Physiologic Treatment of Severe Hypertension in Pregnancy and Postpartum

We aimed to evaluate physiologic treatment of severe hypertension. This was a retrospective cohort study of pregnant and postpartum patients with severe hypertension (systolic blood pressure [BP] 160 mm Hg or higher or diastolic BP 110 mm Hg or higher) treated with intravenous labetalol or hydralazine at a single tertiary care center between 2013 and 2018. Patients were classified as having physiologic treatment if they had hyperdynamic physiology (pulse pressure 65 mm Hg or higher) and received labetalol or had vasoconstrictive physiology (diastolic BP 100 mm Hg or higher) and received hydralazine. The primary outcome was number of antihypertensive doses to achieve nonsevere BP. Of 1,120 patients included in the analysis, 653 had physiologic treatment and 467 had nonphysiologic treatment, with 16 (1.4%) excluded for inability to classify physiology. Physiologic treatment was associated with fewer antihypertensive doses (1.4±0.9 doses vs 1.6±1.4 doses; adjusted β -0.28, 95% CI, -0.42 to -0.14) and lower odds of medication conversion (2.5% vs 4.7%; adjusted odds ratio 0.48, 95% CI, 0.24-0.93) but no difference in time to nonsevere BP (31 minutes [interquartile range 16-66 minutes] vs 34 minutes [interquartile range 15-76 minutes]; adjusted hazard ratio 1.0, 95% CI, 0.9-1.2). Physiologic treatment of severe hypertension warrants further evaluation.

Occipital Nerve Block Compared With Acetaminophen and Caffeine for Headache Treatment in Pregnancy: A Randomized Controlled Trial

OBJECTIVE

To evaluate the efficacy of occipital nerve block compared with standard care , defined as acetaminophen with caffeine, for treatment of acute headache in pregnancy.

METHODS

We conducted a single-center, unblinded, parallel, randomized controlled trial of pregnant patients with headache and pain score higher than 3 on the visual rating scale. Patients with secondary headache, preeclampsia, or allergy or contraindication to study medications were excluded. Participants were randomized to occipital nerve block or standard care (oral 650 mg acetaminophen and 200 mg caffeine). Crossover treatment was given at 2 hours and second-line treatment at 4 hours to those with worsening visual rating scale score or visual rating scale score higher than 3. The primary outcome was headache improvement to a visual rating scale score of 3 or lower within 2 hours of initial therapy. Secondary outcomes included serial visual rating scale scores, receipt of crossover or second-line therapy, patient satisfaction, and perinatal outcomes. Outcomes were assessed in an intention-to-treat analysis. We estimated that a sample of 62 would provide 80% power to detect a difference from 85% to 50% between groups.

RESULTS

From February 2020 to May 2022, 62 participants were randomized to occipital nerve block (n=31) or standard care (n=31). Groups were similar except payer status. The primary outcome, headache improvement to visual rating scale score of 3 or lower, was not significantly different between groups (64.5% vs 51.6%, P =.30). The occipital nerve block group experienced lower median [interquartile range] visual rating scale scores at 1 hour (2 [0-5] vs 6 [2-7], P =.014), and more patients in the occipital nerve block group had visual rating scale scores of 3 or lower at 1 hour. Among patients receiving crossover treatment at 2 hours, the standard care group had a significantly lower visual rating scale score 1 hour after crossover to occipital nerve block than the occipital nerve block group receiving crossover to standard care ( P =.028). There were no significant differences in second-line treatment, refractory headache, satisfaction, or complications. Patients receiving occipital nerve block delivered earlier (36.6 weeks vs 37.8 weeks), but preterm birth did not differ between groups.

CONCLUSION

Occipital nerve block is an effective and quick-acting treatment option for acute headache in pregnancy.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov , NCT03951649.

Fundamentals of osteoarthritis: outcome evaluation with patient-reported measures and functional tests

Evaluating outcome in osteoarthritis (OA) clinical research and practice requires reliable, valid and responsive patient-reported outcome measures (PROMs) and functional tests that reflect important problems experienced by people with OA. The goal of this work is to provide information to start to guide the reader in selecting measures for people with OA. In this narrative review, we begin by providing an overview of measurement properties that can help clinicians and researchers in making decisions about whether a measure might be appropriate for use in their research or clinical context. We then report evidence supporting the use of measures of pain (e.g., Pain Visual Analogue (VAS), Numeric Pain Rating Scale (NPRS), Intermittent and Constant Osteoarthritis Pain, PROMIS Pain Interference, and, for screening in research, the painDETECT and the Self-report Leeds Assessment of Neuropathic Symptoms and Signs) and fatigue (e.g., PROMIS-Fatigue) at a group level in clinical research. Several multi-dimensional joint-specific measures (e.g., Western Ontario McMaster Universities' Osteoarthritis Outcomes Scale, Knee/Hip Injury and Osteoarthritis Outcome Score, Oxford Hip/Knee Scale) also have evidence for group-level use. Functional tests (e.g., timed walk tests, 30 Second Chair Stand, Timed Up and Go, etc.) have measurement properties supporting their use at the group level in clinical research and at the individual patient level as do the pain VAS and NPRS. Other generic and disease-specific PROMs have been used in or could be used in OA studies but their measurement properties require further evaluation in people with OA.

Metabolic alterations and WNT signaling impact immune response in HGSOC

PURPOSE

Our study used transcriptomic and metabolomic strategies to determine the molecular profiles of HGSOC patient samples derived from primary tumor and ascites cells. These data identified clinically relevant heterogeneity among and within patients and highlighted global and patient-specific cellular responses to neoadjuvant chemotherapy (NACT).

EXPERIMENTAL DESIGN

Tissue from 61 treatment naïve patients with HGSOC were collected. In addition, 11 benign, 32 ascites, and 18 post-NACT samples (matched to the individual patient's pre-NACT sample) were collected. RNA-sequencing (RNA-seq) was performed on all samples collected. Two-dimensional spatial proteomic data was collected for two pairs of pre-and post-NACT. Untargeted metabolomics data using GCxGC-MS was generated for 30 treatment-naive tissues. Consensus clustering, analysis of differential expression, pathway enrichment, and survival analyses were performed.

RESULTS

Treatment-naïve HGSOC tissues had distinct transcriptomic and metabolomic profiles. The mesenchymal subtype harbored a metabolomic profile distinct from the other subtypes. Compared to primary tumor tissue, ascites showed significant changes in immune response and signaling pathways. NACT caused significant alterations in gene expression and WNT activity, and this corresponded to altered immune response. Overall, WNT signaling levels were inversely correlated with immune cell infiltration in HGSOC tissues and WNT signaling post-NACT was inversely correlated with progression-free survival.

CONCLUSIONS

Our study concluded that HGSOC is a heterogenous disease at baseline and growing molecular differences can be observed between primary tumor and ascites cells or within tumors in response to treatment. Our data reveal potential exploratory biomarkers relevant for treatment selection and predicting patient outcomes that warrant further research.

Development of an intervention to manage knee osteoarthritis risk and symptoms following anterior cruciate ligament injury

INTRODUCTION

Anterior cruciate ligament (ACL) injury is a risk factor for developing knee osteoarthritis (OA). We developed an intervention to support people manage risk factors for OA.

METHODS

We conducted one-on-one interviews with 20 individuals with OA symptoms 6-15 years post ACL injury and used a nominal group process during a workshop with 40 patients and healthcare professionals (HCPs) to elicit information on the intervention content and delivery characteristics (timing, HCPs, and methods). Interview data were analyzed using content analysis. Nominal group ideas with importance ratings ≥5 of 7 met criteria for inclusion. Results were integrated, considering similarities and differences.

RESULTS

Eight content categories were identified: 1. understanding knee injury and expectations about recovery; 2. understanding OA risk; 3. understanding OA signs and symptoms; 4. managing OA risk; 5. managing knee OA symptoms; 6. information for influencers; 7. credible sources; and, 8. updates on new evidence and treatments. Delivery timing reflected a lifespan approach from time of injury through symptomatic knee OA management. Although multiple media for delivery were identified, introductory face-to-face discussions and opportunity for re-accessing HCPs were critical. All HCPs who treat people with ACL should be familiar with and able to deliver the intervention.

CONCLUSIONS

This co-development approach identified that an intervention to support people with ACL injury to limit and manage knee OA requires content embedded within an easily accessible, multi-media delivery model with capacity for check-back with HCPs that is appealing to different age groups and personal preferences over the lifespan post injury.

Immediate outcomes following the GLA:D® program in Denmark, Canada and Australia. A longitudinal analysis including 28,370 patients with symptomatic knee or hip osteoarthritis

OBJECTIVE

To report outcomes across three countries for patients with symptomatic knee or hip OA attending the evidence-based education and exercise therapy program Good Life with osteoArthritis from Denmark (GLA:D®).

DESIGN

GLA:D® is a structured treatment program including 2-3 patient education sessions and 12 supervised exercise sessions delivered over 8 weeks by certified health care practitioners. The program was introduced in Denmark in 2013, in Canada 2015 and in Australia 2016. Absolute mean change in pain intensity, number of chair stands in 30 s, 40 m walk test time and Knee injury and Osteoarthritis Outcome Score (KOOS)/Hip dysfunction and Osteoarthritis Outcome Score (HOOS) QOL subscale scores from baseline to immediately after treatment were reported as means and 95 % CIs and proportion of responders for each country.

RESULTS

Patients from the three countries improved 26-33% in mean pain intensity, 8-12% in walking speed, 18-30% in chair stand ability and 12-26% in joint-related quality of life from baseline to immediately after treatment, with no clinically relevant differences between patients with hip and knee OA. These improvements correspond with moderate to large within-group effect sizes and 43-47 % of the patients experienced clinically relevant pain reductions.

CONCLUSION

About half or more of patients across the three countries were categorized as responders for pain and objective function following the implementation of GLA:D®. These findings indicate positive patient outcomes associated with GLA:D® participation across varying health care systems from implementation of guideline-based patient education and exercise therapy for knee and hip OA.

Heating events in the nascent solar system recorded by rare earth element isotopic fractionation in refractory inclusions

Equilibrium condensation of solar gas is often invoked to explain the abundance of refractory elements in planets and meteorites. This is partly motivated, by the observation that the depletions in both the least and most refractory rare earth elements (REEs) in meteoritic group II calcium-aluminum-rich inclusions (CAIs) can be reproduced by thermodynamic models of solar nebula condensation. We measured the isotopic compositions of Ce, Nd, Sm, Eu, Gd, Dy, Er, and Yb in eight CAIs to test this scenario. Contrary to expectation for equilibrium condensation, we find light isotope enrichment for the most refractory REEs and more subdued isotopic variations for the least refractory REEs. This suggests that group II CAIs formed by a two-stage process involving fast evaporation of preexisting materials, followed by near-equilibrium recondensation. The calculated time scales are consistent with heating in events akin to FU Orionis- or EX Lupi-type outbursts of eruptive pre-main-sequence stars.

Weight status and associated comorbidities in children and adults with Down syndrome, autism spectrum disorder and intellectual and developmental disabilities

BACKGROUND

Little is known about body weight status and the association between body weight and common comorbidities in children and adults with Down syndrome (DS), autism spectrum disorder (ASD) and other intellectual and developmental disabilities (IDDs).

METHODS

Data were extracted from the University of Kansas Medical Center's Healthcare Enterprise Repository for Ontological Narration clinical integrated data repository. Measures included demographics (sex, age and race), disability diagnosis, comorbid health conditions, height, weight and body mass index percentiles (BMI%ile; <18 years of age) or BMI (≥18 years of age).

RESULTS

Four hundred and sixty-eight individuals with DS (122 children and 346 adults), 1659 individuals with ASD (1073 children and 585 adults) and 604 individuals with other IDDs (152 children and 452 adults) were identified. A total of 47.0% (DS), 41.9% (ASD) and 33.5% (IDD) of children had overweight/obese (OW/OB), respectively. Children with DS were more likely to have OW/OB compared with children with IDD or ASD [odds ratio (OR) = 1.91, 95% confidence interval (CI): (1.49, 2.46); OR = 1.43, 95% CI: (1.19, 1.72)], respectively. A total of 81.1% (DS), 62.1% (ASD), and 62.4% (IDD) of adults were OW/OB, respectively. Adults with DS were more likely to have OW/OB compared with those with IDD [OR = 2.56, 95% CI: (2.16, 3.02)]. No significant differences were observed by race. In children with ASD, higher OW/OB was associated with significantly higher (compared with non-OW/OB) occurrence of sleep apnoea [OR = 2.94, 95% CI: (2.22, 3.89)], hypothyroidism [OR = 3.14, 95% CI: (2.17, 4.25)] and hypertension [OR = 4.11, 95% CI: (3.05, 5.54)]. In adults with DS, OW/OB was significantly associated with higher risk of sleep apnoea and type 2 diabetes [OR = 2.93, 95% CI: (2.10, 4.09); OR = 1.76, 95% CI: (1.11, 2.79) respectively]. Similarly, in adults with ASD and IDD, OW/OB was significantly associated with higher risk of sleep apnoea [OR = 3.39, 95% CI: (2.37, 4.85) and OR = 6.69, 95% CI: (4.43, 10.10)], type 2 diabetes [OR = 2.25, 95 % CI: (1.68, 3.01) and OR = 5.49, 95% CI: (3.96, 7.61)] and hypertension [OR = 3.55, 95% CI: (2.76, 4.57) and 3.97, 95% CI: (3.17, 4.97)].

CONCLUSION

Findings suggest higher rates of OW/OB in individuals with DS compared with ASD and IDD. Given the increased risk of comorbidities associated with the increased risk of OW/OB, identification of effective interventions for this special population of individuals is critical.

Extending the platinum-free interval: The impact of omitting 2nd line platinum chemotherapy in intermediate platinum-sensitive ovarian cancer

OBJECTIVES

Patients with epithelial ovarian cancer (EOC) recurring between 6 and 12 months after primary platinum chemotherapy have worse prognosis than those recurring in >12 months. Artificially prolonging the platinum-free interval (PFI) with cytotoxic chemotherapy was tested in MITO-8 with poor outcomes. This study aimed to determine the impact of using non-platinum or targeted therapy in 2nd line treatment of EOC patients recurring 6-12 months after completion of primary platinum-based chemotherapy.

METHODS

A multi-institutional retrospective review of 177 patients with recurrent EOC and PFI of 6-12 months following primary chemotherapy was performed comparing platinum versus non-platinum chemotherapy or targeted therapy for 2nd line treatment. PFI1 was defined as the date of last chemotherapy to date of recurrence. PFS2/3 were defined as start of 2nd or 3rd line chemotherapy to start of subsequent line.

RESULTS

Of 177 patients, the majority of patients were Caucasian, had serous histology, and underwent primary cytoreductive surgery. Median PFI1 was 8.2 months (95% CI 8-9 months). Second line platinum was omitted in 28% of patients. Bevacizumab was used in 2nd line in 16% of patients; 19% received other targeted therapies. Median PFS2 for platinum chemotherapy was longer than non-platinum (7.1 vs 3 months, p = 0.0114). Median PFS2 was significantly longer for platinum vs. targeted therapy (7.1 vs. 3 months p = 0.0431). Median OS for platinum in 2nd line vs. no platinum was 43.6 vs. 37.6 months (p = 0.0174).

CONCLUSIONS

Use of non-platinum chemotherapy and even targeted therapy to prolong PFI in patients with EOC recurring between 6 and 12 months leads to worse survival.

Microbiological changes observed over 48 weeks of treatment with inhaled liposomal ciprofloxacin in individuals with non-cystic fibrosis bronchiectasis and chronic Pseudomonas aeruginosa lung infection

OBJECTIVES

Non-cystic fibrosis bronchiectasis (NCFBE) with Pseudomonas aeruginosa has been associated with increased pulmonary exacerbation (PEx) and mortality risk. European Respiratory Society guidelines conditionally recommend inhaled antimicrobials for persons with NCFBE, P aeruginosa and three or more PEx/year. We report microbiological results of two randomized, 48-week placebo-controlled trials of ARD-3150 (inhaled liposomal ciprofloxacin) in individuals with NCFBE with P aeruginosa and PEx history [Lancet Respir Med 2019;7:213-26].

METHODS

Respiratory secretions from 582 participants receiving up to six 28-day on/off treatment cycles were analysed for sputum P. aeruginosa, Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, Staphylococcus aureus and Escherichia coli densities, P. aeruginosa susceptibilities to ciprofloxacin and nine other antimicrobials, and prevalence of other bacterial opportunists. Associations between PEx risk and sputum density, antimicrobial susceptibility and opportunist prevalence changes were studied.

RESULTS

Sputum P. aeruginosa density reductions from baseline after ARD-3150 treatments ranged from 1.77 (95% CI 2.13-1.40) versus 0.54 (95% CI 0.89-0.19) log₁₀ CFU/g for placebo (second period) to 2.07 (95% CI 2.45-1.69) versus 0.70 (95% CI 1.11-0.29) log₁₀ CFU/g for placebo (fourth period) with only modest correlation between density reduction magnitude and PEx benefit. ARD-3150 (but not placebo) treatment was associated with increased P. aeruginosa ciprofloxacin MIC but not emergence of other bacterial opportunists across the study; ciprofloxacin MIC₅₀ increased from 0.5 to 1 mg/L, MIC₉₀ increased from 4 to 16 mg/L. Other antimicrobial MIC were mostly unaffected.

CONCLUSION

Microbiological changes over 48 weeks of ARD-3150 treatment appear modest. Ciprofloxacin susceptibility (but not other antimicrobial susceptibility) decreases were observed that did not appear to preclude PEx risk reduction benefit.

Factors associated with the orthopaedic surgeon's decision to recommend total joint replacement in hip and knee osteoarthritis: an international cross-sectional study of 1905 patients

OBJECTIVE

To determine factors associated with orthopaedic surgeons' decision to recommend total joint replacement (TJR) in people with knee and hip osteoarthritis (OA).

DESIGN

Cross-sectional study in eleven countries. For consecutive outpatients with definite hip or knee OA consulting an orthopaedic surgeon, the surgeon's indication of TJR was collected, as well as patients' characteristics including comorbidities and social situation, OA symptom duration, pain, stiffness and function (Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC]), joint-specific quality of life, Osteoarthritis Research Society International (OARSI) joint space narrowing (JSN) radiographic grade (0-4), and surgeons' characteristics. Univariable and multivariable logistic regressions were performed to identify factors associated with the indication of TJR, adjusted by country.

RESULTS

In total, 1905 patients were included: mean age was 66.5 (standard deviation [SD], 10.8) years, 1082 (58.0%) were women, mean OA symptom duration was 5.0 (SD 7.0) years. TJR was recommended in 561/1127 (49.8%) knee OA and 542/778 (69.7%) hip OA patients. In multivariable analysis on 516 patients with complete data, the variables associated with TJR indication were radiographic grade (Odds Ratio, OR for one grade increase, for knee and hip OA, respectively: 2.90, 95% confidence interval [1.69-4.97] and 3.30 [2.17-5.03]) and WOMAC total score (OR for 10 points increase: 1.65 [1.32-2.06] and 1.38 [1.15-1.66], respectively). After excluding radiographic grade from the analyses, on 1265 patients, greater WOMAC total score was the main predictor for knee and hip OA; older age was also significant for knee OA.

CONCLUSION

Radiographic severity and patient-reported pain and function play a major role in surgeons' recommendation for TJR.

Depression and medication nonadherence in childhood-onset systemic lupus erythematosus

Objectives Depression and medication nonadherence are important in managing chronic diseases, but little is known about these factors in childhood-onset systemic lupus erythematosus (cSLE). The objectives of this cross-sectional study were to estimate prevalence of depression and medication nonadherence, describe demographic and disease characteristics associated with depression and medication nonadherence, and evaluate the association between depression and medication nonadherence in cSLE patients. Methods Patients with cSLE ( n = 51) completed validated screening questionnaires to identify depression and medication nonadherence, Patient Health Questionnaire-9 and Medication Adherence Self-Report Inventory, respectively. Demographic and disease characteristics were obtained via chart abstraction, and compared between groups of depression or medication nonadherence status. A multivariable linear regression model adjusting for propensity scores was conducted to evaluate the association between depression and medication nonadherence. Results The prevalence of a positive depression screen was 58.8%, and seven patients reported suicidal ideation (13.7%). The prevalence of self-reported medication nonadherence was 19.7%. No statistically significant differences for demographic and disease characteristics were found between patients with a positive vs. negative depression screen. Patients reporting medication nonadherence were more likely to have longer disease duration (4.8 vs. 2.6 years, p = 0.035). As the severity of depression symptoms increased, the degree of medication nonadherence also increased (beta = -1.89; p = 0.011). Conclusions The prevalence of depression and medication nonadherence is high in cSLE, and these factors have a direct relationship. Interventions that better recognize and treat depression and increase rates of medication adherence are needed to improve outcomes in cSLE.

First detection of Edwardsiella ictaluri (Proteobacteria: Enterobacteriaceae) in wild Australian catfish

The bacterium Edwardsiella ictaluri is considered to be one of the most significant pathogens of farmed catfish in the United States of America and has also caused mortalities in farmed and wild fishes in many other parts of the world. E. ictaluri is not believed to be present in wild fish populations in Australia, although it has previously been detected in imported ornamental fishes held in quarantine facilities. In an attempt to confirm freedom from the bacterium in Australian native fishes, we undertook a risk-based survey of wild catfishes from 15 sites across northern Australia. E. ictaluri was detected by selective culturing, followed by DNA testing, in Wet Tropics tandan (Tandanus tropicanus) from the Tully River, at a prevalence of 0.40 (95% CI 0.21-0.61). The bacterium was not found in fishes sampled from any of the other 14 sites. This is the first report of E. ictaluri in wild fishes in Australia.

Cross-cultural adaptation and implementation of Good Life with osteoarthritis in Denmark (GLA:D™): group education and exercise for hip and knee osteoarthritis is feasible in Canada

OBJECTIVE

Adapt and evaluate the feasibility of implementing Good Life with osteoArthritis in Denmark (GLA:D^TM) in Canada for people with mild to severe hip/knee osteoarthritis.

METHODS

Patients triaged to non-surgical management participated in two education sessions and 12 supervised, neuromuscular exercise classes. We used the RE-AIM implementation framework evaluating outcomes of Reach, Effectiveness/Efficacy, Adoption, Implementation and Maintenance. Patients completed surveys pre-program and at 3 months follow-up. Program fidelity was evaluated at four observations against a priori criteria. We conducted semi-structured interviews with therapists post-program.

RESULTS

72 patients consented to participate, 59 started the program and one withdrew on physician advice. The remaining 58 provided follow-up data. Mean age was 67 years; 78% were female and 52% had body mass index (BMI) >25. The effect of the program was demonstrated: 40% improvement in pain with 59% achieving a clinically important improvement of ≥2 points on the Numeric Pain Rating scale. Statistically significant improvement also occurred in the Hip disability/Knee injury and Osteoarthritis Outcome Score subscales. 24% reported increased physical activity. Program fidelity was demonstrated with all criteria met. Therapists emphasized that rolling recruitment allowed appropriate supervision and resulted in participants encouraging each other. 99% of participants indicated they benefitted from and were satisfied with the program and 90% reported using the knowledge daily. 52% were willing to pay >$250 Cdn for the program.

CONCLUSION

GLA:D^TM implementation was feasible in the Canadian context with results similar to those of >7,000 participants in Denmark. Implementation and evaluation of GLA:D^TM Canada is now occurring nationally.

A prospective cohort study examining medical and social factors associated with engagement in life activities following total hip replacement

OBJECTIVES

Studies show limited improvement in the frequency of engaging in life activities after joint replacement. However, there is a paucity of research that has examined factors, including other life events, which influence engagement following total hip replacement (THR). This research sought to identify factors associated with engaging in life activities following THR.

METHODS

A prospective cohort study was conducted with 376 people who had a THR for osteoarthritis (OA). Data were collected pre-surgery and 1 year post-surgery. The primary outcome was change in frequency in engagement in life activities (Late Life Disability Index (LLDI): higher scores indicate higher frequency of engagement (range 0-80)). Analyses included multivariable regression. Factors considered included: positive/negative life events, a new comorbidity, another joint replacement and complications post-surgery.

RESULTS

Participants' mean age was 64 years; 46% were male. 68% of participants had at least one comorbidity pre-surgery; 36% reported at least one new comorbidity after surgery. The mean change in LLDI frequency was an increase of 6.29 (±8.10). 36% reported one or more positive impact life events in the year following surgery; 63% reported one or more negative life events. The number of positive life events (beta = 1.24; 95% CI: 0.49, 1.99) was significantly associated with change in LLDI frequency after adjusting for age, sex, education, body mass index (BMI), comorbidities pre-surgery, number of symptomatic joints and pre-surgery pain and function, LLDI limitations and depression.

CONCLUSIONS

These findings highlight the significant influence of social factors and life circumstances on engagement in life activities following THR.

Patient Perceptions of Care as Influenced by a Large Institutional Pharmacogenomic Implementation Program

Despite growing clinical use of genomic information, patient perceptions of genomic-based care are poorly understood. We prospectively studied patient-physician pairs who participated in an institutional pharmacogenomic implementation program. Trust/privacy/empathy/medical decision-making (MDM)/personalized care dimensions were assessed through patient surveys after clinic visits at which physicians had access to preemptive pharmacogenomic results (Likert scale, 1 = minimum/5 = maximum; mean [SD]). From 2012-2015, 1,261 surveys were issued to 507 patients, with 792 (62.8%) returned. Privacy, empathy, MDM, and personalized care scores were significantly higher after visits when physicians considered pharmacogenomic results. Importantly, personalized care scores were significantly higher after physicians used pharmacogenomic information to guide medication changes (4.0 [1.4] vs. 3.0 [1.6]; P < 0.001) compared with prescribing visits without genomic guidance. Multivariable modeling controlling for clinical factors confirmed personalized care scores were more favorable after visits with genomic-influenced prescribing (odds ratio [OR] = 3.26; 95% confidence interval [CI] = (1.31-8.14); P < 0.05). Physicians seem to individualize care when utilizing pharmacogenomic results and this decision-making augmentation is perceived positively by patients.

Cross-cultural validation of the ICOAP and physical function short forms of the HOOS and KOOS in a multi-country study of patients with hip and knee osteoarthritis

OBJECTIVE

To evaluate the internal consistency and construct validity of the Physical Function short-forms for the Hip and Knee Injury Osteoarthritis Outcome Scores (HOOS-PS/KOOS-PS) and the Intermittent and Constant Osteoarthritis Pain (ICOAP) in a nine country study of patients consulting for total hip or knee replacement (THR or TKR).

METHODS

Patients completed HOOS-PS or KOOS-PS, ICOAP and Western Ontario and McMaster Universities' Osteoarthritis Index (WOMAC) pain and physical function subscales at their consultation visit. Internal consistency was calculated using Cronbach's alpha. The association of HOOS-PS/KOOS-PS and ICOAP with WOMAC pain and function subscales was calculated with Spearman correlation coefficients with 95% confidence intervals.

RESULTS

HOOS-PS/KOOS-PS and ICOAP demonstrated high internal consistency across countries (alpha 0.75-0.96 (hip) and 0.76-0.95 (knee)). Both HOOS-PS and KOOS-PS demonstrated high correlations (0.76-0.90 and 0.75-0.91, respectively) with WOMAC function in all countries. ICOAP exhibited moderate to high correlations with WOMAC pain and function subscales (0.53-0.84 (hip) and 0.43-0.84 (knee)).

CONCLUSION

The psychometric properties of the HOOS-PS/KOOS-PS, and ICOAP were maintained across all countries.

A Novel Mechanism for Human Cardiac Ankyrin-B Syndrome due to Reciprocal Chromosomal Translocation

BACKGROUND

Cardiac rhythm abnormalities are a leading cause of morbidity and mortality in developed countries. Loss-of-function variants in the ANK2 gene can cause a variety of cardiac rhythm abnormalities including sinus node dysfunction, atrial fibrillation and ventricular arrhythmias (called the "ankyrin-B syndrome"). ANK2 encodes ankyrin-B, a molecule critical for the membrane targeting of key cardiac ion channels, transporters, and signalling proteins.

METHODS AND RESULTS

Here, we describe a family with a reciprocal chromosomal translocation between chromosomes 4q25 and 9q26 that transects the ANK2 gene on chromosome 4 resulting in loss-of-function of ankyrin-B. Select family members with ankyrin-B haploinsufficiency due to the translocation displayed clinical features of ankyrin-B syndrome. Furthermore, evaluation of primary lymphoblasts from a carrier of the translocation showed altered levels of ankyrin-B as well as a reduced expression of downstream ankyrin-binding partners.

CONCLUSIONS

Thus, our data conclude that, similar to previously described ANK2 loss-of-function "point mutations", large chromosomal translocations resulting in ANK2 haploinsufficiency are sufficient to cause the human cardiac ankyrin-B syndrome. The unexpected ascertainment of ANK2 dysfunction via the discovery of a chromosomal translocation in this family, the determination of the familial phenotype, as well as the complexities in formulating screening and treatment strategies are discussed.

Primary care physicians' perceptions about and confidence in deciding which patients to refer for total joint arthroplasty of the hip and knee

OBJECTIVE

The purpose of this study is to examine the perceptions of primary care physicians (PCPs) regarding indications, contraindications, risks and benefits of total joint arthroplasty (TJA) and their confidence in selecting patients for referral for TJA.

DESIGN

PCPs recruited from among those providing care to participants in an established community cohort with hip or knee osteoarthritis (OA). Self-completed questionnaires were used to collect demographic and practice characteristics and perceptions about TJA. Confidence in referring appropriate patients for TJA was measured on a scale from 1 to 10; respondents scoring in the lowest tertile were considered to have 'low confidence'. Descriptive analyses were conducted and multiple logistic regression was used to determine key predictors of low confidence.

RESULTS

212 PCPs participated (58% response rate) (65% aged 50+ years, 45% female, 77% >15 years of practice). Perceptions about TJA were highly variable but on average, PCPs perceived that a typical surgical candidate would have moderate pain and disability, identified few absolute contraindications to TJA, and overestimated both the effectiveness and risks of TJA. On average, PCPs indicated moderate confidence in deciding who to refer. Independent predictors of low confidence were female physicians (OR = 2.18, 95% confidence interval (CI): 1.06-4.46) and reporting a 'lack of clarity about surgical indications' (OR = 3.54, 95% CI: 1.87-6.66).

CONCLUSIONS

Variability in perceptions and lack of clarity about surgical indications underscore the need for decision support tools to inform PCP - patient decision making regarding referral for TJA.

Understanding why people do or do not engage in activities following total joint replacement: a longitudinal qualitative study

OBJECTIVE

Numerous studies report large and significant improvements in basic mobility and activities of daily living following total hip or knee replacement (TJR). Nevertheless, quantitative research has shown minimal increase in participation in activities that benefit overall health. This study explored why people do or do not engage in activities following hip or knee TJR.

METHOD

This was a longitudinal qualitative study. Sampling was guided by constructivist grounded theory and data collected using open-ended, semi-structured interviews. Participants were recruited using maximum variation sampling based on age, sex and joint replaced (hip or knee). Data were analysed using a constant comparative approach and coded for thematic patterns and relationships from which overarching themes were constructed.

RESULTS

Twenty-nine patients participated in interviews prior to, and 8 and 18 months post following TJR. A high degree of variability with regard to participants' return to activities was found and five emergent themes were identified that accounted for this variability. These themes highlight the importance of issues beyond medical factors alone, such as socio-cultural factors that partially determine participants' participation in activity following TJR.

CONCLUSION

Findings suggest that multi-faceted experiences impact participation in activity following TJR. These experiences include changes in identity and lifestyle that preclude a 'return to normal'. There is an urgent need for supports to increase people's activity post-TJR in order to facilitate enhancement of post-surgery levels of engagement. Approaches that take into consideration more personalized interventions may be critical to promoting healthy aging in people with TJR.

The potential benefits of herbicide regulation: a cautionary note for the Great Barrier Reef catchment area

Industry transitions away from traditional photosystem II inhibiting (PSII) herbicides towards an 'alternative' herbicide suite are now widely advocated as a key component of improved environmental outcomes for Australia's Great Barrier Reef and improved environmental stewardship on the part of the Queensland sugar industry. A systematic desktop risk analysis found that based on current farming practices, traditional PSII herbicides can pose significant environmental risks. Several of the 'alternatives' that can directly fill a specific pre-emergent ('soil residual') weed control function similar to regulated PSII herbicides also, however, presented a similar environmental risk profile, regardless of farming systems and bio-climatic zones being considered. Several alternatives with a pre-emergent residual function as well as alternative post-emergent (contact or 'knockdown') herbicides were, predicted to pose lower environmental risks than the regulated PSII herbicides to most trophic levels, although environmental risks could still be present. While several herbicides may well be viable alternatives in terms of weed control, they can still present equal or possibly higher risks to the environment. Imposing additional regulations (or even de-registrations) on particular herbicides could result in marginal, and possibly perverse environmental impacts in the long term, if usage shifts to alternative herbicides with similar risk profiles. Regardless of any regulatory efforts, improved environmental sustainability outcomes in pesticide practices within the Great Barrier Reef catchment area will hinge primarily on the continuing adoption of integrated, strategic pest management systems and technologies applied to both traditional and 'alternative' herbicides. One of the emerging policy challenges is ensuring the requisite technical and extension support for cane growers to ensure effective adoption of rapidly evolving farming system technologies, in a very dynamic and scrutinised herbicide management environment.

Return to work and workplace activity limitations following total hip or knee replacement

OBJECTIVE

Total hip (THR) and knee (TKR) replacements increasingly are performed on younger people making return to work a salient outcome. This research evaluates characteristics of individuals with early and later return to work following THR and TKR. Additionally, at work limitations pre-surgery and upon returning to work, and factors associated with work limitations were evaluated.

METHODS

190 THR and 170 TKR of a total 931 cohort participants were eligible (i.e., working or on short-term disability pre-surgery). They completed questionnaires pre-surgery and 1, 3, 6 and 12 months post-surgery that included demographics, type of occupation, and the Workplace Activity Limitations Scale (WALS).

RESULTS

166 (87%) and 144 (85%) returned to work by 12 months following THR and TKR, respectively. Early (1 month) return to work was associated with, male gender, university education, working in business, finance or administration, and low physical demand work. People with THR returned to work earlier than those with TKR. For both groups, less pain and every day functional limitations were associated with less workplace activity limitations at the time return to work.

CONCLUSIONS

The majority of individuals working prior to surgery return to work following hip or knee replacement for osteoarthritis (OA) and experience fewer limitations at work than pre-surgery. The changing workforce dynamics and trends toward surgery at younger ages mean that these are important outcomes for clinicians to assess. Additionally, this is important information for employers in understanding continued participation in employment for people with OA.

Neuropathic pain symptoms on the modified painDETECT correlate with signs of central sensitization in knee osteoarthritis

OBJECTIVE

Clinical tools are needed to identify and target a neuropathic-like phenotype, which may be associated with central sensitization (CS), in osteoarthritis (OA). The modified painDETECT questionnaire (mPD-Q) has face and content validity for identifying neuropathic-like symptoms in knee OA. To further validate the mPD-Q, this study assessed the unknown relationship between mPD-Q scores and signs of CS on quantitative sensory testing (QST) in knee OA.

DESIGN

36 Individuals were recruited with chronic, symptomatic, knee OA without other pain/neurological conditions. Reference QST data were obtained from 18 controls/32 eligible knees, enabling identification of sensory abnormalities/CS among case knees. A standardized questionnaire assessed psychological factors (depressive symptoms and pain catastrophizing), and for individual knees, mPD-Q and pain intensity scores. A standardized/comprehensive QST protocol was conducted for each knee. QST signs of CS were defined as: mechanical hyperalgesia and/or enhanced temporal summation and/or allodynia. The relationship between the presence of CS (yes/no) and a pre-selected mPD-Q score (≤12 or >12), by knees, was assessed using generalized estimating equations.

RESULTS

Among 57 eligible case knees, 45.6% had ≥1 sign of CS. Controlling for age, knees with higher mPD-Q scores (>12.0) had higher odds of having QST signs of CS (adjusted odds ratio (OR) = 5.6; 95% confidence interval (CI), 1.3-22.9). This relationship was unaffected by controlling for depression and pain intensity, but was attenuated by pain catastrophizing.

CONCLUSIONS

Among painful OA knees, higher mPD-Q scores were associated with greater odds of having signs of CS. Thus, the mPD-Q may aid the identification of CS in people with chronic knee OA.

The importance of perceived helplessness and emotional health in understanding the relationship among pain, function, and satisfaction following revision knee replacement surgery

OBJECTIVE

Little is known about the relationships among pain, function, psychological variables like perceived helplessness and emotional health, and patient satisfaction in people with revision knee replacement surgery. We hypothesized that pain and function would have a direct association with satisfaction as well as an indirect association through patient perceptions of helplessness and emotional health.

DESIGN

This longitudinal study included 145 participants undergoing revision knee replacement surgery. Demographic data and expectation of benefit from surgery were recorded prior to surgery. The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), the Arthritis Helplessness Scale (AHS) and the Mental Component Scale (MCS) of the SF-36 (emotional health) were collected prior to and 2 years post-surgery. Satisfaction was recorded 2 years post-surgery. Regression analyses were conducted to test for mediation effects of helplessness and MCS.

RESULTS

Participants were on average 69 years old and 54% were women. Participants were satisfied with the results of the surgery (mean ± standard deviation (SD) = 70.42 ± 31.46). Less pain and functional disability were associated with increased patient satisfaction and, the effect of pain or function was also mediated through helplessness whereby more pain and disability were associated with perceptions of helplessness and helplessness was associated with lower satisfaction. MCS did not mediate the relationship of pain and function with satisfaction.

CONCLUSION

Helplessness plays an important role in understanding patient satisfaction. Interventions aimed at improving patient outcome should target not only pain and function but also should address strategies to support people in managing following knee revision surgery to maximize satisfaction with outcome.

Insurer and employer views on pediatric obesity treatment: a qualitative study

OBJECTIVE

The effectiveness of group-based comprehensive, multidisciplinary (stage 3) pediatric weight management programs is backed by a growing body of literature, yet insurance coverage of these programs is scarce to nonexistent, limiting their reach and long-term survival. The objective of this study was to better understand the perspectives of insurers and large employers on the issue of group-based treatment coverage.

DESIGN AND METHODS

The authors performed a qualitative study utilizing structured interviews with these stakeholders, following accepted techniques.

RESULTS

Six major themes emerged: cost, program effectiveness, corporate social responsibility, secondary parental (employee) benefits, coverage options and new benefit determination.

CONCLUSION

Future efforts to secure payment for group-based pediatric weight management programs should address these key themes.

Lack of biologically active estrogens in commercial cow milk

Recently, many studies have investigated potential estrogenic compounds in the human diet. Several of these investigations have studied cow milk, a mainstay of the diets of both young and old. In vitro studies have determined that estrogens can be found in milk, and that the concentration of estrogen may be correlated to the fat content in the milk. Regardless, the majority of these studies have concluded that the levels of estrogens in milk are too low to have a physiological effect. However, a recent study found that commercial 1% cow milk was uterotrophic in rats, suggesting that it contained biologically significant levels of estrogen. Using the rat model, we tested milk samples from commercial sources and with varying fat content for estrogenic activity. Ovariectomized female rats were given milk ad libitum for a period of 2 wk. After 12 d of treatment, rats were tested sequentially in an open field and an elevated plus maze to determine any effect of milk on anxiety levels. Upon completion of the behavior testing, uterine weights were examined. Regardless of milk type, no difference was observed in daily volume of milk consumed. Contrary to previous publications, no differences existed in either the behavior or the uterine weights between animals that consumed any milk type and the negative controls. These results demonstrated that none of the commercial milk types that we tested contained biologically significant estrogenic activity.

Terrestrial pollutant runoff to the Great Barrier Reef: An update of issues, priorities and management responses

The Great Barrier Reef (GBR) is a World Heritage Area and contains extensive areas of coral reef, seagrass meadows and fisheries resources. From adjacent catchments, numerous rivers discharge pollutants from agricultural, urban, mining and industrial activity. Pollutant sources have been identified and include suspended sediment from erosion in cattle grazing areas; nitrate from fertiliser application on crop lands; and herbicides from various land uses. The fate and effects of these pollutants in the receiving marine environment are relatively well understood. The Australian and Queensland Governments responded to the concerns of pollution of the GBR from catchment runoff with a plan to address this issue in 2003 (Reef Plan; updated 2009), incentive-based voluntary management initiatives in 2007 (Reef Rescue) and a State regulatory approach in 2009, the Reef Protection Package. This paper reviews new research relevant to the catchment to GBR continuum and evaluates the appropriateness of current management responses.

Functional outcome in limb-salvage surgery for soft tissue tumours of the foot and ankle

Purpose. This paper describes the functional and oncologic outcome of 30 cases (in 29 patients) treated with limb-salvage surgery for localized soft tissue sarcoma (STS) or fibromatosis of the foot and ankle.Subjects. Patients were eligible for the study if they had a STS or fibromatosis in the distal one-third of the tibia or the foot such that ablative surgery would require a below-knee amputation; had no metastatic disease at presentation; and had a minimum of 2 years of follow-up.Methods. Function was prospectively evaluated using the modified Enneking functional rating scale (MSTS) at 3, 6, 12 months and at most recent follow-up. Premorbid work status and change following surgery, lower leg oedema, and the use of orthotics and ambulatory aids were consecutively assessed. Tumour characteristics were recorded and patients were followed for systemic and local recurrence.Results. Thirty-six consecutive cases were managed by a multi-disciplinary sarcoma team. Six patients underwent below-knee amputation due to extensive local disease, while 30 cases were treated with limb-salvage surgery. Of the patients treated with limb salvage, there were 19 high-grade sarcomas, five low-grade sarcomas and six cases of fibromatosis. Microscopically negative margins were achieved in 26 of 30 cases. Ten cases required bone excision, and eight patients needed free vascularized tissue flaps. Twenty-five patients received adjuvant radiotherapy. Seven patients had post-operative complications. At mean follow-up of 52 months (range 24-109 months), four patients had developed systemic recurrence. There was one local recurrence in a patient with fibromatosis, while another patient with fibromatosis developed recurrence a considerable distance from the surgical and radiation field. Mean scores on the MSTS were 27.5 (range 11-35), 29.9 (range 13-35), 31.4 (range 17-35) and 31.0 (range 13-35) at 3, 6, 12 months and at most recent follow-up, respectively. Eighty-five per cent of the patients scored good to excellent at their last visit. Twelve patients reported persistent pain with two continuing to require occasional narcotics. Six had persistent mild oedema. Four required shoe modifications and three continue to use a cane. Six patients were unable to return to their premorbid employment with the majority of these previously employed in jobs requiring physical labour or long periods of either standing or walking.Discussion. Thirty of 36 patients (83%) presenting with foot and ankle STS or fibromatosis were candidates for limb preservation. With excellent local control and good functional outcome demonstrated in this study, limb salvage should be a primary goal in the management of selected patients with STS and fibromatosis of the foot and ankle.

Symptoms and their Relationship to Disability Following Treatment for Lower Extremity Tumours

Purpose. The aims of this study were to describe the symptoms experienced by patients in the first year following treatment for lower extremity sarcoma by limb conservation and to describe the relationship between symptoms and physical disability.

Subjects. Eighty consecutive patients treated for primary bone or soft tissue sarcoma (STS) of the lower limb who were treated with limb preservation surgery.

Methods. Subjects were evaluated by questionnaire at 6 weeks, and 3, 6, and 12 months post surgery. They identified whether they experienced any of the following symptoms: pain, stiffness, fatigue, weakness, limited range of motion, or swelling.The Toronto Extremity Salvage Score (TESS), a measure of physical disability, was also completed. Frequency of symptoms over time was calculated and change was evaluated using the Cochrane test. The relationship of symptoms to disability was analyzed with regression methods.

Results. The mean age was 43.0, SD=20.4 with a gender ratio of 1:1. There were 38 bone tumours and 42 STS.The most frequently reported symptoms were: stiffness 48 (60%), weakness 41 (51%), fatigue 26 (33%), and pain 25 (31%) at 6 weeks. Stiffness and fatigue decreased and plateaued by 3 months. Complaints of weakness and pain continued to decrease over time. At 6 weeks, pain, stiffness, weakness and limited motion predicted disability in both univariate and multivariate analyses. At 12 months, pain, stiffness, fatigue, weakness and limited motion were significant predictors of the TESS in univariate analysis with only pain, stiffness and limited motion significant predictors in the multivariate model.

Discussion. Pain, stiffness, fatigue, weakness and limited motion are common symptoms with stiffness and weakness decreasing significantly over time. The symptoms predictive of disability differ between the acute and late phases of recovery.

A comparison of outcome of osteoarticular allograft reconstruction and shoulder arthrodesis following resection of primary tumours of the proximal humerus

Purpose. The purpose of this study was to compare the oncologic, reconstructive and functional outcomes of patients who underwent osteoarticular allograft reconstruction with those who underwent arthrodesis for a primary malignant bone tumour of the proximal humerus.

Patients. Eleven patients were treated with osteoarticular allograft reconstruction of the proximal humerus. Five of these reconstructions failed, necessitating revision to a secondary arthrodesis. Five patients underwent arthrodesis as a primary reconstruction, for a total of ten patients in the arthrodesis group.

Methods. End points included local and systemic disease recurrence, complications and functional outcome (measured using the 1987 and 1993 Musculoskeletal Tumour Society Rating Scales (MSTS) and the Toronto Extremity Salvage Score (TESS)).

Results. One patient died of systemic disease 2 years post-operatively and one patient had an axillary node recurrence resected 10 months post-operatively and remains free of disease 53 months later. The other 14 patients were alive with no evidence of disease at the time of the last follow-up. Complications after the osteochondral allografts (n=11) included two infections, four fractures and three subluxations in eight patients. Six of these patients required removal of the allograft; one had a repeat osteochondral allograft and five were converted to an arthrodesis. Complications after arthrodesis in the ten patients (five primary and five secondary arthrodeses) included two non-unions, one infection and one fracture in three patients. Patients who underwent shoulder arthrodesis scored better in all outcome measures and this was statistically significant in the MSTS 1993 (p=0.001, Mann–Whitney U Test).

Discussion. In this study, there was a trend towards improved function following arthrodesis compared to osteochondral allograft reconstruction following proximal humerus bone tumour resection.

The geometric osteotomy: joint preservation in juxta-articular surface bone neoplasms

Purpose. To present the oncologic and functional results of a consecutive series of patients treated by geometric osteotomy and allograft reconstruction for juxta-articular surface bone neoplasms.

Patients. Twelve consecutive patients (mean age 28 years) underwent excision of benign aggressive or malignant juxta-articular surface bone neoplasms. In each case, only part of the circumference of the bone was excised, and the joint surface was preserved and kept in continuity with the remainder of the bone. The defects were filled with allograft or autograff, and internally fixed as appropriate.

Methods. Patients were eligible for the study if they had a histologically proven, primary tumour of bone adjacent to a joint such that the turnout could be completely excised with a partial cortical resection and preservation of the joint. The database at the University Musculoskeletal Oncology Unit was used to identify all cases. Patient demographics and oncologic results were recorded. Functional assessment was performed using the Musculoskeletal Tumor Society rating scale and the Toronto Extremity Salvage Score.

Results. Nine tumours were about the knee and three were in the proximal humerus. Negative margins were achieved in all cases. No patient had metastatic disease at a mean follow-up of 56.5 months. There was one local recurrence and this was managed by conversion to a Van Nes rotationplasty. Functional results were excellent in the proximal humeral cases and in cases about the knee where the stabilizing ligaments were preserved. Cases with post-operative knee instability were less successful but none the less were well controlled with bracing.

Discussion. This technique offers an alternative to joint excision and prosthetic replacement in a group of young patients.

Neuropathic pain symptoms in a community knee OA cohort

OBJECTIVE

A neuropathic pain (NP) questionnaire may facilitate the identification of a neuropathic component to osteoarthritis (OA) pain. An existing questionnaire, the painDETECT, was modified for use in knee OA and administered to measure the prevalence and correlates of NP symptoms among adults with this condition.

METHOD

Sensibility of the modified painDETECT (mPD-Q) was assessed in 20 OA subjects followed by mail administration in an established knee OA cohort. NP symptoms were defined using a previously established, painDETECT cut-point. Correlates of NP symptoms, including OA severity (Western Ontario and McMaster Universities Osteoarthritis Index, Von Korff Chronic Pain Grade pain subscale score), psychological factors (Centre for Epidemiological Studies Depression Scale, Pain Catastrophizing Scale), and concomitant medical conditions, were evaluated using logistic regression. Construct validity of the mPD-Q was evaluated through co-administration with another NP questionnaire (S-LANSS).

RESULTS

The mPD-Q had face and content validity. Of 259 eligible cohort members, 171 (66%) completed the questionnaire; 28% had NP symptoms on the mPD-Q (19% among those without neurological conditions). Independent correlates of NP symptoms were: pain intensity (adjusted odds ratio [OR]=2.1 per 10 unit increase, P<0.0001), the presence of referred back/hip pain (adjusted OR=2.9, P=0.024), number of painful joints (OR=1.2, P=0.20) and one or more self-reported neurological condition (OR=3.0, P=0.026).

CONCLUSIONS

Among older adults with chronic symptomatic knee OA, over one-quarter had NP symptoms localized to their knees using the mPD-Q. The mPD-Q may facilitate the identification of a neuropathic component to pain in adults with knee OA who may benefit from further evaluation and/or treatment for NP.

39Ar detection at the 10(-16) isotopic abundance level with atom trap trace analysis

Atom trap trace analysis, a laser-based atom counting method, has been applied to analyze atmospheric 39Ar (half-life=269  yr), a cosmogenic isotope with an isotopic abundance of 8×10(-16). In addition to the superior selectivity demonstrated in this work, the counting rate and efficiency of atom trap trace analysis have been improved by 2 orders of magnitude over prior results. The significant applications of this new analytical capability lie in radioisotope dating of ice and water samples and in the development of dark matter detectors.

Trophic ecology of northern Australia's terapontids: ontogenetic dietary shifts and feeding classification

The diets of 21 terapontid species from freshwater environments in northern Australia were investigated to determine the similarity and dissimilarity among species and the extent of any ontogenetic shifts. Distinct ontogenetic dietary shifts occurred in all species for which sufficient data were available, with many species passing through several discrete trophic categories during their life histories. Diets of all juvenile terapontids were similar, mainly comprising aquatic insects and zooplankton. Larger size classes of terapontids diverged into a broad spectrum of feeding groups comprising carnivorous dietary modes (including piscivory and lepidophagy), omnivory (including frugivory and consumption of allochthonous prey), herbivory and detritivory. The results indicate that the terapontids represent Australia's most trophically diverse freshwater fish family.

Memory of pain and anxiety associated with tooth extraction

Concerns regarding pain constitute a large component of dental anxiety, and patients with high dental anxiety are likely to have exaggerated memory and prediction of dental pain. It remains to be investigated, however, if memory of anxiety is exaggerated in a manner similar to that of pain, and if anxiety and pain assimilate in memory over time. A sample of 79 patients presenting for emergency extraction rated their anxiety and pain before, during, and two weeks after the procedure. Measures of trait dental anxiety and fear of pain also were collected. All patients exaggerated their recall of procedure pain, but only those high in trait dental anxiety exaggerated their recall of anxiety. Highly anxious patients reported more pain prior to the procedure and expected more pain; ratings of anxiety and pain for all participants assimilated over time.

Evaluating the responsiveness of the ICOAP following hip or knee replacement

OBJECTIVE

The Intermittent and Constant Osteoarthritis (OA) Pain (ICOAP) questionnaire evaluates the constructs of 'intermittent'(tm) and 'constant'(tm) pain. Theses are conceptually different from 'pain on activity'(tm) and pain 'intensity'(tm) as measured by the WOMAC and Chronic Pain Grade (CPG), measures commonly used in OA. The purpose of this study was to evaluate the responsiveness of the ICOAP, and different pain constructs in primary total hip (THR) and total knee (TKR) replacement.

METHODS

Patients completed the ICOAP, WOMAC and HOOS/KOOS pain and the CPG pre- and 6 months post surgery. Scores were standardized to 0 to 100, where higher scores indicate worse pain. Descriptive statistics were calculated for all data. The standardized response mean (SRM) was calculated for each measure as were correlations of change scores.

RESULTS

The THR group (n = 34) ranged in age from 37-85 years with 74% male. The TKR group (n = 44) ranged in age from 45-86 years with 75% female. Both groups had significant improvement (p < .0001) on all pain measures but the TKR group had smaller improvements. For THR, the SMR was 1.50, 2.31 and 2.29 for constant, intermittent and total scores and for TKR, was 0.84, 1.02 and 1.02 respectively. The SMR ranged from 2.05 to 2.99 for the other measures for THR and from 1.13 to 1.44 for TKR patients. Correlations of the change scores were ranged from 0.26 to 0.81.

CONCLUSION

Multi-faceted constructs of pain are effectively relieved through joint replacement and all measures including the ICOAP demonstrated responsiveness.

Psychometric properties of the French translation of the reduced KOOS and HOOS (KOOS-PS and HOOS-PS)

OBJECTIVE

To evaluate the psychometric properties of the French KOOS physical function (KOOS-PS) and HOOS physical function (HOOS-PS), specifically its feasibility, reliability, construct validity, and responsiveness.

METHODS

Consecutive outpatients consulting for primary knee or hip osteoarthritis (OA) in a rheumatology department were included. During the initial assessment, patients were asked to complete the Knee injury and Osteoarthritis Outcome Score (KOOS) or Hip disability and Osteoarthritis Outcome Score (HOOS) questionnaire and the OsteoArthritis Knee and Hip Quality Of Life questionnaire (OAKHQOL). The patients were given a second KOOS or HOOS questionnaire to complete and return by mail 2 weeks later. Feasibility was assessed by calculating the percentage of missing items and the floor and ceiling effects. Test-retest reliability was evaluated using the intra-class correlation coefficient (ICC). Convergent and divergent construct validity was determined by comparing the results of the KOOS-PS or HOOS-PS and OAKHQOL questionnaires using Spearman's rank test. Responsiveness was evaluated using data obtained in other hip or knee OA patients prior to and 1 month after intra-articular hyaluronic acid injection, using standardized response mean (SRM) and effect-size (ES).

RESULTS

Eighty-seven patients with knee OA and 50 hip OA patients were included. The KOOS-PS and HOOS-PS scores were obtained for all patients as there were no missing items. Neither a floor nor a ceiling effect was observed. The ICC of KOOS-PS and HOOS-PS was 0.861 (0.763-0.921) and 0.859 (0.725-0.929), respectively. A strong or moderate correlation was observed, as expected, between KOOS-PS, HOOS-PS, and the OAKHQOL physical activities, pain, and mental health domains. A weak correlation was observed, as expected, between KOOS-PS, HOOS-PS, and the other OAKHQOL domains, except for a moderate correlation between the KOOS-PS and social functioning. The responsiveness was demonstrated with SRM and ES of 0.80 and 0.51 (KOOS-PS), 1.10 and 0.62 (HOOS-PS), respectively.

CONCLUSION

The French versions of KOOS-PS and HOOS-PS are reliable, valid, and responsive questionnaires for capturing functional disability in people with knee and hip OA.

Comparative, validity and responsiveness of the HOOS-PS and KOOS-PS to the WOMAC physical function subscale in total joint replacement for osteoarthritis

OBJECTIVE

To evaluate the internal consistency of the Hip disability and Osteoarthritis Outcome Score-Physical Function Short-form (HOOS-PS) and the Knee injury and Osteoarthritis Outcome Score-Physical Function Short-form (KOOS-PS) in total hip replacement (THR) and total knee (TKR) replacement. Construct validity and responsiveness were compared to the Western Ontario McMaster Universities' Osteoarthritis Index (WOMAC) Likert 3.0 physical function (PF) subscale and the PF excluding the items in the short measures (PF-exclusions).

METHODS

Participants completed the full HOOS or KOOS, measures of fatigue, anxiety, depression and the Chronic Pain Grade (CPG) pre-surgery and the HOOS or KOOS 6 months post-surgery. Internal consistency for the HOOS-PS and KOOS-PS was calculated using Cronbach's alpha. For construct validity, it was hypothesized that correlations between the HOOS-PS or KOOS-PS and PF and PF-exclusions with fatigue, CPG, anxiety and depression and HOOS/KOOS pain scales would differ by magnitudes of <0.1. Standardized response means (SRMs) were calculated for the HOOS-PS, KOOS-PS, PF and PF-exclusions and hypothesized to be >1.

RESULTS

The THR group (n=201) had a mean age of 62.3 years; 53.2% were female. The TKR group (n=248) had a mean age of 64.5 years; 63.7% were female. Cronbach's alpha was 0.79 and 0.89 for the HOOS-PS and KOOS-PS, respectively, confirming that the measures represented a homogeneous construct. The correlation of the HOOS-PS to the PF and PF-exclusions was 0.90 and 0.86, respectively; r=0.90 (PF) and r=0.85 (PF-exclusions) for the KOOS-PS. The results supported the construct validity hypotheses. For THR, the SRM was 1.5, 1.7 and 1.7 for the HOOS-PS, PF and PF-exclusions; for TKR, the SRM was 1.4, 1.5 and 1.7, respectively.

CONCLUSIONS

The short HOOS-PS and KOOS-PS represent homogenous short measures of PF with similar construct validity and responsiveness to the 17-item PF. The HOOS-PS and KOOS-PS are parsimonious, valid and responsive for evaluating PF in THR and TKR.

In vivo spectral domain optical coherence tomography volumetric imaging and spectral Doppler velocimetry of early stage embryonic chicken heart development

Progress toward understanding embryonic heart development has been hampered by the inability to image embryonic heart structure and simultaneously measure blood flow dynamics in vivo. We have developed a spectral domain optical coherence tomography system for in vivo volumetric imaging of the chicken embryo heart. We have also developed a technique called spectral Doppler velocimetry (SDV) for quantitative measurement of blood flow dynamics. We present in vivo volume images of the embryonic heart from initial tube formation to development of endocardial cushions of the same embryo over several stages of development. SDV measurements reveal the influence of heart tube structure on blood flow dynamics.

The development of a short measure of physical function for hip OA HOOS-Physical Function Shortform (HOOS-PS): an OARSI/OMERACT initiative

OBJECTIVE

To derive a cross-culturally valid, short measure of physical function using function subscales (daily living and sports and recreation) of the Hip disability and Osteoarthritis Outcome Score (HOOS).

METHODS

Rasch analysis was conducted on data from individuals from multiple countries who had hip osteoarthritis (OA). Fit of the data to the Rasch model was evaluated by model chi(2) and item fit statistics (chi(2), size of residual, and F-test). Differential item functioning was evaluated by gender, age and country. Unidimensionality was evaluated by factor analysis of residuals. Individual data sets were analyzed and data pooled and re-analyzed for fit to the model. Regression modeling was conducted to derive a nomogram converting raw summed scores to Rasch derived interval scores.

RESULTS

Seven data sets were included (n=2991), ages 19-96 years, male/female ratio was 1:1.23. The final model included five HOOS items. From the easiest to most difficult, the items (logit) were as follows: sitting (1.832), descending stairs (0.729), getting in/out of bath or shower (0.255), twisting/pivoting on loaded leg (-0.221) and running (-2.595). The separation index was 0.80.

CONCLUSION

The daily activity and sports and recreational items of the HOOS were reduced to five items achieving a feasible, short measure of physical function with interval level properties. This tool has potential for use as the function component of an OA severity scoring system. Further testing of this measure is warranted.

The development of a short measure of physical function for knee OA KOOS-Physical Function Shortform (KOOS-PS) - an OARSI/OMERACT initiative

OBJECTIVE

To develop a short measure of physical function for knee osteoarthritis (OA) using multi-national data from individuals with varying degrees of severity of knee OA.

METHODS

Rasch analysis, based on the partial credit model, was conducted on Knee injury and Osteoarthritis Outcome Score and Western Ontario McMaster Universities' Osteoarthritis Index data from individuals with knee OA, ranging from community to pre-total knee replacement samples from five countries. Fit of the data to the Rasch model was evaluated by overall model fit and item-level fit statistics (chi(2), size of residual, F-test). Invariance across age, gender and country was evaluated. Unidimensionality was evaluated by factor analysis of residuals. The derived short measure was further tested for fit through re-analyses in individual sub-samples. A nomogram converting raw summed scores to Rasch-derived interval scores was developed.

RESULTS

Thirteen data sets were included (n=2145), with an age range of 26-95 years, and a male/female ratio of 1:1.4. The final model included seven of the original 22 items. From easiest to most difficult, the items (logit) were as follows: rising from bed (1.366), putting on socks/stockings (1.109), rising from sitting (0.537), bending to the floor (0.433), twisting/pivoting on injured knee (-0.861), kneeling (-1.292) and squatting (-1.292). Sub-sample analyses confirmed findings.

CONCLUSION

Based on the use of accepted Rasch-based measurement methods and the compliment of countries, languages and OA severity represented in this study, our seven item short measure of physical function for knee OA is likely generalizable and widely applicable. This measure has potential for use as the function component in an OA severity scoring system.

Age and drug therapy are key prognostic factors for first clinical fracture in patients with primary osteoporosis

We evaluated the characteristics of 1,142 women and men who attended Canadian osteoporosis clinics and had T-score < or = -2.0 and no prior fractures to determine the predictors of first clinical fracture. Greater age and failure to start osteoporosis drug treatment increased the risk of first clinical fracture.

INTRODUCTION

Although risk factors for osteoporotic fractures are well-known, it is unclear which factors predict poor prognosis in patients with primary osteoporosis. The purpose of this study was to determine prognostic factors for first clinical fracture in patients with T-score < or = -2.0 and no previous clinical fracture.

METHODS

We examined prospectively collected data from 1,142 patients aged 40 and over in the Canadian Database of Osteoporosis and Osteopenia. We used prognosis methodology and performed survival analysis to determine factors that increase the risk of first clinical fracture.

RESULTS

Our inception cohort (mean age = 60.6 years, 91% females) had a cumulative fracture incidence of 5.1% (incidence rate: 2.53/100 person-years). Age and osteoporosis drug use predicted incident clinical fractures in multivariable regression analyses. The risk of first fracture increased by 3% per year. Failing to initiate osteoporosis treatment increased fracture risk by 2.4 times. In addition, low physical activity, high body mass index and low T-scores were found to predict fracture risk in certain patient subgroups using tree-structured survival analysis. These findings were robust and did not change with most sensitivity analyses.

CONCLUSION

Age and osteoporosis drug treatment are the main prognostic predictors of first clinical fracture in patients with T-score < or = -2.0.

α-Lactalbumin-rich infant formula fed to healthy term infants in a multicenter study: plasma essential amino acids and gastrointestinal tolerance

OBJECTIVE

To evaluate the efficacy and safety of an alpha-lactalbumin-enriched formula with a protein profile and total protein concentration closer to human milk (HM) and lower than conventional formulas.

SUBJECTS/METHODS

Two hundred and sixteen healthy, term infants, <or=14 days post-natal age were enrolled and 166 (76.9%) completed the study. Timed post-prandial plasma essential amino-acid levels were determined after 8 weeks of ad libitum study feeding. Study events were assessed every 2 weeks.

RESULTS

At 8 weeks, all mean plasma essential amino-acid levels in the experimental formula (EF) group were as high as the standard formula (SF) and HM groups. The incidence of feeding-related gastrointestinal (GI) events varied significantly (P=0.025) across groups: SF (31.3%), EF (17.2%) and HM (13.6%), with SF being significantly higher than HM (P=0.015). Study withdrawals due to feeding-related GI events were significantly different (P=0.001) across groups: SF (12.5%), EF (4.7%), and HM (0%). The timing of GI events was also significantly different across groups (P=0.010).

CONCLUSION

The study demonstrated that feeding a higher quality, lower protein concentration formula (alpha-lactalbumin-enriched) met all essential amino acid and protein requirements of infants. The GI tolerance profile of infants receiving the EF was similar to HM-fed infants.

Thermal beam of metastable krypton atoms produced by optical excitation

A room-temperature beam of krypton atoms in the metastable 5s[3/2]2 level is demonstrated via an optical excitation method. A Kr-discharge lamp is used to produce vacuum ultraviolet photons at 124 nm for the first-step excitation from the ground level 4p6 1S0 to the 5s[3/2]1 level. An 819 nm Ti:sapphire laser is used for the second-step excitation from 5s[3/2]1 to 5s[3/2]2 followed by a spontaneous decay to the 5s[3/2]2 metastable level. A metastable atomic beam with an angular flux density of 3 x 10(14) s(-1) sr(-1) is achieved at the total gas flow rate of 0.01 cm3/s at STP (or 3 x 10(17) at./s). The dependences of the flux on the gas flow rate, laser power, and lamp parameters are investigated.

Maternal diet composition alters serum steroid and free fatty acid concentrations and vaginal pH in mice

We examined the effects of three maternal diets (very high fat (VHF), low fat (LF), and control (Purina 5015)) on serum steroids, free fatty acids (FFA), and vaginal pH in National Institutes of Health Swiss mice. Females were fed (VHF, n = 33; LF, n = 33; 5015, n = 48) from 4 to 16 weeks of age. Following breeding, female serum was collected at 0.5 (pre-implantation, early diestrus) or 8.5 (post-implantation, mid-diestrus) days post-coitus (dpc). The serum concentrations of 17beta-estradiol, testosterone, progesterone, and FFA were analyzed at both collection points, and vaginal pH at 0.5 dpc. Striking differences in steroids and FFA were observed at 0.5 dpc among the groups. Estradiol was higher in the VHF (14.1 +/- 3.0 pg/ml), compared with LF mice (5.2 +/- 2.3 pg/ml; P< or = 0.05). In contrast, 0.5 dpc testosterone was lower in the VHF (10.5 +/- 3.0 pg/ml) versus the LF group (32.7 +/- 8.4 pg/ml; P< or = 0.05). At 8.5 dpc, progesterone was higher in the VHF (89.6 +/- 6.7 ng/ml) versus the 5015 group (60.1 +/- 4.9 ng/ml; P< or = 0.05). VHF mice had higher FFA concentrations at 0.5 dpc (1.0 +/- 0.2 mmol/l) than LF and control mice (0.5 +/- 0.1 and 0.6 +/- 0.1 mmol/l respectively; P< or = 0.05). At 8.5 dpc, VHF females had higher serum FFA (0.8 +/- 0.1 mmol/l) than LF and control females (0.4 +/- 0.1 and 0.6 +/- 0.1 mmol/l; P< or = 0.05). Mean vaginal pH of VHF females (6.41 +/- 0.09) was lower than 5015 females (6.76 +/- 0.10; P< or = 0.05). These diet-induced alterations in serum steroid and FFA concentrations might affect several reproductive processes, including preferential fertilization by one class of sperm over the other and sex bias in pre- and post-implantational embryonic development.

Optimisation and validation of a medium-throughput electrophysiology-based hERG assay using IonWorks™ HT

INTRODUCTION

Regulatory and competitive pressure to reduce the QT interval prolongation risk of potential new drugs has led to focus on methods to test for inhibition of the human ether-a-go-go-related gene (hERG)-encoded K+ channel, the primary molecular target underlying this safety issue. Here we describe the validation of a method that combines medium-throughput with direct assessment of channel function.

METHODS

The electrophysiological and pharmacological properties of hERG were compared using two methods: conventional, low-throughput electrophysiology and planar-array-based, medium-throughput electrophysiology (IonWorks HT). A pharmacological comparison was also made between IonWorks HT and an indirect assay (Rb+ efflux).

RESULTS

Basic electrophysiological properties of hERG were similar whether recorded conventionally (HEK cells) or using IonWorks HT (CHO cells): for example, tail current V1/2 -12.1+/-5.0 mV (32) for conventional and -9.5+/-6.0 mV (46) for IonWorks HT (mean+/-S.D. (n)). A key finding was that as the number of cells per well was increased in IonWorks HT, the potency reported for a given compound decreased. Using the lowest possible cell concentration (250,000 cells/ml) and 89 compounds spanning a broad potency range, the pIC50 values from IonWorks HT (CHO-hERG) were found to correlate well with those obtained using conventional methodology (HEK-hERG)(r=0.90; p<0.001). Further validation using CHO-hERG cells with both methods confirmed the correlation (r=0.94; p<0.001). In contrast, a comparison of IonWorks HT and Rb+ efflux data with 649 compounds using CHO-hERG cells showed that the indirect assay consistently reported compounds as being, on average, 6-fold less potent, though the differences varied depending on chemical series.

DISCUSSION

The main finding of this work is that providing a relatively low cell concentration is used in IonWorks HT, the potency information generated correlates well with that determined using conventional electrophysiology. The effect on potency of increasing cell concentration may relate to a reduced free concentration of test compound owing to partitioning into cell membranes. In summary, the IonWorks HT hERG assay can generate pIC50 values based on a direct assessment of channel function in a timeframe short enough to influence chemical design.