participation in sports and athletic activities and development of secondary OA in the joints of the major upper and lower limbs (ie, knee, hip, elbow, and shoulder) in athletes without injury. Most studies examining the connection between participation in sports and later development of OA usually provide low-level evidence and have many methodological weaknesses. Based on the literature reviewed in this article, it may be concluded that the connection between participation in athletic activities and development of OA has not been proven; however, the condition is highly likely to occur in the hip and knee joints. Definite conclusions regarding the connection between development of glenohumeral and/or elbow OA and participation in athletic activities cannot be drawn.
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Affiliation(s)
- Kyriakos A Papavasiliou
- 3rd Orthopaedic Department, Aristotle University of Thessaloniki Medical School, Thessaloniki, Greece
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Park H, Lee SK. Association of obesity with osteoarthritis in elderly Korean women. Maturitas 2011; 70:65-8. [DOI: 10.1016/j.maturitas.2011.05.014] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2011] [Revised: 05/23/2011] [Accepted: 05/23/2011] [Indexed: 11/26/2022]
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