Evaluating Osteoarthritis Management Programs: outcome domain recommendations from the OARSI Joint Effort Initiative

OBJECTIVE

To develop sets of core and optional recommended domains for describing and evaluating Osteoarthritis Management Programs (OAMPs), with a focus on hip and knee Osteoarthritis (OA).

DESIGN

We conducted a 3-round modified Delphi survey involving an international group of researchers, health professionals, health administrators and people with OA. In Round 1, participants ranked the importance of 75 outcome and descriptive domains in five categories: patient impacts, implementation outcomes, and characteristics of the OAMP and its participants and clinicians. Domains ranked as "important" or "essential" by ≥80% of participants were retained, and participants could suggest additional domains. In Round 2, participants rated their level of agreement that each domain was essential for evaluating OAMPs: 0 = strongly disagree to 10 = strongly agree. A domain was retained if ≥80% rated it ≥6. In Round 3, participants rated remaining domains using same scale as in Round 2; a domain was recommended as "core" if ≥80% of participants rated it ≥9 and as "optional" if ≥80% rated it ≥7.

RESULTS

A total of 178 individuals from 26 countries participated; 85 completed all survey rounds. Only one domain, "ability to participate in daily activities", met criteria for a core domain; 25 domains met criteria for an optional recommendation: 8 Patient Impacts, 5 Implementation Outcomes, 5 Participant Characteristics, 3 OAMP Characteristics and 4 Clinician Characteristics.

CONCLUSION

The ability of patients with OA to participate in daily activities should be evaluated in all OAMPs. Teams evaluating OAMPs should consider including domains from the optional recommended set, with representation from all five categories and based on stakeholder priorities in their local context.

Facing the Ethical Challenges: Consumer Involvement in COVID-19 Pandemic Research

Consumer involvement in clinical research is an essential component of a comprehensive response during emergent health challenges. During the COVID-19 pandemic, the moderation of research policies and regulation to facilitate research may raise ethical issues. Meaningful, diverse consumer involvement can help to identify practical approaches to prioritize, design, and conduct rapidly developed clinical research amid current events. Consumer involvement might also elucidate the acceptability of flexible ethics review approaches that aim to protect participants whilst being sensitive to the challenging context in which research is taking place. This article describes the main ethical challenges arising from pandemic research and how involving consumers and the community could enable resolution of such issues.

Including a Student with Multiple Disabilities and Visual Impairment in Her Neighborhood School

This article begins with a literature review of main-streaming students with multiple disabilities and visual impairment in general schools, stressing the importance of opportunities for peer interaction that are prevalent in regular settings. It then describes a program carried out with a 5-year-old student attending her neighborhood school in Auckland, New Zealand. Comments of the people involved in the program, including the principal, the teachers, the teacher's aide, family members, and fellow pupils, are reported, and the success of the program is discussed.

Correction to: Effectiveness of a new model of primary care management on knee pain and function in patients with knee osteoarthritis: Protocol for THE PARTNER STUDY

After the publication of this protocol [1], our collaborator Prima Health solutions advised us of their intent to withdraw from the study.

Effectiveness and response predictors of omalizumab in a severe allergic asthma population with a high prevalence of comorbidities: the Australian Xolair Registry

BACKGROUND

Severe asthma is a high impact disease. Omalizumab targets the allergic inflammatory pathway; however, effectiveness data in a population with significant comorbidities are limited.

AIMS

To describe severe allergic asthma, omalizumab treatment outcomes and predictors of response among the Australian Xolair Registry participants.

METHODS

A web-based post-marketing surveillance registry was established to characterise the use, effectiveness and adverse effects of omalizumab (Xolair) for severe allergic asthma.

RESULTS

Participants (n = 192) (mean age 51 years, 118 female) with severe allergic asthma from 21 clinics in Australia were assessed, and 180 received omalizumab therapy. They had poor asthma control (Asthma Control Questionnaire, ACQ-5, mean score 3.56) and significant quality of life impairment (Asthma-related Quality of Life Questionnaire score 3.57), and 52% were using daily oral corticosteroid (OCS). Overall, 95% had one or more comorbidities (rhinitis 48%, obesity 45%, cardiovascular disease 23%). The omalizumab responder rate, assessed by an improvement of at least 0.5 in ACQ-5, was high at 83%. OCS use was significantly reduced. The response in participants with comorbid obesity and cardiovascular disease was similar to those without these conditions. Baseline ACQ-5 ≥ 2.0 (P = 0.002) and older age (P = 0.05) predicted the magnitude of change in ACQ-5 in response to omalizumab. Drug-related adverse events included anaphylactoid reactions (n = 4), headache (n = 2) and chest pains (n = 1).

CONCLUSION

Australian patients with severe allergic asthma report a high disease burden and have extensive comorbidity. Symptomatic response to omalizumab was high despite significant comorbid disease. Omalizumab is an effective targeted therapy for severe allergic asthma with comorbidity in a real-life setting.

Assessing causality in associations between cannabis use and schizophrenia risk: a two-sample Mendelian randomization study

BACKGROUND

Observational associations between cannabis and schizophrenia are well documented, but ascertaining causation is more challenging. We used Mendelian randomization (MR), utilizing publicly available data as a method for ascertaining causation from observational data.

METHOD

We performed bi-directional two-sample MR using summary-level genome-wide data from the International Cannabis Consortium (ICC) and the Psychiatric Genomics Consortium (PGC2). Single nucleotide polymorphisms (SNPs) associated with cannabis initiation (p < 10-5) and schizophrenia (p < 5 × 10-8) were combined using an inverse-variance-weighted fixed-effects approach. We also used height and education genome-wide association study data, representing negative and positive control analyses.

RESULTS

There was some evidence consistent with a causal effect of cannabis initiation on risk of schizophrenia [odds ratio (OR) 1.04 per doubling odds of cannabis initiation, 95% confidence interval (CI) 1.01-1.07, p = 0.019]. There was strong evidence consistent with a causal effect of schizophrenia risk on likelihood of cannabis initiation (OR 1.10 per doubling of the odds of schizophrenia, 95% CI 1.05-1.14, p = 2.64 × 10-5). Findings were as predicted for the negative control (height: OR 1.00, 95% CI 0.99-1.01, p = 0.90) but weaker than predicted for the positive control (years in education: OR 0.99, 95% CI 0.97-1.00, p = 0.066) analyses.

CONCLUSIONS

Our results provide some that cannabis initiation increases the risk of schizophrenia, although the size of the causal estimate is small. We find stronger evidence that schizophrenia risk predicts cannabis initiation, possibly as genetic instruments for schizophrenia are stronger than for cannabis initiation.

Real-life effectiveness of omalizumab in severe allergic asthma above the recommended dosing range criteria

BACKGROUND

Omalizumab (Xolair) dosing in severe allergic asthma is based on serum IgE and bodyweight. In Australia, patients eligible for omalizumab but exceeding recommended ranges for IgE (30-1500 IU/mL) and bodyweight (30-150 kg) may still receive a ceiling dose of 750 mg/4 weeks. About 62% of patients receiving government-subsidized omalizumab are enrolled in the Australian Xolair Registry (AXR).

OBJECTIVES

To determine whether AXR participants above the recommended dosing ranges benefit from omalizumab and to compare their response to within-range participants.

METHODS

Data were stratified according to dose range status (above-range or within-range). Further sub-analyses were conducted according to the reason for being above the dosing range (IgE only vs. IgE and weight).

RESULTS

Data for 179 participants were analysed. About 55 (31%) were above recommended dosing criteria; other characteristics were similar to within-range participants. Above-range participants had higher baseline IgE [812 (IQR 632, 1747) IU/mL vs. 209 (IQR 134, 306) IU/mL] and received higher doses of omalizumab [750 (IQR 650, 750) mg] compared to within-range participants [450 (IQR, 300, 600) mg]. At 6 months, improvements in Juniper 5-item Asthma Control Questionnaire (ACQ-5, 3.61 down to 2.01 for above-range, 3.47 down to 1.93 for within-range, P < 0.0001 for both) and Asthma Quality of Life Questionnaire (AQLQ mean score (3.22 up to 4.41 for above-range, 3.71 up to 4.88 for within-range, P < 0.0001) were observed in both groups. Forced expiratory volume in one second (FEV₁ ) improved among above-range participants. There was no difference in response between above-range and within-range participants. Above-range participants due to either IgE alone or IgE and weight had similar improvements in ACQ-5, AQLQ and FEV₁ .

CONCLUSIONS AND CLINICAL RELEVANCE

Patients with severe allergic asthma above recommended dosing criteria for omalizumab have significantly improved symptom control, quality of life and lung function to a similar degree to within-range participants, achieved without dose escalation above 750 mg.

Two-year survival following discharge from hospital after spinal cord injury in Bangladesh

STUDY DESIGN

Mixed retrospective-prospective cohort study.

OBJECTIVES

To determine 2-year survival following discharge from hospital after spinal cord injury in Bangladesh.

SETTING

Bangladesh.

METHODS

Medical records were used to identify all patients admitted in 2011 with a recent spinal cord injury to the Centre for Rehabilitation of the Paralysed, a large Bangladeshi hospital that specialises in care of people with spinal cord injury. Patients or their families were subsequently visited or contacted by telephone in 2014. Vital status and, where relevant, date and cause of death were determined by verbal autopsy.

RESULTS

350 of 371 people admitted with a recent spinal cord injury in 2011 were discharged alive from hospital. All but eleven were accounted for two years after discharge (97% follow-up). Two-year survival was 87% (95% CI 83% to 90%). Two-year survival of those who were wheelchair-dependent was 81% (95% CI 76% to 86%). The most common cause of death was sepsis due to pressure ulcers.

CONCLUSION

In Bangladesh, approximately one in five people with spinal cord injury who are wheelchair-dependent die within two years of discharge from hospital. Most deaths are due to sepsis from potentially preventable pressure ulcers.

How well do randomised controlled trials of physical interventions for people with spinal cord injury adhere to the CONSORT guidelines? An analysis of trials published over a 10-year period

STUDY DESIGN

Cross-sectional descriptive study of randomised controlled trials involving physical interventions for people with spinal cord injury (SCI) published between 2003 and 2013.

OBJECTIVES

To determine how well randomised controlled trials of physical interventions for people with SCI adhere to the CONSORT (Consolidated Standards of Reporting Trials) guidelines.

SETTING

University of Sydney, Sydney, NSW, Australia.

METHODS

A search was conducted for randomised controlled trials designed to determine the effectiveness of physical interventions for people with SCI published between 2003 and 2013. The CONSORT checklist for the reporting of randomised controlled trials was used to determine how well each trial adhered to the guidelines. Two independent reviewers rated each trial on each of the 37 items on the CONSORT checklist using the following criteria: 'fully reported', 'partially reported', 'not reported', 'not relevant' or 'not reported but unable to determine if relevant/done'.

RESULTS

Fifty-three trials were retrieved. None of the trials 'fully reported' all items of the CONSORT guidelines. The median (IQR) number of items that was 'fully reported' was 11/37 (7-20). The median (IQR) number of items that was either 'fully reported' or 'not relevant' or 'not reported but unable to determine if relevant' was 20/37 items (17-27).

CONCLUSION

The reporting of randomised controlled trials in SCI is only partially adhering to the CONSORT guidelines. Journals can help lift standards by encouraging authors of randomised controlled trials to adhere to the CONSORT guidelines.

A review and re-interpretation of a group-sequential approach to sample size re-estimation in two-stage trials

In this paper, we review the adaptive design methodology of Li et al. (Biostatistics 3:277-287) for two-stage trials with mid-trial sample size adjustment. We argue that it is closer in principle to a group sequential design, in spite of its obvious adaptive element. Several extensions are proposed that aim to make it even more attractive and transparent alternative to a standard (fixed sample size) trial for funding bodies to consider. These enable a cap to be put on the maximum sample size and for the trial data to be analysed using standard methods at its conclusion. The regulatory view of trials incorporating unblinded sample size re-estimation is also discussed.

Mapping the motor point in the human tibialis anterior muscle

OBJECTIVE

Percutaneous electrical stimulation of the motor point permits selective activation of a muscle. However, the definition and number of motor points reported for a given muscle varies. Our goal was to address these problems.

METHODS

The area, location and number of motor points in human tibialis anterior were examined, using isometric dorsiflexion torque responses to electrical stimuli. Three methods were used: lowest electrical threshold, maximum muscle response, and approximate motor point.

RESULTS

A single motor point was identified in 39/40 subjects regardless of method. The area of the site of lowest electrical threshold was smaller (median, 35 mm(2)) than those using the maximum muscle response (144 mm(2)) and approximate motor point (132 mm(2)). There was substantial, but not significant, between-subject variation in motor point location. Fifty three percent of motor points would have been missed if located only by reference to anatomical landmarks.

CONCLUSIONS

These results suggested that the motor point's location cannot be determined a priori and that the identification method will affect both area and location.

SIGNIFICANCE

If it is important to maximally activate a single muscle in isolation, the motor point is best represented by the site producing a maximal but isolated muscle response at the lowest stimulation intensity.

Bayesian methods for meta-analysis of causal relationships estimated using genetic instrumental variables

Genetic markers can be used as instrumental variables, in an analogous way to randomization in a clinical trial, to estimate the causal relationship between a phenotype and an outcome variable. Our purpose is to extend the existing methods for such Mendelian randomization studies to the context of multiple genetic markers measured in multiple studies, based on the analysis of individual participant data. First, for a single genetic marker in one study, we show that the usual ratio of coefficients approach can be reformulated as a regression with heterogeneous error in the explanatory variable. This can be implemented using a Bayesian approach, which is next extended to include multiple genetic markers. We then propose a hierarchical model for undertaking a meta-analysis of multiple studies, in which it is not necessary that the same genetic markers are measured in each study. This provides an overall estimate of the causal relationship between the phenotype and the outcome, and an assessment of its heterogeneity across studies. As an example, we estimate the causal relationship of blood concentrations of C-reactive protein on fibrinogen levels using data from 11 studies. These methods provide a flexible framework for efficient estimation of causal relationships derived from multiple studies. Issues discussed include weak instrument bias, analysis of binary outcome data such as disease risk, missing genetic data, and the use of haplotypes.

Reliability of rapid testing for hepatitis B in a region of high HIV endemicity

Hepatitis B (HBV) and HIV co-infection is common in resource-poor settings. A recent study from Malawi revealed poor correlation between hepatitis B surface antigen (HBsAg) point-of-care tests and reference tests in patients co-infected with HIV. We studied a cohort of 300 Malawian adults entering a treatment programme for HIV. Sera were tested for HBsAg first using the Determine rapid test and re-tested using a commercial enzyme immunoassay (EIA). All tests were done under optimal conditions in Liverpool, UK. Sera from all 25 patients positive for HBsAg using the rapid test and from 50 who were negative, were re-tested using the EIA, with complete concordance of results. The kappa correlation was 1, specificity 100% (93-100%) and sensitivity 100% (86-100%) compared to the reference test. Patients had advanced immune suppression (mean CD4=175 cells x 10(6)/l). In a non-field setting, the results of point-of-care Determine rapid hepatitis B tests appear reliable in patients with HIV-1 co-infection.

Needle breakage following inferior alveolar nerve block: implications and management

Needle breakage following inferior alveolar nerve block is a rare complication in current dental practice. We report a case of delayed retrieval of a broken needle with the use of modern imaging modalities. In addition, possible causes of needle breakage and preventative measures, indications and timing of removal, localisation techniques and surgical approaches are discussed.

A two-stage approach to the correction of ascertainment bias in complex genetic studies involving variance components

Correction for ascertainment bias is a vital part of the analysis of genetic epidemiology studies that needs to be undertaken whenever subjects are not recruited at random. Adjustment often requires extensive numerical integration, which can be very slow or even computationally infeasible, especially if the model includes many fixed and random effects. In this paper we propose a two-stage method for ascertainment bias correction. In the first stage we estimate parameters that pertain to the ascertained population, that is the population that would be selected into the sample if the ascertainment criterion were applied to everyone. In the second stage we convert the estimates for the ascertained population into general population parameter estimates. We illustrate the method with simulations based on a simple model and then describe how the method can be used with complex models. The two-stage approach avoids some of the integration required in direct adjustment, hence speeding up the process of model fitting.

Expression of inducible nitric oxide synthase in cutaneous adnexal tumours of the head and neck

Adnexal tumours are a rare heterogeneous group of neoplasms, most commonly found in the head and neck region. Although most are benign, malignant adnexal tumours often behave aggressively, resulting in early metastasis. There is increasing interest in the role that nitric oxide (NO) plays in the behaviour of many cancers. It is thought that NO, produced by the enzyme inducible NO synthase (iNOS), facilitates tumour growth and dissemination. iNOS has been studied in the common skin cancers, where its expression correlates with tumour behaviour, but it has not been previously investigated in cutaneous adnexal tumours. An immunhistochemical study was performed using a monoclonal antibody to iNOS in 37 cases of adnexal tumours (19 benign, 18 malignant). iNOS expression was weakly expressed by basal keratinocytes of adjacent skin in all cases and it was variably expressed in the tumours. Malignant tumours had significantly increased iNOS expression when compared to both adjacent skin (P<0.001) and the benign tumour group (P<0.001). No significant difference was found between iNOS expression in benign tumour and adjacent skin (P=0.5). The role of iNOS in this rare group of tumours and the possibility of pharmacologically inhibiting it in the clinical setting warrants further investigation.

Nitric oxide synthase expression is downregulated in basal cell carcinoma of the head and neck

The small molecule nitric oxide (NO) has many actions, most of which are poorly understood. Recently, NO and related compounds have been implicated in skin damage caused by ultraviolet light although their exact role is not clear. We undertook an immuno histochemical study to assess the expression of type II NO synthase (NOS2) and type III (NOS3) in basal cell carcinomas (BCCs) of the head and neck. In all 48 cases studied, NOS2 was found in the basal cell layer of the skin at the tumour margin but it w as significantly reduced in the tumour epithelial cells (P=0.001). NOS3 was localized to the endothelium of the blood vessels in both skin and tumour in all cases, and it was not seen in the tumour epithelial cells. The results suggest that expression of NOS is down-regulated in basal cell carcinomas.

Challenges of establishing a nursing center in rural eastern Oregon

The success of the center, in fact its very existence, is the result of cooperation among many persons and agencies. Financial gifts, loans and grants have given the clinic a three-year time period to learn valuable lessons on how to organize for self-sufficiency. Staff have learned how to market to increase patient visit and have obtained Federal Rural Health Clinic status which will increase revenues substantially. Nurse Practitioners are learning appropriate visit coding and hold regular brainstorming meetings to develop creative business opportunities to assure financial stability. As a result of these experiences, the NP faculty have been able to design learning experiences for the nurse practitioner students which introduce them to entrepreneurial realities. Challenges are being met by the NPs in this rural practice which require vigor, creativity, and vigilance. Once the center reaches the level of self-sufficiency, it is the intent of the community to build a facility which can support a significant increase in patient load and still have room for other social and health services to operate within the facility. Bridges to the medical community are being strengthened through better communication and more community involvement. Educating the public and the medical community about the role of nurse practitioners and the broad base of nursing centers is a continual challenge for both faculty and students at the School of Nursing.

An intergenerational program for persons with dementia using Montessori methods

An intergenerational program bringing together older adults with dementia and preschool children in one-on-one interactions is described. Montessori activities, which have strong ties to physical and occupational therapy, as well as to theories of developmental and cognitive psychology, are used as the context for these interactions. Our experience indicates that older adults with dementia can still serve as effective mentors and teachers to children in an appropriately structured setting.

Inability of histamine to regulate TNF-alpha production by human alveolar macrophages

Tumor necrosis factor alpha (TNF-alpha), a major product of alveolar macrophages (AM), has been implicated in many pulmonary diseases. Histamine, a mediator important in pulmonary inflammation, has been demonstrated to regulate the production of TNF-alpha by monocytes. In this study, we show that human AM and monocytes differ in their responses to histamine. Whereas histamine suppressed lipopolysaccharide (LPS)-stimulated TNF-alpha production by monocytes through a cAMP-dependent mechanism, it had no effect on either cAMP levels or TNF-alpha production by AM. In contrast, both PGE2 and IL-10 suppressed LPS-stimulated TNF-alpha production by AM and monocytes. The lack of response of AM to histamine appears unique, as histamine suppressed LPS-stimulated TNF-alpha production by mononuclear cells isolated from sites of acute and chronic inflammation, as well as from noninflammatory tissues, and by macrophages differentiated in vitro. In the presence of the phosphodiesterase (PDE) inhibitor 3-isobutyl-1-methylxanthine, histamine increased cAMP levels in AM. Freshly isolated monocytes and AM did not differ in PDE activity. However, PDE activity in AM, but not in monocytes, was increased 15 min after culture with histamine and may, in part, be responsible for the inability of histamine to suppress TNF-alpha production by AM. However, this increase was small and we hypothesize that additional mechanisms may contribute to the unresponsiveness of AM to histamine. We suggest that the lack of response of AM to histamine may be important in the host defense function of AM in the distal lung.

Clinical effects of chlorhexidine mouthwashes on patients undergoing orthodontic treatment

This study compared the short-term clinical effect of 0.12% chlorhexidine gluconate and placebo mouthrinses in 30 adolescents (ages 11 to 15) undergoing orthodontic treatment. Subjects were randomized into experimental (CHX) and control (C) groups. Baseline values were recorded 10 days after prophylaxis and included Plaque index (PI), Gingival index (GI), Rentention Index (RI), Discoloration index (DI), and probing depths (PD). Both groups (CHX and C) received soft toothbrushes with instructions to brush twice daily, as well as the CHX and placebo mouthrinses, respectively, with oral and written instructions for rinsing twice daily with 15 ml for 30 seconds. Reevaluations were performed 1, 2, and 3 months after baseline, except for the DI and PD, which were only assessed at 3 months. The Student's t test and the paired t test were used to analyze the data at the P < 0.05 level of significance. No differences between groups were seen at baseline for any of the parameters. At 30 days, there was a significant difference for the RI between CHX (0.15 +/- 0.16; mean +/- SD) and C (0.05 +/- 0.06) at the mesial buccal, and for CHX (0.07 +/- 0.10) and C (0.02 +/- 0.05) at the midbuccal. The 60-day evaluation showed similar results. At 90 days, lower PI were observed in the CHX group at the distal buccal (0.38 +/- 0.19), midbuccal (0.22 +/- 0.17), and mesial buccal (0.47 +/- 0.22) sites as compared with the C group (0.97 +/- 0.38, 0.83 +/- 0.40, and 0.95 +/- 0.43, respectively). A similar trend was noted with the GI, as the lower values were related to the CHX group. The changes of the PI and GI, at 30, 60, and 90 days, as analyzed by the paired t test, were statistically significant in the case of the experimental group, as the changes in the means were a reflection of significantly lower scores observed in the experimental group. After 3 months, the DI showed higher scores in the experimental group as compared with the control, but they were not statistically significant. Deeper PD were detected in the C group at 90 days, and they were statistically significant, except for the midlingual site. The RI did not show significant differences at 90 days, but higher values were recorded in the CHX group. The data indicate that the use of the CHX, in addition to regular oral hygiene habits, was effective in reducing plaque and gingivitis in adolescents undergoing orthodontic treatment.

Pustular and erythrodermic psoriasis complicated by acute respiratory distress syndrome

BACKGROUND

The pustular and erythrodermic types of psoriasis have been associated with a number of systemic complications, including congestive heart failure and pneumonia. Acute respiratory distress syndrome (ARDS) refers to acute noncardiogenic pulmonary edema with hypoxemia of various causes and has been attributed to pulmonary capillary leak. Recently, 4 cases of generalized pustular or erythrodermic psoriasis have been described associated with a pulmonary capillary leak syndrome.

OBSERVATIONS

We describe 2 additional patients, 1 with pustular and erythrodermic psoriasis and 1 with erythrodermic psoriasis; who developed ARDS. Radiographic findings, pulmonary capillary wedge pressures, echocardiograms, and, in one case, an open lung biopsy specimen, were consistent with the diagnosis of ARDS. In neither case could we document any of the common causes of acute respiratory failure.

CONCLUSIONS

Generalized pustular and erythrodermic psoriasis may be complicated by ARDS. The pathogenesis of this complication is unclear, but proinflammatory cytokines may be involved.