Background: The relation between knee meniscal structural damage and cartilage degradation is plausible but not yet clearly proven. Objectives: To quantitate the cartilage volume changes in knee ...osteoarthritis using magnetic resonance imaging (MRI), and determine whether meniscal alteration predicts cartilage volume loss over time. Methods: 32 patients meeting ACR criteria for symptomatic knee osteoarthritis were studied. MRI knee acquisitions were done every six months for two years. The cartilage volumes of different knee regions were measured. Three indices of structural change in the medial and lateral menisci were evaluated—degeneration, tear, and extrusion—using a semiquantitative scale. Results: 24 patients (75%) had mild to moderate or severe meniscal damage (tear or extrusion) at baseline. A highly significant difference in global cartilage volume loss was observed between severe medial meniscal tear and absence of tear (mean (SD), −10.1 (2.1)% v −5.1 (2.4)%, p = 0.002). An even greater difference was found between the medial meniscal changes and medial compartment cartilage volume loss (−14.3 (3.0)% in the presence of severe tear v −6.3 (2.7)% in the absence of tear; p<0.0001). Similarly, a major difference was found between the presence of a medial meniscal extrusion and loss of medial compartment cartilage volume (−15.4 (4.1)% in the presence of extrusion v −4.5 (1.7)% with no extrusion; p<0.001). Conclusions: Meniscal tear and extrusion appear to be associated with progression of symptomatic knee osteoarthritis.
CONTEXT Measurement of change in patients' health status is central to both
clinical trials and clinical practice. Trials commonly use serial measurements
by the patients at 2 points in time while ...clinicians use the patient's retrospective
assessment of change made at 1 point in time. How well these measures correlate
is not known. OBJECTIVE To compare the 2 methods in measurement of changes in pain and disability. DESIGN Longitudinal survey of patients starting new therapy for chronic arthritis
in 1994 and 1995. Surveys were completed at baseline (before intervention)
and at 6 weeks and 4 months. SETTING Community health education program and university medical and orthopedic
services. SUBJECTS A total of 202 patients undertaking self-management education (n=140),
therapy with prednisone or methotrexate (n=34), or arthroplasty of the knee
or hip (n=28). MAIN OUTCOME MEASURES Concordance between serial (visual analog scale for pain and Health
Assessment Questionnaire for disability) and retrospective (7-point Likert
scale) measures, sensitivities of these measures, and their correlation with
patients' satisfaction with the change (7-point Likert scale). RESULTS When change was small (education group), serial measures correlated
poorly with retrospective assessments (eg, r=0.13-0.21
at 6 weeks). With greater change, correlations improved (eg,r=0.45-0.71 at 6 weeks). Average agreement between all pairs of assessments
was 29%. Significant lack of concordance was confirmed in all 12 comparisons
by McNemar tests (P=.02 to <.001) and by t tests (P=.03 to <.001). Retrospective
measures were more sensitive to change than serial measures and correlated
more strongly with patients' satisfaction with change. CONCLUSION The 2 methods for measuring health status change did not give concordant
results. Including patient retrospective assessments in clinical trials might
increase the comprehensiveness of information gained and its accord with clinical
practice.
Revision knee replacement (KR) is technically challenging, expensive, and outcomes can be poor. It is well established that increasing surgeon and unit volumes results in improved outcomes and ...cost-effectiveness for complex procedures. The aim of this study was to 1) describe the current provision of revision KR in England, Wales and Northern Ireland at the individual surgeon and unit level and 2) investigate the effect on workload of case distribution in a network model.
Current practice was mapped using NJR summary statistics containing all revision KR procedures performed over a three-year period (2016–2018). Units were identified as revision centres based on threshold volumes. Units undertaking <20 revisions per year were classified as Primary Arthroplasty Units (PAUs) in calculations on the effect of workload centralisation.
Revision KR was performed by 1353 surgeons at 232 NHS sites. The majority of surgeons and units were low-volume; >1000 surgeons performed <7 and 125 sites performed <20 procedures per year. Reallocation of work from these 125 PAUs (1235 cases, 21% of total workload) to a network model with even redistribution of cases between centres undertaking revision surgery would result in an additional average annual case increase of 11 per unit per year (range six to 14).
Revision KR workload re-allocation would lift all revision centres above a 30 per year threshold and would appear to be a manageable increase in workload for specialist revision KR centres. Case complexity and local referral agreements will significantly affect the real increase in workload; these factors were not incorporated here.
The burden of knee replacement prosthetic joint infection (KR PJI) is increasing.
KR PJI is difficult to treat, outcomes can be poor and it is financially expensive and limited evidence is available ...to guide treatment decisions.
To provide guidelines for surgeons and units treating KR PJI.
Guideline formation by consensus process undertaken by BASK's Revision Knee Working Group, supported by outputs from UK-PJI meetings.
Improved outcomes should be achieved through provision of care by revision centres in a network model. Treatment of KR PJI should only be undertaken at specialist units with the required infrastructure and a regular infection MDT.
This document outlines practice guidelines for units providing a KR PJI service and sets out:•The necessary infrastructure required to provide a high-quality KR PJI service•The MDT composition — who and when•The KR PJI care pathway•Medical and surgical treatment strategies•The indications for referral to tertiary units (Major Revision Centres)•Outcome metrics and auditable standards
KR PJI patients treated within the NHS should be provided the best care possible. This report sets out guidance and support for surgeons and units to achieve this.
Abstract Context Radical prostatectomy (RP) approaches have rarely been compared adequately with regard to margin and perioperative complication rates. Objective Review the literature from 2002 to ...2010 and compare margin and perioperative complication rates for open retropubic RP (ORP), laparoscopic RP (LRP), and robot-assisted LRP (RALP). Evidence acquisition Summary data were abstracted from 400 original research articles representing 167 184 ORP, 57 303 LRP, and 62 389 RALP patients (total: 286 876). Articles were found through PubMed and Scopus searches and met a priori inclusion criteria (eg, surgery after 1990, reporting margin rates and/or perioperative complications, study size >25 cases). The primary outcomes were positive surgical margin (PSM) rates, as well as total intra- and perioperative complication rates. Secondary outcomes included blood loss, transfusions, conversions, length of hospital stay, and rates for specific individual complications. Weighted averages were compared for each outcome using propensity adjustment. Evidence synthesis After propensity adjustment, the LRP group had higher positive surgical margin rates than the RALP group but similar rates to the ORP group. LRP and RALP showed significantly lower blood loss and transfusions, and a shorter length of hospital stay than the ORP group. Total perioperative complication rates were higher for ORP and LRP than for RALP. Total intraoperative complication rates were low for all modalities but lowest for RALP. Rates for readmission, reoperation, nerve, ureteral, and rectal injury, deep vein thrombosis, pneumonia, hematoma, lymphocele, anastomotic leak, fistula, and wound infection showed significant differences between groups, generally favoring RALP. The lack of randomized controlled trials, use of margin status as an indicator of oncologic control, and inability to perform cost comparisons are limitations of this study. Conclusions This meta-analysis demonstrates that RALP is at least equivalent to ORP or LRP in terms of margin rates and suggests that RALP provides certain advantages, especially regarding decreased adverse events.
There is increasing evidence that inflammation plays a pivotal role in the pathogenesis of some forms of pulmonary hypertension (PH). We recently demonstrated that deficiency of adiponectin (APN) in ...a mouse model of PH induced by eosinophilic inflammation increases pulmonary arterial remodeling, pulmonary pressures, and the accumulation of eosinophils in the lung. Based on these data, we hypothesized that APN deficiency exacerbates PH indirectly by increasing eosinophil recruitment. Herein, we examined the role of eosinophils in the development of inflammation-induced PH. Elimination of eosinophils in APN-deficient mice by treatment with anti-interleukin-5 antibody attenuated pulmonary arterial muscularization and PH. In addition, we observed that transgenic mice that are devoid of eosinophils also do not develop pulmonary arterial muscularization in eosinophilic inflammation-induced PH. To investigate the mechanism by which APN deficiency increased eosinophil accumulation in response to an allergic inflammatory stimulus, we measured expression levels of the eosinophil-specific chemokines in alveolar macrophages isolated from the lungs of mice with eosinophilic inflammation-induced PH. In these experiments, the levels of CCL11 and CCL24 were higher in macrophages isolated from APN-deficient mice than in macrophages from wild-type mice. Finally, we demonstrate that the extracts of eosinophil granules promoted the proliferation of pulmonary arterial smooth muscle cells in vitro. These data suggest that APN deficiency may exacerbate PH, in part, by increasing eosinophil recruitment into the lung and that eosinophils could play an important role in the pathogenesis of inflammation-induced PH. These results may have implications for the pathogenesis and treatment of PH caused by vascular inflammation.
Summary Objective To evaluate the safety of repeated intra-articular (IA) injections of Euflexxa® (1% sodium hyaluronate; IA--BioHA) for painful knee osteoarthritis (OA). Design Participants who ...completed the randomized, double-blind, 26-week FLEXX Trial comparing IA-BioHA to IA saline (IA-SA) for knee OA received three weekly IA-BioHA injections in a 26-week Extension Study. Adverse events (AEs) were recorded and the effect of treatment on knee pain was measured immediately following a 50-foot walk test using a 100 mm visual analog scale (VAS). Responder rate, Medical Outcomes Study Short Form 36 scores, Patient’s Global Assessment, and intake of rescue medication were also evaluated. Results The Extension Study included 433 subjects, 219 who received IA-BioHA and 214 who received IA-SA during the FLEXX Trial. Safety results from the Extension Study indicated that 43.4% (188/433) of subjects had AEs, of which 4.8% (21/433) were deemed treatment-related AEs. Two AEs in the Extension Study led to discontinuation, and no joint effusion was reported. Patients who continued with IA-BioHA in the Extension Study maintained their improvement from baseline, with an average reduction in pain in the VAS score of −3.5 mm. Patients initially treated with IA-SA in the FLEXX Trial also had a reduction in VAS score of −9.0 mm. Secondary efficacy variables also improved during the Extension Study. Conclusions Repeat injections of IA-BioHA were effective, safe, well tolerated, and not associated with an increase in AEs, such as synovial effusions. Additional symptom improvements were noted for subjects who received either IA-BioHA or IA-SA in the FLEXX Trial. Clinical Trial Registration Number: NCT00379236
Cancer patients with bone metastases have previously been excluded from participation in physical activity programmes due to concerns of skeletal fractures. Our aim was to provide initial information ...on the association between physical activity levels and physical and mental health outcomes in prostate cancer patients with bone metastases. Between 2012 and 2015, 55 prostate cancer patients (mean age 69.7 ± 8.3; BMI 28.6 ± 4.0) with bone metastases (58.2% >2 regions affected) undertook assessments for self‐reported physical activity, physical and mental health outcomes (SF‐36), objective physical performance measures and body composition by DXA. Sixteen men (29%) met the current aerobic exercise guidelines for cancer survivors, while 39 (71%) reported lower aerobic exercise levels. Men not meeting aerobic exercise guidelines had lower physical functioning (p = .004), role functioning (physical and emotional) (p < .05), general health scores (p = .014) as well all lower measures of physical performance (p < .05). Lower levels of aerobic exercise are associated with reduced physical and mental health outcomes in prostate cancer patients with bone metastases. While previous research has focused primarily in those with non‐metastatic disease, our initial results suggest that higher levels of aerobic exercise may preserve physical and mental health outcomes in prostate cancer patients with bone metastases.
Clinical Trial Registry: Trial Registration: ACTRN12611001158954
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