Improving diet over time consistently reduces all-cause and cardiovascular mortality, according to an analysis of two large U.S. databases.

Researchers examined the association between dietary change over a 12-year period (1986-1998) and subsequent mortality during a further 12 years of follow-up (1998-2010), using data for 47,994 women participating in the Nurses’ Health Study and 25,745 men participating in the Health Professionals Follow-Up Study. They calculated dietary quality using three different methods: the Alternate Healthy Eating Index-2010 score, the Alternate Mediterranean Diet score, and the Dietary Approaches to Stop Hypertension (DASH) diet score.

©Lisovskaya/ThinkStock

cardnews@frontlinemedcom.com

Improving diet over time consistently reduces all-cause and cardiovascular mortality, according to an analysis of two large U.S. databases.

Researchers examined the association between dietary change over a 12-year period (1986-1998) and subsequent mortality during a further 12 years of follow-up (1998-2010), using data for 47,994 women participating in the Nurses’ Health Study and 25,745 men participating in the Health Professionals Follow-Up Study. They calculated dietary quality using three different methods: the Alternate Healthy Eating Index-2010 score, the Alternate Mediterranean Diet score, and the Dietary Approaches to Stop Hypertension (DASH) diet score.

©Lisovskaya/ThinkStock

cardnews@frontlinemedcom.com

Improving diet over time consistently reduces all-cause and cardiovascular mortality, according to an analysis of two large U.S. databases.

Researchers examined the association between dietary change over a 12-year period (1986-1998) and subsequent mortality during a further 12 years of follow-up (1998-2010), using data for 47,994 women participating in the Nurses’ Health Study and 25,745 men participating in the Health Professionals Follow-Up Study. They calculated dietary quality using three different methods: the Alternate Healthy Eating Index-2010 score, the Alternate Mediterranean Diet score, and the Dietary Approaches to Stop Hypertension (DASH) diet score.

©Lisovskaya/ThinkStock

cardnews@frontlinemedcom.com

To the Editor:

Temporal triangular alopecia (TTA), a condition first described by Sabouraud¹ in 1905, is a circumscribed nonscarring form of alopecia. Also referred to as congenital triangular alopecia, TTA presents as a triangular or lancet-shaped area of hair loss involving the frontotemporal hairline. Temporal triangular alopecia is characterized histologically by a normal number of miniaturized hair follicles without notable inflammation.² Although the majority of cases arise between birth and 9 years of age,^3,4 rare cases of adult-onset TTA also have been reported.^5,6 Adult-onset cases can cause notable diagnostic confusion and inappropriate treatment, as reported in our patient.

A 25-year-old woman with a history of Hashimoto thyroiditis presented with hair loss affecting the right temporal scalp of 3 years' duration that was first noticed by her husband. The lesion was an asymptomatic, 6×8-cm, roughly lancet-shaped patch of alopecia located on the right temporal scalp, bordering on the frontal hairline (Figure 1). Centrally, the patch appeared almost hairless with a few retained terminal hairs. The frontal hairline was thinned but still present. There was no scaling or erythema, and fine vellus hairs and a few isolated terminal hairs covered the area. The corresponding skin on the contralateral temporal scalp showed normal hair density. The patient insisted that she had normal hair at the affected area until 22 years of age, and she denied a history of trauma or tight hairstyles. Initially diagnosed with alopecia areata by her primary care provider, the patient was treated with topical corticosteroids for 6 months without benefit. She was subsequently referred to a dermatologist who again offered a diagnosis of alopecia areata and treated the lesions with 2 intralesional corticosteroid injections without benefit. No biopsies of the affected area were performed, and the patient was given a trial of topical minoxidil.

The patient consulted a new primary care provider and was diagnosed with scarring alopecia. She was referred to our dermatology department for further treatment. An initial biopsy at the edge of the affected area was interpreted as normal, but after failing additional intralesional corticosteroid injections, she was referred to our hair clinic where another biopsy was performed in the central portion of the lesion. A 4-mm diameter punch biopsy specimen revealed a normal epidermis and dermis; however, in the lower dermis only a single terminal follicle was seen (Figure 2). Sections through the upper dermis (Figure 3) showed that the total number of hairs was normal or nearly normal with at least 22 follicles, but most were vellus and indeterminate hairs with only a single terminal hair. The dermal architecture was otherwise normal. Given the clinical and histologic findings, a diagnosis of TTA was made. Subsequent to the diagnosis, the patient did not pursue any additional treatment options and preferred to style her hair so that the area of TTA remained covered.

The differential diagnosis in adults presenting with a patch of localized alopecia includes alopecia areata, trichotillomania, pressure-induced alopecia, traction alopecia, lichen planopilaris, discoid lupus erythematosus, and rarely TTA. Temporal triangular alopecia is a fairly common, if underreported, nonscarring form of alopecia that mainly affects young children. A PubMed search of articles indexed for MEDLINE using the terms temporal triangular alopecia or congenital triangular alopecia or triangular alopecia documented only 76 cases of TTA including our own, with the majority of patients diagnosed before 9 years of age. Only 2 cases of adult-onset TTA have been reported,^5,6 possibly leading to misdiagnosis of adult patients who present with similar areas of hair loss. As with some prior cases of TTA,^5,7 our patient was misdiagnosed with alopecia areata and scarring alopecia, both treated unsuccessfully before a diagnosis of TTA was considered. Clues to the diagnosis included the location, the lack of change in size and shape, the lack of response to intralesional corticosteroids, and the presence of numerous vellus hairs on the surface. A biopsy of the visibly hairless zone was confirmatory. The normal or nearly normal number of miniaturized hairs in specimens of TTA suggest that topical minoxidil therapy (eg, 5% solution twice daily for at least 6 months) might be useful, but the authors have tried it on a few other patients with clinically typical TTA without discernible benefit. When lesions are small, excision provides a fast and permanent solution to the problem, albeit with the usual risks of minor surgery.

To the Editor:

Temporal triangular alopecia (TTA), a condition first described by Sabouraud¹ in 1905, is a circumscribed nonscarring form of alopecia. Also referred to as congenital triangular alopecia, TTA presents as a triangular or lancet-shaped area of hair loss involving the frontotemporal hairline. Temporal triangular alopecia is characterized histologically by a normal number of miniaturized hair follicles without notable inflammation.² Although the majority of cases arise between birth and 9 years of age,^3,4 rare cases of adult-onset TTA also have been reported.^5,6 Adult-onset cases can cause notable diagnostic confusion and inappropriate treatment, as reported in our patient.

A 25-year-old woman with a history of Hashimoto thyroiditis presented with hair loss affecting the right temporal scalp of 3 years' duration that was first noticed by her husband. The lesion was an asymptomatic, 6×8-cm, roughly lancet-shaped patch of alopecia located on the right temporal scalp, bordering on the frontal hairline (Figure 1). Centrally, the patch appeared almost hairless with a few retained terminal hairs. The frontal hairline was thinned but still present. There was no scaling or erythema, and fine vellus hairs and a few isolated terminal hairs covered the area. The corresponding skin on the contralateral temporal scalp showed normal hair density. The patient insisted that she had normal hair at the affected area until 22 years of age, and she denied a history of trauma or tight hairstyles. Initially diagnosed with alopecia areata by her primary care provider, the patient was treated with topical corticosteroids for 6 months without benefit. She was subsequently referred to a dermatologist who again offered a diagnosis of alopecia areata and treated the lesions with 2 intralesional corticosteroid injections without benefit. No biopsies of the affected area were performed, and the patient was given a trial of topical minoxidil.

The patient consulted a new primary care provider and was diagnosed with scarring alopecia. She was referred to our dermatology department for further treatment. An initial biopsy at the edge of the affected area was interpreted as normal, but after failing additional intralesional corticosteroid injections, she was referred to our hair clinic where another biopsy was performed in the central portion of the lesion. A 4-mm diameter punch biopsy specimen revealed a normal epidermis and dermis; however, in the lower dermis only a single terminal follicle was seen (Figure 2). Sections through the upper dermis (Figure 3) showed that the total number of hairs was normal or nearly normal with at least 22 follicles, but most were vellus and indeterminate hairs with only a single terminal hair. The dermal architecture was otherwise normal. Given the clinical and histologic findings, a diagnosis of TTA was made. Subsequent to the diagnosis, the patient did not pursue any additional treatment options and preferred to style her hair so that the area of TTA remained covered.

The differential diagnosis in adults presenting with a patch of localized alopecia includes alopecia areata, trichotillomania, pressure-induced alopecia, traction alopecia, lichen planopilaris, discoid lupus erythematosus, and rarely TTA. Temporal triangular alopecia is a fairly common, if underreported, nonscarring form of alopecia that mainly affects young children. A PubMed search of articles indexed for MEDLINE using the terms temporal triangular alopecia or congenital triangular alopecia or triangular alopecia documented only 76 cases of TTA including our own, with the majority of patients diagnosed before 9 years of age. Only 2 cases of adult-onset TTA have been reported,^5,6 possibly leading to misdiagnosis of adult patients who present with similar areas of hair loss. As with some prior cases of TTA,^5,7 our patient was misdiagnosed with alopecia areata and scarring alopecia, both treated unsuccessfully before a diagnosis of TTA was considered. Clues to the diagnosis included the location, the lack of change in size and shape, the lack of response to intralesional corticosteroids, and the presence of numerous vellus hairs on the surface. A biopsy of the visibly hairless zone was confirmatory. The normal or nearly normal number of miniaturized hairs in specimens of TTA suggest that topical minoxidil therapy (eg, 5% solution twice daily for at least 6 months) might be useful, but the authors have tried it on a few other patients with clinically typical TTA without discernible benefit. When lesions are small, excision provides a fast and permanent solution to the problem, albeit with the usual risks of minor surgery.

To the Editor:

Temporal triangular alopecia (TTA), a condition first described by Sabouraud¹ in 1905, is a circumscribed nonscarring form of alopecia. Also referred to as congenital triangular alopecia, TTA presents as a triangular or lancet-shaped area of hair loss involving the frontotemporal hairline. Temporal triangular alopecia is characterized histologically by a normal number of miniaturized hair follicles without notable inflammation.² Although the majority of cases arise between birth and 9 years of age,^3,4 rare cases of adult-onset TTA also have been reported.^5,6 Adult-onset cases can cause notable diagnostic confusion and inappropriate treatment, as reported in our patient.

A 25-year-old woman with a history of Hashimoto thyroiditis presented with hair loss affecting the right temporal scalp of 3 years' duration that was first noticed by her husband. The lesion was an asymptomatic, 6×8-cm, roughly lancet-shaped patch of alopecia located on the right temporal scalp, bordering on the frontal hairline (Figure 1). Centrally, the patch appeared almost hairless with a few retained terminal hairs. The frontal hairline was thinned but still present. There was no scaling or erythema, and fine vellus hairs and a few isolated terminal hairs covered the area. The corresponding skin on the contralateral temporal scalp showed normal hair density. The patient insisted that she had normal hair at the affected area until 22 years of age, and she denied a history of trauma or tight hairstyles. Initially diagnosed with alopecia areata by her primary care provider, the patient was treated with topical corticosteroids for 6 months without benefit. She was subsequently referred to a dermatologist who again offered a diagnosis of alopecia areata and treated the lesions with 2 intralesional corticosteroid injections without benefit. No biopsies of the affected area were performed, and the patient was given a trial of topical minoxidil.

The patient consulted a new primary care provider and was diagnosed with scarring alopecia. She was referred to our dermatology department for further treatment. An initial biopsy at the edge of the affected area was interpreted as normal, but after failing additional intralesional corticosteroid injections, she was referred to our hair clinic where another biopsy was performed in the central portion of the lesion. A 4-mm diameter punch biopsy specimen revealed a normal epidermis and dermis; however, in the lower dermis only a single terminal follicle was seen (Figure 2). Sections through the upper dermis (Figure 3) showed that the total number of hairs was normal or nearly normal with at least 22 follicles, but most were vellus and indeterminate hairs with only a single terminal hair. The dermal architecture was otherwise normal. Given the clinical and histologic findings, a diagnosis of TTA was made. Subsequent to the diagnosis, the patient did not pursue any additional treatment options and preferred to style her hair so that the area of TTA remained covered.

The differential diagnosis in adults presenting with a patch of localized alopecia includes alopecia areata, trichotillomania, pressure-induced alopecia, traction alopecia, lichen planopilaris, discoid lupus erythematosus, and rarely TTA. Temporal triangular alopecia is a fairly common, if underreported, nonscarring form of alopecia that mainly affects young children. A PubMed search of articles indexed for MEDLINE using the terms temporal triangular alopecia or congenital triangular alopecia or triangular alopecia documented only 76 cases of TTA including our own, with the majority of patients diagnosed before 9 years of age. Only 2 cases of adult-onset TTA have been reported,^5,6 possibly leading to misdiagnosis of adult patients who present with similar areas of hair loss. As with some prior cases of TTA,^5,7 our patient was misdiagnosed with alopecia areata and scarring alopecia, both treated unsuccessfully before a diagnosis of TTA was considered. Clues to the diagnosis included the location, the lack of change in size and shape, the lack of response to intralesional corticosteroids, and the presence of numerous vellus hairs on the surface. A biopsy of the visibly hairless zone was confirmatory. The normal or nearly normal number of miniaturized hairs in specimens of TTA suggest that topical minoxidil therapy (eg, 5% solution twice daily for at least 6 months) might be useful, but the authors have tried it on a few other patients with clinically typical TTA without discernible benefit. When lesions are small, excision provides a fast and permanent solution to the problem, albeit with the usual risks of minor surgery.

Clostridium difficile infection (CDI) remains a major cause of health care–associated diarrhea in industrialized countries and is a common target of antimicrobial stewardship programs (ASPs).

While the burden of CDI has been well described in tertiary metropolitan hospitals, there is a lack of published evidence from regional and rural hospitals. Our recent study published in the Journal of Hospital Infection explores the effect of an ASP on health care–associated CDI rates and the impact of CDI on length of stay and hospital costs.

Stuart Bond, BPharm, DipPharmPrac, is an antimicrobial stewardship pharmacist based at Wollongong Hospital in New South Wales, Australia.

Clostridium difficile infection (CDI) remains a major cause of health care–associated diarrhea in industrialized countries and is a common target of antimicrobial stewardship programs (ASPs).

While the burden of CDI has been well described in tertiary metropolitan hospitals, there is a lack of published evidence from regional and rural hospitals. Our recent study published in the Journal of Hospital Infection explores the effect of an ASP on health care–associated CDI rates and the impact of CDI on length of stay and hospital costs.

Stuart Bond, BPharm, DipPharmPrac, is an antimicrobial stewardship pharmacist based at Wollongong Hospital in New South Wales, Australia.

Clostridium difficile infection (CDI) remains a major cause of health care–associated diarrhea in industrialized countries and is a common target of antimicrobial stewardship programs (ASPs).

While the burden of CDI has been well described in tertiary metropolitan hospitals, there is a lack of published evidence from regional and rural hospitals. Our recent study published in the Journal of Hospital Infection explores the effect of an ASP on health care–associated CDI rates and the impact of CDI on length of stay and hospital costs.

Stuart Bond, BPharm, DipPharmPrac, is an antimicrobial stewardship pharmacist based at Wollongong Hospital in New South Wales, Australia.

Many surgeons let out a collective cheer recently when the American Board of Surgery announced that, as of 2018, they will no longer have to take a high-stakes, pass-fail exam every 10 years to maintain certification.

The Board also announced, effective immediately, that it’s extending its continuing medical education (CME) reporting cycle from 3 to 5 years and reducing the number of required self-assessment CMEs – lectures and articles with a short quiz at the end – by a third. Surgeons now have to report 150 credits over 5 years, 50 from self-assessment CMEs. Under the old system, it was 90 credits over 3 years, 60 of which had to include self-assessment.

Alternative evaluation options

What’s on the minds of many, though, is what the alternatives to the 10-year exam will be. “That’s the $64,000 question,” said Emery Chen, MD, FACS, a general surgeon in private practice in Lancaster, Calif.

ABS is considering models that have worked well for other medical boards and hopes to roll out the alternative pathways at its winter meeting in January 2018, according to ABS Executive Director Frank Lewis, MD, FACS.

A changing world

Like the country’s many other medical boards, ABS has been under pressure to make its MOC process less burdensome and more useful. A major problem is that general surgery isn’t very general anymore; it covers everything from transplants and bariatrics to trauma, endocrine, and vascular operations and more. Surgeons who have specialized have chafed at being examined every 10 years on areas that are no longer part of their practice and at questions about rare diseases such as multiple endocrine neoplasia I and II.

“They remember that one question that kind of stuck in their craw,” said Carol Scott-Conner, MD, FACS, emeritus professor and former head of surgery at the University of Iowa, Iowa City. At one point in her career, Dr. Scott-Conner helped write questions for the exam. “It wasn’t designed to be tricky, but, if you were not practicing in all these fields,” it was tough. “What you’re tested on should be relevant to your practice and help you get better at what you are doing. I think it’s a good change,” she said.

The group will be at national and regional medical meetings this summer and fall to ask surgeons, in person, what they want their MOC system to be. There might be surveys as well, and ABS plans to be at the ACS Clinical Congress in October to solicit input.

The Board is looking to help surgeons with multiple certificates, whether from ABS or other boards, as well. “If we can create a more flexible assessment program that helps them maintain all their certifications, that’s what we want to do. We are looking at options to make it easier for them,” said ABS Director of Communications and Public Affairs Christine Shiffer, who noted that ABS will still likely require a 12-month case log every 10 years, even if surgeons opt out of the 10-year exam.

Will the new system have a negative impact on patient outcomes? After all, even specialized surgeons take night call sometimes. “ABS is responsible to surgeons but also the American public. If we say somebody is certified, it has to mean something. People would argue that there’s no real evidence that the recertification process improves surgical competence. Time will tell,” Dr. Scott-Conner said.

Dr. Lewis said he doesn’t know if the changes will save any money on MOC but noted that, instead of one $1,600 fee every 10 years, there’ll be an option to spread payments out.

Dr. Hughes is on the editorial advisory board of this publication.

aotto@frontlinemedcom.com

Many surgeons let out a collective cheer recently when the American Board of Surgery announced that, as of 2018, they will no longer have to take a high-stakes, pass-fail exam every 10 years to maintain certification.

The Board also announced, effective immediately, that it’s extending its continuing medical education (CME) reporting cycle from 3 to 5 years and reducing the number of required self-assessment CMEs – lectures and articles with a short quiz at the end – by a third. Surgeons now have to report 150 credits over 5 years, 50 from self-assessment CMEs. Under the old system, it was 90 credits over 3 years, 60 of which had to include self-assessment.

Alternative evaluation options

What’s on the minds of many, though, is what the alternatives to the 10-year exam will be. “That’s the $64,000 question,” said Emery Chen, MD, FACS, a general surgeon in private practice in Lancaster, Calif.

ABS is considering models that have worked well for other medical boards and hopes to roll out the alternative pathways at its winter meeting in January 2018, according to ABS Executive Director Frank Lewis, MD, FACS.

A changing world

Like the country’s many other medical boards, ABS has been under pressure to make its MOC process less burdensome and more useful. A major problem is that general surgery isn’t very general anymore; it covers everything from transplants and bariatrics to trauma, endocrine, and vascular operations and more. Surgeons who have specialized have chafed at being examined every 10 years on areas that are no longer part of their practice and at questions about rare diseases such as multiple endocrine neoplasia I and II.

“They remember that one question that kind of stuck in their craw,” said Carol Scott-Conner, MD, FACS, emeritus professor and former head of surgery at the University of Iowa, Iowa City. At one point in her career, Dr. Scott-Conner helped write questions for the exam. “It wasn’t designed to be tricky, but, if you were not practicing in all these fields,” it was tough. “What you’re tested on should be relevant to your practice and help you get better at what you are doing. I think it’s a good change,” she said.

The group will be at national and regional medical meetings this summer and fall to ask surgeons, in person, what they want their MOC system to be. There might be surveys as well, and ABS plans to be at the ACS Clinical Congress in October to solicit input.

The Board is looking to help surgeons with multiple certificates, whether from ABS or other boards, as well. “If we can create a more flexible assessment program that helps them maintain all their certifications, that’s what we want to do. We are looking at options to make it easier for them,” said ABS Director of Communications and Public Affairs Christine Shiffer, who noted that ABS will still likely require a 12-month case log every 10 years, even if surgeons opt out of the 10-year exam.

Will the new system have a negative impact on patient outcomes? After all, even specialized surgeons take night call sometimes. “ABS is responsible to surgeons but also the American public. If we say somebody is certified, it has to mean something. People would argue that there’s no real evidence that the recertification process improves surgical competence. Time will tell,” Dr. Scott-Conner said.

Dr. Lewis said he doesn’t know if the changes will save any money on MOC but noted that, instead of one $1,600 fee every 10 years, there’ll be an option to spread payments out.

Dr. Hughes is on the editorial advisory board of this publication.

aotto@frontlinemedcom.com

Many surgeons let out a collective cheer recently when the American Board of Surgery announced that, as of 2018, they will no longer have to take a high-stakes, pass-fail exam every 10 years to maintain certification.

The Board also announced, effective immediately, that it’s extending its continuing medical education (CME) reporting cycle from 3 to 5 years and reducing the number of required self-assessment CMEs – lectures and articles with a short quiz at the end – by a third. Surgeons now have to report 150 credits over 5 years, 50 from self-assessment CMEs. Under the old system, it was 90 credits over 3 years, 60 of which had to include self-assessment.

Alternative evaluation options

What’s on the minds of many, though, is what the alternatives to the 10-year exam will be. “That’s the $64,000 question,” said Emery Chen, MD, FACS, a general surgeon in private practice in Lancaster, Calif.

ABS is considering models that have worked well for other medical boards and hopes to roll out the alternative pathways at its winter meeting in January 2018, according to ABS Executive Director Frank Lewis, MD, FACS.

A changing world

Like the country’s many other medical boards, ABS has been under pressure to make its MOC process less burdensome and more useful. A major problem is that general surgery isn’t very general anymore; it covers everything from transplants and bariatrics to trauma, endocrine, and vascular operations and more. Surgeons who have specialized have chafed at being examined every 10 years on areas that are no longer part of their practice and at questions about rare diseases such as multiple endocrine neoplasia I and II.

“They remember that one question that kind of stuck in their craw,” said Carol Scott-Conner, MD, FACS, emeritus professor and former head of surgery at the University of Iowa, Iowa City. At one point in her career, Dr. Scott-Conner helped write questions for the exam. “It wasn’t designed to be tricky, but, if you were not practicing in all these fields,” it was tough. “What you’re tested on should be relevant to your practice and help you get better at what you are doing. I think it’s a good change,” she said.

The group will be at national and regional medical meetings this summer and fall to ask surgeons, in person, what they want their MOC system to be. There might be surveys as well, and ABS plans to be at the ACS Clinical Congress in October to solicit input.

The Board is looking to help surgeons with multiple certificates, whether from ABS or other boards, as well. “If we can create a more flexible assessment program that helps them maintain all their certifications, that’s what we want to do. We are looking at options to make it easier for them,” said ABS Director of Communications and Public Affairs Christine Shiffer, who noted that ABS will still likely require a 12-month case log every 10 years, even if surgeons opt out of the 10-year exam.

Will the new system have a negative impact on patient outcomes? After all, even specialized surgeons take night call sometimes. “ABS is responsible to surgeons but also the American public. If we say somebody is certified, it has to mean something. People would argue that there’s no real evidence that the recertification process improves surgical competence. Time will tell,” Dr. Scott-Conner said.

Dr. Lewis said he doesn’t know if the changes will save any money on MOC but noted that, instead of one $1,600 fee every 10 years, there’ll be an option to spread payments out.

Dr. Hughes is on the editorial advisory board of this publication.

aotto@frontlinemedcom.com

Incidence rate ratios of children hospitalized with acute otitis media (hAOM) or more advanced stages, such as mastoidismus and acute mastoiditis (M+AM) declined by 10% and 20%, respectively, after introduction of pneumococcal conjugate vaccines (PCV) in the central region of Denmark, reported Bjarke B. Laursen of Aarhus University in Denmark, and associates.

The use of antibiotics for AOM prior to hospitalization increased markedly during the study period, and that may have impacted the modest reduction in hAOM and M+AM, the researchers said.

copyright luiscar/Thinkstock

Incidence rate ratios of children hospitalized with acute otitis media (hAOM) or more advanced stages, such as mastoidismus and acute mastoiditis (M+AM) declined by 10% and 20%, respectively, after introduction of pneumococcal conjugate vaccines (PCV) in the central region of Denmark, reported Bjarke B. Laursen of Aarhus University in Denmark, and associates.

The use of antibiotics for AOM prior to hospitalization increased markedly during the study period, and that may have impacted the modest reduction in hAOM and M+AM, the researchers said.

copyright luiscar/Thinkstock

Incidence rate ratios of children hospitalized with acute otitis media (hAOM) or more advanced stages, such as mastoidismus and acute mastoiditis (M+AM) declined by 10% and 20%, respectively, after introduction of pneumococcal conjugate vaccines (PCV) in the central region of Denmark, reported Bjarke B. Laursen of Aarhus University in Denmark, and associates.

The use of antibiotics for AOM prior to hospitalization increased markedly during the study period, and that may have impacted the modest reduction in hAOM and M+AM, the researchers said.

copyright luiscar/Thinkstock

LAS VEGAS – Childhood overweight was associated with increased risk of patellar cartilage defects in young adulthood independent of adult weight status in what’s believed to be the first long-term prospective study to address the issue using informative MRI imaging.

“Our data indicate the importance of intervening in childhood obesity for adult joint health,” Benny E. Antony, MD, reported at the World Congress on Osteoarthritis, sponsored by the Osteoarthritis Research Society International.

He presented the 25-year prospective follow-up from the population-based Childhood Determinants of Adult Knee Cartilage Study, a substudy of the Australian Schools Health and Fitness Survey of 1985. The analysis included 322 nationally representative participants who were 7-15 years old at enrollment and 31-41 years old at follow-up, when they underwent screening MRI knee scans in which cartilage defects in the tibial, femoral, and patellar zones were rated by a modified Outerbridge scoring system.

• Women had a higher prevalence of cartilage defects: 43% in the whole knee and 30% at the patella, compared with rates of 34% and 20%, respectively, in men.

• The prevalence of patellar cartilage defects in young adulthood was 24.2% in those who had a normal weight both as children and young adults compared with 40% in participants who were overweight at both time points, for an adjusted 1.77-fold increased risk in subjects who were overweight across the decades, .

• Excess childhood weight per kilogram, fat mass per kilogram, and body mass per unit were each associated with 5%-12% increased risks of patellar cartilage defects 25 years later, independent of adult body weight status, in an analysis adjusted for childhood age, sex, height, duration of follow-up, and history of pediatric or adult knee injury.

• A dose-response relationship was evident between the degree of childhood overweight and the severity of cartilage defects as young adults on a 0-4 rating scale.

Dr. Antony reported having no financial conflicts of interest regarding the study, which was supported by the National Health and Medical Research Council of Australia.

bjancin@frontlinemedcom.com

LAS VEGAS – Childhood overweight was associated with increased risk of patellar cartilage defects in young adulthood independent of adult weight status in what’s believed to be the first long-term prospective study to address the issue using informative MRI imaging.

“Our data indicate the importance of intervening in childhood obesity for adult joint health,” Benny E. Antony, MD, reported at the World Congress on Osteoarthritis, sponsored by the Osteoarthritis Research Society International.

He presented the 25-year prospective follow-up from the population-based Childhood Determinants of Adult Knee Cartilage Study, a substudy of the Australian Schools Health and Fitness Survey of 1985. The analysis included 322 nationally representative participants who were 7-15 years old at enrollment and 31-41 years old at follow-up, when they underwent screening MRI knee scans in which cartilage defects in the tibial, femoral, and patellar zones were rated by a modified Outerbridge scoring system.

• Women had a higher prevalence of cartilage defects: 43% in the whole knee and 30% at the patella, compared with rates of 34% and 20%, respectively, in men.

• The prevalence of patellar cartilage defects in young adulthood was 24.2% in those who had a normal weight both as children and young adults compared with 40% in participants who were overweight at both time points, for an adjusted 1.77-fold increased risk in subjects who were overweight across the decades, .

• Excess childhood weight per kilogram, fat mass per kilogram, and body mass per unit were each associated with 5%-12% increased risks of patellar cartilage defects 25 years later, independent of adult body weight status, in an analysis adjusted for childhood age, sex, height, duration of follow-up, and history of pediatric or adult knee injury.

• A dose-response relationship was evident between the degree of childhood overweight and the severity of cartilage defects as young adults on a 0-4 rating scale.

Dr. Antony reported having no financial conflicts of interest regarding the study, which was supported by the National Health and Medical Research Council of Australia.

bjancin@frontlinemedcom.com

LAS VEGAS – Childhood overweight was associated with increased risk of patellar cartilage defects in young adulthood independent of adult weight status in what’s believed to be the first long-term prospective study to address the issue using informative MRI imaging.

“Our data indicate the importance of intervening in childhood obesity for adult joint health,” Benny E. Antony, MD, reported at the World Congress on Osteoarthritis, sponsored by the Osteoarthritis Research Society International.

He presented the 25-year prospective follow-up from the population-based Childhood Determinants of Adult Knee Cartilage Study, a substudy of the Australian Schools Health and Fitness Survey of 1985. The analysis included 322 nationally representative participants who were 7-15 years old at enrollment and 31-41 years old at follow-up, when they underwent screening MRI knee scans in which cartilage defects in the tibial, femoral, and patellar zones were rated by a modified Outerbridge scoring system.

• Women had a higher prevalence of cartilage defects: 43% in the whole knee and 30% at the patella, compared with rates of 34% and 20%, respectively, in men.

• The prevalence of patellar cartilage defects in young adulthood was 24.2% in those who had a normal weight both as children and young adults compared with 40% in participants who were overweight at both time points, for an adjusted 1.77-fold increased risk in subjects who were overweight across the decades, .

• Excess childhood weight per kilogram, fat mass per kilogram, and body mass per unit were each associated with 5%-12% increased risks of patellar cartilage defects 25 years later, independent of adult body weight status, in an analysis adjusted for childhood age, sex, height, duration of follow-up, and history of pediatric or adult knee injury.

• A dose-response relationship was evident between the degree of childhood overweight and the severity of cartilage defects as young adults on a 0-4 rating scale.

Dr. Antony reported having no financial conflicts of interest regarding the study, which was supported by the National Health and Medical Research Council of Australia.

bjancin@frontlinemedcom.com

The Mesh Type in Ventral Hernia Repair trial is an interventional study currently recruiting patients scheduled for open ventral hernia repair.

Half of ventral hernia repairs utilize synthetic mesh, while the other half use biologic mesh. There is currently little solid evidence that one mesh type is better than the other, although the study investigators hypothesize that biologic mesh is superior to synthetic.

Patients will be included in the trial if they are scheduled for open ventral hernia repair at LBJ General Hospital in Houston and are at least 18 years old. Patients will be excluded if they have an active infection, are unlikely to survive the next 2 years, are individuals in whom a prosthetic would not normally be placed, or are unlikely to follow up.

The primary endpoint goal is zero complications 1 year after the operation. Secondary endpoint goals include patient-centered outcomes, cost, Dindo-Clavien complications (grades I-IV), and to be complication free 3 years after the operation.

Recruitment began on March 27, 2017, and the study is expected to include 50 people. The primary study endpoint will be completed March 31, 2019, with the full study being completed March 31, 2022.

Find more information at the study page on Clinicaltrials.gov.

lfranki@frontlinemedcom.com

The Mesh Type in Ventral Hernia Repair trial is an interventional study currently recruiting patients scheduled for open ventral hernia repair.

Half of ventral hernia repairs utilize synthetic mesh, while the other half use biologic mesh. There is currently little solid evidence that one mesh type is better than the other, although the study investigators hypothesize that biologic mesh is superior to synthetic.

Patients will be included in the trial if they are scheduled for open ventral hernia repair at LBJ General Hospital in Houston and are at least 18 years old. Patients will be excluded if they have an active infection, are unlikely to survive the next 2 years, are individuals in whom a prosthetic would not normally be placed, or are unlikely to follow up.

The primary endpoint goal is zero complications 1 year after the operation. Secondary endpoint goals include patient-centered outcomes, cost, Dindo-Clavien complications (grades I-IV), and to be complication free 3 years after the operation.

Recruitment began on March 27, 2017, and the study is expected to include 50 people. The primary study endpoint will be completed March 31, 2019, with the full study being completed March 31, 2022.

Find more information at the study page on Clinicaltrials.gov.

lfranki@frontlinemedcom.com

The Mesh Type in Ventral Hernia Repair trial is an interventional study currently recruiting patients scheduled for open ventral hernia repair.

Half of ventral hernia repairs utilize synthetic mesh, while the other half use biologic mesh. There is currently little solid evidence that one mesh type is better than the other, although the study investigators hypothesize that biologic mesh is superior to synthetic.

Patients will be included in the trial if they are scheduled for open ventral hernia repair at LBJ General Hospital in Houston and are at least 18 years old. Patients will be excluded if they have an active infection, are unlikely to survive the next 2 years, are individuals in whom a prosthetic would not normally be placed, or are unlikely to follow up.

The primary endpoint goal is zero complications 1 year after the operation. Secondary endpoint goals include patient-centered outcomes, cost, Dindo-Clavien complications (grades I-IV), and to be complication free 3 years after the operation.

Recruitment began on March 27, 2017, and the study is expected to include 50 people. The primary study endpoint will be completed March 31, 2019, with the full study being completed March 31, 2022.

Find more information at the study page on Clinicaltrials.gov.

lfranki@frontlinemedcom.com

Study Overview

Objective. To determine the effects of intra-articular triamcinolone acetonide at a dose of 40 mg administered at 3-month intervals on knee pain and progression of knee cartilage loss.

Design. Randomized, double-blind, placebo-controlled trial.

Setting and participants. 140 patients with ultrasonic features of synovitis and symptomatic knee osteoarthritis were selected from the patient pool at Tufts Medical Center in Boston, Massachusetts, between June 2011 and January 2015. Patients selected were age 45 years or older and met American College of Rheumatology osteoarthritis diagnostic criteria. Western Ontario and McMaster Universities (WOMAC) pain scores were between 2 and 8 on weight-bearing questions. Tibiofemoral osteoarthritis on posteroanterior weight bearing semi-flexed radiographs was evident in participants at a Kellegren-Lawrence grade 2 or 3. Eligible patients also had ultra-sonographic evidence of synovitis with an effusion larger than 2 mm in the study knee. Participants were excluded if they had undergone any trauma to the study joint such as osteonecrosis or a poorly controlled systemic illness. If the patient had used antibiotics, hyaluronic acid, glucosamine, chondroitin or had undergone recent intra-articular steroids in 3 months or fewer prior to the enrollment period the patient was excluded from the study. Further, patients were excluded if they were unable to undergo an MRI. Prior to pain assessments, patients were to discontinue any analgesics for 48 hours with the exception of acetaminophen if needed. The mean age of patients in this study was 58 years and the mean body mass index was 30. Half of patients had malalignment of the knee joint.

Intervention. 40 mg of a preparation of 40 mg/mL (total volume 1 mL) was injected into the intervention patients’ affected knees while 1 mL of 0.9% sodium chloride (saline solution) was injected into the control patients’ affected knees. Local anesthetic was not used. If present, synovial fluid was aspirated from the knee prior to injection. Injections were administered every 12 weeks for 2 years. Needle placement by ultrasound was utilized to ensure accurate injections, however, the probe was removed prior to injection. The injecting clinician was not involved in measuring outcomes in the study. Both intervention solutions were in identical syringes and were masked so the patient was blinded to which intervention he or she may have received.

Main outcome measure. Cartilage loss, pain, articular structural damage and physical function were the main outcome measures. Cartilage loss and structural damage were determined by MRI using validated quantitative and semi-quantitative assessments. Pain was measured with WOMAC scores and physical function was assessed using the 20-m walk test and the chair stand test. Patients were assessed during 9 scheduled visits at 3-month intervals when subjective data, blood pressure, and hemoglobin A1c levels were obtained. At 6-month intervals, patients underwent objective measures of function measured by a timed 20-m walk and chair stand testing. Evaluation of quantitative measures of cartilage analysis, semi-quantitative assessment of cartilage damage, bone marrow lesion and effusion volume measurement by MRI were done at time zero, 12 months and 24 months. The 36-Item Short-Form Health Survey was administered at these times as well. Results were computed with intention-to-treat analysis for all outcomes.

Main results. 140 patients were randomized out of 445 patients who were assessed for eligibility. Ten patients in the saline arm and 11 in the glucocorticoid arm were lost to follow-up. Groups were similar in age, BMI, varus or valgus malalignment, ultrasound measures, pain, and function measures. The group injected with triamcinolone had a higher rate of cartilage loss than the group injected with saline (–0.21 mm vs. –0.10 mm, P = 0.01) and had a higher rate of cartilage damage (–133.66 vs –72.41, P = 0.048). Cartilage denudation, bone marrow lesions, trabecular morphology and effusion volumes were not significantly different between groups. WOMAC pain measure differences from baseline in the groups were similar (–1.2 for triamcinolone group vs. –1.9 for the saline group, P = 0.17). There were also no differences between groups for the Visual Analog Scale pain score, stiffness, the 20-m walk test, or the chair stand test. Adverse events were similar between groups. At the end of the study protocol, only 45% of patients were able to correctly identify the group to which they were assigned.

Conclusion. In patients meeting American College of Rheumatology diagnostic criteria for osteoarthritis and evidence of inflammation in the affected joint, 40 mg of triamcinolone administered intra-articularly is no more effective in relieving pain or physical functioning after 2 years of injections every 3 months than normal saline. Injecting 40 mg of triamcinolone may hasten cartilage loss and damage as measured by MRI.

Commentary

In the current study, the rate of cartilage loss in the saline group was on par with prior studies examining the natural history of cartilage loss, suggesting that intra-articular steroid may actually be hastening the loss of cartilage observed in this study. The effect size was deemed moderate by the authors, though clinically significant minimal change has not been determined. Intra-articular cartilage loss is positively correlated with arthroplasty rates [1]. While this study was not designed to investigate the rate of joint replacement after intra-articular corticosteroid measurement, this may be an area for future study. Interestingly, pain and function scores were not significantly different between the 2 groups, despite the changes in cartilage. Of note, prior studies have shown the largest gains in pain relief occur during the first 4 weeks after an injection and pain measurements in this study were performed 3 months after the injections. While helpful for determining the long-term effects of intra-articular glucocorticoid administration, short-term benefits were not measured.

The Osteoarthritis Research Society International guidelines for the nonpharmacologic management of knee osteoarthritis recommend intra-articular steroids for short-term pain management based on meta-analysis of randomized controlled trials [2]. Guidelines set forth by the American College of Rheumatology in 2012 for management of osteoarthritis of the knee also recommend intra-articular steroids [3]. Intra-articular corticosteroid injections were listed as interchangeable, in the absence of comorbid conditions leading to contraindications, with oral acetaminophen, oral and topical NSAIDs, and tramadol.

Hemoglobin A1c and blood pressure were not negatively affected by intra-articular steroids in this study.

Applications for Clinical Practice

While this study overall showed hastening of cartilage loss/damage without long-term pain relief benefit, there are instances where intra-articular steroid injection may still be appropriate. For example, in patients for whom joint replacement therapy has been scheduled and temporary pain relief is needed prior to surgery, intra-articular steroids may provide the pain relief desired without cartilage loss being a clinical concern. Further, if a patient is in need of temporary pain relief to attend an important event and is at a level of marginal functional status due to pain, the benefit may outweigh the risk of hastening cartilage damage/loss to that particular patient. In light of the knowledge gained by this study, any time an intra-articular steroid injection is offered to a patient it should be made clear that the pain relief gained may be temporary and could result in faster deterioration of the cartilage.

Nonpharmacologic therapies for osteoarthritis, including water-based and land-based physical therapy and weight reduction, should be utilized before offering intra-articular corticosteroid injections. These interventions not only have a positive effect on knee osteoarthritis [2] but also promote general health and well-being.

—Christina Downey, MD, Geisinger Medical Center, Danville, PA

Study Overview

Objective. To determine the effects of intra-articular triamcinolone acetonide at a dose of 40 mg administered at 3-month intervals on knee pain and progression of knee cartilage loss.

Design. Randomized, double-blind, placebo-controlled trial.

Setting and participants. 140 patients with ultrasonic features of synovitis and symptomatic knee osteoarthritis were selected from the patient pool at Tufts Medical Center in Boston, Massachusetts, between June 2011 and January 2015. Patients selected were age 45 years or older and met American College of Rheumatology osteoarthritis diagnostic criteria. Western Ontario and McMaster Universities (WOMAC) pain scores were between 2 and 8 on weight-bearing questions. Tibiofemoral osteoarthritis on posteroanterior weight bearing semi-flexed radiographs was evident in participants at a Kellegren-Lawrence grade 2 or 3. Eligible patients also had ultra-sonographic evidence of synovitis with an effusion larger than 2 mm in the study knee. Participants were excluded if they had undergone any trauma to the study joint such as osteonecrosis or a poorly controlled systemic illness. If the patient had used antibiotics, hyaluronic acid, glucosamine, chondroitin or had undergone recent intra-articular steroids in 3 months or fewer prior to the enrollment period the patient was excluded from the study. Further, patients were excluded if they were unable to undergo an MRI. Prior to pain assessments, patients were to discontinue any analgesics for 48 hours with the exception of acetaminophen if needed. The mean age of patients in this study was 58 years and the mean body mass index was 30. Half of patients had malalignment of the knee joint.

Intervention. 40 mg of a preparation of 40 mg/mL (total volume 1 mL) was injected into the intervention patients’ affected knees while 1 mL of 0.9% sodium chloride (saline solution) was injected into the control patients’ affected knees. Local anesthetic was not used. If present, synovial fluid was aspirated from the knee prior to injection. Injections were administered every 12 weeks for 2 years. Needle placement by ultrasound was utilized to ensure accurate injections, however, the probe was removed prior to injection. The injecting clinician was not involved in measuring outcomes in the study. Both intervention solutions were in identical syringes and were masked so the patient was blinded to which intervention he or she may have received.

Main outcome measure. Cartilage loss, pain, articular structural damage and physical function were the main outcome measures. Cartilage loss and structural damage were determined by MRI using validated quantitative and semi-quantitative assessments. Pain was measured with WOMAC scores and physical function was assessed using the 20-m walk test and the chair stand test. Patients were assessed during 9 scheduled visits at 3-month intervals when subjective data, blood pressure, and hemoglobin A1c levels were obtained. At 6-month intervals, patients underwent objective measures of function measured by a timed 20-m walk and chair stand testing. Evaluation of quantitative measures of cartilage analysis, semi-quantitative assessment of cartilage damage, bone marrow lesion and effusion volume measurement by MRI were done at time zero, 12 months and 24 months. The 36-Item Short-Form Health Survey was administered at these times as well. Results were computed with intention-to-treat analysis for all outcomes.

Main results. 140 patients were randomized out of 445 patients who were assessed for eligibility. Ten patients in the saline arm and 11 in the glucocorticoid arm were lost to follow-up. Groups were similar in age, BMI, varus or valgus malalignment, ultrasound measures, pain, and function measures. The group injected with triamcinolone had a higher rate of cartilage loss than the group injected with saline (–0.21 mm vs. –0.10 mm, P = 0.01) and had a higher rate of cartilage damage (–133.66 vs –72.41, P = 0.048). Cartilage denudation, bone marrow lesions, trabecular morphology and effusion volumes were not significantly different between groups. WOMAC pain measure differences from baseline in the groups were similar (–1.2 for triamcinolone group vs. –1.9 for the saline group, P = 0.17). There were also no differences between groups for the Visual Analog Scale pain score, stiffness, the 20-m walk test, or the chair stand test. Adverse events were similar between groups. At the end of the study protocol, only 45% of patients were able to correctly identify the group to which they were assigned.

Conclusion. In patients meeting American College of Rheumatology diagnostic criteria for osteoarthritis and evidence of inflammation in the affected joint, 40 mg of triamcinolone administered intra-articularly is no more effective in relieving pain or physical functioning after 2 years of injections every 3 months than normal saline. Injecting 40 mg of triamcinolone may hasten cartilage loss and damage as measured by MRI.

Commentary

In the current study, the rate of cartilage loss in the saline group was on par with prior studies examining the natural history of cartilage loss, suggesting that intra-articular steroid may actually be hastening the loss of cartilage observed in this study. The effect size was deemed moderate by the authors, though clinically significant minimal change has not been determined. Intra-articular cartilage loss is positively correlated with arthroplasty rates [1]. While this study was not designed to investigate the rate of joint replacement after intra-articular corticosteroid measurement, this may be an area for future study. Interestingly, pain and function scores were not significantly different between the 2 groups, despite the changes in cartilage. Of note, prior studies have shown the largest gains in pain relief occur during the first 4 weeks after an injection and pain measurements in this study were performed 3 months after the injections. While helpful for determining the long-term effects of intra-articular glucocorticoid administration, short-term benefits were not measured.

The Osteoarthritis Research Society International guidelines for the nonpharmacologic management of knee osteoarthritis recommend intra-articular steroids for short-term pain management based on meta-analysis of randomized controlled trials [2]. Guidelines set forth by the American College of Rheumatology in 2012 for management of osteoarthritis of the knee also recommend intra-articular steroids [3]. Intra-articular corticosteroid injections were listed as interchangeable, in the absence of comorbid conditions leading to contraindications, with oral acetaminophen, oral and topical NSAIDs, and tramadol.

Hemoglobin A1c and blood pressure were not negatively affected by intra-articular steroids in this study.

Applications for Clinical Practice

While this study overall showed hastening of cartilage loss/damage without long-term pain relief benefit, there are instances where intra-articular steroid injection may still be appropriate. For example, in patients for whom joint replacement therapy has been scheduled and temporary pain relief is needed prior to surgery, intra-articular steroids may provide the pain relief desired without cartilage loss being a clinical concern. Further, if a patient is in need of temporary pain relief to attend an important event and is at a level of marginal functional status due to pain, the benefit may outweigh the risk of hastening cartilage damage/loss to that particular patient. In light of the knowledge gained by this study, any time an intra-articular steroid injection is offered to a patient it should be made clear that the pain relief gained may be temporary and could result in faster deterioration of the cartilage.

Nonpharmacologic therapies for osteoarthritis, including water-based and land-based physical therapy and weight reduction, should be utilized before offering intra-articular corticosteroid injections. These interventions not only have a positive effect on knee osteoarthritis [2] but also promote general health and well-being.

—Christina Downey, MD, Geisinger Medical Center, Danville, PA

Study Overview

Objective. To determine the effects of intra-articular triamcinolone acetonide at a dose of 40 mg administered at 3-month intervals on knee pain and progression of knee cartilage loss.

Design. Randomized, double-blind, placebo-controlled trial.

Setting and participants. 140 patients with ultrasonic features of synovitis and symptomatic knee osteoarthritis were selected from the patient pool at Tufts Medical Center in Boston, Massachusetts, between June 2011 and January 2015. Patients selected were age 45 years or older and met American College of Rheumatology osteoarthritis diagnostic criteria. Western Ontario and McMaster Universities (WOMAC) pain scores were between 2 and 8 on weight-bearing questions. Tibiofemoral osteoarthritis on posteroanterior weight bearing semi-flexed radiographs was evident in participants at a Kellegren-Lawrence grade 2 or 3. Eligible patients also had ultra-sonographic evidence of synovitis with an effusion larger than 2 mm in the study knee. Participants were excluded if they had undergone any trauma to the study joint such as osteonecrosis or a poorly controlled systemic illness. If the patient had used antibiotics, hyaluronic acid, glucosamine, chondroitin or had undergone recent intra-articular steroids in 3 months or fewer prior to the enrollment period the patient was excluded from the study. Further, patients were excluded if they were unable to undergo an MRI. Prior to pain assessments, patients were to discontinue any analgesics for 48 hours with the exception of acetaminophen if needed. The mean age of patients in this study was 58 years and the mean body mass index was 30. Half of patients had malalignment of the knee joint.

Intervention. 40 mg of a preparation of 40 mg/mL (total volume 1 mL) was injected into the intervention patients’ affected knees while 1 mL of 0.9% sodium chloride (saline solution) was injected into the control patients’ affected knees. Local anesthetic was not used. If present, synovial fluid was aspirated from the knee prior to injection. Injections were administered every 12 weeks for 2 years. Needle placement by ultrasound was utilized to ensure accurate injections, however, the probe was removed prior to injection. The injecting clinician was not involved in measuring outcomes in the study. Both intervention solutions were in identical syringes and were masked so the patient was blinded to which intervention he or she may have received.

Main outcome measure. Cartilage loss, pain, articular structural damage and physical function were the main outcome measures. Cartilage loss and structural damage were determined by MRI using validated quantitative and semi-quantitative assessments. Pain was measured with WOMAC scores and physical function was assessed using the 20-m walk test and the chair stand test. Patients were assessed during 9 scheduled visits at 3-month intervals when subjective data, blood pressure, and hemoglobin A1c levels were obtained. At 6-month intervals, patients underwent objective measures of function measured by a timed 20-m walk and chair stand testing. Evaluation of quantitative measures of cartilage analysis, semi-quantitative assessment of cartilage damage, bone marrow lesion and effusion volume measurement by MRI were done at time zero, 12 months and 24 months. The 36-Item Short-Form Health Survey was administered at these times as well. Results were computed with intention-to-treat analysis for all outcomes.

Main results. 140 patients were randomized out of 445 patients who were assessed for eligibility. Ten patients in the saline arm and 11 in the glucocorticoid arm were lost to follow-up. Groups were similar in age, BMI, varus or valgus malalignment, ultrasound measures, pain, and function measures. The group injected with triamcinolone had a higher rate of cartilage loss than the group injected with saline (–0.21 mm vs. –0.10 mm, P = 0.01) and had a higher rate of cartilage damage (–133.66 vs –72.41, P = 0.048). Cartilage denudation, bone marrow lesions, trabecular morphology and effusion volumes were not significantly different between groups. WOMAC pain measure differences from baseline in the groups were similar (–1.2 for triamcinolone group vs. –1.9 for the saline group, P = 0.17). There were also no differences between groups for the Visual Analog Scale pain score, stiffness, the 20-m walk test, or the chair stand test. Adverse events were similar between groups. At the end of the study protocol, only 45% of patients were able to correctly identify the group to which they were assigned.

Conclusion. In patients meeting American College of Rheumatology diagnostic criteria for osteoarthritis and evidence of inflammation in the affected joint, 40 mg of triamcinolone administered intra-articularly is no more effective in relieving pain or physical functioning after 2 years of injections every 3 months than normal saline. Injecting 40 mg of triamcinolone may hasten cartilage loss and damage as measured by MRI.

Commentary

In the current study, the rate of cartilage loss in the saline group was on par with prior studies examining the natural history of cartilage loss, suggesting that intra-articular steroid may actually be hastening the loss of cartilage observed in this study. The effect size was deemed moderate by the authors, though clinically significant minimal change has not been determined. Intra-articular cartilage loss is positively correlated with arthroplasty rates [1]. While this study was not designed to investigate the rate of joint replacement after intra-articular corticosteroid measurement, this may be an area for future study. Interestingly, pain and function scores were not significantly different between the 2 groups, despite the changes in cartilage. Of note, prior studies have shown the largest gains in pain relief occur during the first 4 weeks after an injection and pain measurements in this study were performed 3 months after the injections. While helpful for determining the long-term effects of intra-articular glucocorticoid administration, short-term benefits were not measured.

The Osteoarthritis Research Society International guidelines for the nonpharmacologic management of knee osteoarthritis recommend intra-articular steroids for short-term pain management based on meta-analysis of randomized controlled trials [2]. Guidelines set forth by the American College of Rheumatology in 2012 for management of osteoarthritis of the knee also recommend intra-articular steroids [3]. Intra-articular corticosteroid injections were listed as interchangeable, in the absence of comorbid conditions leading to contraindications, with oral acetaminophen, oral and topical NSAIDs, and tramadol.

Hemoglobin A1c and blood pressure were not negatively affected by intra-articular steroids in this study.

Applications for Clinical Practice

While this study overall showed hastening of cartilage loss/damage without long-term pain relief benefit, there are instances where intra-articular steroid injection may still be appropriate. For example, in patients for whom joint replacement therapy has been scheduled and temporary pain relief is needed prior to surgery, intra-articular steroids may provide the pain relief desired without cartilage loss being a clinical concern. Further, if a patient is in need of temporary pain relief to attend an important event and is at a level of marginal functional status due to pain, the benefit may outweigh the risk of hastening cartilage damage/loss to that particular patient. In light of the knowledge gained by this study, any time an intra-articular steroid injection is offered to a patient it should be made clear that the pain relief gained may be temporary and could result in faster deterioration of the cartilage.

Nonpharmacologic therapies for osteoarthritis, including water-based and land-based physical therapy and weight reduction, should be utilized before offering intra-articular corticosteroid injections. These interventions not only have a positive effect on knee osteoarthritis [2] but also promote general health and well-being.

—Christina Downey, MD, Geisinger Medical Center, Danville, PA

SAN DIEGO – A new study of medical records offers insights into the persistence of opioid use: Most patients who were prescribed opioid painkillers did not go back for a refill right away, but nearly half of patients who stopped taking the drugs for at least 6 months ended up using them again over a 3-year period.

“This key finding indicates that programs that address opioid use need to focus on long-term support and education to ensure that individuals do not become long-term users,” psychiatrist and lead author Shareh Ghani, MD, vice president and medical director of Magellan Health Services, San Francisco, said in an interview.

Researchers also found that opioid use appeared linked to three unexpected conditions – lipid disorders, hypertension, and sleep-wake disorders – and found that more than half of those who had at least two prescriptions for high-dose opioids kept taking the drugs over 18 months after an initial 90-day period.

SAN DIEGO – A new study of medical records offers insights into the persistence of opioid use: Most patients who were prescribed opioid painkillers did not go back for a refill right away, but nearly half of patients who stopped taking the drugs for at least 6 months ended up using them again over a 3-year period.

“This key finding indicates that programs that address opioid use need to focus on long-term support and education to ensure that individuals do not become long-term users,” psychiatrist and lead author Shareh Ghani, MD, vice president and medical director of Magellan Health Services, San Francisco, said in an interview.

Researchers also found that opioid use appeared linked to three unexpected conditions – lipid disorders, hypertension, and sleep-wake disorders – and found that more than half of those who had at least two prescriptions for high-dose opioids kept taking the drugs over 18 months after an initial 90-day period.

SAN DIEGO – A new study of medical records offers insights into the persistence of opioid use: Most patients who were prescribed opioid painkillers did not go back for a refill right away, but nearly half of patients who stopped taking the drugs for at least 6 months ended up using them again over a 3-year period.

“This key finding indicates that programs that address opioid use need to focus on long-term support and education to ensure that individuals do not become long-term users,” psychiatrist and lead author Shareh Ghani, MD, vice president and medical director of Magellan Health Services, San Francisco, said in an interview.

Researchers also found that opioid use appeared linked to three unexpected conditions – lipid disorders, hypertension, and sleep-wake disorders – and found that more than half of those who had at least two prescriptions for high-dose opioids kept taking the drugs over 18 months after an initial 90-day period.

SAN FRANCISCO – Parathyroid hormone and parathyroid hormone–related protein analogs show promise for treating osteoporosis, but, for now, they’re reserved for the most severe cases.

Teriparatide, a parathyroid hormone analog, is the first treatment that stimulates bone formation instead of inhibiting bone resorption, but studies to date are too small to evaluate its effect on hip fractures, Jeffrey A. Tice, MD, said at the UCSF Annual Advances in Internal Medicine meeting.

dbrunk@frontlinemedcom.com

SAN FRANCISCO – Parathyroid hormone and parathyroid hormone–related protein analogs show promise for treating osteoporosis, but, for now, they’re reserved for the most severe cases.

Teriparatide, a parathyroid hormone analog, is the first treatment that stimulates bone formation instead of inhibiting bone resorption, but studies to date are too small to evaluate its effect on hip fractures, Jeffrey A. Tice, MD, said at the UCSF Annual Advances in Internal Medicine meeting.

dbrunk@frontlinemedcom.com

SAN FRANCISCO – Parathyroid hormone and parathyroid hormone–related protein analogs show promise for treating osteoporosis, but, for now, they’re reserved for the most severe cases.

Teriparatide, a parathyroid hormone analog, is the first treatment that stimulates bone formation instead of inhibiting bone resorption, but studies to date are too small to evaluate its effect on hip fractures, Jeffrey A. Tice, MD, said at the UCSF Annual Advances in Internal Medicine meeting.

dbrunk@frontlinemedcom.com