A consensus-based framework for conducting and reporting osteoarthritis phenotype research.

BACKGROUND: The concept of osteoarthritis (OA) heterogeneity is evolving and gaining renewed interest. According to this concept, distinct subtypes of OA need to be defined that will likely require recognition in research design and different approaches to clinical management. Although seemingly plausible, a wide range of views exist on how best to operationalize this concept. The current project aimed to provide consensus-based definitions and recommendations that together create a framework for conducting and reporting OA phenotype research. METHODS: A panel of 25 members with expertise in OA phenotype research was composed. First, panel members participated in an online Delphi exercise to provide a number of basic definitions and statements relating to OA phenotypes and OA phenotype research. Second, panel members provided input on a set of recommendations for reporting on OA phenotype studies. RESULTS: Four Delphi rounds were required to achieve sufficient agreement on 11 definitions and statements. OA phenotypes were defined as subtypes of OA that share distinct underlying pathobiological and pain mechanisms and their structural and functional consequences. Reporting recommendations pertaining to the study characteristics, study population, data collection, statistical analysis, and appraisal of OA phenotype studies were provided. CONCLUSIONS: This study provides a number of consensus-based definitions and recommendations relating to OA phenotypes. The resulting framework is intended to facilitate research on OA phenotypes and increase combined efforts to develop effective OA phenotype classification. Success in this endeavor will hopefully translate into more effective, differentiated OA management that will benefit a multitude of OA patients.

Brief pain re-assessment provided more accurate prognosis than baseline information for low-back or shoulder pain.

BACKGROUND: Research investigating prognosis in musculoskeletal pain conditions has only been moderately successful in predicting which patients are unlikely to recover. Clinical decision making could potentially be improved by combining information taken at baseline and re-consultation. METHODS: Data from four prospective clinical cohorts of adults presenting to UK and Dutch primary care with low-back or shoulder pain was analysed, assessing long-term disability at 6 or 12 months and including baseline and 4-6 week assessments of pain. Baseline versus short-term assessments of pain, and previously validated multivariable prediction models versus repeat assessment, were compared to assess predictive performance of long-term disability outcome. A hypothetical clinical scenario was explored which made efficient use of both baseline and repeated assessment to identify patients likely to have a poor prognosis and decide on further treatment. RESULTS: Short-term repeat assessment of pain was better than short-term change or baseline score at predicting long-term disability improvement across all cohorts. Short-term repeat assessment of pain was only slightly more predictive of long-term recovery (c-statistics 0.78, 95% CI 0.74 to 0.83 and 0.75, 95% CI 0.69 to 0.82) than a multivariable baseline prognostic model in the two cohorts presenting such a model (c-statistics 0.71, 95% CI 0.67 to 0.76 and 0.72, 95% CI 0.66 to 0.78). Combining optimal prediction at baseline using a multivariable prognostic model with short-term repeat assessment of pain in those with uncertain prognosis in a hypothetical clinical scenario resulted in reduction in the number of patients with an uncertain probability of recovery, thereby reducing the instances where patients may be inappropriately referred or reassured. CONCLUSIONS: Incorporating short-term repeat assessment of pain into prognostic models could potentially optimise the clinical usefulness of prognostic information.

Demographic and clinical factors associated with radiographic severity of first metatarsophalangeal joint osteoarthritis: cross-sectional findings from the Clinical Assessment Study of the Foot.

OBJECTIVE: To explore demographic and clinical factors associated with radiographic severity of first metatarsophalangeal joint osteoarthritis (OA) (First MTPJ OA). DESIGN: Adults aged ≥50 years registered with four general practices were mailed a Health Survey. Responders reporting foot pain within the last 12 months were invited to undergo a clinical assessment and weight-bearing dorso-plantar and lateral radiographs of both feet. Radiographic first MTPJ OA in the most severely affected foot was graded into four categories using a validated atlas. Differences in selected demographic and clinical factors were explored across the four radiographic severity subgroups using analysis of variance (ANOVA) and ordinal regression. RESULTS: Clinical and radiographic data were available from 517 participants, categorised as having no (n = 105), mild (n = 228), moderate (n = 122) or severe (n = 62) first MTPJ OA. Increased radiographic severity was associated with older age and lower educational attainment. After adjusting for age, increased radiographic first MTPJ OA severity was significantly associated with an increased prevalence of dorsal hallux and first MTPJ pain, hallux valgus, first interphalangeal joint (IPJ) hyperextension, keratotic lesions on the dorsal aspect of the hallux and first MTPJ, decreased first MTPJ dorsiflexion, ankle/subtalar joint eversion and ankle joint dorsiflexion range of motion, and a trend towards a more pronated foot posture. CONCLUSIONS: This cross-sectional study has identified several dose-response associations between radiographic severity of first MTPJ OA and a range of demographic and clinical factors. These findings highlight the progressive nature of first MTPJ OA and provide insights into the spectrum of presentation of the condition in clinical practice.

Pain management program follow-ups. a national survey of current practice in the United Kingdom.

In the United Kingdom (UK), the number of multidisciplinary pain management programs (PMP) has sharply increased in the last decade. Treatment aims to effect long-term changes, yet arrangements for evaluating long-term treatment outcome in routine practice remain unknown. All PMPs identified in the UK were invited to provide information by mailed questionnaire on aspects of follow-up evaluation. Sixty-six of 70 PMPs identified were successfully contacted (94% response rate). Ten of 48 PMPs (21%) provided complete data and met suggested criteria for adequate length and rates of follow-up, and outcome measurement. Levels of staffing and content explained only a proportion of the variability seen. A general commitment to follow-up outcome evaluation by PMPs was identified but there was substantial variability among programs in length of follow-up, attendance rates, and outcome measurement. These findings raise issues about the consistency of follow-up evaluation across the UK and the ability of current arrangements in some PMPs to accurately determine the longer-term outcome of chronic pain patients. Incorporating follow-ups into existing desirable criteria and agreeing on core outcome measures are two options available to service providers.

Nursing audit in a neonatal intensive care unit.

The amount and quality of work conducted by nurses in a neonatal intensive care unit was assessed by analysing records of observations, investigations and treatment. Work had been standardised as much as possible to ensure continuity and to prevent mishaps. Seventy-seven infants were treated over a 5-month period and 6 died of causes unrelated to patient care. Nursing staff were responsible for all observations and for the collection of most specimens for investigations. They also performed 20% of emergency procedures, such as endotracheal intubation and the insertion of venous catheters. The only errors which could be detected were omissions in observations (2.9%), nursing procedures (2.9%), and drug doses (1.2%). The nurse-to-baby ratio of 1:3 was adequate for patient care but not for other recognised functions of an intensive care unit such as education programmes.

Feeding intervals and fat absorption in preterm babies.

Fat absorption studies were conducted on 18 preterm babies to determine whether continuous nasogastric feeding is as effective as intermittent feeding. The infants ranged from 1 290 g to 1 960 g in birth weight and were assessed at a mean postnatal age of 34 days. Each served as a control by receiving an evaporated milk 1-hourly, 2-hourly, 3-hourly or continuously in random order. Equivalent volumes of milk were ingested over each 3-day period irrespective of the method of feeding and the daily weight gain was similar for the various regimens. Stool transit times did not vary and fat absorption and retention showed no significant differences. Continuous feeding appears to be suitable for preterm babies, especially when there is a need to avoid abdominal distension.

Alpha-fetoprotein: a marker for recurrent apnoea of prematurity?

Plasma alpha-fetoprotein was measured each week for 28 days on 132 preterm babies who were admitted to an intensive care unit. Reference values were established on 53 of these infants who were relatively normal and whose gestations ranged from 29 to 33.9 weeks. Similar studies were done on 79 of the 132 infants with comparable gestational ages who suffered from hyaline membrane disease, transient tachypnoea, recurrent apnoea or growth retardation. Plasma AFP was significantly raised in those with recurrent apnoea but a reason was not established for this observation. The risk of apnoea persisted until AFP levels had reached the reference range. Infants with hyaline membrane disease had lower levels of plasma AFP than the recurrent apnoea group but significantly higher values than controls. Babies who are liable to develop recurrent apnoea can probably be identified at birth as their plasma AFP is exceptionally high. These conclusions refer only to babies who receive a maintenance dose of theophylline from the first week.

Protein and fat absorption in prolonged diarrhoea in infancy.

15N-yeast protein absorption, nitrogen and fat retention, stool reducing substances, and lactate concentrations were measured in 22 infants who had had severe diarrhoea for 7 days. Stool losses of nitrogen and fat were large, and an appreciable proportion appeared to be endogenous. The supply of nitrogen and energy might have been a limiting factor in tissue repair if stool weight exceeded 30 g/kg body weight a day. These results differ from those in older children with kwashiorkor complicated by diarrhoea of similar severity.