OP0188 CLINICAL EFFECTIVENESS OF STRATIFIED EXERCISE THERAPY COMPARED TO USUAL EXERCISE THERAPY IN PATIENTS WITH KNEE OSTEOARTHRITIS: A CLUSTER RANDOMIZED CONTROLLED TRIAL (OCTOPuS-STUDY)

Background

There is strong, high-quality evidence for the effectiveness of exercise therapy in people with knee osteoarthritis (OA).1 However, although effective, the average effect size is only moderate (approximately 0.5).1 This may be attributed to the current ‘one-size-fits-all’ exercise approach, while a stratified approach may yield superior clinical and economic outcomes. We are the first to test a model of stratified exercise therapy in patients in knee OA. This model was based on 3 previously identified subgroups2 that are aligned with well-accepted OA phenotypes3, namely a ‘low muscle strength subgroup’ (‘age-induced phenotype’), ‘high muscle strength subgroup’ (‘post-traumatic phenotype’) and ‘obesity subgroup’ (‘metabolic phenotype’). For each subgroup, a subgroup-specific exercise therapy intervention was developed and pilot-tested4, which was supplemented by a dietary intervention for the ‘obesity subgroup’.

Objectives

The OCTOPuS-trial aimed to determine the effectiveness of stratified exercise therapy in reducing knee pain and improving physical function, compared to usual, ‘non-stratified’ exercise therapy, in patients with knee OA.

Methods

We conducted a pragmatic cluster randomized controlled trial in a primary care setting in 335 people with knee osteoarthritis: 153 in the experimental arm and 182 in the control arm. Physiotherapy practices were randomized into the experimental arm providing the model of stratified exercise therapy supplemented by a dietary intervention from a dietician for the ‘obesity subgroup’ or the control arm proving usual, ‘non-stratified’ exercise therapy. Primary outcomes were knee pain severity (NRS pain, 0-10) and physical function (KOOS subscale daily living, 0-100). Measurements were performed at baseline, and 3- (primary endpoint), 6-, and 12-months follow-up. Intention-to-treat, multilevel, regression analysis was performed.

Results

We found statistically non-significant differences in knee pain (mean difference (95% confidence interval): 0.19 (-0.31, 0.69)) and physical function (-0.40 (-3.91, 3.12)) at 3-months follow-up, with within-group effect sizes ranging between 0.5 and 0.7. Non-significant differences were also found for all other time points and for nearly all secondary outcome measures. Moreover, effects of experimental and control intervention were similar in each of the 3 subgroup separately.

Conclusion

This trial demonstrated no added value with respect to clinical outcomes of our model of stratified exercise therapy compared to usual exercise therapy. This could be attributed to the experimental arm therapists facing difficulty in effectively applying the model (especially in the ‘obesity subgroup’) and to elements of the model possibly being applied in the control arm.

References

[1]Fransen M et al. Exercise for osteoarthritis of the knee. Cochrane Database Syst Rev. 2015 Jan 9;1:CD004376.

[2]Knoop J et al. Identification of phenotypes with different clinical outcomes in knee osteoarthritis: data from the Osteoarthritis Initiative. Arthritis Care Res (Hoboken). 2011;63(11):1535-1542.

[3]Bijlsma JW et al. Osteoarthritis: an update with relevance for clinical practice. Lancet. 2011; Jun 18;377(9783):2115-26.

[4]Knoop J et al. Is a model of stratified exercise therapy by physical therapists in primary care feasible in patients with knee osteoarthritis? A mixed methods study. Physiotherapy. 2019.

Disclosure of Interests

None declared

[Hysteroscopy: useful in diagnosis and surgical treatment of intrauterine lesions]

Hysteroscopic surgery has an established role in the field of gynaecologic surgery. With the introduction of thinner scopes and simpler instruments part of the interventions can now be performed on an outpatient basis. Hysteroscopy can be used for the removal of polyps and myomas, endometrial resection, synechiolysis, sterilisation, septum resection and the removal of remnants from pregnancy. Hysteroscopic surgery can be an option for patients who wish to preserve the uterus and for the treatment of infertility. The complication rate associated with hysteroscopic interventions is low. The most common events are intravasation of distension fluid, uterine perforation, and haemorrhage. The complication rate depends on the complexity of the procedure.

Diagnostic hysteroscopy in abnormal uterine bleeding: a systematic review and meta-analysis

BACKGROUND

This study was conducted to assess the accuracy and feasibility of diagnostic hysteroscopy in the evaluation of intrauterine abnormalities in women with abnormal uterine bleeding.

SEARCH STRATEGY

Electronic databases were searched from 1 January 1965 to 1 January 2006 without language selection. The medical subject heading (MeSH) and textwords for the following terms were used: hysteroscopy, diagnosis, histology, histopathology, hysterectomy, biopsy, sensitivity and specificity.

SETTING

University Hospital.

SELECTION CRITERIA

The inclusion criteria were report on accuracy of diagnostic hysteroscopy in women with abnormal uterine bleeding compared to histology collected with guided biopsy during hysteroscopy, operative hysteroscopy or hysterectomy.

DATA COLLECTION AND ANALYSIS

Electronic databases were searched for relevant studies and references were cross-checked. Validity was assessed and data were extracted independently by two authors. Heterogeneity was calculated and data were pooled. Subgroup analysis was performed according to validity criteria, study quality, menopausal state, time, setting and performance of the procedure. The pooled sensitivity, specificity, likelihood ratios, post-test probabilities and feasibility of diagnostic hysteroscopy on the prediction of uterine cavity abnormalities. Post-test probabilities were derived from the likelihood ratios and prevalence of intrauterine abnormalities among included studies. Feasibility included technical success rate and complication rate.

MAIN RESULTS

One population of homogeneous data could be identified, consisting of patients with postmenopausal bleeding. In this subgroup the positive and negative likelihood ratios were 7.9 (95% CI 4.79-13.10) and 0.04 (95% CI 0.02-0.09), raising the pre-test probability from 0.61 to a post-test probability of 0.93 (95% CI 0.88-0.95) for positive results and reducing it to 0.06 (95% CI 0.03-0.13) for negative results. The pooled likelihood ratios of all studies included, calculated with the random effects model, were 6.5 (95% CI 4.1-10.4) and 0.08 (95% CI 0.07-0.10), changing the pre-test probability of 0.46 to post-test probabilities of 0.85 (95% CI 0.78-0.90) and 0.07 (0.06-0.08) for positive and negative results respectively. Subgroup analyses gave similar results. The overall success rate of diagnostic hysteroscopy was estimated at 96.9% (SD 5.2%, range 83-100%).

CONCLUSIONS

This systematic review and meta-analysis shows that diagnostic hysteroscopy is both accurate and feasible in the diagnosis of intrauterine abnormalities.

Comparison of long term outcome of patients with rheumatoid arthritis presenting with undifferentiated arthritis or with rheumatoid arthritis: an observational cohort study

BACKGROUND

The outcome of undifferentiated arthritis (UA) ranges from remission to rheumatoid arthritis (RA) fulfilling the American College of Rheumatology (ACR) classification criteria.

OBJECTIVES

To report the outcome of UA after 1 year of follow up and compare the disease course of patients who presented with UA, but evolved into RA within 1 year (UA-RA group), with that of patients who presented with RA fulfilling the ACR criteria (RA-RA group).

METHODS

The diagnosis of 330 patients who presented with UA was recorded at 1 year. The UA-RA and RA-RA groups were then followed up for 3 more years. Outcome measurements were radiographic progression, disease activity, and functional capacity.

RESULTS

From 330 patients who were diagnosed UA, 91 had evolved into RA at 1 year; 62 patients had presented with RA. No significant differences were detected between the UA-RA and RA-RA groups in median Sharp/van der Heijde score at baseline, radiographic progression rates, disease activity, and functional capacity. However, significantly more disease modifying antirheumatic drugs were prescribed in the RA-RA group.

CONCLUSION

The disease outcome of patients who present with UA that evolves into RA within 1 year is the same as that of patients who present with RA as measured by radiographic progression, disease activity, and functional capacity.

Non-invasive tests to predict fetal anemia in Kell-alloimmunized pregnancies

OBJECTIVES

To compare test characteristics of ultrasound and Doppler parameters in the prediction of fetal anemia in Kell-alloimmunized pregnancies.

METHODS

In this prospective study, 27 fetuses at risk for anemia due to Kell alloimmunization were evaluated with ultrasound and Doppler imaging. Spleen perimeter, liver length, middle cerebral artery (MCA) peak systolic velocity and intrahepatic umbilical venous (IHUV) maximum velocity were measured. Results were compared with fetal hemoglobin values at first intrauterine blood sampling or delivery. Severe fetal anemia was defined as a hemoglobin deficit of at least 5 SD below the mean for gestational age.

RESULTS

Eighteen fetuses were anemic and required intrauterine transfusions. In the other nine pregnancies no transfusions were performed; one of these fetuses was severely anemic at birth. MCA and IHUV flow velocities were the best predictors of fetal anemia in Kell alloimmunized fetuses (sensitivity 89% for each test). Sensitivities for spleen perimeter (15%) and liver length (14%) were disappointing.

CONCLUSIONS

Doppler evaluation of MCA peak systolic velocity and IHUV maximum velocity can be used to reliably predict severe fetal anemia in Kell alloimmunization.

Undifferentiated arthritis--disease course assessed in several inception cohorts

The prognosis of patients with undifferentiated arthritis (UA) may vary from self-limited to severe destructive rheumatoid arthritis (RA). Because early aggressive treatment might offer an effective means to slow disease progression in RA, it is important to identify UA patients who will develop RA and treat them as early as possible. At the same time, inappropriate treatment of patients with a more benign disease course should be avoided. Here, an overview is given of the characteristics and numbers of patients with UA who evolve into RA. UA is defined as any arthritis that has the potential for a persistent course, without fulfilling the classification criteria for specific rheumatic disorders. To compare endpoints in the different databases, the 1987 ACR criteria for RA were used. In the nine databases employing a similar definition for undifferentiated arthritis, the proportion of patients with UA that evolved into RA within 1 year varied from 6% to 55%. These differences arise in large part from differences in the inclusion criteria and in the definitions used for UA and RA. The data from the various cohorts support a hypothesis that a considerable proportion of UA patients are actually patients with RA in a very early stage. Controlled intervention studies with early antirheumatic treatment in these patients are mandatory in order to provide further insight into the natural course of UA and to define a treatment strategy that will successfully slow or prevent disease progression.

[Cerebellar mutism syndromes with subsequent dysarthria: a study of three children and a review of the literature]

Cerebellar mutism and subsequent dysarthria (MSD) is a possible complication of posterior fossa surgery. It is usually seen in children after resection of a cerebellar mass lesion. Most patients become mute after a period of (near)normal postoperative speech, and are dysarthric once speech resumes. The pathophysiological mechanisms underlying MSD are most probably multifactorial, combining neuroanatomical, neurophysiological, neuropsychological, and psychological factors. The aim of the present article is to better define the MSD syndrome. The cerebellum is not only involved in motor control. It is also part of a distributed neural circuitry which underlies higher cognitive functions such as, for instance, those associated with the programming of kinetic parameters before motor initiation of a movement. We hypothesize that it could also be involved in the mental initiation which precedes the programming of any intentional bucco-phonatory movements to be performed in order to express oneself.

Relationship of polymorphisms of the Interleukin-1 gene cluster to occurrence and severity of rheumatoid arthritis

Interleukin-1 (IL-1) has been implicated in the pathogenesis of rheumatoid arthritis (RA). We investigated whether IotaL-1 gene locus polymorphisms are associated with susceptibility to or severity of RA. Genotyping for IL-1alpha, IL-1beta and IL-1Ra single nucleotide polymorphisms (SNPs) performed in a cross-sectional group of 312 consecutive RA patients (RA-group 1) and a cohort of 94 incident female RA patients (RA-group 2) revealed that the rare IL-1RN + 2017 C allele was significantly increased in RA compared to controls (n = 245). A retrospective analysis in RA-group 1 showed no significant associations between IL-1 genotypes and disease severity. A prospective study in RA-group 2 demonstrated that the extent of joint destruction over 12 years was higher in patients genotyped heterozygous for the IL-1 A + 4845, IL-1B + 3953 and IL-1RN + 5111 SNPs compared to homozygous wildtype patients, although differences did not reach statistical significance. These data indicate that the IL-1RN + 2017 polymorphism is associated with susceptibility to RA.

The ER-TR4 monoclonal antibody recognizes murine thymic epithelial cells (type 1) and inhibits their capacity to interact with immature thymocytes: immuno-electron microscopic and functional studies

The thymic stroma is heterogeneous with regard to cellular morphology and cellular function. In this study, we employed the monoclonal antibody ER-TR4 to characterize stromal cells at the ultrastructural level. To identify the labelled cell type, we used two techniques: immunogold labelling on ultrathin frozen sections and immunoperoxidase staining on thick "vibratome" sections. ER-TR4 reacted with thymic Type 1 epithelial cells (according to our classification). A dense labelling appears in the cytoplasm of cortical cells using the two techniques. Immunogold labelling identified small cytoplasmic vesicles whereas the cytoplasm and the cell membrane seem to be labelled with the immunoperoxidase technique. ER-TR4 also identified isolated thymic nurse cells (TNC), and was observed in vitro to inhibit the capacity of some type 1 epithelial cells to establish interactions with immature thymocytes. This finding supports the hypothesis that the factor is involved in the formation of lymphoepithelial interactions within thymic nurse cells, and thus in the relations that immature thymocytes establish with the thymic microenvironment.

A case of acquired stuttering

This case study of acquired stuttering confirms the reality of acquired or neurogenic stuttering. It further shows that the syndrome can exist in its own right. It is not simply a secondary psychological consequence of brain damage but a direct result of the cerebral lesion.

Problems in measuring cognitive recovery after acute brain injury

The measurement of cognitive recovery after traumatic brain damage raises a number of methodological and practical problems. The precise schedule of testing, the specification of functions to be measured, the separation of practice from recovery, and the specification of appropriate control or comparison groups must all be considered by the researcher. In addition, strenuous efforts must be made to achieve as high a follow-up rate as possible.