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OARSI recommends physical function tests for knee, hip OA
PHILADELPHIA – The Osteoarthritis Research Society International is recommending a set of user-friendly physical performance measures for patients with established hip and knee osteoarthritis.
The minimal core set of tests includes the 30-second chair stand test, 40-m fast-paced-walk, and stair negotiation.
Two further tests, the timed up-and-go and 6-minute walk, also are highly recommended, depending on the research setting, to measure ambulatory transitions and aerobic capacity.
The tests had to cover multiple physical activities, use minimal equipment, and be user friendly and inexpensive, steering committee member Kim L. Bennell, Ph.D., said at the World Congress on Osteoarthritis.
For example, the 30-second chair stand test requires only a stop watch and a chair to count how many times a patient can rise from a chair with hips and knees fully extended and sit back down in 30 seconds. The tests are best suited for adults older than 40 years but are relevant for patients with mild to end-stage hip and/or knee osteoarthritis (OA) and following joint replacement.
Currently, there are no international recommendations on which performance-based measures of physical function should be used to measure outcomes in patients with hip and/or knee OA. The hope is that the new recommendations will facilitate a more consistent use of performance-based outcome measures across clinical trials and the clinical setting, said Dr. Bennell, a research physiotherapist and director of the multidisciplinary Centre for Health, Exercise and Sports Medicine, University of Melbourne (Australia).
An international advisory committee of 10 rheumatologists, physical therapists, and an orthopedic surgeon identified the main activity themes of walking, stair negotiation, and sit-to-stand from a systematic review of the literature and by consensus opinion. Another 138 clinicians and researchers also were surveyed and asked to rank the difficulty and feasibility of 23 functional tests for OA patients.
"We wanted to identify the most feasible tests considering practical issues such as time, cost, equipment, space, and administration burden," she said at the meeting, which was sponsored by OARSI.
In the end, none of the tests satisfied all desirable clinimetric criteria of reliability, measurement error, validity, responsiveness, and interpretability. The experts felt stair negotiation was an important measure of mobility, lower-body strength, and balance but balked at recommending a specific test because of insufficient clinimetric evidence and the simple, practical fact that not all facilities have enough stairs to conduct a 9- or 12-step test.
"What we really found in our discussions and our work is that there really wasn’t a lot of good clinimetric evidence across the board on these tests," Dr. Bennell said.
To boost the evidence base, OARSI has put out a call on its website to collect future prospective data and to pool existing data so researchers can calculate minimal clinically important difference (MCID) estimates for different OA subgroups, longitudinal responsiveness estimates for interventions, and normative data for various OA subgroups.
Further details on the tests, including an instructional manual, clinimetric measurement properties, and normative values, are available on the OARSI website. Videos will also be available shortly.
The project was sponsored by OARSI, the Australian National Health and Medical Research Council, Arthritis Australia, and the University of Otago. Dr. Bennell reported having no financial disclosures.
PHILADELPHIA – The Osteoarthritis Research Society International is recommending a set of user-friendly physical performance measures for patients with established hip and knee osteoarthritis.
The minimal core set of tests includes the 30-second chair stand test, 40-m fast-paced-walk, and stair negotiation.
Two further tests, the timed up-and-go and 6-minute walk, also are highly recommended, depending on the research setting, to measure ambulatory transitions and aerobic capacity.
The tests had to cover multiple physical activities, use minimal equipment, and be user friendly and inexpensive, steering committee member Kim L. Bennell, Ph.D., said at the World Congress on Osteoarthritis.
For example, the 30-second chair stand test requires only a stop watch and a chair to count how many times a patient can rise from a chair with hips and knees fully extended and sit back down in 30 seconds. The tests are best suited for adults older than 40 years but are relevant for patients with mild to end-stage hip and/or knee osteoarthritis (OA) and following joint replacement.
Currently, there are no international recommendations on which performance-based measures of physical function should be used to measure outcomes in patients with hip and/or knee OA. The hope is that the new recommendations will facilitate a more consistent use of performance-based outcome measures across clinical trials and the clinical setting, said Dr. Bennell, a research physiotherapist and director of the multidisciplinary Centre for Health, Exercise and Sports Medicine, University of Melbourne (Australia).
An international advisory committee of 10 rheumatologists, physical therapists, and an orthopedic surgeon identified the main activity themes of walking, stair negotiation, and sit-to-stand from a systematic review of the literature and by consensus opinion. Another 138 clinicians and researchers also were surveyed and asked to rank the difficulty and feasibility of 23 functional tests for OA patients.
"We wanted to identify the most feasible tests considering practical issues such as time, cost, equipment, space, and administration burden," she said at the meeting, which was sponsored by OARSI.
In the end, none of the tests satisfied all desirable clinimetric criteria of reliability, measurement error, validity, responsiveness, and interpretability. The experts felt stair negotiation was an important measure of mobility, lower-body strength, and balance but balked at recommending a specific test because of insufficient clinimetric evidence and the simple, practical fact that not all facilities have enough stairs to conduct a 9- or 12-step test.
"What we really found in our discussions and our work is that there really wasn’t a lot of good clinimetric evidence across the board on these tests," Dr. Bennell said.
To boost the evidence base, OARSI has put out a call on its website to collect future prospective data and to pool existing data so researchers can calculate minimal clinically important difference (MCID) estimates for different OA subgroups, longitudinal responsiveness estimates for interventions, and normative data for various OA subgroups.
Further details on the tests, including an instructional manual, clinimetric measurement properties, and normative values, are available on the OARSI website. Videos will also be available shortly.
The project was sponsored by OARSI, the Australian National Health and Medical Research Council, Arthritis Australia, and the University of Otago. Dr. Bennell reported having no financial disclosures.
PHILADELPHIA – The Osteoarthritis Research Society International is recommending a set of user-friendly physical performance measures for patients with established hip and knee osteoarthritis.
The minimal core set of tests includes the 30-second chair stand test, 40-m fast-paced-walk, and stair negotiation.
Two further tests, the timed up-and-go and 6-minute walk, also are highly recommended, depending on the research setting, to measure ambulatory transitions and aerobic capacity.
The tests had to cover multiple physical activities, use minimal equipment, and be user friendly and inexpensive, steering committee member Kim L. Bennell, Ph.D., said at the World Congress on Osteoarthritis.
For example, the 30-second chair stand test requires only a stop watch and a chair to count how many times a patient can rise from a chair with hips and knees fully extended and sit back down in 30 seconds. The tests are best suited for adults older than 40 years but are relevant for patients with mild to end-stage hip and/or knee osteoarthritis (OA) and following joint replacement.
Currently, there are no international recommendations on which performance-based measures of physical function should be used to measure outcomes in patients with hip and/or knee OA. The hope is that the new recommendations will facilitate a more consistent use of performance-based outcome measures across clinical trials and the clinical setting, said Dr. Bennell, a research physiotherapist and director of the multidisciplinary Centre for Health, Exercise and Sports Medicine, University of Melbourne (Australia).
An international advisory committee of 10 rheumatologists, physical therapists, and an orthopedic surgeon identified the main activity themes of walking, stair negotiation, and sit-to-stand from a systematic review of the literature and by consensus opinion. Another 138 clinicians and researchers also were surveyed and asked to rank the difficulty and feasibility of 23 functional tests for OA patients.
"We wanted to identify the most feasible tests considering practical issues such as time, cost, equipment, space, and administration burden," she said at the meeting, which was sponsored by OARSI.
In the end, none of the tests satisfied all desirable clinimetric criteria of reliability, measurement error, validity, responsiveness, and interpretability. The experts felt stair negotiation was an important measure of mobility, lower-body strength, and balance but balked at recommending a specific test because of insufficient clinimetric evidence and the simple, practical fact that not all facilities have enough stairs to conduct a 9- or 12-step test.
"What we really found in our discussions and our work is that there really wasn’t a lot of good clinimetric evidence across the board on these tests," Dr. Bennell said.
To boost the evidence base, OARSI has put out a call on its website to collect future prospective data and to pool existing data so researchers can calculate minimal clinically important difference (MCID) estimates for different OA subgroups, longitudinal responsiveness estimates for interventions, and normative data for various OA subgroups.
Further details on the tests, including an instructional manual, clinimetric measurement properties, and normative values, are available on the OARSI website. Videos will also be available shortly.
The project was sponsored by OARSI, the Australian National Health and Medical Research Council, Arthritis Australia, and the University of Otago. Dr. Bennell reported having no financial disclosures.
AT THE WORLD CONGRESS ON OSTEOARTHRITIS
Periostin levels linked to osteoarthritis prevalence, progression
PHILADELPHIA – Women with prevalent knee osteoarthritis had significantly lower levels of periostin, particularly those with progressive disease, than did women without the condition in an analysis of the OFELY study.
Although the mechanism remains to be investigated, the vitamin-K dependent protein "may be a new biological marker of prevalence and progression of knee OA in women," Jean-Charles Rousseau, Ph.D., said at the meeting, sponsored by Osteoarthritis Research Society International.
Periostin is secreted by osteoblasts and chondrocytes, and is one of only a handful of gamma-carboxyglutamic acid-containing proteins so far identified in humans. It was recently shown to be overexpressed in human OA cartilage and to regulate cartilage metabolism via matrix metallopeptidase-13 activation (Osteoarthritis Cartilage 2011;19 [Suppl. 1]:S34).
OFELY (Os des Femmes de Lyon) is the first study to report an association between periostin OA prevalence and progression, Dr. Rousseau said at the meeting.
To evaluate its role in OA, the investigators used a new commercially available ELISA sandwich assay to evaluate blood samples from 594 women in the ongoing, prospective OFELY study. Of these, 511 had no knee OA and 83 had radiographic knee OA, Kellgren-Lawrence grade of 2 or more. The average age was 60 years in those free of OA and 70 in those with OA; 78% and 98%, respectively, were menopausal.
Baseline serum periostin averaged 1,101 ng/mL in women with OA vs. 1,181 ng/mL in those without OA, after researchers adjusted for age (P = .011), said Dr. Rousseau of INSERM Research Unit 1033, University of Lyon (France).
Collagen type II cross-linked C-telopeptide levels (CTX-II) were significantly higher in women with OA vs. those without (278 ng/mL vs. 173 ng/mL; P less than .001), whereas serum levels were similar for type I CTX (0.43 ng/mL vs. 0.39 ng/mL), intact N-terminal propeptide of type I procollagen (38.1 mcg/L vs. 37.2 mcg/L) and osteocalcin (28.4 ng/mL vs. 25.7 ng/mL).
During the 4-year follow-up period, 82 women had radiological progression of their knee OA, defined by an increase of 1 or more Kellgren-Lawrence grade regardless of the baseline grade.
Baseline periostin levels were significantly lower in progressors than nonprogressors, after adjustment for age (1,112 ng/mL vs. 1,179 ng/mL; P = .046), Dr. Rousseau said.
For each increase of one periostin quartile, the risk of progression decreased by 21% after adjusting for age, KL score at baseline, and OA at other anatomical sites, including hand, hip, and lumbar spine (odds ratio 0.79; P = .038), he said.
During a discussion of the paper, an attendee questioned whether periostin is exclusive to bone metabolites, highlighting a recent randomized trial indicating that it is highly relevant in lung function. In that trial (N. Engl. J. Med. 2011;365:1088-98), anti-interleukin-13 therapy was more effective in asthmatic adults who had high serum periostin levels.
Dr. Rousseau acknowledged that periostin is distributed in nonarticular tissues including periodontal ligament and cardiac valves, and that the specificity of the periostin assay for circulating forms is unknown.
Session moderator Ali Mobasheri, D.Phil., of the University of Nottingham, England, said in an interview that it can be difficult to differentiate between a biomarker emanating from bone, articular cartilage, and tendon and other tissues such as heart and lung, "and in this particular case, I think it’s going to be extremely difficult to differentiate where it’s coming from."
He went on to say that periostin may be differentially processed in different tissues, which could be the differentiator in the future, but that the Chinese assay (USCNK, China) used in the study doesn’t make that distinction.
"So a lot more validation is required in this case," Dr. Mobasheri said.
Dr. Rousseau said in an interview that overlap exists with osteoarthritis biomarkers, but that they remain useful, even when OA is limited to a single knee.
OFELY was sponsored by Prévention des Maladies Osseuses. Dr. Rousseau reported no relevant disclosures.
PHILADELPHIA – Women with prevalent knee osteoarthritis had significantly lower levels of periostin, particularly those with progressive disease, than did women without the condition in an analysis of the OFELY study.
Although the mechanism remains to be investigated, the vitamin-K dependent protein "may be a new biological marker of prevalence and progression of knee OA in women," Jean-Charles Rousseau, Ph.D., said at the meeting, sponsored by Osteoarthritis Research Society International.
Periostin is secreted by osteoblasts and chondrocytes, and is one of only a handful of gamma-carboxyglutamic acid-containing proteins so far identified in humans. It was recently shown to be overexpressed in human OA cartilage and to regulate cartilage metabolism via matrix metallopeptidase-13 activation (Osteoarthritis Cartilage 2011;19 [Suppl. 1]:S34).
OFELY (Os des Femmes de Lyon) is the first study to report an association between periostin OA prevalence and progression, Dr. Rousseau said at the meeting.
To evaluate its role in OA, the investigators used a new commercially available ELISA sandwich assay to evaluate blood samples from 594 women in the ongoing, prospective OFELY study. Of these, 511 had no knee OA and 83 had radiographic knee OA, Kellgren-Lawrence grade of 2 or more. The average age was 60 years in those free of OA and 70 in those with OA; 78% and 98%, respectively, were menopausal.
Baseline serum periostin averaged 1,101 ng/mL in women with OA vs. 1,181 ng/mL in those without OA, after researchers adjusted for age (P = .011), said Dr. Rousseau of INSERM Research Unit 1033, University of Lyon (France).
Collagen type II cross-linked C-telopeptide levels (CTX-II) were significantly higher in women with OA vs. those without (278 ng/mL vs. 173 ng/mL; P less than .001), whereas serum levels were similar for type I CTX (0.43 ng/mL vs. 0.39 ng/mL), intact N-terminal propeptide of type I procollagen (38.1 mcg/L vs. 37.2 mcg/L) and osteocalcin (28.4 ng/mL vs. 25.7 ng/mL).
During the 4-year follow-up period, 82 women had radiological progression of their knee OA, defined by an increase of 1 or more Kellgren-Lawrence grade regardless of the baseline grade.
Baseline periostin levels were significantly lower in progressors than nonprogressors, after adjustment for age (1,112 ng/mL vs. 1,179 ng/mL; P = .046), Dr. Rousseau said.
For each increase of one periostin quartile, the risk of progression decreased by 21% after adjusting for age, KL score at baseline, and OA at other anatomical sites, including hand, hip, and lumbar spine (odds ratio 0.79; P = .038), he said.
During a discussion of the paper, an attendee questioned whether periostin is exclusive to bone metabolites, highlighting a recent randomized trial indicating that it is highly relevant in lung function. In that trial (N. Engl. J. Med. 2011;365:1088-98), anti-interleukin-13 therapy was more effective in asthmatic adults who had high serum periostin levels.
Dr. Rousseau acknowledged that periostin is distributed in nonarticular tissues including periodontal ligament and cardiac valves, and that the specificity of the periostin assay for circulating forms is unknown.
Session moderator Ali Mobasheri, D.Phil., of the University of Nottingham, England, said in an interview that it can be difficult to differentiate between a biomarker emanating from bone, articular cartilage, and tendon and other tissues such as heart and lung, "and in this particular case, I think it’s going to be extremely difficult to differentiate where it’s coming from."
He went on to say that periostin may be differentially processed in different tissues, which could be the differentiator in the future, but that the Chinese assay (USCNK, China) used in the study doesn’t make that distinction.
"So a lot more validation is required in this case," Dr. Mobasheri said.
Dr. Rousseau said in an interview that overlap exists with osteoarthritis biomarkers, but that they remain useful, even when OA is limited to a single knee.
OFELY was sponsored by Prévention des Maladies Osseuses. Dr. Rousseau reported no relevant disclosures.
PHILADELPHIA – Women with prevalent knee osteoarthritis had significantly lower levels of periostin, particularly those with progressive disease, than did women without the condition in an analysis of the OFELY study.
Although the mechanism remains to be investigated, the vitamin-K dependent protein "may be a new biological marker of prevalence and progression of knee OA in women," Jean-Charles Rousseau, Ph.D., said at the meeting, sponsored by Osteoarthritis Research Society International.
Periostin is secreted by osteoblasts and chondrocytes, and is one of only a handful of gamma-carboxyglutamic acid-containing proteins so far identified in humans. It was recently shown to be overexpressed in human OA cartilage and to regulate cartilage metabolism via matrix metallopeptidase-13 activation (Osteoarthritis Cartilage 2011;19 [Suppl. 1]:S34).
OFELY (Os des Femmes de Lyon) is the first study to report an association between periostin OA prevalence and progression, Dr. Rousseau said at the meeting.
To evaluate its role in OA, the investigators used a new commercially available ELISA sandwich assay to evaluate blood samples from 594 women in the ongoing, prospective OFELY study. Of these, 511 had no knee OA and 83 had radiographic knee OA, Kellgren-Lawrence grade of 2 or more. The average age was 60 years in those free of OA and 70 in those with OA; 78% and 98%, respectively, were menopausal.
Baseline serum periostin averaged 1,101 ng/mL in women with OA vs. 1,181 ng/mL in those without OA, after researchers adjusted for age (P = .011), said Dr. Rousseau of INSERM Research Unit 1033, University of Lyon (France).
Collagen type II cross-linked C-telopeptide levels (CTX-II) were significantly higher in women with OA vs. those without (278 ng/mL vs. 173 ng/mL; P less than .001), whereas serum levels were similar for type I CTX (0.43 ng/mL vs. 0.39 ng/mL), intact N-terminal propeptide of type I procollagen (38.1 mcg/L vs. 37.2 mcg/L) and osteocalcin (28.4 ng/mL vs. 25.7 ng/mL).
During the 4-year follow-up period, 82 women had radiological progression of their knee OA, defined by an increase of 1 or more Kellgren-Lawrence grade regardless of the baseline grade.
Baseline periostin levels were significantly lower in progressors than nonprogressors, after adjustment for age (1,112 ng/mL vs. 1,179 ng/mL; P = .046), Dr. Rousseau said.
For each increase of one periostin quartile, the risk of progression decreased by 21% after adjusting for age, KL score at baseline, and OA at other anatomical sites, including hand, hip, and lumbar spine (odds ratio 0.79; P = .038), he said.
During a discussion of the paper, an attendee questioned whether periostin is exclusive to bone metabolites, highlighting a recent randomized trial indicating that it is highly relevant in lung function. In that trial (N. Engl. J. Med. 2011;365:1088-98), anti-interleukin-13 therapy was more effective in asthmatic adults who had high serum periostin levels.
Dr. Rousseau acknowledged that periostin is distributed in nonarticular tissues including periodontal ligament and cardiac valves, and that the specificity of the periostin assay for circulating forms is unknown.
Session moderator Ali Mobasheri, D.Phil., of the University of Nottingham, England, said in an interview that it can be difficult to differentiate between a biomarker emanating from bone, articular cartilage, and tendon and other tissues such as heart and lung, "and in this particular case, I think it’s going to be extremely difficult to differentiate where it’s coming from."
He went on to say that periostin may be differentially processed in different tissues, which could be the differentiator in the future, but that the Chinese assay (USCNK, China) used in the study doesn’t make that distinction.
"So a lot more validation is required in this case," Dr. Mobasheri said.
Dr. Rousseau said in an interview that overlap exists with osteoarthritis biomarkers, but that they remain useful, even when OA is limited to a single knee.
OFELY was sponsored by Prévention des Maladies Osseuses. Dr. Rousseau reported no relevant disclosures.
AT THE 2013 OARSI WORLD CONGRESS
Major finding: Baseline serum periostin averaged 1,101 ng/mL in women with OA and 1,181 ng/mL in those without OA, after researchers adjusted for age (P = .011).
Data source: Retrospective analysis of 594 women participating in the OFELY study.
Disclosures: OFELY was sponsored by Prévention des Maladies Osseuses. Dr. Rousseau reported no relevant disclosures.
Over 5 L of crystalloids raises morbidity
SCOTTSDALE, ARIZ. – Morbidity increased with the use of more than 5 L of crystalloid solution during high-ratio hemostatic resuscitation, according to the results of a retrospective study of 451 trauma patients.
This is the first multicenter analysis to demonstrate the deleterious effect on morbidity in high-ratio resuscitation (HRR) patients, Dr. Juan Duchesne said at the annual scientific assembly of the Eastern Association for the Surgery of Trauma.
"These patients already have acute insult, so when you add the double-hit phenomenon of crystalloids, you are definitely jeopardizing their outcomes," said Dr. Duchesne, director of the surgical intensive care unit at Tulane University, New Orleans.
The retrospective analysis included 451 patients treated at five centers in the United States. All received at least 10 units of packed red blood cells (PBRC) over 24 hours and damage control laparotomy. Of these, 365 received fresh frozen plasma (FFP) and PRBC at a ratio of at least 1:2 (HRR); the ratio was less than 1:2 (low-ratio resuscitation) in the other 86 patients.
The average Injury Severity Score was 23.5 (on a scale of 0-75), and the average FFP:PRBC ratio was 1.06 in the HRR group and 1.32 in the low-ratio resuscitation group.
As observed in other studies, patients in the HRR group had a significant survival advantage over those in the low-resuscitation group at 24 hours (85% vs. 69%; P = .0004), Dr. Duchesne said.
In 200 HRR patients with full data, an analysis of 24-hour crystalloid volume revealed that 9.5% received less than 5 L, 25% got 5-10 L, and 65.5% got more than 10 L. The 24-hour crystalloid volume was statistically different between the three subgroups (3.64 L vs. 7.81 L vs. 17.82 L; P = .0001), but there were no statistically significant differences in mortality.
The risk of certain morbidities, however, increased with crystalloid volume in the three subgroups. Rates of bacteremia rose significantly (0% [less than 5 L]), 13% [5-10 L], and 29% [more than 10 L]; P = .029), as did sepsis (0% [less than 5 L], 13% [5-10 L], and 22% [more than 10 L]); P = .028).
The differences were not significant for acute respiratory distress syndrome (1% [less than 5 L], 0% [5-10 L], and 8% [more than 10 L]; P = .163) and for acute respiratory failure (2% [less than 5 L], 12% [5-10 L], and 24% [more than 10 L]; P = .457).
In multiple logistic regression analysis, morbidity was significantly associated with 24-hour crystalloid volume (odds ratio, 1.11; P = .001), systolic blood pressure level in the emergency department (OR, 1.19; P = .043), and base deficit level in the emergency department (OR, 1.02; P = .002). Morbidity was not associated with high ratio resuscitation (OR, 1.34; P = .065), Dr. Duchesne observed.
Dr. Duchesne reported having no disclosures.
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Patrice Wendling/IMNG Medical Media
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This study elucidates the tangible evils of crystalloid. Despite more than a decade of research pointing to concern about overuse of these solutions, some practitioners have been slow to come around. But as I look at this study, I question why the choice was to focus on the sickest of the sick.
I readily acknowledge that morbidity will have its worst effects on those most susceptible, thus increasing the power of the findings, but I am curious about the decision on those patients.
Further, 100% data capture for all items analyzed was only possible for 451 patients out of 1,484 patients who received at least one unit of packed red blood cells with massive transfusion protocol activation. Thus, a high number of patients were excluded from the study, raising the possibility of erroneous conclusions due to missing data.
The increase in morbidity associated with crystalloids would likely not have been observed if the cohort included all mass transfusion patients, and eliminated the Injury Severity Score and damage control laparotomy criteria.
Dr. Donald Jenkins, is past president of the Eastern Association for the Surgery of Trauma and is with the Mayo Clinic in Rochester, Minn. He was the invited discussant for the study at the meeting and reported having no disclosures.
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Patrice Wendling/IMNG Medical Media
|
This study elucidates the tangible evils of crystalloid. Despite more than a decade of research pointing to concern about overuse of these solutions, some practitioners have been slow to come around. But as I look at this study, I question why the choice was to focus on the sickest of the sick.
I readily acknowledge that morbidity will have its worst effects on those most susceptible, thus increasing the power of the findings, but I am curious about the decision on those patients.
Further, 100% data capture for all items analyzed was only possible for 451 patients out of 1,484 patients who received at least one unit of packed red blood cells with massive transfusion protocol activation. Thus, a high number of patients were excluded from the study, raising the possibility of erroneous conclusions due to missing data.
The increase in morbidity associated with crystalloids would likely not have been observed if the cohort included all mass transfusion patients, and eliminated the Injury Severity Score and damage control laparotomy criteria.
Dr. Donald Jenkins, is past president of the Eastern Association for the Surgery of Trauma and is with the Mayo Clinic in Rochester, Minn. He was the invited discussant for the study at the meeting and reported having no disclosures.
|
|
Patrice Wendling/IMNG Medical Media
|
This study elucidates the tangible evils of crystalloid. Despite more than a decade of research pointing to concern about overuse of these solutions, some practitioners have been slow to come around. But as I look at this study, I question why the choice was to focus on the sickest of the sick.
I readily acknowledge that morbidity will have its worst effects on those most susceptible, thus increasing the power of the findings, but I am curious about the decision on those patients.
Further, 100% data capture for all items analyzed was only possible for 451 patients out of 1,484 patients who received at least one unit of packed red blood cells with massive transfusion protocol activation. Thus, a high number of patients were excluded from the study, raising the possibility of erroneous conclusions due to missing data.
The increase in morbidity associated with crystalloids would likely not have been observed if the cohort included all mass transfusion patients, and eliminated the Injury Severity Score and damage control laparotomy criteria.
Dr. Donald Jenkins, is past president of the Eastern Association for the Surgery of Trauma and is with the Mayo Clinic in Rochester, Minn. He was the invited discussant for the study at the meeting and reported having no disclosures.
SCOTTSDALE, ARIZ. – Morbidity increased with the use of more than 5 L of crystalloid solution during high-ratio hemostatic resuscitation, according to the results of a retrospective study of 451 trauma patients.
This is the first multicenter analysis to demonstrate the deleterious effect on morbidity in high-ratio resuscitation (HRR) patients, Dr. Juan Duchesne said at the annual scientific assembly of the Eastern Association for the Surgery of Trauma.
"These patients already have acute insult, so when you add the double-hit phenomenon of crystalloids, you are definitely jeopardizing their outcomes," said Dr. Duchesne, director of the surgical intensive care unit at Tulane University, New Orleans.
The retrospective analysis included 451 patients treated at five centers in the United States. All received at least 10 units of packed red blood cells (PBRC) over 24 hours and damage control laparotomy. Of these, 365 received fresh frozen plasma (FFP) and PRBC at a ratio of at least 1:2 (HRR); the ratio was less than 1:2 (low-ratio resuscitation) in the other 86 patients.
The average Injury Severity Score was 23.5 (on a scale of 0-75), and the average FFP:PRBC ratio was 1.06 in the HRR group and 1.32 in the low-ratio resuscitation group.
As observed in other studies, patients in the HRR group had a significant survival advantage over those in the low-resuscitation group at 24 hours (85% vs. 69%; P = .0004), Dr. Duchesne said.
In 200 HRR patients with full data, an analysis of 24-hour crystalloid volume revealed that 9.5% received less than 5 L, 25% got 5-10 L, and 65.5% got more than 10 L. The 24-hour crystalloid volume was statistically different between the three subgroups (3.64 L vs. 7.81 L vs. 17.82 L; P = .0001), but there were no statistically significant differences in mortality.
The risk of certain morbidities, however, increased with crystalloid volume in the three subgroups. Rates of bacteremia rose significantly (0% [less than 5 L]), 13% [5-10 L], and 29% [more than 10 L]; P = .029), as did sepsis (0% [less than 5 L], 13% [5-10 L], and 22% [more than 10 L]); P = .028).
The differences were not significant for acute respiratory distress syndrome (1% [less than 5 L], 0% [5-10 L], and 8% [more than 10 L]; P = .163) and for acute respiratory failure (2% [less than 5 L], 12% [5-10 L], and 24% [more than 10 L]; P = .457).
In multiple logistic regression analysis, morbidity was significantly associated with 24-hour crystalloid volume (odds ratio, 1.11; P = .001), systolic blood pressure level in the emergency department (OR, 1.19; P = .043), and base deficit level in the emergency department (OR, 1.02; P = .002). Morbidity was not associated with high ratio resuscitation (OR, 1.34; P = .065), Dr. Duchesne observed.
Dr. Duchesne reported having no disclosures.
SCOTTSDALE, ARIZ. – Morbidity increased with the use of more than 5 L of crystalloid solution during high-ratio hemostatic resuscitation, according to the results of a retrospective study of 451 trauma patients.
This is the first multicenter analysis to demonstrate the deleterious effect on morbidity in high-ratio resuscitation (HRR) patients, Dr. Juan Duchesne said at the annual scientific assembly of the Eastern Association for the Surgery of Trauma.
"These patients already have acute insult, so when you add the double-hit phenomenon of crystalloids, you are definitely jeopardizing their outcomes," said Dr. Duchesne, director of the surgical intensive care unit at Tulane University, New Orleans.
The retrospective analysis included 451 patients treated at five centers in the United States. All received at least 10 units of packed red blood cells (PBRC) over 24 hours and damage control laparotomy. Of these, 365 received fresh frozen plasma (FFP) and PRBC at a ratio of at least 1:2 (HRR); the ratio was less than 1:2 (low-ratio resuscitation) in the other 86 patients.
The average Injury Severity Score was 23.5 (on a scale of 0-75), and the average FFP:PRBC ratio was 1.06 in the HRR group and 1.32 in the low-ratio resuscitation group.
As observed in other studies, patients in the HRR group had a significant survival advantage over those in the low-resuscitation group at 24 hours (85% vs. 69%; P = .0004), Dr. Duchesne said.
In 200 HRR patients with full data, an analysis of 24-hour crystalloid volume revealed that 9.5% received less than 5 L, 25% got 5-10 L, and 65.5% got more than 10 L. The 24-hour crystalloid volume was statistically different between the three subgroups (3.64 L vs. 7.81 L vs. 17.82 L; P = .0001), but there were no statistically significant differences in mortality.
The risk of certain morbidities, however, increased with crystalloid volume in the three subgroups. Rates of bacteremia rose significantly (0% [less than 5 L]), 13% [5-10 L], and 29% [more than 10 L]; P = .029), as did sepsis (0% [less than 5 L], 13% [5-10 L], and 22% [more than 10 L]); P = .028).
The differences were not significant for acute respiratory distress syndrome (1% [less than 5 L], 0% [5-10 L], and 8% [more than 10 L]; P = .163) and for acute respiratory failure (2% [less than 5 L], 12% [5-10 L], and 24% [more than 10 L]; P = .457).
In multiple logistic regression analysis, morbidity was significantly associated with 24-hour crystalloid volume (odds ratio, 1.11; P = .001), systolic blood pressure level in the emergency department (OR, 1.19; P = .043), and base deficit level in the emergency department (OR, 1.02; P = .002). Morbidity was not associated with high ratio resuscitation (OR, 1.34; P = .065), Dr. Duchesne observed.
Dr. Duchesne reported having no disclosures.
AT THE EAST SCIENTIFIC ASSEMBLY
Major finding: With a rise in the volume of crystalloid solutions, rates of sepsis rose significantly (0% [less than 5 L], 13% [5-10 L], 22% [more than 10 L]); P = .028).
Data source: Retrospective multicenter analysis of 451 patients undergoing hemostatic resuscitation.
Disclosures: Dr. Duchesne and Dr. Jenkins reported having no disclosures.
ARROW: Clinical monitoring suffices in pediatric ART
ATLANTA – HIV treatment can be delivered safely to children with good clinical care alone, without any need for routine laboratory monitoring of side effects, according to researchers involved in the ARROW Trial.
Routine CD4 and toxicity laboratory monitoring every 12 weeks had no impact on HIV disease progression during the first year of antiretroviral therapy (ART). There was a small, but significant impact on progression after the first year, but overall event rates were very low and occurred mostly in older children whose adherence to therapy may have played a role in the poorer outcomes, Dr. Adeodata Kekitiinwa said at the Conference on Retroviruses and Opportunistic Infections.
The findings indicate that expensive lab monitoring is not essential to good outcomes for children, especially those in impoverished countries.
"Resources should be focused on getting as many children onto treatment as possible, rather than providing routine laboratory monitoring to the few on ART," Dr. Kekitiinwa said, noting that 90% of HIV-infected children live in Sub-Saharan Africa, and only 28% of those in need of ART are receiving it.
Trials in adults have shown routine CD4 monitoring provides small, but significant benefits on disease progression and death, while routine toxicity monitoring has no impact on toxicity outcomes, observed Dr. Kekitiinwa of the pediatric infectious diseases clinic, Baylor College of Medicine, Children’s Foundation–Uganda in Mulago.
The ARROW (Anti-Retroviral Research for Watoto) trial randomized 1,206 antiretroviral-naive children and adolescents in Uganda and Zimbabwe to either clinically or laboratory-driven monitoring and to one of three groups of standard three- or four-drug induction ART. Group A received a non-nucleoside reverse transcriptase inhibitor (NNRTI), lamivudine, and abacavir. Groups B and C received an NNRTI, lamivudine, abacavir, and zidovudine therapy; after week 36, the regimen was reduced to a three-drug NNRTI, lamivudine plus abacavir in group B and lamivudine, abacavir plus zidovudine in group C.
Both groups received 12 weekly biochemistry profiles and full blood counts to monitor for toxicity and CD4 counts to monitor for efficacy. The laboratory arm, however, had their results returned every 12 weeks, while the clinical arm received toxicity results only if requested or a grade 4-toxicity occurred and never had their CD4 counts returned, Dr. Kekitiinwa explained.
More than 30% of the children were less than 3 years old (range, 4 months to 17 years); 70% had grade 3/4 disease. Median follow-up was 4 years and 3% of children were lost to follow-up.
The primary endpoint of grade 4 toxicity or death occurred in 39 patients in the lab arm and 47 in the clinical arm (1.7 vs. 2.0 events/100 child-years). This resulted in a hazard ratio of 1.13 (95% confidence interval 0.73-1.53; P = .59), and translated into an absolute difference of 0.3 (95% CI –0.5-1.1), which fell within the prespecified noninferiority margin, she said.
In years 2-5, the number of events increased significantly in the clinical care arm (1.3 vs. 0.4/100 child-years). Once again, the absolute difference remained within the noninferiority margin (1.0/100 child-years; P = .002; 95% CI 0.4-1.6), although Dr. Kekitiinwa acknowledged that "there may be a role for targeted, as opposed to routine, laboratory monitoring from the second year of ART."
Mortality was low, with 96% of the clinical arm and 95% of the lab arm still alive at the end of 4 years. Two deaths occurred in the lab arm vs. 14 in the clinical arm, of which 12 were in children 8 years or older.
Excess grade 3 and 4 adverse events were reported in 40% of children in group A, 47% in group B and 54% in group C. These events were driven by asymptomatic neutropenia in children receiving zidovudine-containing regimens, and by failure to thrive in group A.
"Monitoring of weight gain should be emphasized as an important clinical aid for identifying first-line failure," Dr. Kekitiinwa said.
Viral load suppression did not differ by monitoring strategy. Full details of ARROW were simultaneously published online (Lancet 2013 [doi:10.1016/S0140-6736(12)62198-9])
ARROW is funded by the U.K. Department for International Development and U.K. Medical Research Council. Study drugs were donated and viral load assays funded by ViiV Healthcare and GlaxoSmithKline. Dr. Kekitiinwa reported having no financial disclosures.
ATLANTA – HIV treatment can be delivered safely to children with good clinical care alone, without any need for routine laboratory monitoring of side effects, according to researchers involved in the ARROW Trial.
Routine CD4 and toxicity laboratory monitoring every 12 weeks had no impact on HIV disease progression during the first year of antiretroviral therapy (ART). There was a small, but significant impact on progression after the first year, but overall event rates were very low and occurred mostly in older children whose adherence to therapy may have played a role in the poorer outcomes, Dr. Adeodata Kekitiinwa said at the Conference on Retroviruses and Opportunistic Infections.
The findings indicate that expensive lab monitoring is not essential to good outcomes for children, especially those in impoverished countries.
"Resources should be focused on getting as many children onto treatment as possible, rather than providing routine laboratory monitoring to the few on ART," Dr. Kekitiinwa said, noting that 90% of HIV-infected children live in Sub-Saharan Africa, and only 28% of those in need of ART are receiving it.
Trials in adults have shown routine CD4 monitoring provides small, but significant benefits on disease progression and death, while routine toxicity monitoring has no impact on toxicity outcomes, observed Dr. Kekitiinwa of the pediatric infectious diseases clinic, Baylor College of Medicine, Children’s Foundation–Uganda in Mulago.
The ARROW (Anti-Retroviral Research for Watoto) trial randomized 1,206 antiretroviral-naive children and adolescents in Uganda and Zimbabwe to either clinically or laboratory-driven monitoring and to one of three groups of standard three- or four-drug induction ART. Group A received a non-nucleoside reverse transcriptase inhibitor (NNRTI), lamivudine, and abacavir. Groups B and C received an NNRTI, lamivudine, abacavir, and zidovudine therapy; after week 36, the regimen was reduced to a three-drug NNRTI, lamivudine plus abacavir in group B and lamivudine, abacavir plus zidovudine in group C.
Both groups received 12 weekly biochemistry profiles and full blood counts to monitor for toxicity and CD4 counts to monitor for efficacy. The laboratory arm, however, had their results returned every 12 weeks, while the clinical arm received toxicity results only if requested or a grade 4-toxicity occurred and never had their CD4 counts returned, Dr. Kekitiinwa explained.
More than 30% of the children were less than 3 years old (range, 4 months to 17 years); 70% had grade 3/4 disease. Median follow-up was 4 years and 3% of children were lost to follow-up.
The primary endpoint of grade 4 toxicity or death occurred in 39 patients in the lab arm and 47 in the clinical arm (1.7 vs. 2.0 events/100 child-years). This resulted in a hazard ratio of 1.13 (95% confidence interval 0.73-1.53; P = .59), and translated into an absolute difference of 0.3 (95% CI –0.5-1.1), which fell within the prespecified noninferiority margin, she said.
In years 2-5, the number of events increased significantly in the clinical care arm (1.3 vs. 0.4/100 child-years). Once again, the absolute difference remained within the noninferiority margin (1.0/100 child-years; P = .002; 95% CI 0.4-1.6), although Dr. Kekitiinwa acknowledged that "there may be a role for targeted, as opposed to routine, laboratory monitoring from the second year of ART."
Mortality was low, with 96% of the clinical arm and 95% of the lab arm still alive at the end of 4 years. Two deaths occurred in the lab arm vs. 14 in the clinical arm, of which 12 were in children 8 years or older.
Excess grade 3 and 4 adverse events were reported in 40% of children in group A, 47% in group B and 54% in group C. These events were driven by asymptomatic neutropenia in children receiving zidovudine-containing regimens, and by failure to thrive in group A.
"Monitoring of weight gain should be emphasized as an important clinical aid for identifying first-line failure," Dr. Kekitiinwa said.
Viral load suppression did not differ by monitoring strategy. Full details of ARROW were simultaneously published online (Lancet 2013 [doi:10.1016/S0140-6736(12)62198-9])
ARROW is funded by the U.K. Department for International Development and U.K. Medical Research Council. Study drugs were donated and viral load assays funded by ViiV Healthcare and GlaxoSmithKline. Dr. Kekitiinwa reported having no financial disclosures.
ATLANTA – HIV treatment can be delivered safely to children with good clinical care alone, without any need for routine laboratory monitoring of side effects, according to researchers involved in the ARROW Trial.
Routine CD4 and toxicity laboratory monitoring every 12 weeks had no impact on HIV disease progression during the first year of antiretroviral therapy (ART). There was a small, but significant impact on progression after the first year, but overall event rates were very low and occurred mostly in older children whose adherence to therapy may have played a role in the poorer outcomes, Dr. Adeodata Kekitiinwa said at the Conference on Retroviruses and Opportunistic Infections.
The findings indicate that expensive lab monitoring is not essential to good outcomes for children, especially those in impoverished countries.
"Resources should be focused on getting as many children onto treatment as possible, rather than providing routine laboratory monitoring to the few on ART," Dr. Kekitiinwa said, noting that 90% of HIV-infected children live in Sub-Saharan Africa, and only 28% of those in need of ART are receiving it.
Trials in adults have shown routine CD4 monitoring provides small, but significant benefits on disease progression and death, while routine toxicity monitoring has no impact on toxicity outcomes, observed Dr. Kekitiinwa of the pediatric infectious diseases clinic, Baylor College of Medicine, Children’s Foundation–Uganda in Mulago.
The ARROW (Anti-Retroviral Research for Watoto) trial randomized 1,206 antiretroviral-naive children and adolescents in Uganda and Zimbabwe to either clinically or laboratory-driven monitoring and to one of three groups of standard three- or four-drug induction ART. Group A received a non-nucleoside reverse transcriptase inhibitor (NNRTI), lamivudine, and abacavir. Groups B and C received an NNRTI, lamivudine, abacavir, and zidovudine therapy; after week 36, the regimen was reduced to a three-drug NNRTI, lamivudine plus abacavir in group B and lamivudine, abacavir plus zidovudine in group C.
Both groups received 12 weekly biochemistry profiles and full blood counts to monitor for toxicity and CD4 counts to monitor for efficacy. The laboratory arm, however, had their results returned every 12 weeks, while the clinical arm received toxicity results only if requested or a grade 4-toxicity occurred and never had their CD4 counts returned, Dr. Kekitiinwa explained.
More than 30% of the children were less than 3 years old (range, 4 months to 17 years); 70% had grade 3/4 disease. Median follow-up was 4 years and 3% of children were lost to follow-up.
The primary endpoint of grade 4 toxicity or death occurred in 39 patients in the lab arm and 47 in the clinical arm (1.7 vs. 2.0 events/100 child-years). This resulted in a hazard ratio of 1.13 (95% confidence interval 0.73-1.53; P = .59), and translated into an absolute difference of 0.3 (95% CI –0.5-1.1), which fell within the prespecified noninferiority margin, she said.
In years 2-5, the number of events increased significantly in the clinical care arm (1.3 vs. 0.4/100 child-years). Once again, the absolute difference remained within the noninferiority margin (1.0/100 child-years; P = .002; 95% CI 0.4-1.6), although Dr. Kekitiinwa acknowledged that "there may be a role for targeted, as opposed to routine, laboratory monitoring from the second year of ART."
Mortality was low, with 96% of the clinical arm and 95% of the lab arm still alive at the end of 4 years. Two deaths occurred in the lab arm vs. 14 in the clinical arm, of which 12 were in children 8 years or older.
Excess grade 3 and 4 adverse events were reported in 40% of children in group A, 47% in group B and 54% in group C. These events were driven by asymptomatic neutropenia in children receiving zidovudine-containing regimens, and by failure to thrive in group A.
"Monitoring of weight gain should be emphasized as an important clinical aid for identifying first-line failure," Dr. Kekitiinwa said.
Viral load suppression did not differ by monitoring strategy. Full details of ARROW were simultaneously published online (Lancet 2013 [doi:10.1016/S0140-6736(12)62198-9])
ARROW is funded by the U.K. Department for International Development and U.K. Medical Research Council. Study drugs were donated and viral load assays funded by ViiV Healthcare and GlaxoSmithKline. Dr. Kekitiinwa reported having no financial disclosures.
AT CROI 2013
Major finding: The primary endpoint of grade 4-toxicity or death occurred in 39 patients monitored with laboratory testing and in 47 patients with clinically driven monitoring (1.7 vs. 2.0 events per 100 child years).
Data source: Open-label randomized trial in 1,206 HIV-positive children receiving first-line antiretroviral therapy.
Disclosures: ARROW is funded by the U.K. Department for International Development and U.K. Medical Research Council. Study drugs were donated and viral load assays funded by ViiV Healthcare and GlaxoSmith Kline. Dr. Kekitiinwa reported having no financial disclosures.
Lower costs documented in hospitals with palliative care programs
NEW ORLEANS – Hospitals with palliative care programs had lower treatment intensity on average at the end of life than did those without palliative care, in a national sample of 3,593 hospitals.
ICU length of stay in the last 6 months of life was 0.4 days shorter (P less than .001) and hospice length of stay 1.6 days longer (P = .013) at hospitals with palliative care versus those without.
The study strengthens claims that palliative care cuts costs, and is the first to examine the impact of palliative care in such a large national sample of hospitals, Jay R. Horton said at the annual meeting of the American Academy of Hospice and Palliative Medicine.
Prior studies focused on the effects of palliative care. Mr. Horton’s study considers outcomes for the entire older adult population in the hospital.
The researchers considered data from 3,593 hospitals with a palliative care status noted on the 2008 American Hospital Association survey. In all, 1,657 hospitals had palliative care programs and 1,936 hospitals did not. The researchers then linked the hospital data with the data from the Dartmouth Atlas on 896,097 fee-for-service Medicare patients, aged 67-99 years, with one or more chronic illnesses, who died in 2007. Patients were assigned to a hospital where they received the majority of their care in the last 2 years of life.
Covariates predictive of outcomes such as age, sex, race and comorbidities were already corrected for in the Dartmouth Atlas. Propensity scoring was used for variables predictive of outcomes or the presence of palliative care in the AHA survey such as Joint Commission Accreditation and total bed count. Finally, propensity scores were used to reweight the sample to reduce selection bias.
The effect of palliative care would very likely be stronger if the data had identified those patients who actually received palliative care, said Mr. Horton , director of the palliative care consult service at The Lilian and Benjamin Hertzberg Palliative Care Institute, Icahn School of Medicine at Mount Sinai Hospital, New York. Ongoing research uses data from the National Palliative Care Registry to better identify palliative care programs and socioeconomic factors to further reduce potential selection bias.
Treatment intensity for patients with serious illness varies widely across the country. One study showed that more than 40% of the variation is due to the supply of specialists and hospital capacity (BMJ 2002;325:961-4). Put another way, the greater the supply of physicians, the greater the utilization, even after adjustment for factors that should drive utilization, such as patient preference and disease severity.
"This supply-sensitive care, as it is sometimes called, is at the discretion of clinicians and to a certain extent at the discretion of patients, but more troubling is that much of this care may be unnecessary," said Mr. Horton.
Mr. Horton reported having no financial disclosures.
NEW ORLEANS – Hospitals with palliative care programs had lower treatment intensity on average at the end of life than did those without palliative care, in a national sample of 3,593 hospitals.
ICU length of stay in the last 6 months of life was 0.4 days shorter (P less than .001) and hospice length of stay 1.6 days longer (P = .013) at hospitals with palliative care versus those without.
The study strengthens claims that palliative care cuts costs, and is the first to examine the impact of palliative care in such a large national sample of hospitals, Jay R. Horton said at the annual meeting of the American Academy of Hospice and Palliative Medicine.
Prior studies focused on the effects of palliative care. Mr. Horton’s study considers outcomes for the entire older adult population in the hospital.
The researchers considered data from 3,593 hospitals with a palliative care status noted on the 2008 American Hospital Association survey. In all, 1,657 hospitals had palliative care programs and 1,936 hospitals did not. The researchers then linked the hospital data with the data from the Dartmouth Atlas on 896,097 fee-for-service Medicare patients, aged 67-99 years, with one or more chronic illnesses, who died in 2007. Patients were assigned to a hospital where they received the majority of their care in the last 2 years of life.
Covariates predictive of outcomes such as age, sex, race and comorbidities were already corrected for in the Dartmouth Atlas. Propensity scoring was used for variables predictive of outcomes or the presence of palliative care in the AHA survey such as Joint Commission Accreditation and total bed count. Finally, propensity scores were used to reweight the sample to reduce selection bias.
The effect of palliative care would very likely be stronger if the data had identified those patients who actually received palliative care, said Mr. Horton , director of the palliative care consult service at The Lilian and Benjamin Hertzberg Palliative Care Institute, Icahn School of Medicine at Mount Sinai Hospital, New York. Ongoing research uses data from the National Palliative Care Registry to better identify palliative care programs and socioeconomic factors to further reduce potential selection bias.
Treatment intensity for patients with serious illness varies widely across the country. One study showed that more than 40% of the variation is due to the supply of specialists and hospital capacity (BMJ 2002;325:961-4). Put another way, the greater the supply of physicians, the greater the utilization, even after adjustment for factors that should drive utilization, such as patient preference and disease severity.
"This supply-sensitive care, as it is sometimes called, is at the discretion of clinicians and to a certain extent at the discretion of patients, but more troubling is that much of this care may be unnecessary," said Mr. Horton.
Mr. Horton reported having no financial disclosures.
NEW ORLEANS – Hospitals with palliative care programs had lower treatment intensity on average at the end of life than did those without palliative care, in a national sample of 3,593 hospitals.
ICU length of stay in the last 6 months of life was 0.4 days shorter (P less than .001) and hospice length of stay 1.6 days longer (P = .013) at hospitals with palliative care versus those without.
The study strengthens claims that palliative care cuts costs, and is the first to examine the impact of palliative care in such a large national sample of hospitals, Jay R. Horton said at the annual meeting of the American Academy of Hospice and Palliative Medicine.
Prior studies focused on the effects of palliative care. Mr. Horton’s study considers outcomes for the entire older adult population in the hospital.
The researchers considered data from 3,593 hospitals with a palliative care status noted on the 2008 American Hospital Association survey. In all, 1,657 hospitals had palliative care programs and 1,936 hospitals did not. The researchers then linked the hospital data with the data from the Dartmouth Atlas on 896,097 fee-for-service Medicare patients, aged 67-99 years, with one or more chronic illnesses, who died in 2007. Patients were assigned to a hospital where they received the majority of their care in the last 2 years of life.
Covariates predictive of outcomes such as age, sex, race and comorbidities were already corrected for in the Dartmouth Atlas. Propensity scoring was used for variables predictive of outcomes or the presence of palliative care in the AHA survey such as Joint Commission Accreditation and total bed count. Finally, propensity scores were used to reweight the sample to reduce selection bias.
The effect of palliative care would very likely be stronger if the data had identified those patients who actually received palliative care, said Mr. Horton , director of the palliative care consult service at The Lilian and Benjamin Hertzberg Palliative Care Institute, Icahn School of Medicine at Mount Sinai Hospital, New York. Ongoing research uses data from the National Palliative Care Registry to better identify palliative care programs and socioeconomic factors to further reduce potential selection bias.
Treatment intensity for patients with serious illness varies widely across the country. One study showed that more than 40% of the variation is due to the supply of specialists and hospital capacity (BMJ 2002;325:961-4). Put another way, the greater the supply of physicians, the greater the utilization, even after adjustment for factors that should drive utilization, such as patient preference and disease severity.
"This supply-sensitive care, as it is sometimes called, is at the discretion of clinicians and to a certain extent at the discretion of patients, but more troubling is that much of this care may be unnecessary," said Mr. Horton.
Mr. Horton reported having no financial disclosures.
AT THE AAHPM ANNUAL ASSEMBLY
Major finding: ICU length of stay in the last 6 months of life was 0.4 days shorter and hospice length of stay was 1.6 days longer at hospitals with palliative care (P less than .001, P = .013).
Data source: A retrospective analysis of 3,593 hospitals with palliative care data.
Disclosures: Mr. Horton reported having no financial disclosures.
Trial shows benefits of patellofemoral brace for kneecap osteoarthritis
PHILADELPHIA – A lightweight brace on the patellofemoral joint significantly improves the pain and symptoms of knee osteoarthritis, according to BRACE, the largest patellofemoral bracing trial to date.
After 6 weeks of brace wearing, pain fell an average of 16.87 points on a visual analog scale (VAS) during an activity patients reported as aggravating, compared with no brace (–18.16 vs. –1.29, P less than .001).
A 12-point reduction is considered clinically relevant on the 100-mm VAS pain scale, where 0 is no pain and 100 is worst pain, Michael Callaghan, Ph.D., said at the World Congress on Osteoarthritis.
"The feedback we got from patients each time is that the brace made their knee feel more supported, they felt more comfortable, they felt more confident," he said. "One of the things we’re thinking is that perhaps the brace gave patients the ability to use their knee a little bit more comfortably, functionally better than they could previously, and that was enough to start improving muscle strength."
Data are available to show that muscle strength did improve with brace wearing, and a recently completed biomechanical analysis should determine whether biomechanical changes were actually occurring.
Although nonpharmacologic interventions are urgently needed for knee osteoarthritis (OA), little attention has been paid to treatments specifically for the patellofemoral (PF) joint, said Dr. Callaghan, a research physiotherapist at the University of Manchester (England). About 24% of patients with knee OA have symptomatic patellofemoral (PF) OA in the absence of tibiofemoral arthritis, but more importantly, 41% have a combination of tibiofemoral and PF knee OA. Despite this, a recent editorial (Osteoarthritis Cartilage 2011;19:765-7) called the patellofemoral joint "the forgotten joint" in knee OA, he observed.
Nonsurgical treatments include anti-inflammatory medications, physical therapy, and cortisone shots. Arthroscopic debridement, lateral retinacular release, and partial or full knee replacement are reserved for more severe cases.
The one prior study of PF braces showed no effect on pain, but it compared the same brace with and without a patellar strap (Osteoarthritis Cartilage 2011;19:792-800). In clinical practice, the more relevant question is the benefit of PF bracing versus no bracing, Dr. Callaghan observed.
The 126 patients in the trial had a radiographic Kellgren-Lawrence score of 2 or 3 in the PF joint; daily knee pain for the previous 3 months with stair climbing, kneeling, prolonged sitting, or squatting; and tenderness over the lateral or medial patellar facet on palpation or a positive patellar compression test. In the trial, the mean VAS pain score was 64.6 mm, 57% of the participants were women, and the patients’ mean body mass index was 30.8 kg/m2. Their average age was 55.5 years.
Patients were randomly assigned to immediate brace treatment with the Bioskin Patellar Tracking Q Brace (Ossur, Manchester, England) or delayed treatment at 6 weeks. All patients ultimately received 12 weeks of brace, and wore their brace for an average of 7.35 hours per day.
At 6 weeks, Knee Osteoarthritis Outcome Score subscale scores for pain and activities of daily living improved significantly with the brace vs. no brace by an average of –6.70 and –5.64, respectively (8.78 vs. 2.08 and 6.67 vs. 1.03; both P = .02), Dr. Callaghan reported at the meeting, sponsored by the Osteoarthritis Research Society International.
There was a trend toward improved aggregated locomotor function with the PT brace (–2.5 vs. –1.21; P = .065) in the study, which was led by colleague Dr. David Felson, professor of medicine at the University of Manchester and Boston University.
During a discussion of the study, an attendee said that in her practice she avoids using the type of brace used in the study with a cutout over the knee in younger patients with PF pain, because of data suggesting that bracing compresses the patella and increases the contact area between the patella and the trochlear notch, thereby increasing stress rather than changing the patella position or movement. Dr. Callaghan acknowledged that compression could be an issue and said MRI data available on 30 patients are being evaluated for evidence of compression and joint space narrowing.
Arthritis Research UK funded the trial. The authors reported no relevant disclosures.
PHILADELPHIA – A lightweight brace on the patellofemoral joint significantly improves the pain and symptoms of knee osteoarthritis, according to BRACE, the largest patellofemoral bracing trial to date.
After 6 weeks of brace wearing, pain fell an average of 16.87 points on a visual analog scale (VAS) during an activity patients reported as aggravating, compared with no brace (–18.16 vs. –1.29, P less than .001).
A 12-point reduction is considered clinically relevant on the 100-mm VAS pain scale, where 0 is no pain and 100 is worst pain, Michael Callaghan, Ph.D., said at the World Congress on Osteoarthritis.
"The feedback we got from patients each time is that the brace made their knee feel more supported, they felt more comfortable, they felt more confident," he said. "One of the things we’re thinking is that perhaps the brace gave patients the ability to use their knee a little bit more comfortably, functionally better than they could previously, and that was enough to start improving muscle strength."
Data are available to show that muscle strength did improve with brace wearing, and a recently completed biomechanical analysis should determine whether biomechanical changes were actually occurring.
Although nonpharmacologic interventions are urgently needed for knee osteoarthritis (OA), little attention has been paid to treatments specifically for the patellofemoral (PF) joint, said Dr. Callaghan, a research physiotherapist at the University of Manchester (England). About 24% of patients with knee OA have symptomatic patellofemoral (PF) OA in the absence of tibiofemoral arthritis, but more importantly, 41% have a combination of tibiofemoral and PF knee OA. Despite this, a recent editorial (Osteoarthritis Cartilage 2011;19:765-7) called the patellofemoral joint "the forgotten joint" in knee OA, he observed.
Nonsurgical treatments include anti-inflammatory medications, physical therapy, and cortisone shots. Arthroscopic debridement, lateral retinacular release, and partial or full knee replacement are reserved for more severe cases.
The one prior study of PF braces showed no effect on pain, but it compared the same brace with and without a patellar strap (Osteoarthritis Cartilage 2011;19:792-800). In clinical practice, the more relevant question is the benefit of PF bracing versus no bracing, Dr. Callaghan observed.
The 126 patients in the trial had a radiographic Kellgren-Lawrence score of 2 or 3 in the PF joint; daily knee pain for the previous 3 months with stair climbing, kneeling, prolonged sitting, or squatting; and tenderness over the lateral or medial patellar facet on palpation or a positive patellar compression test. In the trial, the mean VAS pain score was 64.6 mm, 57% of the participants were women, and the patients’ mean body mass index was 30.8 kg/m2. Their average age was 55.5 years.
Patients were randomly assigned to immediate brace treatment with the Bioskin Patellar Tracking Q Brace (Ossur, Manchester, England) or delayed treatment at 6 weeks. All patients ultimately received 12 weeks of brace, and wore their brace for an average of 7.35 hours per day.
At 6 weeks, Knee Osteoarthritis Outcome Score subscale scores for pain and activities of daily living improved significantly with the brace vs. no brace by an average of –6.70 and –5.64, respectively (8.78 vs. 2.08 and 6.67 vs. 1.03; both P = .02), Dr. Callaghan reported at the meeting, sponsored by the Osteoarthritis Research Society International.
There was a trend toward improved aggregated locomotor function with the PT brace (–2.5 vs. –1.21; P = .065) in the study, which was led by colleague Dr. David Felson, professor of medicine at the University of Manchester and Boston University.
During a discussion of the study, an attendee said that in her practice she avoids using the type of brace used in the study with a cutout over the knee in younger patients with PF pain, because of data suggesting that bracing compresses the patella and increases the contact area between the patella and the trochlear notch, thereby increasing stress rather than changing the patella position or movement. Dr. Callaghan acknowledged that compression could be an issue and said MRI data available on 30 patients are being evaluated for evidence of compression and joint space narrowing.
Arthritis Research UK funded the trial. The authors reported no relevant disclosures.
PHILADELPHIA – A lightweight brace on the patellofemoral joint significantly improves the pain and symptoms of knee osteoarthritis, according to BRACE, the largest patellofemoral bracing trial to date.
After 6 weeks of brace wearing, pain fell an average of 16.87 points on a visual analog scale (VAS) during an activity patients reported as aggravating, compared with no brace (–18.16 vs. –1.29, P less than .001).
A 12-point reduction is considered clinically relevant on the 100-mm VAS pain scale, where 0 is no pain and 100 is worst pain, Michael Callaghan, Ph.D., said at the World Congress on Osteoarthritis.
"The feedback we got from patients each time is that the brace made their knee feel more supported, they felt more comfortable, they felt more confident," he said. "One of the things we’re thinking is that perhaps the brace gave patients the ability to use their knee a little bit more comfortably, functionally better than they could previously, and that was enough to start improving muscle strength."
Data are available to show that muscle strength did improve with brace wearing, and a recently completed biomechanical analysis should determine whether biomechanical changes were actually occurring.
Although nonpharmacologic interventions are urgently needed for knee osteoarthritis (OA), little attention has been paid to treatments specifically for the patellofemoral (PF) joint, said Dr. Callaghan, a research physiotherapist at the University of Manchester (England). About 24% of patients with knee OA have symptomatic patellofemoral (PF) OA in the absence of tibiofemoral arthritis, but more importantly, 41% have a combination of tibiofemoral and PF knee OA. Despite this, a recent editorial (Osteoarthritis Cartilage 2011;19:765-7) called the patellofemoral joint "the forgotten joint" in knee OA, he observed.
Nonsurgical treatments include anti-inflammatory medications, physical therapy, and cortisone shots. Arthroscopic debridement, lateral retinacular release, and partial or full knee replacement are reserved for more severe cases.
The one prior study of PF braces showed no effect on pain, but it compared the same brace with and without a patellar strap (Osteoarthritis Cartilage 2011;19:792-800). In clinical practice, the more relevant question is the benefit of PF bracing versus no bracing, Dr. Callaghan observed.
The 126 patients in the trial had a radiographic Kellgren-Lawrence score of 2 or 3 in the PF joint; daily knee pain for the previous 3 months with stair climbing, kneeling, prolonged sitting, or squatting; and tenderness over the lateral or medial patellar facet on palpation or a positive patellar compression test. In the trial, the mean VAS pain score was 64.6 mm, 57% of the participants were women, and the patients’ mean body mass index was 30.8 kg/m2. Their average age was 55.5 years.
Patients were randomly assigned to immediate brace treatment with the Bioskin Patellar Tracking Q Brace (Ossur, Manchester, England) or delayed treatment at 6 weeks. All patients ultimately received 12 weeks of brace, and wore their brace for an average of 7.35 hours per day.
At 6 weeks, Knee Osteoarthritis Outcome Score subscale scores for pain and activities of daily living improved significantly with the brace vs. no brace by an average of –6.70 and –5.64, respectively (8.78 vs. 2.08 and 6.67 vs. 1.03; both P = .02), Dr. Callaghan reported at the meeting, sponsored by the Osteoarthritis Research Society International.
There was a trend toward improved aggregated locomotor function with the PT brace (–2.5 vs. –1.21; P = .065) in the study, which was led by colleague Dr. David Felson, professor of medicine at the University of Manchester and Boston University.
During a discussion of the study, an attendee said that in her practice she avoids using the type of brace used in the study with a cutout over the knee in younger patients with PF pain, because of data suggesting that bracing compresses the patella and increases the contact area between the patella and the trochlear notch, thereby increasing stress rather than changing the patella position or movement. Dr. Callaghan acknowledged that compression could be an issue and said MRI data available on 30 patients are being evaluated for evidence of compression and joint space narrowing.
Arthritis Research UK funded the trial. The authors reported no relevant disclosures.
AT THE WORLD CONGRESS ON OSTEOARTHRITIS
Major finding: VAS pain scores were reduced by an average of 18.16 points after 6 weeks of patellofemoral bracing vs. 1.29 points without bracing (P less than .001).
Data source: Randomized, open-label study of 126 patients with patellofemoral osteoarthritis.
Disclosures: Arthritis Research UK funded the trial. The authors reported no relevant disclosures.
Hypercoagulability occurred despite VTE prophylaxis in burn patients
SCOTTSDALE, ARIZ. – Despite thromboprophylaxis, burn patients become hypercoagulable during recovery, putting them at increased risk of venous thromboembolism, a small, prospective study has shown.
"The hypercoagulable state is likely multifactorial, and we believe that additional prophylaxis and monitoring may be needed," Dr. Robert Van Haren said at the annual scientific assembly of the Eastern Association for the Surgery of Trauma.
Hypercoagulability has long been known to contribute to venous thromboembolism (VTE), but it’s only more recently that the increased incidence of thromboembolic complications in burn patients has been appreciated.
A study using duplex ultrasound screening reported that 23% of burn patients developed deep venous thrombosis at an average of 6.7 days after admission (J. Burn Care Rehabil. 2002;23:439-43).
More recent work reports that such in-hospital risk factors as number of operations, pneumonia, and central venous access are significantly associated with VTE after thermal injury (J. Burn Care Res. 2012;33:84-8).
Dr. Van Haren and his colleagues at the University of Miami used thromboelastography (TEG) and coagulation tests to analyze blood samples drawn from indwelling catheters upon admission and at 1 week in 24 patients. All patients were placed on unfractionated or low-molecular-weight heparin at admission.
Their median age was 49 years, 88% were male, and the median total body surface area burned was 29%. Inhalation injuries also were present in 17%.
TEG values were within normal limits at admission for clotting time (R = 11.5 minutes), initial clot formation (K = 2.8 minutes), clot kinetics (alpha angle = 54.6 degrees), and clot strength (maximum amplitude = 62.5 mm).
Repeat TEG at 1 week in 16 patients who remained hospitalized revealed significantly decreased R (8.3 minutes) and K (2.0 minutes) times, and elevated alpha angle (65.5 degrees) and maximum amplitude (73.1 mm; all statistically significant, P less than .05).
"All of these changes demonstrate that these patients became more hypercoagulable at week 1," said Dr. Van Haren, a 4th-year general surgery resident.
Coagulation tests were generally supportive of TEG findings. From admission to week 1, significant decreases were observed in median prothrombin time (17.4 seconds vs. 15.7 seconds; P = .013) and international normalized ratio (1.47 vs. 1.28; P = .013). At the same time, significant elevations occurred in protein C activity (75% vs. 93%; P = .017), protein S activity (69% vs. 76%; P = .030), antithrombin III (62% vs. 88%; P = .005), and fibrinogen (524 mg/dL vs. 676 mg/dL; P = .047).
The changes suggest a procoagulant state, and cannot be attributed to hemoconcentration, as fluid balance was more positive and hematocrit was lower on repeat samples, Dr. Van Haren reported.
The only in-hospital risk factor significant for hypercoagulability at 1 week was a pre-TEG operation, he said. Men, however, were more likely to be hypercoagulable than women.
Two patients, both male, developed a deep venous thrombosis. Contrary to previous studies, the only predictive markers of VTE were decreased partial thromboplastin time and fibrinogen and elevated prothrombin fragment 1 + 2.
During the discussion period after Dr. Van Haren’s presentation, audience members asked why hypercoagulability was evaluated at 1 week, since hypercoagulability has been shown to develop quite rapidly in trauma patients. Other questions addressed whether clinicians should use the data to increase thromboprophylaxis or begin dosing based on body mass index in burn patients.
Dr. Van Haren said the 1-week time point was somewhat arbitrary, and plans to look at earlier time periods in another cohort to determine exactly when the transition to hypercoagulability occurs. "I think the most interesting thing would be to see if you can guide your thromboprophylaxis based on TEG, and use it to titrate your dose to see if it will result in decreases in VTE rates."
The study was funded in part by grants from the Office of Naval Research and U.S. Army. Dr. Van Haren and his coauthors reported no relevant financial conflicts.
SCOTTSDALE, ARIZ. – Despite thromboprophylaxis, burn patients become hypercoagulable during recovery, putting them at increased risk of venous thromboembolism, a small, prospective study has shown.
"The hypercoagulable state is likely multifactorial, and we believe that additional prophylaxis and monitoring may be needed," Dr. Robert Van Haren said at the annual scientific assembly of the Eastern Association for the Surgery of Trauma.
Hypercoagulability has long been known to contribute to venous thromboembolism (VTE), but it’s only more recently that the increased incidence of thromboembolic complications in burn patients has been appreciated.
A study using duplex ultrasound screening reported that 23% of burn patients developed deep venous thrombosis at an average of 6.7 days after admission (J. Burn Care Rehabil. 2002;23:439-43).
More recent work reports that such in-hospital risk factors as number of operations, pneumonia, and central venous access are significantly associated with VTE after thermal injury (J. Burn Care Res. 2012;33:84-8).
Dr. Van Haren and his colleagues at the University of Miami used thromboelastography (TEG) and coagulation tests to analyze blood samples drawn from indwelling catheters upon admission and at 1 week in 24 patients. All patients were placed on unfractionated or low-molecular-weight heparin at admission.
Their median age was 49 years, 88% were male, and the median total body surface area burned was 29%. Inhalation injuries also were present in 17%.
TEG values were within normal limits at admission for clotting time (R = 11.5 minutes), initial clot formation (K = 2.8 minutes), clot kinetics (alpha angle = 54.6 degrees), and clot strength (maximum amplitude = 62.5 mm).
Repeat TEG at 1 week in 16 patients who remained hospitalized revealed significantly decreased R (8.3 minutes) and K (2.0 minutes) times, and elevated alpha angle (65.5 degrees) and maximum amplitude (73.1 mm; all statistically significant, P less than .05).
"All of these changes demonstrate that these patients became more hypercoagulable at week 1," said Dr. Van Haren, a 4th-year general surgery resident.
Coagulation tests were generally supportive of TEG findings. From admission to week 1, significant decreases were observed in median prothrombin time (17.4 seconds vs. 15.7 seconds; P = .013) and international normalized ratio (1.47 vs. 1.28; P = .013). At the same time, significant elevations occurred in protein C activity (75% vs. 93%; P = .017), protein S activity (69% vs. 76%; P = .030), antithrombin III (62% vs. 88%; P = .005), and fibrinogen (524 mg/dL vs. 676 mg/dL; P = .047).
The changes suggest a procoagulant state, and cannot be attributed to hemoconcentration, as fluid balance was more positive and hematocrit was lower on repeat samples, Dr. Van Haren reported.
The only in-hospital risk factor significant for hypercoagulability at 1 week was a pre-TEG operation, he said. Men, however, were more likely to be hypercoagulable than women.
Two patients, both male, developed a deep venous thrombosis. Contrary to previous studies, the only predictive markers of VTE were decreased partial thromboplastin time and fibrinogen and elevated prothrombin fragment 1 + 2.
During the discussion period after Dr. Van Haren’s presentation, audience members asked why hypercoagulability was evaluated at 1 week, since hypercoagulability has been shown to develop quite rapidly in trauma patients. Other questions addressed whether clinicians should use the data to increase thromboprophylaxis or begin dosing based on body mass index in burn patients.
Dr. Van Haren said the 1-week time point was somewhat arbitrary, and plans to look at earlier time periods in another cohort to determine exactly when the transition to hypercoagulability occurs. "I think the most interesting thing would be to see if you can guide your thromboprophylaxis based on TEG, and use it to titrate your dose to see if it will result in decreases in VTE rates."
The study was funded in part by grants from the Office of Naval Research and U.S. Army. Dr. Van Haren and his coauthors reported no relevant financial conflicts.
SCOTTSDALE, ARIZ. – Despite thromboprophylaxis, burn patients become hypercoagulable during recovery, putting them at increased risk of venous thromboembolism, a small, prospective study has shown.
"The hypercoagulable state is likely multifactorial, and we believe that additional prophylaxis and monitoring may be needed," Dr. Robert Van Haren said at the annual scientific assembly of the Eastern Association for the Surgery of Trauma.
Hypercoagulability has long been known to contribute to venous thromboembolism (VTE), but it’s only more recently that the increased incidence of thromboembolic complications in burn patients has been appreciated.
A study using duplex ultrasound screening reported that 23% of burn patients developed deep venous thrombosis at an average of 6.7 days after admission (J. Burn Care Rehabil. 2002;23:439-43).
More recent work reports that such in-hospital risk factors as number of operations, pneumonia, and central venous access are significantly associated with VTE after thermal injury (J. Burn Care Res. 2012;33:84-8).
Dr. Van Haren and his colleagues at the University of Miami used thromboelastography (TEG) and coagulation tests to analyze blood samples drawn from indwelling catheters upon admission and at 1 week in 24 patients. All patients were placed on unfractionated or low-molecular-weight heparin at admission.
Their median age was 49 years, 88% were male, and the median total body surface area burned was 29%. Inhalation injuries also were present in 17%.
TEG values were within normal limits at admission for clotting time (R = 11.5 minutes), initial clot formation (K = 2.8 minutes), clot kinetics (alpha angle = 54.6 degrees), and clot strength (maximum amplitude = 62.5 mm).
Repeat TEG at 1 week in 16 patients who remained hospitalized revealed significantly decreased R (8.3 minutes) and K (2.0 minutes) times, and elevated alpha angle (65.5 degrees) and maximum amplitude (73.1 mm; all statistically significant, P less than .05).
"All of these changes demonstrate that these patients became more hypercoagulable at week 1," said Dr. Van Haren, a 4th-year general surgery resident.
Coagulation tests were generally supportive of TEG findings. From admission to week 1, significant decreases were observed in median prothrombin time (17.4 seconds vs. 15.7 seconds; P = .013) and international normalized ratio (1.47 vs. 1.28; P = .013). At the same time, significant elevations occurred in protein C activity (75% vs. 93%; P = .017), protein S activity (69% vs. 76%; P = .030), antithrombin III (62% vs. 88%; P = .005), and fibrinogen (524 mg/dL vs. 676 mg/dL; P = .047).
The changes suggest a procoagulant state, and cannot be attributed to hemoconcentration, as fluid balance was more positive and hematocrit was lower on repeat samples, Dr. Van Haren reported.
The only in-hospital risk factor significant for hypercoagulability at 1 week was a pre-TEG operation, he said. Men, however, were more likely to be hypercoagulable than women.
Two patients, both male, developed a deep venous thrombosis. Contrary to previous studies, the only predictive markers of VTE were decreased partial thromboplastin time and fibrinogen and elevated prothrombin fragment 1 + 2.
During the discussion period after Dr. Van Haren’s presentation, audience members asked why hypercoagulability was evaluated at 1 week, since hypercoagulability has been shown to develop quite rapidly in trauma patients. Other questions addressed whether clinicians should use the data to increase thromboprophylaxis or begin dosing based on body mass index in burn patients.
Dr. Van Haren said the 1-week time point was somewhat arbitrary, and plans to look at earlier time periods in another cohort to determine exactly when the transition to hypercoagulability occurs. "I think the most interesting thing would be to see if you can guide your thromboprophylaxis based on TEG, and use it to titrate your dose to see if it will result in decreases in VTE rates."
The study was funded in part by grants from the Office of Naval Research and U.S. Army. Dr. Van Haren and his coauthors reported no relevant financial conflicts.
AT THE EAST SCIENTIFIC ASSEMBLY
Major Finding: Repeat TEG at 1 week in 16 hospitalized burn patients revealed significantly decreased clotting (8.3 minutes) and initial clot formation (2.0 minutes) times, and elevated alpha angle (65.5 degrees) and maximum amplitude (73.1 mm; all statistically significant, P less than .05).
Data Source: A prospective study of 24 patients with thermal injuries.
Disclosures: The study was funded in part by grants from the Office of Naval Research and U.S. Army. Dr. Van Haren and his coauthors reported no relevant financial conflicts.
Studies raise red flag of CVD risk in osteoarthritis
PHILADELPHIA – Concerns are being raised over a possible link between osteoarthritis and an increased risk of cardiovascular disease, with the signal strongest among those with walking disability.
A recent British population-based cohort study reported an excess of premature death from all causes among patients with knee or hip osteoarthritis (standardized mortality ratio, 1.55) as well as disease-specific increases that were particularly striking for cardiovascular disease (SMR, 1.71). Further, OA patients were twice as likely to die if they had a walking disability (BMJ 2011;342:d1165).
This comes on the heels of a systematic review involving seven studies that found moderate evidence of increased mortality in patients with OA (Clin. Exp. Rheumatol. 2008;26:S120-4).
However, a new, population-based study from the Netherlands found no link between OA and future cardiovascular disease (CVD) among adults aged 55 years and older. On the other hand, the presence of disability significantly predicted cardiovascular disease, independent of other CVD risk factors and the presence of OA, Sita Bierma-Zeinstra, Ph.D., reported.
She suggested that OA-related disability and co-morbidity may explain the earlier findings, but many in the audience were not convinced.
Fellow presenter Dr. Peter Jüni, professor of clinical epidemiology at the University of Bern, Switzerland where, the British analysis was performed, said what’s most impressive about their data is that the annual cardiovascular mortality rate of 2% in patients with OA and walking disability mirrors mortality rates observed in patients with an established diagnosis of coronary artery disease.
"We’re talking about a frequency of cardiovascular deaths that is comparable with what you see in cardiological patients who actually deserve invasive treatment," he said at the World Congress on Osteoarthritis, sponsored by Osteoarthritis Research Society International.
Dr. Jüni said randomized trials are needed to better define the association between OA and CVD, but the bottom line is that clinicians need to start looking differently at OA as a prognostic marker and consider including it in their risk assessment and management strategy.
These data need to be brought to the attention of the OA community so clinicians can "monitor the cardiovascular status of these patients because they are at risk, and I don’t think that’s commonly known yet. There is a signal here that we need to pay attention to," commented Dr. Stefan Lohmander of Lund (Sweden) University and coauthor of the recent European League Against Rheumatism (EULAR) recommendations for the nonpharmacological core management of knee and hip OA (Ann. Rheum. Dis. 2013 [doi:10.1136/annrheumdis-2012-202745]).
"You are my hero; I love this work, it’s incredible," attendee Dr. Gillian Hawker, professor of medicine and rheumatology at the University of Toronto, rose to say following Dr. Jüni’s lecture.
She noted that her group has been following a very similar cohort in the Ontario Osteoarthritis study, and that unpublished data confirm the British findings of increased all-cause mortality and CVD mortality, particularly with increasing disability, when assessed using the Western Ontario and McMaster Universities Arthritis Index (WOMAC) disability subscale, but not its pain subscale.
"People think of it [OA] as normal aging, wear and tear, grin and bear it, but if we can make links to mortality or worsening of other conditions like cardiovascular disease and diabetes, which everyone cares about, then maybe we’ll start paying attention to disability from OA," Dr. Hawker said in an interview. "If we can get people to care, then maybe we can get some effective drugs."
One possible explanation for the conflicting results between the two studies is that the British study included patients with a different OA phenotype, including patients with hip or knee OA and Kellgren-Lawrence grades 1-3, whereas the Dutch study also included patients with hand OA and only K-L grades 2-3, Dr. Jüni suggested. The Dutch study also used a different, "considerably softer" CVD composite outcome, he said in an interview.
"The way our study was set up, we couldn’t look at things the same way that they did, but what came out is that risks are particularly pronounced in people with disability and this message doesn’t change," he added.
The Dutch investigators used radiographs and symptoms of knee, hip, and hand OA to classify 4,648 persons in the 1990-1992 cohort of the prospective Rotterdam Study as having any disability versus none. At baseline, patients were free of CVD, 61% were women and their mean age was 67.6 years. Radiographic evidence of knee OA was present in 21%, hip OA in 10%, and hand OA in 30%. Clinical symptoms of OA were seen in 7%, 3%, and 7%, respectively.
After a mean of 14.4 years follow-up, 1,230 cardiovascular events occurred, of which 101 were in the clinical knee OA group.
In a model that adjusted for age and gender, radiographic OA was not related to future CVD, a composite of coronary heart disease or stroke (hazard ratio, 1.00; P = .96); nor was the presence of clinical OA (HR, 1.08; P = .45), said Dr. Bierma-Zeinstra, professor of arthritis and related disorders at Erasmus Medical Center in Rotterdam, the Netherlands.
After researchers further adjusted for the cardiovascular risk factors of diabetes, body mass index, hypertension, total cholesterol/HDL cholesterol ratio, and current smoking, again, no relationship was observed with CVD and radiographic OA (HR, 0.99; P = .92) or clinical OA (HR, 1.09; P = .43). Data were not shown for hand and hip OA, but the results were similar, she said.
"We didn’t see any increased risk for future cardiovascular disease in this particular cohort of people 55 years or older ... but maybe you could see it in younger cohorts or find it in people with new-onset osteoarthritis, but in this particular cohort, we did not see an association," Dr. Bierma-Zeinstra said.
As noted above, the risk of suffering a cardiovascular event was significantly elevated in individuals with a disability in model one and model two (HR, 1.30 and HR, 1.26, respectively; both P less than .001) and in those with a lower-limb disability in model one (HR, 1.22; P =.002) and model two (HR, 1.19; P =.008).
Dr. Jüni and Dr. Bierma-Zeinstra reported no relevant disclosures.
PHILADELPHIA – Concerns are being raised over a possible link between osteoarthritis and an increased risk of cardiovascular disease, with the signal strongest among those with walking disability.
A recent British population-based cohort study reported an excess of premature death from all causes among patients with knee or hip osteoarthritis (standardized mortality ratio, 1.55) as well as disease-specific increases that were particularly striking for cardiovascular disease (SMR, 1.71). Further, OA patients were twice as likely to die if they had a walking disability (BMJ 2011;342:d1165).
This comes on the heels of a systematic review involving seven studies that found moderate evidence of increased mortality in patients with OA (Clin. Exp. Rheumatol. 2008;26:S120-4).
However, a new, population-based study from the Netherlands found no link between OA and future cardiovascular disease (CVD) among adults aged 55 years and older. On the other hand, the presence of disability significantly predicted cardiovascular disease, independent of other CVD risk factors and the presence of OA, Sita Bierma-Zeinstra, Ph.D., reported.
She suggested that OA-related disability and co-morbidity may explain the earlier findings, but many in the audience were not convinced.
Fellow presenter Dr. Peter Jüni, professor of clinical epidemiology at the University of Bern, Switzerland where, the British analysis was performed, said what’s most impressive about their data is that the annual cardiovascular mortality rate of 2% in patients with OA and walking disability mirrors mortality rates observed in patients with an established diagnosis of coronary artery disease.
"We’re talking about a frequency of cardiovascular deaths that is comparable with what you see in cardiological patients who actually deserve invasive treatment," he said at the World Congress on Osteoarthritis, sponsored by Osteoarthritis Research Society International.
Dr. Jüni said randomized trials are needed to better define the association between OA and CVD, but the bottom line is that clinicians need to start looking differently at OA as a prognostic marker and consider including it in their risk assessment and management strategy.
These data need to be brought to the attention of the OA community so clinicians can "monitor the cardiovascular status of these patients because they are at risk, and I don’t think that’s commonly known yet. There is a signal here that we need to pay attention to," commented Dr. Stefan Lohmander of Lund (Sweden) University and coauthor of the recent European League Against Rheumatism (EULAR) recommendations for the nonpharmacological core management of knee and hip OA (Ann. Rheum. Dis. 2013 [doi:10.1136/annrheumdis-2012-202745]).
"You are my hero; I love this work, it’s incredible," attendee Dr. Gillian Hawker, professor of medicine and rheumatology at the University of Toronto, rose to say following Dr. Jüni’s lecture.
She noted that her group has been following a very similar cohort in the Ontario Osteoarthritis study, and that unpublished data confirm the British findings of increased all-cause mortality and CVD mortality, particularly with increasing disability, when assessed using the Western Ontario and McMaster Universities Arthritis Index (WOMAC) disability subscale, but not its pain subscale.
"People think of it [OA] as normal aging, wear and tear, grin and bear it, but if we can make links to mortality or worsening of other conditions like cardiovascular disease and diabetes, which everyone cares about, then maybe we’ll start paying attention to disability from OA," Dr. Hawker said in an interview. "If we can get people to care, then maybe we can get some effective drugs."
One possible explanation for the conflicting results between the two studies is that the British study included patients with a different OA phenotype, including patients with hip or knee OA and Kellgren-Lawrence grades 1-3, whereas the Dutch study also included patients with hand OA and only K-L grades 2-3, Dr. Jüni suggested. The Dutch study also used a different, "considerably softer" CVD composite outcome, he said in an interview.
"The way our study was set up, we couldn’t look at things the same way that they did, but what came out is that risks are particularly pronounced in people with disability and this message doesn’t change," he added.
The Dutch investigators used radiographs and symptoms of knee, hip, and hand OA to classify 4,648 persons in the 1990-1992 cohort of the prospective Rotterdam Study as having any disability versus none. At baseline, patients were free of CVD, 61% were women and their mean age was 67.6 years. Radiographic evidence of knee OA was present in 21%, hip OA in 10%, and hand OA in 30%. Clinical symptoms of OA were seen in 7%, 3%, and 7%, respectively.
After a mean of 14.4 years follow-up, 1,230 cardiovascular events occurred, of which 101 were in the clinical knee OA group.
In a model that adjusted for age and gender, radiographic OA was not related to future CVD, a composite of coronary heart disease or stroke (hazard ratio, 1.00; P = .96); nor was the presence of clinical OA (HR, 1.08; P = .45), said Dr. Bierma-Zeinstra, professor of arthritis and related disorders at Erasmus Medical Center in Rotterdam, the Netherlands.
After researchers further adjusted for the cardiovascular risk factors of diabetes, body mass index, hypertension, total cholesterol/HDL cholesterol ratio, and current smoking, again, no relationship was observed with CVD and radiographic OA (HR, 0.99; P = .92) or clinical OA (HR, 1.09; P = .43). Data were not shown for hand and hip OA, but the results were similar, she said.
"We didn’t see any increased risk for future cardiovascular disease in this particular cohort of people 55 years or older ... but maybe you could see it in younger cohorts or find it in people with new-onset osteoarthritis, but in this particular cohort, we did not see an association," Dr. Bierma-Zeinstra said.
As noted above, the risk of suffering a cardiovascular event was significantly elevated in individuals with a disability in model one and model two (HR, 1.30 and HR, 1.26, respectively; both P less than .001) and in those with a lower-limb disability in model one (HR, 1.22; P =.002) and model two (HR, 1.19; P =.008).
Dr. Jüni and Dr. Bierma-Zeinstra reported no relevant disclosures.
PHILADELPHIA – Concerns are being raised over a possible link between osteoarthritis and an increased risk of cardiovascular disease, with the signal strongest among those with walking disability.
A recent British population-based cohort study reported an excess of premature death from all causes among patients with knee or hip osteoarthritis (standardized mortality ratio, 1.55) as well as disease-specific increases that were particularly striking for cardiovascular disease (SMR, 1.71). Further, OA patients were twice as likely to die if they had a walking disability (BMJ 2011;342:d1165).
This comes on the heels of a systematic review involving seven studies that found moderate evidence of increased mortality in patients with OA (Clin. Exp. Rheumatol. 2008;26:S120-4).
However, a new, population-based study from the Netherlands found no link between OA and future cardiovascular disease (CVD) among adults aged 55 years and older. On the other hand, the presence of disability significantly predicted cardiovascular disease, independent of other CVD risk factors and the presence of OA, Sita Bierma-Zeinstra, Ph.D., reported.
She suggested that OA-related disability and co-morbidity may explain the earlier findings, but many in the audience were not convinced.
Fellow presenter Dr. Peter Jüni, professor of clinical epidemiology at the University of Bern, Switzerland where, the British analysis was performed, said what’s most impressive about their data is that the annual cardiovascular mortality rate of 2% in patients with OA and walking disability mirrors mortality rates observed in patients with an established diagnosis of coronary artery disease.
"We’re talking about a frequency of cardiovascular deaths that is comparable with what you see in cardiological patients who actually deserve invasive treatment," he said at the World Congress on Osteoarthritis, sponsored by Osteoarthritis Research Society International.
Dr. Jüni said randomized trials are needed to better define the association between OA and CVD, but the bottom line is that clinicians need to start looking differently at OA as a prognostic marker and consider including it in their risk assessment and management strategy.
These data need to be brought to the attention of the OA community so clinicians can "monitor the cardiovascular status of these patients because they are at risk, and I don’t think that’s commonly known yet. There is a signal here that we need to pay attention to," commented Dr. Stefan Lohmander of Lund (Sweden) University and coauthor of the recent European League Against Rheumatism (EULAR) recommendations for the nonpharmacological core management of knee and hip OA (Ann. Rheum. Dis. 2013 [doi:10.1136/annrheumdis-2012-202745]).
"You are my hero; I love this work, it’s incredible," attendee Dr. Gillian Hawker, professor of medicine and rheumatology at the University of Toronto, rose to say following Dr. Jüni’s lecture.
She noted that her group has been following a very similar cohort in the Ontario Osteoarthritis study, and that unpublished data confirm the British findings of increased all-cause mortality and CVD mortality, particularly with increasing disability, when assessed using the Western Ontario and McMaster Universities Arthritis Index (WOMAC) disability subscale, but not its pain subscale.
"People think of it [OA] as normal aging, wear and tear, grin and bear it, but if we can make links to mortality or worsening of other conditions like cardiovascular disease and diabetes, which everyone cares about, then maybe we’ll start paying attention to disability from OA," Dr. Hawker said in an interview. "If we can get people to care, then maybe we can get some effective drugs."
One possible explanation for the conflicting results between the two studies is that the British study included patients with a different OA phenotype, including patients with hip or knee OA and Kellgren-Lawrence grades 1-3, whereas the Dutch study also included patients with hand OA and only K-L grades 2-3, Dr. Jüni suggested. The Dutch study also used a different, "considerably softer" CVD composite outcome, he said in an interview.
"The way our study was set up, we couldn’t look at things the same way that they did, but what came out is that risks are particularly pronounced in people with disability and this message doesn’t change," he added.
The Dutch investigators used radiographs and symptoms of knee, hip, and hand OA to classify 4,648 persons in the 1990-1992 cohort of the prospective Rotterdam Study as having any disability versus none. At baseline, patients were free of CVD, 61% were women and their mean age was 67.6 years. Radiographic evidence of knee OA was present in 21%, hip OA in 10%, and hand OA in 30%. Clinical symptoms of OA were seen in 7%, 3%, and 7%, respectively.
After a mean of 14.4 years follow-up, 1,230 cardiovascular events occurred, of which 101 were in the clinical knee OA group.
In a model that adjusted for age and gender, radiographic OA was not related to future CVD, a composite of coronary heart disease or stroke (hazard ratio, 1.00; P = .96); nor was the presence of clinical OA (HR, 1.08; P = .45), said Dr. Bierma-Zeinstra, professor of arthritis and related disorders at Erasmus Medical Center in Rotterdam, the Netherlands.
After researchers further adjusted for the cardiovascular risk factors of diabetes, body mass index, hypertension, total cholesterol/HDL cholesterol ratio, and current smoking, again, no relationship was observed with CVD and radiographic OA (HR, 0.99; P = .92) or clinical OA (HR, 1.09; P = .43). Data were not shown for hand and hip OA, but the results were similar, she said.
"We didn’t see any increased risk for future cardiovascular disease in this particular cohort of people 55 years or older ... but maybe you could see it in younger cohorts or find it in people with new-onset osteoarthritis, but in this particular cohort, we did not see an association," Dr. Bierma-Zeinstra said.
As noted above, the risk of suffering a cardiovascular event was significantly elevated in individuals with a disability in model one and model two (HR, 1.30 and HR, 1.26, respectively; both P less than .001) and in those with a lower-limb disability in model one (HR, 1.22; P =.002) and model two (HR, 1.19; P =.008).
Dr. Jüni and Dr. Bierma-Zeinstra reported no relevant disclosures.
AT THE 2013 OARSI WORLD CONGRESS ON OSTEOARTHRITIS
Meniscal abnormalities linked to poor knee proprioception
PHILADELPHIA – Meniscal abnormality has long been suggested to be a contributor to poor joint proprioception, but evidence to make the case was not available until now.
An analysis of MRI data from 105 patients with knee osteoarthritis (OA) revealed that reduced proprioceptive accuracy was significantly associated with the number of regions with meniscal abnormalities (P = .006) and the extent of abnormality (P = .02).
This was true independent of muscle strength, joint laxity, pain, age, gender, body mass index, or duration of knee complaints. Patients with other neurologic conditions that could compound the results were also excluded from the analysis.
"This is the first study showing that reduced proprioceptive accuracy is associated with medial meniscal abnormalities in knee osteoarthritis," Dr. Martin van der Esch said at the World Congress on Osteoarthritis.
Knee proprioception is important for protection against excessive movement, stabilization during static postures, and coordination of movements. It diminishes with age and in the presence of OA.
The clinical implication of the results could be a predictive one, said Dr. van der Esch, who is with the Amsterdam Rehabilitation Research Center-Reade, the Netherlands.
"Patients with knee OA and meniscal abnormalities are strongly at risk for developing neuromuscular impairments and therefore at risk for developing limitations in daily activities," he said in an interview. "The knowledge has no consequences at the moment for therapeutic interventions."
Meniscal abnormalities can lead to impaired proprioceptive accuracy and knee OA through knee instability and overloading of the medial meniscus. Conversely, knee OA can lead to a meniscal abnormality through weakening of the meniscal structure, thereby reducing proprioceptive accuracy and creating something of a self-perpetuating cycle, he explained at the meeting, sponsored by the Osteoarthritis Research Society International.
To explore these associations, 105 patients with established knee OA in the Amsterdam Osteoarthritis cohort underwent 3-Tesla MRI of the affected knee. The Boston-Leeds OA Knee Scoring (BLOKS) system was used to score the number of regions with a meniscal abnormality and the extent of the abnormality. In the case of bilateral disease, the knee most affecting daily activities was imaged.
Proprioception was measured in a movement detection test using a computer-controlled, motion-detecting device created at the University of Amsterdam. In motion tests, the joint is moved slowly and passively and the patient is asked to detect the start of the movement as quickly as possible.
At baseline, the mean proprioceptive accuracy was 2.9°, mean quadriceps strength 0.89 N-m/kg, and mean joint laxity 6.9°.
Patients had been symptomatic for an average of 11 years, were mostly women (70%), and had an average age of 61.4 years.
MRI-detected medial meniscal abnormalities were found in the anterior horn in 78% of patients, in the meniscal body in 80%, and in the posterior horn in 89.5%. Specifically, tears were present in 5%, 12.5%, and 28.6%, respectively, and maceration in 26.7%, 45%, and 36%.
The mean proprioceptive inaccuracy increased from 1.83°when no region had a meniscal abnormality to 2.09° for one region with an abnormality, 2.57° with two regions, and 3.20° with three regions, indicating that the patient needed more time to detect a movement, Dr. van der Esch said.
Proprioceptive inaccuracy followed a similar pattern with regard to the extent of abnormality: 1.83° with no abnormality, 2.70° with a meniscal signal abnormality, 2.85° with a tear, and 3.19° with maceration.
Members of the audience questioned whether ligamentous laxity may have contributed to poor proprioception, but previous studies have shown no association between laxity and proprioception, Dr. van der Esch said. "So, it’s hard to believe this could be influencing these results," he added.
A follow-up study is underway to find causal relationships between meniscal abnormalities and knee joint proprioception, with additional MRIs of the cohort to be taken at the end of the year, he said.
As for what might be causing the poor knee proprioception, one of the most fitting hypotheses is the existence of low-grade inflammation in the joint, which is responsible for a decrease in mechanoreceptors within the inner layers of the capsule. Another feasible explanation is mechanical destruction of the capsule due to a loss of the meniscus itself, partly by meniscectomy or maceration by degeneration, he said.
Dr. van der Esch reported no relevant disclosures.
PHILADELPHIA – Meniscal abnormality has long been suggested to be a contributor to poor joint proprioception, but evidence to make the case was not available until now.
An analysis of MRI data from 105 patients with knee osteoarthritis (OA) revealed that reduced proprioceptive accuracy was significantly associated with the number of regions with meniscal abnormalities (P = .006) and the extent of abnormality (P = .02).
This was true independent of muscle strength, joint laxity, pain, age, gender, body mass index, or duration of knee complaints. Patients with other neurologic conditions that could compound the results were also excluded from the analysis.
"This is the first study showing that reduced proprioceptive accuracy is associated with medial meniscal abnormalities in knee osteoarthritis," Dr. Martin van der Esch said at the World Congress on Osteoarthritis.
Knee proprioception is important for protection against excessive movement, stabilization during static postures, and coordination of movements. It diminishes with age and in the presence of OA.
The clinical implication of the results could be a predictive one, said Dr. van der Esch, who is with the Amsterdam Rehabilitation Research Center-Reade, the Netherlands.
"Patients with knee OA and meniscal abnormalities are strongly at risk for developing neuromuscular impairments and therefore at risk for developing limitations in daily activities," he said in an interview. "The knowledge has no consequences at the moment for therapeutic interventions."
Meniscal abnormalities can lead to impaired proprioceptive accuracy and knee OA through knee instability and overloading of the medial meniscus. Conversely, knee OA can lead to a meniscal abnormality through weakening of the meniscal structure, thereby reducing proprioceptive accuracy and creating something of a self-perpetuating cycle, he explained at the meeting, sponsored by the Osteoarthritis Research Society International.
To explore these associations, 105 patients with established knee OA in the Amsterdam Osteoarthritis cohort underwent 3-Tesla MRI of the affected knee. The Boston-Leeds OA Knee Scoring (BLOKS) system was used to score the number of regions with a meniscal abnormality and the extent of the abnormality. In the case of bilateral disease, the knee most affecting daily activities was imaged.
Proprioception was measured in a movement detection test using a computer-controlled, motion-detecting device created at the University of Amsterdam. In motion tests, the joint is moved slowly and passively and the patient is asked to detect the start of the movement as quickly as possible.
At baseline, the mean proprioceptive accuracy was 2.9°, mean quadriceps strength 0.89 N-m/kg, and mean joint laxity 6.9°.
Patients had been symptomatic for an average of 11 years, were mostly women (70%), and had an average age of 61.4 years.
MRI-detected medial meniscal abnormalities were found in the anterior horn in 78% of patients, in the meniscal body in 80%, and in the posterior horn in 89.5%. Specifically, tears were present in 5%, 12.5%, and 28.6%, respectively, and maceration in 26.7%, 45%, and 36%.
The mean proprioceptive inaccuracy increased from 1.83°when no region had a meniscal abnormality to 2.09° for one region with an abnormality, 2.57° with two regions, and 3.20° with three regions, indicating that the patient needed more time to detect a movement, Dr. van der Esch said.
Proprioceptive inaccuracy followed a similar pattern with regard to the extent of abnormality: 1.83° with no abnormality, 2.70° with a meniscal signal abnormality, 2.85° with a tear, and 3.19° with maceration.
Members of the audience questioned whether ligamentous laxity may have contributed to poor proprioception, but previous studies have shown no association between laxity and proprioception, Dr. van der Esch said. "So, it’s hard to believe this could be influencing these results," he added.
A follow-up study is underway to find causal relationships between meniscal abnormalities and knee joint proprioception, with additional MRIs of the cohort to be taken at the end of the year, he said.
As for what might be causing the poor knee proprioception, one of the most fitting hypotheses is the existence of low-grade inflammation in the joint, which is responsible for a decrease in mechanoreceptors within the inner layers of the capsule. Another feasible explanation is mechanical destruction of the capsule due to a loss of the meniscus itself, partly by meniscectomy or maceration by degeneration, he said.
Dr. van der Esch reported no relevant disclosures.
PHILADELPHIA – Meniscal abnormality has long been suggested to be a contributor to poor joint proprioception, but evidence to make the case was not available until now.
An analysis of MRI data from 105 patients with knee osteoarthritis (OA) revealed that reduced proprioceptive accuracy was significantly associated with the number of regions with meniscal abnormalities (P = .006) and the extent of abnormality (P = .02).
This was true independent of muscle strength, joint laxity, pain, age, gender, body mass index, or duration of knee complaints. Patients with other neurologic conditions that could compound the results were also excluded from the analysis.
"This is the first study showing that reduced proprioceptive accuracy is associated with medial meniscal abnormalities in knee osteoarthritis," Dr. Martin van der Esch said at the World Congress on Osteoarthritis.
Knee proprioception is important for protection against excessive movement, stabilization during static postures, and coordination of movements. It diminishes with age and in the presence of OA.
The clinical implication of the results could be a predictive one, said Dr. van der Esch, who is with the Amsterdam Rehabilitation Research Center-Reade, the Netherlands.
"Patients with knee OA and meniscal abnormalities are strongly at risk for developing neuromuscular impairments and therefore at risk for developing limitations in daily activities," he said in an interview. "The knowledge has no consequences at the moment for therapeutic interventions."
Meniscal abnormalities can lead to impaired proprioceptive accuracy and knee OA through knee instability and overloading of the medial meniscus. Conversely, knee OA can lead to a meniscal abnormality through weakening of the meniscal structure, thereby reducing proprioceptive accuracy and creating something of a self-perpetuating cycle, he explained at the meeting, sponsored by the Osteoarthritis Research Society International.
To explore these associations, 105 patients with established knee OA in the Amsterdam Osteoarthritis cohort underwent 3-Tesla MRI of the affected knee. The Boston-Leeds OA Knee Scoring (BLOKS) system was used to score the number of regions with a meniscal abnormality and the extent of the abnormality. In the case of bilateral disease, the knee most affecting daily activities was imaged.
Proprioception was measured in a movement detection test using a computer-controlled, motion-detecting device created at the University of Amsterdam. In motion tests, the joint is moved slowly and passively and the patient is asked to detect the start of the movement as quickly as possible.
At baseline, the mean proprioceptive accuracy was 2.9°, mean quadriceps strength 0.89 N-m/kg, and mean joint laxity 6.9°.
Patients had been symptomatic for an average of 11 years, were mostly women (70%), and had an average age of 61.4 years.
MRI-detected medial meniscal abnormalities were found in the anterior horn in 78% of patients, in the meniscal body in 80%, and in the posterior horn in 89.5%. Specifically, tears were present in 5%, 12.5%, and 28.6%, respectively, and maceration in 26.7%, 45%, and 36%.
The mean proprioceptive inaccuracy increased from 1.83°when no region had a meniscal abnormality to 2.09° for one region with an abnormality, 2.57° with two regions, and 3.20° with three regions, indicating that the patient needed more time to detect a movement, Dr. van der Esch said.
Proprioceptive inaccuracy followed a similar pattern with regard to the extent of abnormality: 1.83° with no abnormality, 2.70° with a meniscal signal abnormality, 2.85° with a tear, and 3.19° with maceration.
Members of the audience questioned whether ligamentous laxity may have contributed to poor proprioception, but previous studies have shown no association between laxity and proprioception, Dr. van der Esch said. "So, it’s hard to believe this could be influencing these results," he added.
A follow-up study is underway to find causal relationships between meniscal abnormalities and knee joint proprioception, with additional MRIs of the cohort to be taken at the end of the year, he said.
As for what might be causing the poor knee proprioception, one of the most fitting hypotheses is the existence of low-grade inflammation in the joint, which is responsible for a decrease in mechanoreceptors within the inner layers of the capsule. Another feasible explanation is mechanical destruction of the capsule due to a loss of the meniscus itself, partly by meniscectomy or maceration by degeneration, he said.
Dr. van der Esch reported no relevant disclosures.
AT THE WORLD CONGRESS ON OSTEOARTHRITIS
Major finding: Reduced proprioceptive accuracy was significantly associated with both the number of regions with meniscal abnormalities (P = .006) and the extent of abnormality (P = .02) after adjustment for several confounders.
Data source: Cross-sectional study in 105 patients with established knee osteoarthritis.
Disclosures: Dr. van der Esch reported no relevant disclosures.
Metabolic monitoring of antipsychotics remains vital
CHICAGO – Monitoring patients on second-generation antipsychotic medications for metabolic adverse effects continues to be a clinical challenge, nearly a decade after monitoring recommendations came out.
"After that, if you talked to psychiatrists, almost everyone was aware of the issue and the need to monitor, but the monitoring unfortunately has not caught up," Dr. Rajiv Tandon said at Psychiatry Update 2013.
The consequences are high for patients on second-generation antipsychotics, with metabolic disorders such as diabetes, hypertension, and hyperlipidemia collectively exceeding 50% in some studies of patients with schizophrenia. Moreover, antipsychotic use and diabetes are both rising among Americans. Yet, in the landmark CATIE (Clinical Antipsychotic Trials of Intervention Effectiveness) study, rates of nontreatment ranged from 30% for diabetes to 62.4% for hypertension and 88% for dyslipidemia (Schizophr. Res. 2006;86:15-22).
Barriers to monitoring for psychiatrists include a lack of time, not knowing what to do with the information when their patient lacks a primary care provider, and patient compliance/reimbursement issues, said Dr. Tandon, of the North Florida/South Georgia Veterans Health System in Gainesville, Fla.
Given that monitoring is such a difficult task for most psychiatrists to take on and do confidently, he suggests they devote the time and effort to cultivating relationships with primary care providers.
"At the VA [Veterans Affairs department] where I work, the place where I’m spending most of my effort with regard to this problem is actually with primary care, trying to help them understand how serious this issue is and why we have to work together in order to help our patients," said Dr. Tandon, who also is a professor of psychiatry at the University of Florida in Gainesville.
"I’ve not been particularly successful thus far; all I’ve been able to accomplish is to get them to listen. It takes time, but it’s well worth it."
The good news is that the Department of Veterans Affairs is spending $60 million annually on metabolic monitoring of veterans on second-generation antipsychotics. The bad news is that anecdotally, metabolic outcomes are only modestly better, Dr. Tandon acknowledged.
Still, he recommends that psychiatrists monitor all their patients on antipsychotics at the start of treatment, at 90 days, and annually thereafter. Monitoring frequency might need to be stepped up in higher-risk patients, such as those with insulin resistance.
Providers also should start patients on an antipsychotic least likely to cause metabolic complications, avoid polypharmacy, and consider adjunctive treatments like metformin in some patients and also lifestyle interventions in combination with patient education.
In a study of 128 adults with first-episode schizophrenia who gained more than 10% of their weight on antipsychotics, 12 weeks of metformin 750 mg/day and lifestyle intervention was superior to either intervention alone, decreasing body mass index on average by 1.8 kg/m2, insulin resistance index by 3.6, and waist circumference by 2 cm (JAMA 2008;299:185-93).
In the future, genetic alterations might help unravel the cross talk between schizophrenia and diabetes, and lead to candidates for drug targets. A recent study identified 33 highly significant susceptibility genes linked to both schizophrenia and type 2 diabetes, including 12 related to tumor necrosis factor and 4 to v-akt murine thymoma viral oncogene homolog 1 (AKT1) (BMC Med. Genomics 2013;6 Suppl. 1:S17).
Dr. Tandon disclosed that he is a member of the World Psychiatry Association Pharmacopsychiatry section. The meeting was sponsored by Current Psychiatry and the American Academy of Clinical Psychiatrists. Current Psychiatry and this news organization are owned by the same parent company.
CHICAGO – Monitoring patients on second-generation antipsychotic medications for metabolic adverse effects continues to be a clinical challenge, nearly a decade after monitoring recommendations came out.
"After that, if you talked to psychiatrists, almost everyone was aware of the issue and the need to monitor, but the monitoring unfortunately has not caught up," Dr. Rajiv Tandon said at Psychiatry Update 2013.
The consequences are high for patients on second-generation antipsychotics, with metabolic disorders such as diabetes, hypertension, and hyperlipidemia collectively exceeding 50% in some studies of patients with schizophrenia. Moreover, antipsychotic use and diabetes are both rising among Americans. Yet, in the landmark CATIE (Clinical Antipsychotic Trials of Intervention Effectiveness) study, rates of nontreatment ranged from 30% for diabetes to 62.4% for hypertension and 88% for dyslipidemia (Schizophr. Res. 2006;86:15-22).
Barriers to monitoring for psychiatrists include a lack of time, not knowing what to do with the information when their patient lacks a primary care provider, and patient compliance/reimbursement issues, said Dr. Tandon, of the North Florida/South Georgia Veterans Health System in Gainesville, Fla.
Given that monitoring is such a difficult task for most psychiatrists to take on and do confidently, he suggests they devote the time and effort to cultivating relationships with primary care providers.
"At the VA [Veterans Affairs department] where I work, the place where I’m spending most of my effort with regard to this problem is actually with primary care, trying to help them understand how serious this issue is and why we have to work together in order to help our patients," said Dr. Tandon, who also is a professor of psychiatry at the University of Florida in Gainesville.
"I’ve not been particularly successful thus far; all I’ve been able to accomplish is to get them to listen. It takes time, but it’s well worth it."
The good news is that the Department of Veterans Affairs is spending $60 million annually on metabolic monitoring of veterans on second-generation antipsychotics. The bad news is that anecdotally, metabolic outcomes are only modestly better, Dr. Tandon acknowledged.
Still, he recommends that psychiatrists monitor all their patients on antipsychotics at the start of treatment, at 90 days, and annually thereafter. Monitoring frequency might need to be stepped up in higher-risk patients, such as those with insulin resistance.
Providers also should start patients on an antipsychotic least likely to cause metabolic complications, avoid polypharmacy, and consider adjunctive treatments like metformin in some patients and also lifestyle interventions in combination with patient education.
In a study of 128 adults with first-episode schizophrenia who gained more than 10% of their weight on antipsychotics, 12 weeks of metformin 750 mg/day and lifestyle intervention was superior to either intervention alone, decreasing body mass index on average by 1.8 kg/m2, insulin resistance index by 3.6, and waist circumference by 2 cm (JAMA 2008;299:185-93).
In the future, genetic alterations might help unravel the cross talk between schizophrenia and diabetes, and lead to candidates for drug targets. A recent study identified 33 highly significant susceptibility genes linked to both schizophrenia and type 2 diabetes, including 12 related to tumor necrosis factor and 4 to v-akt murine thymoma viral oncogene homolog 1 (AKT1) (BMC Med. Genomics 2013;6 Suppl. 1:S17).
Dr. Tandon disclosed that he is a member of the World Psychiatry Association Pharmacopsychiatry section. The meeting was sponsored by Current Psychiatry and the American Academy of Clinical Psychiatrists. Current Psychiatry and this news organization are owned by the same parent company.
CHICAGO – Monitoring patients on second-generation antipsychotic medications for metabolic adverse effects continues to be a clinical challenge, nearly a decade after monitoring recommendations came out.
"After that, if you talked to psychiatrists, almost everyone was aware of the issue and the need to monitor, but the monitoring unfortunately has not caught up," Dr. Rajiv Tandon said at Psychiatry Update 2013.
The consequences are high for patients on second-generation antipsychotics, with metabolic disorders such as diabetes, hypertension, and hyperlipidemia collectively exceeding 50% in some studies of patients with schizophrenia. Moreover, antipsychotic use and diabetes are both rising among Americans. Yet, in the landmark CATIE (Clinical Antipsychotic Trials of Intervention Effectiveness) study, rates of nontreatment ranged from 30% for diabetes to 62.4% for hypertension and 88% for dyslipidemia (Schizophr. Res. 2006;86:15-22).
Barriers to monitoring for psychiatrists include a lack of time, not knowing what to do with the information when their patient lacks a primary care provider, and patient compliance/reimbursement issues, said Dr. Tandon, of the North Florida/South Georgia Veterans Health System in Gainesville, Fla.
Given that monitoring is such a difficult task for most psychiatrists to take on and do confidently, he suggests they devote the time and effort to cultivating relationships with primary care providers.
"At the VA [Veterans Affairs department] where I work, the place where I’m spending most of my effort with regard to this problem is actually with primary care, trying to help them understand how serious this issue is and why we have to work together in order to help our patients," said Dr. Tandon, who also is a professor of psychiatry at the University of Florida in Gainesville.
"I’ve not been particularly successful thus far; all I’ve been able to accomplish is to get them to listen. It takes time, but it’s well worth it."
The good news is that the Department of Veterans Affairs is spending $60 million annually on metabolic monitoring of veterans on second-generation antipsychotics. The bad news is that anecdotally, metabolic outcomes are only modestly better, Dr. Tandon acknowledged.
Still, he recommends that psychiatrists monitor all their patients on antipsychotics at the start of treatment, at 90 days, and annually thereafter. Monitoring frequency might need to be stepped up in higher-risk patients, such as those with insulin resistance.
Providers also should start patients on an antipsychotic least likely to cause metabolic complications, avoid polypharmacy, and consider adjunctive treatments like metformin in some patients and also lifestyle interventions in combination with patient education.
In a study of 128 adults with first-episode schizophrenia who gained more than 10% of their weight on antipsychotics, 12 weeks of metformin 750 mg/day and lifestyle intervention was superior to either intervention alone, decreasing body mass index on average by 1.8 kg/m2, insulin resistance index by 3.6, and waist circumference by 2 cm (JAMA 2008;299:185-93).
In the future, genetic alterations might help unravel the cross talk between schizophrenia and diabetes, and lead to candidates for drug targets. A recent study identified 33 highly significant susceptibility genes linked to both schizophrenia and type 2 diabetes, including 12 related to tumor necrosis factor and 4 to v-akt murine thymoma viral oncogene homolog 1 (AKT1) (BMC Med. Genomics 2013;6 Suppl. 1:S17).
Dr. Tandon disclosed that he is a member of the World Psychiatry Association Pharmacopsychiatry section. The meeting was sponsored by Current Psychiatry and the American Academy of Clinical Psychiatrists. Current Psychiatry and this news organization are owned by the same parent company.
EXPERT ANALYSIS FROM PSYCHIATRY UPDATE 2013