EULAR recommendations for the non-pharmacological core management of hip and knee osteoarthritis

The objective was to develop evidence -based recommendations and a research and educational agenda for the non-pharmacological management of hip and knee osteoarthritis (OA). The multidisciplinary task force comprised 21 experts: nurses, occupational therapists, physiotherapists, rheumatologists, orthopaedic surgeons, general practitioner, psychologist, dietician, clinical epidemiologist and patient representatives. After a preliminary literature review, a first task force meeting and five Delphi rounds, provisional recommendations were formulated in order to perform a systematic review. A literature search of Medline and eight other databases was performed up to February 2012. Evidence was graded in categories I-IV and agreement with the recommendations was determined through scores from 0 (total disagreement) to 10 (total agreement). Eleven evidence-based recommendations for the non-pharmacological core management of hip and knee OA were developed, concerning the following nine topics: assessment, general approach, patient information and education, lifestyle changes, exercise, weight loss, assistive technology and adaptations, footwear and work. The average level of agreement ranged between 8.0 and 9.1. The proposed research agenda included an overall need for more research into non-pharmacological interventions for hip OA, moderators to optimise individualised treatment, healthy lifestyle with economic evaluation and long-term follow-up, and the prevention and reduction of work disability. Proposed educational activities included the required skills to teach, initiate and establish lifestyle changes. The 11 recommendations provide guidance on the delivery of non-pharmacological interventions to people with hip or knee OA. More research and educational activities are needed, particularly in the area of lifestyle changes.

Adalimumab effectively reduces the signs and symptoms of active ankylosing spondylitis in patients with total spinal ankylosis

OBJECTIVE

To evaluate the long-term safety and efficacy of adalimumab in patients with ankylosing spondylitis (AS) and total spinal ankylosis (TSA).

DESIGN

Patients (n = 315) with active AS were randomised in a 2:1 ratio to receive adalimumab 40 mg every other week or placebo for 24 weeks followed by open-label adalimumab for up to 5 years. Two-year efficacy and safety data for 11 patients with investigator-defined TSA were evaluated. The primary end point was the ASsessment in AS International Working Group criteria for 20% improvement (ASAS20) at Week 12. On or after Week 12, ASAS20 non-responders could switch to open-label adalimumab. Other efficacy measurements included ASAS40, ASAS 5/6, ASAS partial remission, and 50% improvement in the Bath AS Disease Activity Index (BASDAI 50).

RESULTS

6 of 11 TSA patients were randomised to adalimumab and 5 to placebo. At Week 12, 50% of the adalimumab-treated patients achieved an ASAS20 response and 33% achieved an ASAS40, ASAS 5/6 and BASDAI 50. No placebo-treated patients achieved any response criteria at Week 12. 4 placebo- and 2 adalimumab-treated patients switched to open-label adalimumab before Week 24. After 1 year of adalimumab treatment, 8 of 11 patients achieved an ASAS20 response. After 2 years, 6 of the remaining 8 patients with TSA reported an ASAS20 response. There were no serious adverse events or adverse event-related study discontinuations.

CONCLUSION

In patients with TSA, adalimumab treatment resulted in rapid and clinically significant improvement in the signs and symptoms of active disease. Adalimumab effectiveness and safety were sustained for at least 2 years.

TRIAL REGISTRATION NUMBER

NCT00085644.

Simple high-performance liquid chromatography method for alpha-tocopherol measurement in Rosmarinus officinalis leaves. New data on alpha-tocopherol content

A simple HPLC method for vitamin E (alpha-tocopherol) measurement in the leaves of Rosmarinus officinalis has been developed and validated. It has enabled new data for alpha-tocopherol content to be established. The leaves, recently harvested, were dried in a microwave oven and crushed; then, alpha-tocopherol was directly extracted from portions of ground material with acetone, by probe sonication. After centrifugation the acetonic extract was analysed by HPLC with ergocalciferol (vitamin D2) added as internal standard and a gradient elution with a Nucleosil C18 column at 35 degrees C. Validation parameters of the method can be considered adequate. For standards: linearity is r=0.999, recovery is 100+/-2%, intra-assay precision has RSD=+/-3% and inter-assay precision has RSD=+/-6%. For samples: linearity is r=0.99, recovery: 93+/-7%, intra-assay precision has RSD=+/-4% and inter-assay precision has RSD=+/-7%.

Prevention and management of osteoporotic fractures by non-physician health professionals: a systematic literature review to inform EULAR points to consider

Objective

To perform a systematic literature review (SLR) about the effect of non-pharmacological interventions delivered by non-physician health professionals to prevent and manage osteoporotic fractures.

Methods

Eight clinical questions based on two criteria guided the SLR: (1) adults≥50 years at high risk of osteoporotic fracture and (2) interventions delivered by non-physician health professionals to prevent and manage osteoporotic fractures. Interventions focused on diagnostic procedures to identify risk of falling, therapeutic approaches and implementation strategies. Outcomes included fractures, falls, risk of falling and change in bone mineral density. Systematic reviews and randomised controlled trials were preferentially selected. Data were synthesised using a qualitative descriptive approach.

Results

Of 15 917 records, 43 articles were included. Studies were clinically and methodologically diverse. We identified sufficient evidence that structured exercise, incorporating progressive resistance training delivered to people who had undergone hip fracture surgery, and multicomponent exercise, delivered to people at risk of primary fracture, reduced risk of falling. The effectiveness of multidisciplinary fracture liaison services in reducing refracture rate was confirmed. There was insufficient evidence found to support the effectiveness of nutrients and falls prevention programmes in this patient population.

Conclusion

Despite study heterogeneity, our SLR showed beneficial effects of some interventions delivered by non-physician health professionals and the positive impact of multidisciplinary team working and patient educational approaches to prevent and manage osteoporotic fractures. These results informed a EULAR taskforce that developed points to consider for non-physician health professionals to prevent and manage osteoporotic fractures.

Ulnar artery aneurysm with digital ischemia

The case of a young male patient with a thrombosed distal ulnar artery aneurysm and digital emboli is presented. The hypothenar hammer syndrome is reviewed, with particular attention to clinical presentation, differential diagnosis and the non-invasive and invasive diagnostic evaluation. Surgical and thrombolytic therapeutic options are reviewed with reference to the available literature.

Additive inhibition of in vitro rabbit reticulocyte heme and protein synthesis with combinations of isoniazid, chloramphenicol and ethanol

Isoniazid, chloramphenicol and ethanol are well known hematopoietic toxins. These agents inhibit in vitro rabbit reticulocyte heme synthesis and, as a result, inhibit protein synthesis. When combinations of isoniazid (2 x 10(-3)M) and ethanol (0.1M), isoniazid and chloramphenicol (10(-3)M) or ethanol and chloramphenicol were present in the same incubation, their inhibitory effects on heme and protein synthesis were additive. These results suggest that the development of clinical hematological toxicity in man may result from additive interaction of chemically unrelated compounds which inhibit the heme synthetic pathway.