Quantitative estimation of rare adverse events which follow a biological progression: a new model applied to chronic NSAID use

Identification of the active constituents and molecular mechanism of Eulophia nuda extract in the treatment of osteoarthritis by network pharmacology, molecular modelling and experimental assays

Osteoarthritis is a degenerative joint disease that worsens over time, often resulting in chronic pain. Eulophia nuda (Orchidaceae), a medicinal herb widely used by folklore and indigenous healers for treating arthritis but the active ingredients and the molecular mechanisms of action are yet to be explored. The present study systematically investigates the underlying anti-osteoarthritic mechanism of ENE through network pharmacology, molecular dynamics simulation and experimental assays. A comprehensive search on IMPPAT, KNApSAcK and Pubchem databases resulted 26 active compounds from E. nuda, of which 23 passed the drug-likeness criteria. A total of 2344 compound targets, 1370 osteoarthritis targets and 81 overlapping compound-disease targets were identified. The compound-disease target network resulted in five active constituents with degree > 23. Topological analysis of the protein-protein interaction network revealed six hub target genes. KEGG analysis revealed IL-17, TNF and AGE-RAGE signalling pathways as the enriched pathways involved in osteoarthritis. Molecular docking showed eulophiol had the good binding energy (>8.0 kcal/mol) with MMP9, JNK1, p38 and NF-kβ. The molecular dynamics simulations and the MMPBSA analysis indicate high stability and greater binding energy of eulophiol with the target proteins. ENE did not show cytotoxicity on SW982 cells up to a concentration of 100 μg/ml. ENE exhibited considerable anti-inflammatory effect by reducing PGE2, IL-6 and IL8 levels as well as reducing the mRNA expression of matrix metalloproteinases (MMP2 and MMP9). Furthermore, ENE effectively inhibited the NF-kβ nuclear translocation and phosphorylation of ERK2, p38 and JNK in SW982 cells. The current study showed that ENE may act as a potential drug candidate for treating osteoarthritis.

Bisphosphonates show no association with preventing, slowing, or delaying radiographic changes and pain in hip osteoarthritis: A 4-year study in female adults using data from the Osteoarthritis Initiative Study

OBJECTIVE

This study aimed to investigate the association of bisphosphonates with outcomes related to radiographic changes and pain in hip osteoarthritis (OA) over 4 years.

METHODS

This study examined data from the Osteoarthritis Initiative (OAI), which included 4088 hips from 2057 participants. Bisphosphonate users were identified as those who reported usage at least three times, including at baseline and during the subsequent 1, 2, 3, and 4-year follow-up visits. Non-users were participants who did not use bisphosphonates in the 5 years preceding the baseline and at subsequent follow-up visits. Generalized estimating equations were performed to assess the association between bisphosphonate use and outcomes related to radiographic changes and pain in hip OA over a 4-year follow-up.

RESULTS

The analysis revealed no statistically significant difference between bisphosphonate users and non-users concerning outcomes related to radiographic changes and pain in hip OA over 4 years. Specifically, the odds ratios for the incidence and transition of radiographic hip OA were 0.55 (95% Confidence Interval [CI]: 0.26 to 1.17) and 0.78 (95% CI: 0.47 to 1.28), respectively. Furthermore, the odds ratios for the development and resolution of frequent hip pain were 1.04 (95% CI: 0.76 to 1.42) and 0.99 (95% CI: 0.72 to 1.36), respectively.

CONCLUSION

The findings from this longitudinal study do not suggest an association between bisphosphonate use and the prevention, slowing, or delay of development and transition of radiographic changes or pain in hip OA over a 4-year follow-up.

Association of long-term use of non-steroidal anti-inflammatory drugs with knee osteoarthritis: a prospective multi-cohort study over 4-to-5 years

This study examines the long-term impact of non-steroidal anti-inflammatory drugs (NSAIDs) on the progression of symptoms and structural deterioration of the joint in knee osteoarthritis. The study analyzes data from 4197 participants (8394 knees) across the Osteoarthritis Initiative (OAI), Multicenter Osteoarthritis Study (MOST), and Cohort Hip and Cohort Knee (CHECK) over 4-to-5 years. Adjustments were made for major covariates. We focussed on binary outcomes to assess the presence or absence of significant changes. We found that, relative to non-users, individuals using NSAIDs long-term were significantly more likely to experience aggravated symptoms exceeding the minimally clinically important difference, specifically, pain (OR: 2.04, 95% CI: 1.66-2.49), disability (OR: 2.21, 95% CI: 1.74-2.80), and stiffness (OR: 1.58, 95% CI: 1.29-1.93). Long-term users also faced a higher probability than non-users of having total knee replacement (OR: 3.13, 95% CI: 2.08-4.70), although no significant difference between long-term users and non-users was observed for structural deterioration in the knee joint (OR: 1.25, 95% CI: 0.94-1.65). While acknowledging the limitations of this study due to its observational design and the potential for bidirectional causality, these findings suggest that long-term NSAID use could accelerate the progression to total knee replacement by markedly exacerbating symptoms.

Investigation of the association of long-term NSAID use with radiographic hip osteoarthritis over four to five years: Data from the OAI and CHECK studies

Objective

To examine the relationship between long-term use of non-steroidal anti-inflammatory drugs (NSAIDs) and the incidence and progression of radiographic hip osteoarthritis (RHOA), as well as the degeneration of individual radiographic features.

Methods

We analyzed data from the Osteoarthritis Initiative (OAI) and the Cohort Hip and Cohort Knee (CHECK) study. Our exposure was the number of years of NSAID use over a 4-to-5-year follow-up period. Our outcomes were the incidence and progression of RHOA over a 4-to-5-year follow-up as assessed using a modified Croft grade in OAI and the Kellgren-Lawrence (K/L) grade in CHECK. The incidence of RHOA was defined as having RHOA (grade ≥2) at follow-up and investigated in "incidence cohorts" of hips without RHOA at baseline (grade <2). The progression of RHOA was defined as an increase of ≥1 grade at follow-up from baseline and investigated in "progression cohorts" of hips with RHOA at baseline (grade ≥2). Additionally, we assessed the degeneration of nine specific radiographic features, such as joint space narrowing and osteophytes, defined by a grade increase of ≥1 ​at follow-up from baseline, in all cohorts.

Results

In the incidence cohorts, there were 5153 hips in OAI and 1011 in CHECK; in the progression cohorts, there were 285 and 106 hips, respectively. There was no association between NSAID use and the outcomes investigated.

Conclusion

Over 4-to-5 years, long-term NSAID use showed no association with the incidence or progression of RHOA, or with the degeneration of individual radiographic features.

[Concept for integrative pain treatment of osteoarthritis of the knee based on the evidence for conservative and complementary therapies]

BACKGROUND

Osteoarthritis of the knee (gonarthritis) represents a medical challenge.

RESEARCH QUESTION

What is the evidence with respect to approaches of complementary medicine and their integration into multimodal pain management concepts?

MATERIAL AND METHODS

Qualitative nonsystematic literature search on the epidemiology and pathophysiology as well as informative clinical trials, meta-analyses and clinical guidelines about conservative treatment including complementary therapy for gonarthritis.

RESULTS

Osteoarthritis of the knee is a frequent condition with biopsychosocial risks factors for chronification. The German S2k clinical guideline (k = consensus-based, not based on scientific systematic literature searches) published by the Association of the Scientific Medical Societies in Germany (AWMF) in 2017 has not yet been updated. The current guidelines of the American College of Rheumatology (ACR) date from 2020. Both guidelines recommend exercise therapy, weight reduction, short-term analgesics, topical therapy, intra-articular corticoid injections and acupuncture with variable strengths. Furthermore, transcutaneous electrical nerve stimulation (TENS), laser and other electrophysical therapies, shock waves, traction treatment, ergotherapy, comfrey poultices and mudpacks can also be used. Current research supports the benefits of tai chi/qigong and medicinal leaches.

CONCLUSION

Complementary treatment approaches, such as acupuncture, tai chi/qigong, topical naturopathic self-treatment and leeches (with limitations) can, in addition to behavioral changes, exercise therapy and short-term pharmacological treatment, be important evidence-based components of integrative pain management concepts, e.g. in terms of an interdisciplinary multimodal pain treatment (IMPT). Besides pain reduction and functional improvement they promote the internal control conviction through the possibility of self-treatment and self-exercise.

Reduced gastrointestinal-related hospitalisation costs following rescheduling of over-the-counter codeine-containing compound analgesics in Australia: results of a single hospital audit in South Australia

BACKGROUND

Codeine-containing compound analgesics (CCCAs) are associated with dependence and, when taken in excess, significant risks of harm. A previous audit showed significant costs related to admissions for gastrointestinal (GI) complications of CCCA. Based on this and other evidence of harm, the Australian Therapeutic Goods Administration changed CCCAs to prescription only in 2018.

AIMS

We aimed to identify the costs associated with codeine-related GI complications and whether the schedule change in 2018 led to a reduced clinical and financial strain on the health care system.

METHODS

We conducted an audit of GI admissions and associated costs of CCCAs at a tertiary teaching hospital in Adelaide between 2016 and 2020. Patients were grouped by 2-year time periods before (group 1) and following (group 2) schedule change. Costs for the index presentation were multiplied for subsequent presentations. Costs and outcomes were compared for groups (standard statistics; P value < 0.05 significant.) RESULTS: Three hundred forty patients (group 1, n = 164; group 2, n = 119) were identified, with the majority of these admitted due to nonsteroidal anti-inflammatory drugs (NSAIDs) only. For CCCAs (NSAID-containing), the same patients were admitted repeatedly with a reduction from 31 to eight admissions (P = 0.005), following rescheduling. The total cost of CCCA admissions was reduced from AU$ 561 691 for group 1 to AU$ 261 764 for group 2 (P < 0.001).

CONCLUSIONS

Australian rescheduling of CCCAs in 2018 resulted in a reduction in hospital admissions and costs related to GI complications. The cost savings, even in a single hospital department, were substantial.

Development of Prediction Model Using Machine-Learning Algorithms for Nonsteroidal Anti-inflammatory Drug-Induced Gastric Ulcer in Osteoarthritis Patients: Retrospective Cohort Study of a Nationwide South Korean Cohort

Background

Nonsteroidal anti-inflammatory drugs (NSAID) are currently among the most prescribed medications worldwide to relieve pain and reduce inflammation, especially in patients suffering osteoarthritis (OA). However, NSAIDs are known to have adverse effects on the gastrointestinal system. If a gastric ulcer occurs, planned OA treatment needs to be changed, incurring additional treatment costs and causing discomfort for both patients and clinicians. Therefore, it is necessary to create a gastric ulcer prediction model that can reflect the detailed health status of each individual and to use it when making treatment plans.

Methods

Using sample cohort data from 2008 to 2013 from the National Health Insurance Service in South Korea, we developed a prediction model for NSAID-induced gastric ulcers using machine-learning algorithms and investigated new risk factors associated with medication and comorbidities.

Results

The population of the study consisted of 30,808 patients with OA who were treated with NSAIDs between 2008 and 2013. After a 2-year follow-up, these patients were divided into two groups: without gastric ulcer (n=29,579) and with gastric ulcer (n=1,229). Five machine-learning algorithms were used to develop the prediction model, and a gradient boosting machine (GBM) was selected as the model with the best performance (area under the curve, 0.896; 95% confidence interval, 0.883-0.909). The GBM identified 5 medications (loxoprofen, aceclofenac, talniflumate, meloxicam, and dexibuprofen) and 2 comorbidities (acute upper respiratory tract infection [AURI] and gastroesophageal reflux disease) as important features. AURI did not have a dose-response relationship, so it could not be interpreted as a significant risk factor even though it was initially detected as an important feature and improved the prediction performance.

Conclusions

We obtained a prediction model for NSAID-induced gastric ulcers using the GBM method. Since personal prescription period and the severity of comorbidities were considered numerically, individual patients' risk could be well reflected. The prediction model showed high performance and interpretability, so it is meaningful to both clinicians and NSAID users.

Adverse effects associated with acupuncture therapies: An evidence mapping from 535 systematic reviews

BACKGROUND AND OBJECTIVE

Considering that physicians and patients widely use acupuncture, it is necessary to explore its adverse effects during treatment. Herein, an evidence map was generated based on published studies to identify acupuncture-induced adverse effects and assess their severity, with the overarching goal of providing references for safe and effective implementation.

METHODS

A comprehensive literature search was performed in four public databases (PubMed, Embase, Web of science, and the Cochrane Library) to identify relevant studies published up to 15^th June 2022. In addition, relevant studies were explored in the Epistemonikos database and reference lists were retrieved as a supplement. A MeaSurement Tool to Assess systematic Reviews, Version 2 (AMSTAR-2) quality assessment tool was applied to determine the methodological quality of included systematic reviews (SRs) and/or meta-analysis (MAs), whereas Microsoft Excel 2019 tool was used for data extraction and coding. Heatmaps were generated to display disease type, countries of origin for the first authors, and the sample sizes of original studies. Moreover, bubble charts comprehensively presented intervention categories, adverse reaction types, and evidence levels.

RESULTS

A total of 535 SRs involving 33 adverse reactions were included. Among them, 22 studies were rated as high quality, 28 as moderate, 106 as low, and the rest were of critically-low quality. Numerous adverse effects were described in the studies, including syncope (86 SRs), organ or tissue injury (233 SRs), systemic reactions (113 SRs), infection (19 SRs), and other adverse events (373 SRs). Importantly, these adverse reactions were mainly associated with 19 acupuncture techniques, including electroacupuncture (n = 67), manual acupuncture (n = 47) and acupoint catgut embedding (n = 41). Furthermore, the 535 SRs described 23 diseases, among which symptoms, signs or clinical findings (83 SRs), mental, behavioral or neurodevelopmental disorders (67 SRs), and diseases of the nervous system (66 SRs) had the highest incidence.

CONCLUSION

This evidence mapping explores the adverse effects of acupuncture, showing that there are multiple types of adverse reactions to acupuncture, with milder symptoms. The methodological assessment revealed that most of the included studies were of low- or critically low-quality. Therefore, there is a need for future randomized controlled trials and SRs to comprehensively analyze acupuncture-related adverse events in order to provide reliable and credible evidence.

Effect of Cryotherapy plus Flurbiprofen Axetil for Pain Management in Children Undergoing Tonsillectomy

Objective

To investigate the effect of cryotherapy using ice pops for physical analgesia and preventive analgesia using flurbiprofen axetil for pain management in children undergoing tonsillectomy.

Methods

A total of 120 children scheduled for tonsillectomy were recruited after assessment for eligibility and assigned to a control group (group C), flurbiprofen axetil group (group F), cryotherapy group (group I), and cryotherapy plus flurbiprofen axetil group (Group FI) via the random number table method. Groups F and FI were given 1 mg/kg of flurbiprofen axetil through intravenous injection 30 min before surgery, while group C received an equal amount of saline at the same time point. Groups I and FI received sweet ice pops for pain relief after recovery from anesthesia. The modified Children's Hospital of Eastern Ontario Pain Scale (mCHEOPS) scores and pediatric anesthesia emergence delirium (PAED) scores at 5 minutes (T1), 30 minutes (T2), 60 minutes (T3), 4 hours (T4), and 24 hours (T5) postoperatively, and the incidence of postoperative complications in the children were recorded by investigators who were masked to the grouping results.

Results

From T1 to T4, significantly lower mCHEOPS scores and PAED scores were observed in group F, group I, and group FI versus those in group C (P < 0.05). At T2, group FI showed significantly lower mCHEOPS scores and PAED scores versus groups F and I (P < 0.05). There were no significant differences in the mCHEOPS scores and PAED scores between the four groups at 24 h postoperatively (P > 0.05). The differences in the documented postoperative complications between the four groups did not come up to the statistical standard (P > 0.05).

Conclusion

Cryotherapy plus flurbiprofen axetil for pain management significantly mitigates post-tonsillectomy pain and delirium in children and facilitates recovery, with no significant adverse events.

Acute and sub chronic toxicity studies with herbal pain relieving formula (Rhuleave-K™) in rats

Rhuleave-K™ is a proprietary combination of Curcuma longa extract, Boswellia serrata extract and black sesame seed oil. Acute toxicity was evaluated as per OECD guidelines 423. Rhuleave-K™ was fed at 2000 mg/kg to overnight fasted female rats. Clinical signs of abnormality and mortality was observed daily for 14 days. Sub-chronic toxicity was studied by feeding Rhuleave-K™ at 100, 500 and 1000 mg/kg/day to rats as per OECD guidelines 408. After 90 days feeding, heamatological and biochemical parameters were analyzed. Histopathology of all the major organs was also studied. In the acute toxicity study, there was no clinical sign of toxicity in any of the rat at maximum dose of 2000 mg/kg. The LD50 was computed as >2000 mg/kg in rats. The repeated dosing of Rhuleave-K™ at the maximum dose level of 1000 mg/kg for 90 days did not induce any observable toxic effects in rats, when compared to its corresponding control. The hematology and biochemistry profile of treated rats was similar to control animals and difference was non-significant (p > 0.05). The histopathology of major organs of all the control and treated animals was normal. In this study the NOAEL for Rhuleave-K™ was calculated as 1000 mg/kg daily in rats.

Potential role of herbal medicines as a novel approach in sepsis treatment

The growing number of deaths related to sepsis has become a major concern for past few years. Sepsis is a complex pathological reactions that is explained by series of host response to microbial insult. The resulted systemic reactions are manifested by early appearance of proinflammatory cytokines leading to hyperinflammatory phase which is followed by septic shock and death of the patient. The present study has revealed that antibiotics are not self-sufficient to control the complex mechanism of sepsis. Moreover prolonged and unnecessary administration of antibiotics may lead to antibiotic resistance to pathogens. In addition to this, immunosuppressive medications are selective and have targeted approach to certain study population. Drugs from herbal origin have shown to possess a mammoth of immunomodulatory potential by suppressing proinflammatory and anti-inflammatory cytokines exhibiting no or minimal unwanted secondary responses. Concomitantly, herbal plants tend to modulate oxidative stress level and haematological imbalance during inflammatory diseased conditions. Natural compounds have gained much attention for the treatment of several clinical complications. Considering the promising responses of medicinal plants with less/no side effects and easy procurement, comprehensive research on herbal plants to treat sepsis should be contemplated.

The efficacy and safety of Xianling Gubao capsules in the treatment of knee osteoarthritis: A protocol for a randomized, double-blind, controlled trial

BACKGROUND

Knee osteoarthritis (KOA) is a chronic degenerative joint disease, which is the most common type of osteoarthritis. The clinical manifestations are pain, swelling, and dysfunction of the knee joint, which seriously reduces the quality of life of patients and causes a huge social burden. At present, western medicine mainly focuses on symptomatic treatment, such as anti-inflammatory and pain relief, joint cavity injection, joint replacement, etc. The curative effect has certain limitations. Xianling Gubao capsule has some advantages in the treatment of KOA, but it lacks high-quality clinical research to verify it. Therefore, the purpose of this study is to evaluate the efficacy and safety of Xianling Gubao capsule in the treatment of KOA.

METHODS

A randomized, double-blind, double-simulation, parallel controlled trial design was used to study the efficacy and safety of Xianling Gubao capsules in the treatment of KOA. The patients were randomly divided into a treatment group and the control group according to 1:1. The treatment group: Xianling Gubao capsule + glucosamine hydrochloride capsule simulation agent treatment; the control group: glucosamine hydrochloride capsule + Xianling Gubao capsule simulation agent treatment. Both groups received standard treatment for 8 weeks and followed up for 30 days. And at the same time, pay attention to its efficacy and safety indicators. Observation indicators include: the western Ontario and McMaster universities osteoarthritis index, hospital for special surgery knee score, liver and kidney function, adverse reactions, etc. Data analysis was performed using SPSS 25.0 software.

DISCUSSION

This study will evaluate the efficacy and safety of Xianling Gubao capsule in the treatment of KOA. The results of this experiment will provide evidence support for Xianling Gubao capsule in the treatment of KOA.

TRIAL REGISTRATION

OSF Registration number: DOI 10.17605/OSF.IO/ERM9C.

A Review on the Application of Zeolites and Mesoporous Silica Materials in the Removal of Non-Steroidal Anti-Inflammatory Drugs and Antibiotics from Water

Zeolites and mesoporous silica materials are effective adsorbents that can be useful for the removal of various pharmaceuticals including non-steroidal anti-inflammatory drugs and antibiotics from low-quality water. This paper summarizes the properties and basic characteristics of zeolites and mesoporous silica materials and reviews the recent studies on the efficacy of the adsorption of selected non-steroidal medicinal products and antibiotics by these adsorbents to assess the potential opportunities and challenges of using them in water treatment. It was found that the adsorption capacity of sorbents with high silica content is related to their surface hydrophobicity (hydrophilicity) and structural features, such as micropore volume and pore size, as well as the properties of the studied medicinal products. This review can be of help to scientists to develop an effective strategy for reducing the amount of these two groups of pharmaceuticals in wastewater.

Efficacy of serratiopeptidase after impacted third molar surgery: a randomized controlled clinical trial

BACKGROUND

Serratiopeptidase has been clinically used in controlling surgical and non-surgical inflammatory conditions. This study was conducted to assess the therapeutic effect of Serratiopeptidase in patients undergoing surgical removal of impacted mandibular third molar.

METHODS

This randomized clinical trial investigated the efficacy of Serratiopeptidase and Paracetamol after surgical removal of impacted third molar for 5 days (n = 67) as compared with an equivalent dose of placebo and Paracetamol (n = 66). Outcome measures were reported pain, trismus and swelling using Laskin method. All outcome measures were recorded on days 0, 1, 2, 4, and 5 post-surgeries.

RESULTS

In this clinical trail 133 patients (mean age 23 years, 54% female) completed the study. Baseline characteristics were comparable across treatment groups. Serratiopeptidase significantly improved trismus compared with control on the 4^th day (27.30 ± 7.3 mm and 32.06 ± 7.7 mm, respectively (P < 0.001) Swelling markedly improved, The distance from the lower edge of the earlobe to the midpoint of the symphysis for cases vs control were 111.49 ± 8.1 mm and 115.39 ± 9.9 mm, respectively (P < 0.001). Reported pain, showed no statistical significance difference.

CONCLUSION

Serratiopeptidase resulted in better inflammation improvement than placebo over 5 days. Further studies are warranted to assess longer-term and clinical outcomes, as well as safety.

CLINICAL RELEVANCE

Serratiopeptidase administered postoperatively helps in improving trismus and swelling after removal of impacted lower third molars. Trial registration The study was registered in ClinicalTrial.gov under the number NCT02493179. Registered 1st of June 2015, https://clinicaltrials.gov/ct2/results?cond=serratiopeptidase .

Who Needs Gastroprotection in 2020?

Purpose of review

Peptic ulcer disease (PUD) is a recognized complication of non-steroidal anti-inflammatory drugs (NSAIDs). Stress ulcers are a concern for intensive care unit (ICU) patients; PUD is also an issue for patients taking anticoagulation. Helicobacter pylori test and treat is an option for patients starting NSAID therapy, and proton pump inhibitors (PPIs) may reduce PUD in NSAID patients and other high-risk groups.

Recent findings

There are a large number of trials that demonstrate that Helicobacter pylori eradication reduces PUD in NSAID patients. PPI is also effective at reducing PUD in this group and is also effective in ICU patients and those on anticoagulants. The effect is too modest for PPI to be recommended in everyone, and more research is needed as to which groups would benefit the most. Increasing age, past history of PUD, and comorbidity are the most important risk factors.

Summary

H. pylori test and treat should be offered to older patients starting NSAIDS, while PPIs should be prescribed to patients that are at high risk of developing PUD and at risk of dying from PUD complications.

Antinociceptive Interaction and Pharmacokinetics of the Combination Treatments of Methyleugenol Plus Diclofenac or Ketorolac

Although nonsteroidal anti-inflammatory drugs (NSAIDs) are one of the main types of drugs used to treat pain, they have several adverse effects, and such effects can be reduced by combining two analgesic drugs. The aim of this study was to evaluate the nociceptive activity of methyleugenol combined with either diclofenac or ketorolac, and determine certain parameters of pharmacokinetics. For the isobolographic analysis, the experimental effective dose 30 (ED30) was calculated for the drugs applied individually. With these effective doses, the peak plasma concentration (Cmax) was found and the other parameters of pharmacokinetics were established. Methyleugenol plus diclofenac and methyleugenol plus ketorolac decreased licking behavior in a dose-dependent manner in phase II, with an efficacy of 32.9 ± 9.3 and 39.8 ± 9.6%, respectively. According to the isobolographic analysis, the experimental and theoretical ED30 values were similar for methyleugenol plus diclofenac, suggesting an additive effect, but significantly different for methyleugenol plus ketorolac (3.6 ± 0.5 vs. 7.7 ± 0.6 mg/kg, respectively), indicating a probable synergistic interaction. Regarding pharmacokinetics, the only parameter showing a significant difference was Cmax for the methyleugenol plus diclofenac combination. Even with this difference, the combinations studied may be advantageous for treating inflammatory pain, especially for the combination methyleugenol plus ketorolac.

Abortion is associated with knee osteoarthritis among older women in China: A STROBE-compliant article

The current studies revealed inconsistent relationship between reproductive factors and osteoarthritis. Community-based research has not been conducted in China. The study was to examine the association of reproductive factors with the prevalence of knee osteoarthritis (OA).Through a multistage stratified random sampling method, 10 streets or villages from 5 cities in Hunan province were randomly selected, a total 2746 eligible women aged 50 to 83 were recruited in this cross-sectional study. A structured questionnaire including demographic factors, socio-economic status, reproductive factors, and knee OA was used. According to the criteria of American College of Rheumatology, clinical knee OA was assessed by doctors in community or village health clinics for knee pain, age, morning stiffness, crepitus on active motion or for knee pain, morning stiffness, crepitus on active motion, and tenderness of the bony navigation of the joint. Self-reported age of menarche, parity, abortion history, and menopausal status were collected.The prevalence of knee OA was 13.44%. Abortion is associated with knee OA (odds ratio [OR] = 1.271, 95% confidence interval [CI] = 1.007, 1.606), but age at menarche, parity, and menopausal status were not the factors. Furthermore, age (OR = 1.040, 95% CI = 1.020, 1.060), weight (OR = 1.019, 95% CI = 1.004, 1.035), higher education level (OR = 1.530, 95% CI = 1.121, 2.088), higher monthly household income (OR = .583, 95% CI = 0.441, 0.770 for 3000-4999 ¥ and OR = 0.599, 95% CI = 0.431, 0.833 for 5000 ¥ or more), and chronic gastritis (OR = 3.364, 95% CI = 2.548, 4.442) were associated with knee OA.Abortion may increase the risk of knee OA. Special attention should be paid to women with a history of abortion, and women who are planning to abort should be informed of the risk of knee OA later in life. The relationship between abortion and knee OA should be interpreted with caution and further confirmed.

Eroded GDA coil surgically managed with Roux-en-Y reconstruction

Here, we describe the case of a 56-year-old African American male who initially presented to the emergency department with 2 days of abdominal cramping, epigastric pain, loss of consciousness, melena and hematochezia. He underwent coil embolization of his gastroduodenal artery by the interventional radiology team after it was felt he was a high risk for rebleed. The patient then returned to the hospital with 3 weeks of epigastric pain, lightheadedness and melanotic stool. An upper endoscopy revealed a metallic coil embedded into the duodenal bulb. This coil was believed to be from prior embolization to the gastroduodenal artery. The patient then underwent a laparoscopic distal gastrectomy and partial duodenectomy with antecolic antegastric Roux-en-Y reconstruction bypassing the area where erosion occurred.

Comparison of the effects of 10.6-μm infrared laser and traditional moxibustion in the treatment of knee osteoarthritis

Based on two separate randomized controlled trials (RCTs) on traditional Chinese medicine (TCM) moxibustion and 10.6-μm infrared laser moxibustion in treating knee osteoarthritis (OA), we did an indirect and preliminary comparison of the effects of the 10.6-μm laser moxibustion with the traditional moxibustion for knee osteoarthritis. The objective was to see whether the laser moxibustion is non-inferior to the traditional moxibustion in alleviating symptoms of knee osteoarthritis such as pain, stiffness, and joint dysfunction as well as improving quality of life for the patients with knee osteoarthritis, and whether a further RCT directly comparing the laser and traditional moxibustion is necessary. Pooled data from two RCTs in patients with knee osteoarthritis, trial ISRCTN68475405 and trial ISRCTN26065334, were used. In the two RCTs, the eligibility criteria were almost identical, the treatment procedure (i.e., sessions, duration, and points) were similar, and the outcome measurements (i.e., WOMAC for symptoms and SF-36 for quality of life) were the same. The double robustness method was used for the WOMAC scale and the SF-36 endpoints to detect the difference between traditional and laser moxibustion. The analysis comprised 55 patients from ISRCTN68475405 in real moxibustion arm (moxibustion group) and 88 patients from ISRCTN26065334 in real laser moxibustion arm (laser group). Demographic characteristics and course of disease were similar between the two groups. Causal inference, using the doubly robust estimating approach to correct for bias due to baseline differences, showed that there was no statistically significant difference in the WOMAC pain, stiffness, and physical function between the two treatments at midterm, end of treatment, and 4 weeks after the end of treatment (P > 0.05). The exception was that there was statistically significantly more benefit associated with laser moxibustion compared with traditional moxibustion in physical function at the follow-up of 4 weeks after the end of treatment (P=0.006). There was no statistically significant difference in most SF-36 endpoints (P > 0.05) except that physical functioning (PF), mental health (MH), and bodily pain (BP) were statistically significantly better in the laser group than in the traditional moxibustion group at the follow-up of 4 weeks after the end of treatment (P = 0.005, 0.034, 0.002). The benefits of 10.6-μm infrared laser moxibustion and the traditional moxibustion for knee osteoarthritis were comparable in pain, stiffness, physical dysfunction, and in most of the quality of life subdimensions. The laser moxibustion might be more beneficial in terms of physical function, body pain, and mental health in the long term. RCTs directly comparing 10.6-μm laser moxibustion with traditional moxibustion are warranted.

Patterns of drug treatment in patients with osteoarthritis and chronic low back pain in Japan: a retrospective database study

Purpose: Musculoskeletal diseases, including osteoarthritis (OA) and low back pain (LBP), are the leading causes of years lived with disability, and are associated with lowered quality-of-life, lost productivity, and increased healthcare costs. However, information publicly available regarding the Japanese real-world usage of prescription medications is limited. This study aimed to describe the clinical characteristics of patients with OA and chronic LBP (CLBP), and to investigate the patterns of medications and opioid use in Japanese real-world settings.

Materials and methods: A retrospective study was conducted using a Japanese administrative claims database between 2013 and 2017. The outcomes were patient characteristics and prescription medications, and they were evaluated separately for OA and CLBP.

Results: The mean age of 118,996 patients with OA and 256,402 patients with CLBP was 68.8±13.1 years and 64.8±16.4 years, respectively. Approximately 90% of patients with OA and CLBP were prescribed non-steroidal anti-inflammatory drugs (NSAIDs). Other prescriptions included hyaluronate injection (35.6%), acetaminophen (21.4%), and steroid injection (20.0%) in patients with OA, and pregabalin (39.0%) and acetaminophen (22.4%) in patients with CLBP. Weak opioids were prescribed to 10.7% and 20.6% of patients with OA and CLBP, respectively. The prescription of COX-2 inhibitors (OA: +6.5%; CLBP: +6.7%) and acetaminophen (OA: +16.4%; CLBP: +14.4%) increased between 2013 and 2017. The first commonly prescribed medication among patients with OA and CLBP were NSAIDs; hyaluronate injection (patients with OA) and pregabalin (patients with CLBP) were also common first-line medications. Acetaminophen, steroid injection (patients with OA), and weak opioids were prescribed more in the later phases of treatment.

Conclusion: Most patients were prescribed limited classes of pain drugs, with NSAIDs being the most common pain medication in Japan for patients with OA and CLBP. Opioid prescription was uncommon, and were weak opioids when prescribed.

Unmet needs in the treatment of ankylosing spondylitis: a long-term observational study from a single university center

Despite the progress in the treatment of ankylosing spondylitis (AS), a significant number of patients do not achieve low disease activity (LDA). The aim of the study is to estimate the size of unmet needs in the treatment of AS in a long-term observational study. Between January 2003 and December 2017, 220 patients with radiographic SpA were evaluated fulfilling the ASAS criteria. They were followed up at predefined times and were naive to biological treatment with anti-tumor necrosis factor agents (anti-TNFs) and the interleukin (IL)-17 inhibitor. NSAIDs, all anti-TNFs and the IL-17 inhibitor secukinumab were used according to the European, United States and Canadian guidelines for AS. During follow-up, several clinical parameters including disease activity scores were recorded. All 220 patients had an active disease and received at least two NSAIDs for 3 months. The anti-TNF of first choice was infliximab-51%, followed by adalimumab-27% and etanercept-22%. During follow-up, 22 patients were excluded from the study (18 lost, 4 never received anti-TNF due to comorbidities). From the rest (198), 12 did not receive anti-TNFs (8 due to sustained LDA on NSAIDs solely and 4 due to treatment denial). Finally, 186 (94%) were treated with anti-TNFs demonstrating sustained long-term LDA. However, 16 patients never achieved LDA despite they received two or three anti-TNFs or the IL-17 inhibitor. Thus, a total of 20 (10.1%) patients never achieved LDA. This is the first study aiming to estimate the gap and the size of unmet needs in AS patients using the international guidelines and recommendations for AS treatment, which is 10.1%.

Comparison of the Efficacy between Conventional Moxibustion and Smoke-Free Moxibustion on Knee Osteoarthritis: A Randomized Controlled Trial

Objective

The aim of this study was to investigate the difference of efficacy between conventional moxibustion (CM) and smoke-free moxibustion (SM) for patients with osteoarthritis of the knee (KOA).

Methods

This is a multicentre, randomized, single blinded, parallel-group clinical trial. Patients with KOA were randomly allocated to CM group (69) and SM group (69) in 7 hospitals of China. Moxibustion treatment in 12 sessions over 4 weeks was administrated at 3 acupuncture points (EX-LE4, ST35, and ST36). Patients completed standard questionnaires at baseline and after 2 weeks, 4 weeks, 8 weeks, and 12 weeks. The primary outcome was the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) from the baseline to 4 weeks. The secondary outcomes include Visual Analogue Scale (VAS) and Patient Global Assessment score (PGA).

Results

Analyses showed that the WOMAC score improved in pain (95% CI,-0.1[-1.2 to 0.9], p=0.76), stiffness (95% CI,-0.1 [-0.5 to 0.3], p=0.71), and function (95% CI, 2.2 [-1.3 to 5.8], p=0.22) compared between the two groups at 4 weeks, as well as the VAS score (95% CI,0.1 [-0.3 to 0.6], p=0.60). Similar results presented at 8 and 12 weeks. No statistically significant difference was observed between CM and SM groups for outcome measurements.

Conclusions

It suggested that smoke generated during moxibustion treatment does not affect the efficacy of moxibustion in the treatment of KOA, which should be taken into account to be removed for the sake of reducing environmental pollution or moxa smoke exposure of acupuncturists or patients. This trial is registered with Clinical Trials.gov, NCT02772055.

Efficacy of electro-acupuncture and manual acupuncture versus sham acupuncture for knee osteoarthritis: study protocol for a randomised controlled trial

BACKGROUND

Knee osteoarthritis (KOA) is one of the most common musculoskeletal disorders. Although the available evidence for its efficacy is inconclusive, acupuncture is used as an alternative therapy for KOA. The aim of this trial is to determine the efficacy of electro-acupuncture and manual acupuncture versus sham acupuncture for KOA.

METHODS/DESIGN

This is a study protocol for a randomised, three-arm, multicentre, clinical trial. A total of 480 patients with KOA will be randomly assigned to the electro-acupuncture group, the manual acupuncture group or the sham acupuncture group in a 1:1:1 ratio. All patients will receive 24 sessions over 8 weeks. Participants will complete the trial by visiting the research centre at week 26 for a follow-up assessment. The primary outcome is the success rate: the proportion of patients achieving a minimal clinically important improvement, which is defined as ≥2 points on the numerical rating scale and ≥6 points on the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) function score at week 8 compared with baseline. Secondary outcomes include the numerical rating scale, WOMAC score, global patient assessment and quality of life at weeks 4, 8, 16 and 26 after randomisation.

DISCUSSION

This trial may provide high-quality evidence for the efficacy of acupuncture in the treatment of KOA. The results of this study will be published in peer-reviewed journals.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03274713 . Registered on 20 November 2017.

Trigger Point Acupuncture for Treatment of Knee Osteoarthritis – a Preliminary Rct for a Pragmatic Trial

Background

There is evidence for the efficacy of acupuncture treatment in knee osteoarthritis, but it remains unclear which acupuncture modes are most effective. We evaluated the effects of trigger point acupuncture on pain and quality of life in knee osteoarthritis patients, compared with acupuncture at standard points, and sham acupuncture.

Methods

Thirty patients (27 women, 3 men; aged 61–82 years) with non-radiating knee osteoarthritis pain for at least six months and normal neurological examination were randomised to one of three groups for the study period of 21 weeks. Each group received five acupuncture treatment sessions. The standard acupuncture point group ( n=10) received treatment at traditional acupuncture points for knee pain; the trigger point acupuncture group ( n=10) received treatment at trigger points; and the third group ( n=10) received sham acupuncture treatment at the trigger points. Outcome measures were pain intensity (visual analogue scale, VAS) and WOMAC index (Western Ontario and McMaster Universities Arthritis Index). The groups were compared by the area under the curve method.

Results

Five patients dropped out of the study because of lack of improvement, and one patient (in the trigger point acupuncture group) dropped out because of deterioration of symptoms; the remaining 24 patients were included in the analysis. After treatment, the trigger point acupuncture group reported less pain intensity on VAS than the standard acupuncture or sham treatment group, but both the trigger point acupuncture and standard acupuncture groups reported improvement of function of knee. There was a significant reduction in pain intensity between pre-treatment and five weeks after treatment for the trigger point acupuncture (P<0.01) and standard acupuncture groups (P<0.01) included in the analysis, but not for the sham treatment group. Group comparison using the area under the curves demonstrated a significant difference only between trigger point acupuncture and sham treatment groups analysed (P<0.025 for VAS, and P<0.031 for WOMAC).

Conclusion

These results suggest that trigger point acupuncture therapy may be more effective for osteoarthritis of the knee in some elderly patients than standard acupuncture therapy.

The Association Between Musculoskeletal Symptoms and Traditional Chinese Medicine Use Among Chinese Older Adults in the Greater Chicago Area

Older adults disproportionately experience musculoskeletal symptoms, which are associated with morbidity and mortality. Traditional Chinese medicine (TCM) is an important part of Chinese culture and for millennia have been used to maintain health. This article aims to examine the association between musculoskeletal symptoms and different subtypes of TCM usage. Data were collected through the Population Study of Chinese Elderly in Chicago (PINE) study, a community-engaged, epidemiological study of a U.S. Chinese population. Review of systems was used to measure musculoskeletal symptoms. TCM use was measured by using a 5-point scale. Logistic regression analyses were conducted to control for potential confounding factors. Of 3,157 Chinese, older adults aged 60 and older, the mean age was 72.8 (SD = 8.3) and 58.9% were female. Older adults with any musculoskeletal symptoms had greater utilization of overall TCM use (odds ratio [OR] = 2.10, 95% confidence interval [CI] = [1.76, 2.52]), especially massage therapy (OR = 3.41, 95% CI = [2.51, 4.63]), herbal (OR = 2.68, 95% CI = [2.28, 3.14]), and acupuncture (OR = 2.49, 95% CI = [1.87, 3.32]). However, there was no statistically significant association between the presence of musculoskeletal symptoms and Tai-Chi (OR = 1.18, 95% CI = [0.93, 1.50]). This study demonstrated that musculoskeletal symptoms among Chinese older adults were strongly associated with the use of TCM. Future research is needed to examine the effectiveness of TCM in treating musculoskeletal symptoms.

Risk factors associated with nonsteroidal anti-inflammatory drugs (NSAIDs)-induced gastrointestinal bleeding resulting on people over 60 years old in Beijing

Gastrointestinal (GI) bleeding is an unwanted side effect common to all chemical types of nonsteroidal anti-inflammatory drugs (NSAIDs), particularly in elderly people. However, the risk factors of GI bleeding associated with NSAIDs for elderly people remain unknown. This study aims to evaluate the risks of GI bleeding associated with NSAIDs in 4728 elderly people over 60 years old based on database from a hospital in Beijing.This retrospective hospital-based study included 4728 patients over 60 years old prescribed with NSAIDs, of which 928 patients had GI bleeding and 3800 did not have. Odds ratios (OR) for the risk of GI bleeding associated with NSAIDs were determined by logistic regression analysis. Mean Decrease Gini (MDG) involved in random forest algorithm was used to rank the associated factors with GI bleeding.In multivariate analysis, family history of GI bleeding (OR, 3.348; P = .000), history of peptic ulcers (OR, 4.068; P = .000), history of cardiovascular and cerebrovascular disease (OR, 1.476; P = .001), diabetes mellitus (OR, 1.408; P = .000), antiplatelet drugs (OR, 3.106; P = .000), Helicobacter pylori infection (OR, 1.312; P = .001), cholesterol level (OR, 0.516; P = .000), upper abdominal discomfort (OR, 3.467; P = .000), anorexia (OR, 2.038; P = .000), and NSAIDs used for 0.5 to 3 months (OR, 0.780; P = .000) were associated with GI bleeding. After ranked the MDG of each factor, the top 5 ranked factors associated with GI bleeding were melena, hematemesis, antiplatelet drugs, cholesterol level, and upper abdominal discomfort.We found that family history of GI bleeding, history of peptic ulcers, history of cardiovascular and cerebrovascular disease, diabetes mellitus, antiplatelet drugs, Helicobacter pylori infection, hypocholesterolemia, and NSAIDs used for 0.5 to 3 months were independent risk factors for GI bleeding on people over 60 years old. Meanwhile, upper abdominal discomfort might be the predictor of GI bleeding associated with NSAIDs elderly users.

Cost-effectiveness of generic celecoxib in knee osteoarthritis for average-risk patients: a model-based evaluation

OBJECTIVE

The cost-effectiveness of the recently-introduced generic celecoxib in knee OA has not been examined.

METHOD

We used the Osteoarthritis Policy (OAPol) Model, a validated computer simulation of knee OA, to evaluate long-term clinical outcomes, costs, and cost-effectiveness of generic celecoxib in persons with knee OA. We examined eight treatment strategies consisting of generic celecoxib, over-the-counter (OTC) naproxen, or prescription naproxen, with or without prescription or OTC proton-pump-inhibitors (PPIs) to reduce gastrointestinal (GI) toxicity. In the base case, we assumed that annual cost was $130 for OTC naproxen, $360 for prescription naproxen, and $880 for generic celecoxib. We considered a willingness-to-pay threshold of $100,000 per quality-adjusted life year (QALY) and discounted costs and benefits at 3% annually. In sensitivity analyses we varied celecoxib toxicity, discontinuation, cost, and pain level.

RESULTS

In the base case analysis of the high pain cohort (WOMAC 50), celecoxib had an incremental cost-effectiveness ratio (ICER) of $284,630/QALY compared with OTC naproxen. Only under highly favorable cost, toxicity, and discontinuation assumptions (e.g., annual cost below $360, combined with a reduction in the cardiovascular (CV) event rates below baseline values) was celecoxib likely to be cost-effective. Celecoxib might also be cost-effective at an annual cost of $600 if CV toxicity were eliminated completely. In subjects with moderate pain (WOMAC 30), at the base case CV event rate of 0.2%, generic celecoxib was only cost-effective at the lowest plausible cost ($190).

CONCLUSION

In knee OA patients with no comorbidities, generic celecoxib is not cost-effective at its current price.

Caregivers' knowledge and acceptance of complementary and alternative medicine in a tertiary care pediatric hospital

Background

The use of complementary and alternative medicine (CAM) therapies has increased in children, especially in those with chronic health conditions. However, this increase may not translate into acceptance of CAM in the perioperative setting. We surveyed caregivers of patients undergoing surgery to determine their knowledge and acceptance of hypnotherapy, acupuncture, and music therapy as alternatives to standard medication in the perioperative period.

Materials and methods

An anonymous, 12-question survey was administered to caregivers of children undergoing procedures under general anesthesia. Caregivers reported their knowledge about hypnotherapy, music therapy, and acupuncture and interest in one of these methods during the perioperative period. CAM acceptance was defined as interest in one or more CAM methods.

Results

Data from 164 caregivers were analyzed. The majority of caregivers were 20-40 years of age (68%) and mothers of the patient (82%). Caregivers were most familiar with acupuncture (70%), followed by music therapy (60%) and hypnotherapy (38%). Overall CAM acceptance was 51%. The acceptance of specific CAM modalities was highest for music therapy (50%), followed by hypnotherapy (17%) and acupuncture (13%). In multivariable logistic regression, familiarity with music therapy was associated with greater odds of CAM acceptance (odds ratio=3.36; 95% CI: 1.46, 7.74; P=0.004).

Conclusion

Overall CAM acceptance among caregivers of children undergoing surgery was 51%, with music therapy being the most accepted CAM method. Familiarity with music therapy was the only factor that was independently associated with accepting CAM in the perioperative period. The low acceptance for acupuncture and hypnosis in the perioperative situation may be related to insufficient parental knowledge and information.

A Traditional Herbal Formula Xianlinggubao for Pain Control and Function Improvement in Patients with Knee and Hand Osteoarthritis: A Multicenter, Randomized, Open-Label, Controlled Trial

Evidence of efficacy of a traditional herbal formula Xianlinggubao (XLGB) for treatment of osteoarthritis (OA) is limited. The present study was designed to evaluate the efficacy of XLGB in the management of patients with knee and hand OA. This was a multicenter, stratified, open-label, randomized controlled trial conducted at six centers in China. People aged 40 or above, diagnosed with OA of the knee or hand, were randomly assigned to the XLGB treatment group or watchful waiting control group. Main outcome measures were the changes in the numeric pain rating scales (NPRS) and the Western Ontario and McMaster Universities Arthritis Index (WOMAC) or the Australian/Canadian Osteoarthritis Hand Index (AUSCAN) scores, from baseline to 6 months. In total 534 patients (272 to XLGB and 262 to control group) received interventions. Participants in the XLGB group exhibited significant improvement in NPRS (P < 0.001) and WOMAC score (P < 0.001) or AUSCAN score (P < 0.001) compared to control group. Treatment with XLGB at current regime significantly reduced pain and improved function of the knee and hand in patients with OA over a 6-month period, implying that XLGB could be suggested as an alternative treatment for patients with knee or hand OA.

A model for the optimization of anti-inflammatory treatment with chemerin

Routine treatment of mild to moderate pain with a combination of non-steroidal anti-inflammatory drugs such as paracetamol in combination with corticoid opioids can lead to severe complications including death from gastrointestinal injury or to drug dependence. There is a need for the development of new safer drugs. Chemerin is a mediator promoting resolution of inflammation and it is then a promising candidate for a new treatment. A pilot experimental work using the zymosan-induced peritonitis model has found that injecting extra chemerin resulted in an approximately 1% reduction in the total number of inflammatory cells recruited. This paper combines and adapts existing mathematical models of inflammation to reproduce these results and to explore the therapeutic potential of chemerin through simulations. Analysis of the model predicts that the injection of chemerin at a concentration of 2000 ng ml^-1 within the first 5 min of inflammation onset leads to maximal inflammation inhibition. The degree of inhibition is shown to be sensitive to data used for the fit with a mean inhibition of 22 ± 3.7% for a series of remove-one bootstrap tests, whereas optimal chemerin injection parameters were not. Overall sensitivity analysis identifies parameters of the model that need to be measured more accurately or with increased sampling rate to improve model robustness and confirm chemerin's therapeutic potential.

Updated systematic review and meta-analysis of acupuncture for chronic knee pain

OBJECTIVE

To assess the effectiveness and safety of acupuncture for the treatment of chronic knee pain (CKP).

METHODS

We searched the MEDLINE, EMBASE, Cochrane CENTERAL, CINAHL and four Chinese medical databases from their inception to June 2017. We included randomised controlled trials of acupuncture as the sole treatment or as an adjunctive treatment for CKP. The primary outcome was pain intensity measured by visual analogue scale (VAS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain subscale and 11-point numeric rating scale. Secondary outcome measurements included the 36-Item Short Form Health Survey and adverse events. The quality of all included studies was evaluated using the Cochrane risk-of-bias criteria and the STRICTA (Standards for Reporting Interventions in Controlled Trials of Acupuncture) checklist.

RESULTS

Nineteen trials were included in this systematic review. Of these, data from 17 studies were available for analysis. Regarding the effectiveness of acupuncture alone or combined with other treatment, the results of the meta-analysis showed that acupuncture was associated with significantly reduced CKP at 12 weeks on WOMAC pain subscale (mean difference (MD) -1.12, 95% confidence interval (CI) -1.98 to -0.26, I²=62%, 3 trials, 608 participants) and VAS (MD -10.56, 95% CI -17.69 to -3.44, I²=0%, 2 trials, 145 patients). As for safety, no difference was found between the acupuncture and control groups (risk ratio 1.08, 95% CI 0.54 to 2.17, I²=29%).

CONCLUSION

From this systematic review, we conclude that acupuncture may be effective at relieving CKP 12 weeks after acupuncture administration, based on the current evidence and our protocol. However, given the heterogeneity and methodological limitations of the included trials, we are currently unable to draw any strong conclusions regarding the effectiveness of acupuncture for chronic knee pain. In addition, we found that acupuncture appears to have a satisfactory safety profile, although further studies with larger numbers of participants are needed to confirm the safety of this technique.

STRENGTHS

Systematic review without language restrictions.

LIMITATIONS

Only a few high-quality and consistent trials could be included in this review.

Clinical evaluation of Vatari guggulu, Maharasnadi kwatha and Narayan taila in the management of osteoarthritis knee

BACKGROUND

In present era, pharmacological, bio-chemical and surgical interventions are not success remedy for Osteoarthritis (OA). Ayurveda and other complementary medicine have medication for OA.

OBJECTIVES

The main aim of the study was to assess the efficacy and safety of therapeutic combination of Vatari guggulu along with Maharasnadi kwatha and Narayan taila with gentle massage for 15 min daily up to 12 weeks on affected knee joint pain assessed on Visual analogue scale (VAS) and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC).

MATERIALS AND METHODS

It was an open label, multicentre, prospective, clinical study conducted on 142 patients of OA Knee. Vatari guggulu 500 mg thrice in a day along with Maharasnadi kwatha 20 ml with equal amount of water twice daily and Narayan taila 20 ml twice in a day for external application with gentle massage for 15 min up to 12 weeks were used to all the study participants.

RESULTS

VAS, WOMAC score and clinical symptoms were reduced significantly from baseline to end of the treatment (P < 0.001).

CONCLUSIONS

The study provides good evidence in support of the efficacy and safety of the Vatari guggulu along with Maharasnadi kwatha and Narayan taila in the management of Osteoarthritis knee.

The U.K. NICE 2014 Guidelines for Osteoarthritis of the Knee: Lessons Learned in a Narrative Review Addressing Inadvertent Limitations and Bias

Several systematic reviews suggest that acupuncture is effective for knee osteoarthritis (OA), and furthermore a safe and cost-effective treatment for this condition. A recent clinical practice guideline (CPG) from the National Institute for Health and Care Excellence (NICE), in the United Kingdom, recommended against the use of acupuncture on the grounds that the effect size (ES) in comparison with sham acupuncture is too small. Safety data were not considered in the review, in addition the levels of evidence for acupuncture against other recommended therapies were not compared. Consequently, it is argued that this NICE guideline has limitations that lead to several potential biases in its evaluation of acupuncture, which were not addressed correctly: (1) NICE's prior scoping process limited its review. (2) NICE introduced the method of developing recommendations based on the consideration of which interventions make "minimal important differences" of an ES of 0.5 or greater, rather than the statistical significance of the effect of an intervention when compared with an appropriate comparison. (3) Evidence that sham acupuncture is not physiologically inert and has some level of beneficial effect, hence artificially reducing the magnitude of the ES in comparison with sham. (4) The low adverse effects profile of acupuncture. (5) Evidence from trials comparing acupuncture with usual or standard care was not considered, nor was cost-effectiveness data. (6) Lack of the usual CPG "head-to-head" comparisons between interventions. If the same criteria and methods that have been applied to acupuncture were applied to other NICE-recommended therapies for knee OA, including patient centeredness, patient education, self-management and weight loss, nonsteroidal anti-inflammatory drug (NSAIDs), and cyclooxygenase-2 inhibitor (COX-2 inhibitors), these too would no longer be recommended and opiates would become the first line of drug prescription. Given the problems with sham acupuncture, perhaps now is the time to embrace pragmatic studies and employ comparative effectiveness studies instead.

Efficacy and safety of aceclofenac in osteoarthritis: A meta-analysis of randomized controlled trials

OBJECTIVE

To analyze the effects on pain, function, and safety of aceclofenac compared with other nonsteroidal anti-inflammatory drugs (NSAIDs) or pain relief medications in patients with osteoarthritis.

MATERIAL AND METHODS

Two investigators independently searched the database. We included randomized controlled trials evaluating efficacy and/or safety of aceclofenac compared with control interventions (NSAIDs or acetaminophen) in patients with osteoarthritis. We did not include placebo, opioid analgesics, NSAID combinations, and topical analgesics for the control groups. We summarized the efficacy data as standardized mean differences (SMD) with 95% confidence intervals (CI) and safety outcomes as risk ratios (RR) with 95% CI using the inverse variance random effect model. We assessed the heterogeneity by the I² test. We used the GRADE approach to evaluate the quality of the evidence for all outcome parameters.

RESULTS

We included 9 trials (8 double blind and 1 single blind) that evaluated pain (7 trials), function (8 trials) and safety (7 trials). We observed no significant difference in pain reduction between aceclofenac and control interventions [SMD: -0.30 (-0.62, 0.01); I²=88%; GRADE evidence- low]. Aceclofenac was more beneficial than control interventions in improving physical function [SMD: -0.27 (-0.50, -0.03); I²=88%; GRADE evidence- low]. We observed less gastrointestinal adverse events for aceclofenac than in control interventions [RR 0.69 (95% CI: 0.57, 0.83); I²=12%; GRADE evidence- moderate]. We observed no difference in overall adverse events occurrence and dropout rate between aceclofenac and control interventions.

CONCLUSION

We observed that aceclofenac was beneficial over control analgesics for function improvement and to minimize gastrointestinal adverse events. Our findings could be biased due to the heterogeneity of the sample, the fact that the trials were small and methodological issues.

Acupuncture for chronic pain and depression in primary care: a programme of research

Background

There has been an increase in the utilisation of acupuncture in recent years, yet the evidence base is insufficiently well established to be certain about its clinical effectiveness and cost-effectiveness. Addressing the questions related to the evidence base will reduce uncertainty and help policy- and decision-makers with regard to whether or not wider access is appropriate and provides value for money.

Aim

Our aim was to establish the most reliable evidence on the clinical effectiveness and cost-effectiveness of acupuncture for chronic pain by drawing on relevant evidence, including recent high-quality trials, and to develop fresh evidence on acupuncture for depression. To extend the evidence base we synthesised the results of published trials using robust systematic review methodology and conducted a randomised controlled trial (RCT) of acupuncture for depression.

Methods and results

We synthesised the evidence from high-quality trials of acupuncture for chronic pain, consisting of musculoskeletal pain related to the neck and low back, osteoarthritis of the knee, and headache and migraine, involving nearly 18,000 patients. In an individual patient data (IPD) pairwise meta-analysis, acupuncture was significantly better than both sham acupuncture (p < 0.001) and usual care (p < 0.001) for all conditions. Using network meta-analyses, we compared acupuncture with other physical therapies for osteoarthritis of the knee. In both an analysis of all available evidence and an analysis of a subset of better-quality trials, using aggregate-level data, we found acupuncture to be one of the more effective therapies. We developed new Bayesian methods for analysing multiple individual patient-level data sets to evaluate heterogeneous continuous outcomes. An accompanying cost-effectiveness analysis found transcutaneous electrical nerve stimulation (TENS) to be cost-effective for osteoarthritis at a threshold of £20,000 per quality-adjusted life-year when all trials were synthesised. When the analysis was restricted to trials of higher quality with adequate allocation concealment, acupuncture was cost-effective. In a RCT of acupuncture or counselling compared with usual care for depression, in which half the patients were also experiencing comorbid pain, we found acupuncture and counselling to be clinically effective and acupuncture to be cost-effective. For patients in whom acupuncture is inappropriate or unavailable, counselling is cost-effective.

Conclusion

We have provided the most robust evidence from high-quality trials on acupuncture for chronic pain. The synthesis of high-quality IPD found that acupuncture was more effective than both usual care and sham acupuncture. Acupuncture is one of the more clinically effective physical therapies for osteoarthritis and is also cost-effective if only high-quality trials are analysed. When all trials are analysed, TENS is cost-effective. Promising clinical and economic evidence on acupuncture for depression needs to be extended to other contexts and settings. For the conditions we have investigated, the drawing together of evidence on acupuncture from this programme of research has substantially reduced levels of uncertainty. We have identified directions for further research. Our research also provides a valuable basis for considering the potential role of acupuncture as a referral option in health care and enabling providers and policy-makers to make decisions based on robust sources of evidence.

Trial registration

Current Controlled Trials ISRCTN63787732.

Funding

The National Institute for Health Research Programme Grants for Applied Research programme.

[DGRh recommendations for the implementation of current security aspects in the NSAID treatment of musculoskeletal pain]

NSAIDs exert their anti-inflammatory and analgesic effects by inhibition of COX‑2, a key enzyme for proinflammatory prostanoid synthesis. Therapy with NSAIDs is limited by their typical gastrointestinal, cardiovascular and renal side effects, which are caused by inhibition of COX‑1 (gastrointestinal toxicity), COX‑2 (cardiovascular side effects) or both COX-isoenzymes (renal side effects). Appropriate prevention strategies should be employed in patients at risk. If gastrointestinal risk factors are present, co-administration of a proton pump inhibitor or misoprostol is recommended; in patients with cardiovascular risk, coxibs, diclofenac and high-dose ibuprofen should be avoided. Furthermore, drug interactions and contraindications should be considered. In patients with renal impairment (GFR < 30 ml/min) all NSAIDs must be avoided. Ulcer anamnesis is a contraindication for traditional NSAIDs. Preexisting cardio- or cerebrovascular diseases are contraindications for coxibs. Treatment decisions should be individually based with a continuous monitoring of the risk - benefit ratio and exploitation of non-pharmacological treatment options.

GI Risk Factors and Use of GI Protective Agents Among Patients Receiving Nonsteroidal Antiinflammatory Drugs

Background:

Patient characteristics increase the risk of gastrointestinal (GI) complications associated with nonsteroidal antiinflammatory drugs (NSAIDs). Patients at risk may not be prescribed protective therapies that might mitigate their risk of NSAID-associated GI complications.

Objective:

To assess GI risk among Veterans Affairs (VA) patients on NSAID therapy, determine whether therapy conformed to VA guidelines for lessening the risk of GI complications, and identify patient risk factors associated with conformance.

Methods:

Using databases from 3 VA medical centers, we retrospectively identified patients receiving NSAIDs and obtained data regarding age, history of GI bleed over 8 years, GI adverse effects associated with NSAIDs, diagnoses, and medication history over one year. We inferred health status from age-adjusted Charlson comorbidity index values. Each patient's risk of developing GI complications over one year was calculated using these data. Among patients at significant or substantial risk, we assessed conformance to VA guidelines. We used logistic regression to identify risk factors associated with conformance and determine adjusted ORs (AORs) with 95% CIs for each risk factor.

Results:

There were 19122 patients receiving NSAIDs. Of 4589 patients at significant risk and 1246 at substantial risk, 1161 (25.3%) and 356 (28.6%), respectively, were prescribed guideline-conformant therapy. Risk factors associated with conformance (p s 0.001) among patients at significant risk were rheumatoid arthritis (AOR 1.34; 95% CI 1.13 to 1.58) and GI adverse effects (AOR 1.53; 95% CI 1.42 to 1.64). For substantial risk patients, risk factors associated with conformance (p s 0.031) were rheumatoid arthritis (AOR 1.65; 95% CI 1.37 to 1.98), concomitant corticosteroids (AOR 1.21; 95% CI 1.02 to 1.43), GI hospitalization (AOR 2.01; 95% CI 1.57 to 2.59), and GI adverse effects (AOR 1.79; 95% CI 1.47 to 2.18).

Conclusions:

Many patients at risk for GI adverse events do not receive guideline-conformant therapy. Educational interventions to improve conformance could focus on specific risk factors for GI complications.

Implications of analgesics use in osteoporotic-related pain treatment: focus on opioids

Bone loss is asymptomatic and will progress without pain and other symptoms until the occurrence of a fracture. The occurrence of a breaking bone induce acute pain determined and supported by a mechanical, inflammatory and neuropathic component. Very often the acute component evolves in a chronic musculoskeletal component. Overall objectives of the analgesic therapy can be summarized in pain relief, improving sleep, improve mobility, reduce anxiety, emotional component and depression. Osteoporosis is predominantly a condition of the elderly, more likely to have coexisting cardiovascular disease and age-related decline in renal function, receiving treatment for one or more comorbid conditions, taking multiple medications. Analgesic treatment with NSAIDs has negative effects on skeletal health and healing of the injured skeleton and increase risk of adverse events especially in older patients. Despite all opioids therapy represents a mainstay in the treatment of patients with moderate to severe pain, it can induce an endocrinopathy, which may affect bone metabolism. The negative effects of opioids on hormonal axis are not the same for all molecule and the choice of drug can be crucial in the treatment of patients with chronic pain.

A background to acupuncture and its use in chronic painful musculoskeletal conditions

This article gives a brief description of the origins of acupuncture and describes some of the underlying philosophy behind this treatment and attempts to place it in context of the traditional Chinese medicine genre within which acupuncture is set. The article then explains the difference between traditional and Western style acupuncture and explains how point selection is made. The use of acupuncture is steadily increasing for a variety of reasons, it is a very safe intervention particularly when compared to conventional treatment and its lack of serious side effects might in part account for some of its popularity. The science behind acupuncture is also explored in terms of its underlying mechanisms and includes pain gate, endogenous opioids, diffuse noxious inhibitory control, serotonin and bioelectricity as possible explanations. The efficacy of acupuncture for a range of chronic musculoskeletal conditions is then explored and it is concluded that acupuncture has a place in the treatment of chronic musculoskeletal pain and in particular osteo-arthritis (OA). Where degenerative conditions are involved, acupuncture clearly cannot provide a ‘cure’ but can provide symptomatic relief, often over a prolonged period.

Knowledge and Use of, and Attitudes toward, Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) in Practice: A Survey of Ontario Physiotherapists

Purpose: To investigate Ontario physiotherapists' knowledge and use of, and attitudes toward, non-steroidal anti-inflammatory drugs (NSAIDs) to identify whether there is a need for physiotherapists to receive education specific to NSAIDs. Method: An existing survey instrument was modified and tested by five Ontario physiotherapists. The final version was distributed electronically to approximately 4,400 Ontario Physiotherapy Association members as a self-administered online questionnaire. Results: A total of 294 physiotherapists responded to the survey (response rate=6.7%). Respondents demonstrated variability in their knowledge of NSAID contraindications, side effects, and drug interactions. Most respondents (62.6%) were incorrect or unsure about where and how to obtain most NSAIDs, and most demonstrated incorrect or uncertain knowledge of the relevant legislation. Despite this lack of knowledge, 50% of respondents recommend NSAIDs to their patients. Conclusions: Many Ontario physiotherapists who participated in this survey recommend NSAIDs to their patients despite having a variable understanding of the legislation and medication-related factors. A lack of thorough knowledge of risks and contraindications has implications for patient safety. Physiotherapists who incorporate medications into their practice should access comprehensive information on appropriate NSAID use and should inform themselves about legislative restrictions to ensure that associated treatment is provided in a manner that is evidence based, safe, and in keeping with regulatory boundaries.

A randomized, double blind placebo controlled study of efficacy and tolerability of Withaina somnifera extracts in knee joint pain

BACKGROUND

Root extracts of Withania somnifera (Ashwagandha) are known to possess analgesic, anti-inflammatory and chondroprotective effects. An aqueous extract of roots plus leaves of this plant has shown to yield higher percentages of withanolide glycosides and, accordingly, may possess better analgesic, anti-inflammatory and chondroprotective effects than root alone extracts.

OBJECTIVES

To evaluate efficacy and tolerability of a standardized aqueous extract of roots plus leaves of W. somnifera in patients with knee joint pain and discomfort.

MATERIAL AND METHODS

Sixty patients with knee joint pain and discomfort were randomized in a double-blind manner to W. somnifera 250 mg, W. somnifera 125 mg and placebo, all given twice daily. Assessment was done by Modified WOMAC, Knee Swelling Index (KSI), Visual Analogue Scale (VAS) at baseline and at the end of 4, 8, 12 weeks. Tolerability was assessed by incidence of adverse effects in treatment groups. Student's 't' test and ANOVA were used to compare mean change from baseline within and between the study groups. A p < 0.05 was considered significant.

RESULTS

At the end of 12 weeks, compared to baseline and placebo, significant reductions were observed in mean mWOMAC and KSI in W. somnifera 250 mg (p < 0.001), W. somnifera 125 mg (p < 0.05) groups. VAS scores for pain, stiffness and disability were significantly reduced in W. somnifera 250 mg (p < 0.001), W. somnifera 125 mg (p < 0.01) groups. W. somnifera 250 mg group showed earliest efficacy (at 4 weeks). All treatments were well tolerated.

CONCLUSIONS

Both the doses of an aqueous extract of W. somnifera produced significant reduction in outcome variables, with the 250 mg group showing significantly better response. In addition, the therapeutic response appears to be dose-dependent and free of any significant GI disturbances.

The role of aspirin in colorectal cancer chemoprevention

Considerable interest has emerged over the last decade regarding the role of aspirin in prevention of colorectal cancer. This disease is one of the commonest cancers in the Western World, therefore, the existence of a simple "everyday" agent, which could have the ability to prevent the disease, represents an invaluable opportunity clinicians may be able to exploit. Evidence from case-control and cohort studies, and recent updates of randomised controlled trials have been very encouraging-indicating benefit from long term use of aspirin at low dose. Possible mechanisms of chemoprevention include inhibition of the cyclooxygenase (COX) pathway, or COX-independent mechanisms, for example, the PIK3CA pathway, or therapy-induced senescence of cancer cells. The most serious side effect of prolonged aspirin treatment is haemorrhage, especially from the GI tract. This is likely to be less of a problem with chemoprevention at lower doses. One also needs to consider the impact if aspirin resistance, an increasingly recognised clinical entity.

Patient safety incidents associated with failures in communication reported from critical care units in the North West of England between 2009 and 2014

Communication is central to the safe and effective delivery of critical care. We present a retrospective analysis of hospital incident reports attributed to communication that were generated by 30 intensive care units in the North West of England from 2009 to 2014. We reviewed when during the critical care pathway incidents occur, the personnel involved, the method of communication used, the type of information communicated and the level of harm associated with the incident. We found that patient safety incidents tend to occur when patients are transferred into or out of the intensive care unit and when information has to be communicated to other teams during the critical care stay. We then examine ways that the patient handover process may be modified to improve communication and safety.

Efficacy of Acupuncture versus Combined Oral Contraceptive Pill in Treatment of Moderate-to-Severe Dysmenorrhea: A Randomized Controlled Trial

This open-label randomized controlled trial was designed to compare the efficacy of acupuncture and combined oral contraceptive (COC) pill in treating moderate-to-severe primary dysmenorrhea. Fifty-two participants were randomly assigned to receive either acupuncture (n = 27) or COC (n = 25) for three menstrual cycles. Mefenamic acid was prescribed as a recue analgesic drug with both groups. The statistical approach used for efficacy and safety assessments was intention-to-treat analysis. By the end of the study, both treatments had resulted in significant improvement over baselines in all outcomes, that is, maximal dysmenorrhea pain scores, days suffering from dysmenorrhea, amount of rescue analgesic used, and quality of life assessed by SF-36 questionnaire. Over the three treatment cycles, COC caused greater reduction in maximal pain scores than acupuncture, while improvements in the remaining outcomes were comparable. Responders were defined as participants whose maximal dysmenorrhea pain scores decreased at least 33% below their baseline. Response rates following both interventions at the end of the study were not statistically different. Acupuncture commonly caused minimal local side effects but did not cause any hormone-related side effects as did COC. In conclusion, acupuncture is an alternative option for relieving dysmenorrhea, especially when COC is not a favorable choice.

An analysis of the relative frequencies of reported adverse events associated with NSAID administration in dogs and cats in the United Kingdom

This study aimed to analyse UK pharmacovigilance data to quantify adverse events (AEs) associated with the non-steroidal anti-inflammatory drug (NSAID) molecules found in veterinary medicines authorised for use in dogs and cats. It was hypothesised that the frequency of AEs would be lower when associated with cyclo-oxygenase-2 selective (coxib), compared to non-selective (non-coxib) NSAIDs. The UK Veterinary Medicines Directorate (VMD) supplied frequencies of AEs derived from Periodic Safety Update Reports subdivided by formulation and species for each NSAID molecule. Frequencies of AEs were similar between species. The five most reported AEs were emesis, death, anorexia, lethargy, and diarrhoea. Reported frequency of emesis, renal insufficiency and death was higher with injectable compared to oral NSAIDs (P = 0.043). Reported frequency of emesis, lethargy and death was higher with coxib, compared to non-coxib NSAIDs (P = 0.029). Median (range) interval since authorisation was shorter for coxibs at 5 (2.5-9) years compared to non-coxibs at 15 (12-25) years. A negative correlation between time elapsed since authorisation and the frequency of AEs was identified (rs = -0.11 to -0.94). Higher frequency of reported AEs with injectable NSAIDs may be related to perioperative administration. The AE frequency associated with coxib and non-coxib NSAIDs may be confounded by changes in reporting habits over time. This study highlights the value of interrogating passive surveillance data to identify low frequency AEs and the need to facilitate improvement in recording and collecting AEs in small animal practice.

Frequencies and prescription patterns of traditional Chinese medicine use among elderly patients in Taiwan: A population-based study

ETHNOPHARMACOLOGICAL RELEVANCE

Traditional Chinese medicine (TCM), one of the most commonly used complementary and alternative medicines, has been receiving increasing attention among elderly patients. However, epidemiological reports and prescription patterns of geriatric TCM users are few. The aim of this study is to use data from a nationwide cohort database to analyze TCM use by the geriatric population in Taiwan from 2005 to 2009.

MATERIALS AND METHODS

TCM outpatient claims data was obtained from the Taiwan National Health Insurance database. Data for elderly patients aged 65 years and older were included in the analysis during the study period. The demographic data, disease distributions, and frequencies and prescription patterns of TCM use by the geriatric population were analyzed.

RESULTS

The geriatric cohort included 97,210 patients, in which 46,883 patients (48%) had used TCM at least once, with a total of 723,478 TCM outpatient visits. Of these, 175,857 visits (24.3%) were prompted by "diseases of the musculoskeletal system and connective tissue"; more than half of patients with such diseases were treated using acupuncture and traumatology manipulative therapies. Overall, among the 552,835 visits during which Chinese herbal products (CHP) were prescribed, Shu-Jing-Huo-Xie-Tang and Dan Shen (Radix Salvia Miltiorrhizae) were the most frequently prescribed herbal formula and single herb, respectively, for elderly patients. In addition, Shu-Jing-Huo-Xie-Tang was also the most prescribed herbal formula for the most common disease categories of "diseases of the musculoskeletal system and connective tissue" among TCM elderly patients, followed by Du-Huo-Ji-Sheng-Tang, and Shao-Yao-Gan-Cao-Tang.

CONCLUSION

This study elucidated the TCM utilization patterns of the geriatric population. However, additional studies are warranted to determine the safety and efficacy of these CHPs for use by elderly patients in further clinical trials.

Effect of Polycalcium, a mixture of Polycan and calcium lactate-gluconate in a 1:9 weight ratio, on rats with surgery-induced osteoarthritis

In the present study, the beneficial and synergistic effects of Polycalcium, a mixture of Polycan and calcium (Ca) lactate-gluconate in a 1:9 weight ratio, on a rat model of osteoarthritis (OA) were explored. Polycalcium (50, 100 and 200 mg/kg) was administered orally once per day for 28 days from 1 week after the OA-modeling surgery. Diclofenac sodium (2 mg/kg) was administered as a reference drug. Following the OA surgery, increases in the maximum extension angles, edematous changes in knee and capsule thickness, reductions in chondrocyte proliferation and cartilage glycosaminoglycan (GAG) levels, as well as changes in cartilage degeneration were observed. However, these OA-related symptoms were inhibited after 28 days of continuous oral treatment with Polycalcium. Anti-OA effects, including the induction of chondrocyte proliferation, were detected in the Polycalcium-treated rats and were more favorable compared with those in rats treated with Polycan or Ca lactate-gluconate alone (100 mg). Therefore, a mixture of Polycan and Ca lactate-gluconate was demonstrated to have beneficial synergistic effects on OA.