Osteoarthritis year in review 2016: clinical

Both epidemiologic and clinical research continues to be performed in osteoarthritis (OA). While epidemiologic studies identify risk factors for incident and progressive disease, clinical studies explore the role of both non-pharmacologic and pharmacologic treatments, including oral and intra-articular therapies. We performed a systematic review of the literature using PubMed for the time period between April 1, 2015 to February 22, 2016. Selected publications in the areas of both epidemiology and treatment are reviewed in this article.

Association of hip and pelvic geometry with tibiofemoral osteoarthritis: multicenter osteoarthritis study (MOST)

OBJECTIVE

Lateral tibiofemoral osteoarthritis (OA) is overall less common than medial tibiofemoral OA, but it is more prevalent in women. This may be explained by sex differences in hip and pelvic geometry. The aim of this study is to explore sex differences in hip and pelvic geometry and determine if such parameters are associated with the presence of compartment-specific knee OA.

METHODS

This case-control study reports on 1,328 hips/knees from 664 participants and is an ancillary to the Multicenter Osteoarthritis Study (MOST). Of the 1,328 knees, 219 had lateral OA, 260 medial OA, and 849 no OA. Hip and pelvic measurements were taken from full-limb radiographs on the ipsilateral side of the knee of interest. After adjusting for covariates, means were compared between sexes and also between knees with medial and lateral OA vs no OA using separate regression models.

RESULTS

Women were shown to have a reduced femoral offset (FO) (mean 40.9 mm vs 45.9 mm; P = 0.001) and more valgus neck-shaft angle (mean 128.4° vs 125.9°; P < 0.001) compared to men. Compared to those with no OA, knees with lateral OA were associated with a reduced FO (P = 0.012), increased height of hip centre (HHC) (P = 0.003), more valgus neck-shaft angle (P = 0.042), and increased abductor angle (P = 0.031). Knees with medial OA were associated with a more varus neck-shaft angle (P = 0.043) and a decreased abductor angle (P = 0.003).

CONCLUSION

These data suggest anatomical variations at the hip and pelvis are associated with compartment-specific knee OA and may help to explain sex differences in patterns of knee OA.

Alternative pathways for drainage of cerebrospinal fluid in the canine brain

Although the brain has no formal lymphatic system, a substantial quantity of cerebrospinal fluid (CSF) has nonetheless been shown to drain via cervical lymphatics. To pursue further the issue of alternative drainage pathways for CSF, we infused a solution of Ringer's lactate (RL) into the cisterna magna of the dog brain and monitored both the flow and concentration of total protein of cervical lymph. This maneuver promoted a nearly three-fold rise in intracranial pressure and was accompanied by a rise in cervical lymph flow and fall in its protein content. In addition, a profuse nasal discharge (11.4 ml/hr) developed with a moderately high protein content of the rhinorrhea fluid (1.8 g/dl), along with similar appearance times of Evans blue dye (instilled in the cisterna magna) in both cervical lymph and the rhinorrhea fluid (48-70 minutes after infusion). These findings suggest alternative drainage pathways for CSF besides the arachnoid villi (Pacchionian bodies) including connections with lymphatics in the neck and along the olfactory nerve, and around the cribiform plate to the nasal submucosa, and with proptosis, perhaps also through the aqueous humor-canal of Schlemm and nasolacrimal duct.

The quantitation and fractionation of proteins in cerebrospinal fluid

The quantitation of CSF proteins has important clinical applications. Often the total protein level is quite useful but does not provide sufficient information to differentiate the disease state of the patient. The IgG/albumin index is a parameter frequently used as an indication of IgG production within the central nervous system. Hence, the levels of the albumin and globulin fractions must often be determined. Many methods exist for quantitations of total protein in CSF and the levels of the major protein fractions and for separating the various proteins present into their major protein fractions. For total protein quantitation, the turbidimetric method is common, but the Coomassie brilliant blue method may be the method of the future. For separation and quantitation of protein fractions, electrophoresis or some immunologic method is frequently used. The more sophisticated isoelectric focusing and two-dimensional techniques are limited to use mostly by research laboratories. With further sophistication of techniques for separating proteins and interpretation of the results thereby obtained, the methods which are now limited to research may be adapted by routine laboratories in the future.

Empathy levels of occupational therapy students

Certain levels of empathy are vital to health professionals for understanding their patients. The Level I clinical practicum experienced by Ohio State University juniors did not have the anticipated impact upon their empathy scores, but a group process course, where it was possible to teach and evaluate empathy levels, might have positively affected the empathy levels of students.

Syndrome of inappropriate antidiuretic hormone secretion after spontaneous subarachnoid hemorrhage: a reversible cause of clinical deterioration

The syndrome of inappropriate antidiuretic hormone secretion (SIADH) developed approximately 7 days after a spontaneous subarachnoid hemorrhage in a 63-year-old woman with an anterior cerebral artery aneurysm. The hyponatremia associated with this syndrome resulted in a deterioration of the patient's clinical condition and focal neurological signs, which simulated the clinical deterioration after spontaneous subarachnoid hemorrhage that is often caused by other intracranial pathological conditions. The focal neurological signs in particular are likely to be interpreted as indicating one of these other conditions. Prompt recognition and treatment of the SIADH resulted in prompt improvement, and we were then able to proceed with the planned craniotomy for the aneurysm. The syndrome and its importance are discussed.

Stereotactic localization (with computerized tomographic scanning), biopsy, and radiofrequency treatment of deep brain lesions

In eight patients stereotactic biopsy of deep brain lesions was performed. Adequate tissue was obtained, and the information helped considerably in planning further therapy. No significant complications occurred in these patients. In three of the cases, the stereotactic coordinates were determined from the computerized tomographic (CT) scan. In one patient, after biopsy, stereotactic radiofrequency (RF) lesions in the tumor resulted in temporary improvement.

Effect of spinal cord transection on the endocrine and blood pressure responses to intravenous clonidine

To determine whether the inhibitory effect of clonidine (CLON) on renin secretion is due in part to a direct action on the kidneys or due entirely to an action on the brain, the drug was administered intravenously in a dose of 30 microgram/kg to dogs in which the spinal cord had been transected in the cervical region. Renal perfusion pressure was held constant by adjusting a suprarenal aortic clamp. The decrease in plasma renin activity produced by CLON in dogs with intact spinal cords was abolished, and in 5 of 8 dogs tested, plasma renin activity rose. The decrease in blood pressure seen in control dogs was replaced by a prolonged pressor response. The ACTH response, as measured by plasma corticoids, and the growth hormone (GH) response were not significantly reduced. The data indicate that at least at this dose, the depressor response and the decrease in renin secretion produced by CLON are completely central in origin.

Large basal ganglia cyst in site of previously radiated glioma. Case report

A 3 1/2-year-old boy developed a mass lesion in the right basal ganglia and midbrain, compatible with glioma. During radiation therapy, aqueduct obstruction developed, necessitating a ventriculoatrial (VA) shunt. The child improved and remained well for 6 years, when he developed recurrent symptoms. A computerized tomographic (CT) scan and ventriculogram revealed a large cyst arising from the region of the right basal ganglia, the site of the previous tumor. The VA shunt was converted to a cyst atrial shunt. Subsequently, the cyst decreased in size, but hydrocephalus recurred, as demonstrated by a second CT scan. A Y-tube shunt (one catheter in the cyst, one in the ventricle) has controlled symptoms and signs since that time.

Hydrocephalus secondary to intracranial hemorrhage in premature infants

Premature (low birth weight) infants are particularly susceptible to intracranial hemorrhage. This frequently arises from the subependymal area and may dissect into the brain or into the ventricles. If the infant survives, hydrocephalus is a frequent sequela. Because of major improvements in the care of premature infants in recent years and the proliferation of intensive care nurseries, increasing numbers of low birth weight infants are surviving and developing hydrocephalus. Seven cases are described of infants who developed hydrocephalus following intracranial bleeding. Initially, ventricular and lumbar punctures were done to attempt to control head growth but this was unsuccessful. Two were treated with temporary external ventriculostomy which did not permanently control the hydrocephalus. Definitive treatment included ventriculo-atrial shunts using an expandable 'telescopic' cardiac catheter in two and ventriculoperitoneal shunts in five. The pathogenesis and management of the condition are discussed.

A telescopic ventriculoatrial shunt that elongates with growth. Technical note

✓ A ventriculoatrial (VA) shunt catheter has been developed, based on a double telescopic principle, that elongates during longitudinal growth of the child. It is implanted in patients by a technique similar to that used for other VA shunts, with minor modifications. Radiopaque markers on the expandable portion of the shunt allow radiographic measurement of the “growth” of the shunt. These shunts have been implanted in 18 children with hydrocephalus; in 15 they continue to function, a duration of from 1 to 4 years. In eight this was the initial shunt, while in 10 others the telescopic shunt was implanted at the time of revision of a standard shunt. One additional special model was implanted directly in the auricle by thoracotomy and is functioning over 5 months later. This type of shunt may largely eliminate the need for prophylactic lengthening of VA shunts during growth and prevent the problem of distal shunt obstruction due to growth.