Genetic Polymorphisms and Genetic Risk Scores Contribute to the Risk of Coronary Artery Disease (CAD) in a North Indian Population.

Coronary artery disease (CAD) is the leading cause of death in India. Many genetic polymorphisms play a role in regulating oxidative stress, blood pressure and lipid metabolism, contributing to the pathophysiology of CAD. This study examined the association between ten polymorphisms and CAD in the Jat Sikh population from Northern India, also considering polygenic risk scores. This study included 177 CAD cases and 175 healthy controls. The genetic information of GSTM1 (rs366631), GSTT1 (rs17856199), ACE (rs4646994), AGT M235T (rs699), AGT T174M (rs4762), AGTR1 A1166C (rs5186), APOA5 (rs3135506), APOC3 (rs5128), APOE (rs7412) and APOE (rs429358) and clinical information was collated. Statistical analyses were performed using SPSS version 27.0 and SNPstats. Significant independent associations were found for GST*M1, GST*T1, ACE, AGT M235T, AGT T174M, AGTR1 A1166C and APOA5 polymorphisms and CAD risk (all p < 0.05). The AGT CT haplotype was significantly associated with a higher CAD risk, even after controlling for covariates (adjusted OR = 3.93, 95% CI [2.39-6.48], p < 0.0001). The APOA5/C3 CC haplotype was also significantly associated with CAD (adjusted OR = 1.86, 95% CI [1.14-3.03], p < 0.05). A higher polygenic risk score was associated with increased CAD risk (adjusted OR = 1.98, 95% CI [1.68-2.34], p < 0.001). Seven polymorphisms were independently associated with an increase in the risk of CAD in this North Indian population. A considerable risk association of AGT, APOA5/C3 haplotypes and higher genetic risk scores is documented, which may have implications for clinical and public health applications.

Exploring antidiabetic drug targets as potential disease-modifying agents in osteoarthritis.

BACKGROUND: Osteoarthritis is a leading cause of disability, and disease-modifying osteoarthritis drugs (DMOADs) could represent a pivotal advancement in treatment. Identifying the potential of antidiabetic medications as DMOADs could impact patient care significantly. METHODS: We designed a comprehensive analysis pipeline involving two-sample Mendelian Randomization (MR) (genetic proxies for antidiabetic drug targets), summary-based MR (SMR) (for mRNA), and colocalisation (for drug-target genes) to assess their causal relationship with 12 osteoarthritis phenotypes. Summary statistics from the largest genome-wide association meta-analysis (GWAS) of osteoarthritis and gene expression data from the eQTLGen consortium were utilised. FINDINGS: Seven out of eight major types of clinical antidiabetic medications were identified, resulting in fourteen potential drug targets. Sulfonylurea targets ABCC8/KCNJ11 were associated with increased osteoarthritis risk at any site (odds ratio (OR): 2.07, 95% confidence interval (CI): 1.50-2.84, P < 3 × 10-4), while PPARG, influenced by thiazolidinediones (TZDs), was associated with decreased risk of hand (OR: 0.61, 95% CI: 0.48-0.76, P < 3 × 10-4), finger (OR: 0.50, 95% CI: 0.35-0.73, P < 3 × 10-4), and thumb (OR: 0.49, 95% CI: 0.34-0.71, P < 3 × 10-4) osteoarthritis. Metformin and GLP1-RA, targeting GPD1 and GLP1R respectively, were associated with reduced risk of knee and finger osteoarthritis. In the SMR analyses, gene expression of KCNJ11, GANAB, ABCA1, and GSTP1, targeted by antidiabetic drugs, was significantly linked to at least one osteoarthritis phenotype and was replicated across at least two gene expression datasets. Additionally, increased KCNJ11 expression was related to decreased osteoarthritis risk and co-localised with at least one osteoarthritis phenotype. INTERPRETATION: Our findings suggest a potential therapeutic role for antidiabetic drugs in treating osteoarthritis. The results indicate that certain antidiabetic drug targets may modify disease progression, with implications for developing targeted DMOADs. FUNDING: This study was funded by the Shanghai Municipal Education Commission-Gaofeng Clinical Medicine Grant (2022), the Shanghai Municipal Health Commission Health Industry Clinical Research Project (Grant No. 20224Y0139), Beijing Natural Science Foundation (Grant No. 7244458), and the Postdoctoral Fellowship Program (Grade C) of China Postdoctoral Science Foundation (Grant No. GZC20230130).

The Flare-OA-16 questionnaire measuring flare in knee and hip osteoarthritis in the patient perspective: scale reduction and validation using a Rasch model.

OBJETIVE: The recent Flare-OA questionnaire measuring flare in knee and hip osteoarthritis (OA) (19 items in 5 domains, numerical rating scale) showed good psychometric properties along with classical test theory. This study aimed to determine its scaling properties by Rasch analysis and to present evidence for a refined scalable version. STUDY DESIGN AND SETTING: The participants were 398 subjects (mean age 64 years (SD=8.1), 70.4% women) recruited from Australia, France, and the United States, with clinically and radiologically symptomatic knee or hip OA, who completed an online survey. The sample was split into derivation and validation subsamples, stratified by country and joint. Rasch analysis examined differential item functioning (DIF) for sex, age, country and joint. A confirmatory factor analysis (CFA) and an analysis of convergent validity were performed to document the psychometric properties of the short version. RESULTS: To fit the Rasch model, we reordered thresholds of answering modalities when necessary. Two items were removed. A local dependency between 2 items was solved by combining items modalities into a super-item. A uniform DIF (expected and non-removed) was identified for one item that was split by joint, and a non-uniform DIF for one item for age and country (removed). The person-item threshold distribution showed a well focused scale; the CFA and the analysis of convergent validity showed good fit indicators for the short version. CONCLUSIONS: The Rasch analysis was helpful in guiding the decision to refine the measurement instrument. After analysis, the Flare-OA-16 questionnaire self-report questionnaire is available for use in clinical research.

Expanding the genetics and phenotypes of ocular congenital cranial dysinnervation disorders.

PURPOSE: To identify genetic etiologies and genotype/phenotype associations for unsolved ocular congenital cranial dysinnervation disorders (oCCDDs). METHODS: We coupled phenotyping with exome or genome sequencing of 467 probands (550 affected and 1108 total individuals) with genetically unsolved oCCDDs, integrating analyses of pedigrees, human and animal model phenotypes, and de novo variants to identify rare candidate single nucleotide variants, insertion/deletions, and structural variants disrupting protein-coding regions. Prioritized variants were classified for pathogenicity and evaluated for genotype/phenotype correlations. RESULTS: Analyses elucidated phenotypic subgroups, identified pathogenic/likely pathogenic variant(s) in 43/467 probands (9.2%), and prioritized variants of uncertain significance in 70/467 additional probands (15.0%). These included known and novel variants in established oCCDD genes, genes associated with syndromes that sometimes include oCCDDs (e.g., MYH10, KIF21B, TGFBR2, TUBB6), genes that fit the syndromic component of the phenotype but had no prior oCCDD association (e.g., CDK13, TGFB2), genes with no reported association with oCCDDs or the syndromic phenotypes (e.g., TUBA4A, KIF5C, CTNNA1, KLB, FGF21), and genes associated with oCCDD phenocopies that had resulted in misdiagnoses. CONCLUSION: This study suggests that unsolved oCCDDs are clinically and genetically heterogeneous disorders often overlapping other Mendelian conditions and nominates many candidates for future replication and functional studies.

Building a composite score for patient self-report of flare in osteoarthritis: a comparison of methods with the Flare-OA-16 questionnaire.

OBJECTIVE: This study aims to compare methods of constructing a composite score for the Flare-OA-16 self-reported questionnaire. METHODS: Participants with knee and hip osteoarthritis (OA) completed a validated 16-item questionnaire assessing five domains of flare. Three estimation methods were compared: i) second-order confirmatory factor analysis (CFA); ii) logistic regression, according to the participant's self-report of flare (yes/no); and iii) Rasch method, with weighted scores in each dimension. The distribution (floor effect (FF) and ceiling effect (CF)) were described and the known-group validity (by self-reported flare) tested by Wilcoxon rank-sum test. Similarity between the scores was analyzed by intraclass correlation coefficient (ICC) and their performance against self-report compared by areas under ROC curves (AUC). Intra-score test-retest reliability at 14 days was assessed by ICC. RESULTS: In a sample of 381 participants, 247 reported having a flare. CFA showed fit indices (CFI=.95; RMSEA=.08) and estimated composite mean score=4.33(SD=2.85)[FF=14.9%, CF=0%]. For the logistic regression estimation, mean composite score was 6.48 (SD=3.13)[FF=0%, CF=0%]. With Rasch model, mean composite score was 4.35 (SD=2.60)[FF=14.9%, CF=0%]. Similarity analysis indicated a greater concordance between CFA and Rasch scores (ICC=.98) than between logistic regression score and the two others (ICC=.88 with Rasch score and .90 with CFA score). The AUC indicated similar performance of all methods: logistic model (AUC=.89 [.85-.92]), CFA and Rasch model (AUC=.86 [.82-.90]). The difference between groups was significant (p<.05) for scores estimated by CFA (3.98), Rasch model (4.95) and logistic regression (4.30). The reproducibility was ICC=.84[.75-.90] for Rasch and CFA scores and ICC=.78[.66-86] for logistic model. CONCLUSIONS: Three alternatives explored to build a composite score showed similar construct validity. Some metric superiority (better score distribution and reproducibility) of the Rasch model is promising for the detection of occurrence and assessment of severity of a flare in OA.

Development of a core domain set for ankle osteoarthritis: An international consensus study of patients and health professionals.

OBJECTIVES: To develop an internationally agreed-upon core domain set for ankle osteoarthritis (OA). METHODS: In a three-part Delphi process, a group of multidisciplinary health professionals with expertise in ankle OA and people with ankle OA responded to online questionnaires. The questionnaires proposed a list of 29 candidate domains derived from a systematic review of ankle OA research, and interviews with people with ankle OA and health professionals. Consensus was defined a priori as ≥70% agreement in people with ankle OA and health professionals whether a domain should or should not be included in a core domain set. An online consensus meeting was held to discuss and resolve undecided candidate domains. RESULTS: A total of 100 people (75 health professionals and 25 people with ankle OA) from 18 countries (4 continents) participated in this study. Five domains reached consensus for inclusion in a core domain set for ankle OA - pain severity, health-related quality of life, function, disability and ankle range of motion. Twenty-one candidate domains reached agreement not to be included in the core domain set, and three domains remained undecided (ankle instability, physical capacity, and mental health). CONCLUSION: This international consensus study, which included people with ankle OA and health professionals, has established a core domain set for ankle OA with five domains that should be measured and reported in all ankle OA trials - pain severity, health-related quality of life, function, disability and ankle range of motion. This core domain set will guide the reporting of outcomes in clinical trials on ankle OA. Future research should determine which outcome measurement instruments should be used to measure each of the core domains.

Challenges in management of congenital enophthalmos due to anomalous accessory orbital extraocular muscle bands.

INTRODUCTION: Congenital enophthalmos is a rare condition characterized by posterior displacement of the globe, often associated with bony orbital anomalies or whole globe development defects. The purpose of this report is to present two unrelated cases of congenital enophthalmos secondary to anomalous accessory orbital bands and to describe characteristics of orbital imaging that differentiate this condition from the other causes. METHODS: The case records of two patients who presented with congenital enophthalmos and were discovered to have anomalous accessory orbital extraocular muscle bands were reviewed. The clinical features, initial diagnosis, high resolution magnetic resonance imaging (MRI) findings, and surgical outcomes were noted. A 3-dimensional reconstruction model was used to understand the approach and surgical management in one of the cases. RESULTS: Both patients presented with unilateral severe enophthalmos, globe retraction, and restricted ocular motility in all directions since birth. High-resolution MRI of the orbits revealed a short anomalous band, isointense to the muscle, arising from a rectus muscle belly and attaching to the posteroinferior part of the globe adjacent to the optic nerve. The caliber of the extraocular muscles and ocular motor nerves was normal. In one patient, surgery was not pursued due to the extreme posterior location of the band with proximity to the optic nerve. In the other patient, the deviation did not improve, despite successfully severing the accessory band, due to extensive scarring. CONCLUSION: Anomalous accessory orbital extraocular muscle bands are a rare and often overlooked cause of congenital enophthalmos when associated with limited ocular motility. Imaging the orbit can aid in diagnosis and help differentiate it from other causes. Safe surgical approaches to address the problem are limited, and available approaches may not be effective. These two cases highlight that the management of accessory extraocular muscle bands causing enophthalmos can be extremely challenging and difficult to improve even with intensive surgical intervention.

Refractive errors in patients with Bardet Biedl syndrome.

PURPOSE: Bardet-Biedl Syndrome (BBS) is a rare autosomal recessive ciliopathy. Within corneal development, primary cilia serve a critical role. We sought to investigate the association of BBS with corneal astigmatism among a cohort of patients with BBS. METHODS: This was a cross-sectional, retrospective study performed at a pediatric ophthalmology department of a tertiary hospital. The study enrolled 45 patients with genetically confirmed Bardet-Biedl syndrome, encompassing a total of 90 eyes observed from February 2011 to August 2021. Spherical and cylindrical refractive errors and keratometry outcome measures, including diopter (D) values at the flattest and steepest axes, were recorded. Corneal astigmatism of greater than 3D is considered extreme corneal astigmatism based on previously published data. RESULTS: Among 45 patients (M:26; F:19), the mean age was 16.4 ± 8.2 years, and the mean best-corrected visual acuity was 20/60. The most common molecular diagnosis was BBS1, seen in 24 of 45 (53.3%). Among all the patients, the mean spherical refractive error was -2.9 ± 3.8D. The mean cylindrical refractive error was 2.6 ± 1.5D. The mean keratometry values at the flattest axis was 43.5 ± 5.3D (39.4-75.0) and at the steepest axis was 47.2 ± 7.3D(41.5-84.0). Among all the patients with BBS, the mean corneal astigmatism was 3.7 ± 1.0D(0.5-7.1), which is considered extreme. CONCLUSION: A cohort of individuals with BBS demonstrated high corneal astigmatism. These results suggest an association between corneal astigmatism and primary ciliary dysfunction and may assist in clinical management and future therapeutic targets among BBS and other corneal disorders.

Decreased scene-selective activity within the posterior intraparietal cortex in amblyopic adults.

Amblyopia is a developmental disorder associated with reduced performance in visually guided tasks, including binocular navigation within natural environments. To help understand the underlying neurological disorder, we used fMRI to test the impact of amblyopia on the functional organization of scene-selective cortical areas, including the posterior intraparietal gyrus scene-selective (PIGS) area, a recently discovered region that responds selectively to ego-motion within naturalistic environments (Kennedy et al., 2024). Nineteen amblyopic adults (10 female) and thirty age-matched controls (12 female) participated in this study. Amblyopic participants spanned a wide range of amblyopia severity, based on their interocular visual acuity difference and stereoacuity. The visual function questionnaire (VFQ-39) was used to assess the participants' perception of their visual capabilities. Compared to controls, we found weaker scene-selective activity within the PIGS area in amblyopic individuals. By contrast, the level of scene-selective activity across the occipital place area (OPA), parahippocampal place area (PPA), and retrosplenial cortex (RSC)) remained comparable between amblyopic and control participants. The subjects' scores on "general vision" (VFQ-39 subscale) correlated with the level of scene-selective activity in PIGS. These results provide novel and direct evidence for amblyopia-related changes in scene-processing networks, thus enabling future studies to potentially link these changes across the spectrum of documented disabilities in amblyopia.

Squatting biomechanics following physiotherapist-led care or hip arthroscopy for femoroacetabular impingement syndrome: a secondary analysis from a randomised controlled trial.

Background: Femoroacetabular impingement syndrome (FAIS) can cause hip pain and chondrolabral damage that may be managed non-operatively or surgically. Squatting motions require large degrees of hip flexion and underpin many daily and sporting tasks but may cause hip impingement and provoke pain. Differential effects of physiotherapist-led care and arthroscopy on biomechanics during squatting have not been examined previously. This study explored differences in 12-month changes in kinematics and moments during squatting between patients with FAIS treated with a physiotherapist-led intervention (Personalised Hip Therapy, PHT) and arthroscopy. Methods: A subsample (n = 36) of participants with FAIS enrolled in a multi-centre, pragmatic, two-arm superiority randomised controlled trial underwent three-dimensional motion analysis during squatting at baseline and 12-months following random allocation to PHT (n = 17) or arthroscopy (n = 19). Changes in time-series and peak trunk, pelvis, and hip biomechanics, and squat velocity and maximum depth were explored between treatment groups. Results: No significant differences in 12-month changes were detected between PHT and arthroscopy groups. Compared to baseline, the arthroscopy group squatted slower at follow-up (descent: mean difference -0.04 m∙s-1 (95%CI [-0.09 to 0.01]); ascent: -0.05 m∙s-1 [-0.11 to 0.01]%). No differences in squat depth were detected between or within groups. After adjusting for speed, trunk flexion was greater in both treatment groups at follow-up compared to baseline (descent: PHT 7.50° [-14.02 to -0.98]%; ascent: PHT 7.29° [-14.69 to 0.12]%, arthroscopy 16.32° [-32.95 to 0.30]%). Compared to baseline, both treatment groups exhibited reduced anterior pelvic tilt (descent: PHT 8.30° [0.21-16.39]%, arthroscopy -10.95° [-5.54 to 16.34]%; ascent: PHT -7.98° [-0.38 to 16.35]%, arthroscopy -10.82° [3.82-17.81]%), hip flexion (descent: PHT -11.86° [1.67-22.05]%, arthroscopy -16.78° [8.55-22.01]%; ascent: PHT -12.86° [1.30-24.42]%, arthroscopy -16.53° [6.72-26.35]%), and knee flexion (descent: PHT -6.62° [0.56- 12.67]%; ascent: PHT -8.24° [2.38-14.10]%, arthroscopy -8.00° [-0.02 to 16.03]%). Compared to baseline, the PHT group exhibited more plantarflexion during squat ascent at follow-up (-3.58° [-0.12 to 7.29]%). Compared to baseline, both groups exhibited lower external hip flexion moments at follow-up (descent: PHT -0.55 N∙m/BW∙HT[%] [0.05-1.05]%, arthroscopy -0.84 N∙m/BW∙HT[%] [0.06-1.61]%; ascent: PHT -0.464 N∙m/BW∙HT[%] [-0.002 to 0.93]%, arthroscopy -0.90 N∙m/BW∙HT[%] [0.13-1.67]%). Conclusion: Exploratory data suggest at 12-months follow-up, neither PHT or hip arthroscopy are superior at eliciting changes in trunk, pelvis, or lower-limb biomechanics. Both treatments may induce changes in kinematics and moments, however the implications of these changes are unknown. Trial registration details: Australia New Zealand Clinical Trials Registry reference: ACTRN12615001177549. Trial registered 2/11/2015.

Psychosocial factors in knee osteoarthritis: Scoping review of evidence and future opportunities.

OBJECTIVE: Identify, describe and produce an evidence map of studies investigating psychosocial factors association with, or effect on, clinical outcomes for people with knee osteoarthritis. METHODS: Scoping review of interventional and observational studies was performed. Medline (Ovid), Embase (Ovid), Cumulated Index in Nursing and Allied Health Literature, PsycInfo and Web of Science were searched on the 15th May 2023. Screening, data extraction and analysis was performed by two independent researchers. Extracted information included characteristics of studies plus which psychosocial factors were used to investigate association with, or effect on, clinical outcome(s). Descriptive statistics summarized the study design, temporal trend, geographic distribution, frequency of each psychosocial factor and whether associations/effects were observed. RESULTS: 23,065 records were screened, with 108 studies selected. Eighty-two percent of studies (n = 89/108) were cross-sectional in design. Number of studies increased over time and spanned 28 countries. Most research originated from the Americas region (55 %, 59/108). Twenty-four psychosocial factors (11 psychological, 13 social) were identified. Depression (47 %, n = 48/102) and education (28 %, n = 29/102) were the most frequently reported psychological and social factors, respectively. Psychological factors were often reported to have an association with/effect on pain (81 %, n = 71/88) and physical function (75 %, n = 56/74). Social factors were less frequently reported to have an association with or effect on pain (57 %, n = 46/81) and physical function (50 %, n = 18/36). CONCLUSION: Psychosocial factors are often associated with clinical outcomes for people with knee osteoarthritis. High-quality longitudinal studies examining a wide range of psychosocial factors across diverse cultural and geographical settings are key to continue informing the development of biopsychosocial models of care.

How Does Osteoarthritis Education Influence Knowledge, Beliefs, and Behavior in People With Knee and Hip Osteoarthritis? A Systematic Review.

OBJECTIVE: Our goal was to inform the design and implementation of osteoarthritis (OA) education for people with knee and hip OA. This review investigated the impact of OA education on knowledge, beliefs, and behavior and how and why these changes occur. METHODS: Five databases-MEDLINE, Excerpta Medica Database (Embase), Cumulative Index to Nursing and Allied Health Literature (CINAHL), Scopus, Physiotherapy Evidence Database (PEDro)-were searched in August 2023. Eligible studies were quantitative, qualitative, and mixed-methods, involving OA education interventions and assessing knowledge, beliefs, and/or behavioral outcomes. An interpretivist analytic process guided data evaluation, synthesis, and description of meta-themes. RESULTS: Ninety-eight studies were included (80 quantitative, 12 qualitative, 6 mixed-methods). OA education was heterogeneous in content and delivery. Outcome measures varied, with poor distinction among knowledge, beliefs, and behavior constructs. Trends toward short-term knowledge improvement were observed, but there were no clear trends in beliefs or behavior change. Intrinsic factors (eg, pre-existing beliefs) and extrinsic factors (eg, socioeconomic factors) appeared to influence change. Three meta-themes described how and why changes may occur: (i) engagement: how individuals relate with education content and delivery; (ii) embodiment: the role of experiential factors in learning, and (iii) empowerment: the level of agency education generates. CONCLUSION: Beyond the provision of information and instruction, OA education is a complex, relational process influenced by multidimensional factors. This review identifies potentially important strategies at individual, interpersonal, and community levels to support the design and delivery of engaging education that promotes holistic, embodied learning and facilitates meaningful, empowering change.

Report of similar placebo response in one internet versus onsite randomised controlled trials from the literature.

Objective: The aim of this study was to compare the magnitude and the predictors of the placebo response in an internet versus onsite randomised controlled trials (RCTs) in people with hand osteoarthritis (HOA). Method: This study is a post-hoc analysis based on one internet RCT (RADIANT) and previously published onsite RCTs for HOA identified through a rigorous searching and selection strategy. The magnitude of the placebo response in the two different types of RCTs were compared using heterogeneity statistics and forest plots visualisation. Classic placebo predictors as well as a combined model, defined with data from onsite RCTs, were tested to predict the placebo response. Results: We analysed the dataset from RADIANT and fourteen previously published onsite RCTs. None of the analyses showed a significant difference between the placebo response for the internet versus onsite RCTs. The "classic" placebo predictors combined in a multivariate predictive model correlated significantly with the placebo response measured in RADIANT study. Conclusion: Despite the absence of face-to-face interactions with the study personnel, there is no evidence that either the magnitude or the predictors of the placebo response of this internet RCT differ from those of onsite RCTs. This analysis is considered as a first step towards evaluating the difference between these designs and strengthens the argument that internet RCTs remain an acceptable alternative way to assess the efficacy of an active treatment in comparison to a placebo.

Visual narratives in medicine - Bridging the gap in graphic medicine with an illustrated narrative of osteoarthritis.

Objective: Visual narratives have been used in medicine to share information in the form of stories with the potential to improve understanding of conditions and change behaviours. One genre of visual narratives is "graphic medicine", which integrates comics into medical education and the delivery of healthcare. Graphic medicine can maximise the impact of research findings by presenting them in a more accessible format, which may be particularly useful in certain populations, such as those with low levels of health literacy. Those with lower health literacy levels and osteoarthritis (OA) are less likely to manage their condition with guideline recommended management strategies, experience a higher burden of disease, and have lower access to care. Our objectives were to review the current visual narratives in the field of and create a graphic medicine visual narrative based on existing research. Design: This paper summarises the current visual narratives in OA and presents a graphic medicine visual narrative to illustrate the experience of living with OA. Considerations for the dissemination of visual narratives to target audiences are also discussed. Results: The most common visual narratives in are infographics, videos, and graphic medicine. A graphic medicine visual narrative, based on previous qualitative work and informed by a framework, was created to illustrate two distinct narratives - impairment and participatory. Conclusion: Visual narratives remain an emerging field in OA but may serve as a useful resource for patients or clinicians to discuss various aspects of OA management. Future research should evaluate and validate the use of visual narratives in OA.

Clinical assessment and management of lumbar spinal stenosis: clinical dilemmas and considerations for surgical referral.

Lumbar spinal stenosis is the leading indication for spine surgery in older adults. Surgery is recommended in clinical guidelines if non-surgical treatments have been provided with insufficient benefit. The difficulty for clinicians is that the current number of randomised controlled trials is low, which creates uncertainty about which treatments to provide. For non-surgical clinicians this paucity of data leads to a clinical dilemma of whether to continue managing the patient or refer to a spine surgeon. This Viewpoint aims to provide an update on the assessment of lumbar spinal stenosis, treatment recommendations, indications for referral to a spine surgeon, and current clinical dilemmas facing non-surgical clinicians and spinal surgeons.

Clear aligner therapy informed consent forms: A quality and readability evaluation.

OBJECTIVE: The aim of the present study was to evaluate the quality and readability of content contained within clear aligner therapy (CAT) informed consent forms. METHODS: CAT informed consent forms were identified via an online search. The presence of details related to CAT-related processes, risks, benefits and alternatives in each form was recorded. A 4-point Likert type scale was used to determine the quality of content (QOC). The readability of content was evaluated with the Simple Measure of Gobbledegook (SMOG) and Flesch Reading Ease Score (FRES). RESULTS: A total of 42 forms satisfied selection criteria. Nineteen (45.2%) were authored by companies who provided aligners to patients via clinicians. The QOC regarding CAT-related treatment processes [median 2.0; IQR 0, 2] and benefits [median 2.0; IQR 1, 2] was adequate. The QOC scores regarding treatment alternatives, consequences of no treatment and relapse were poor. There was no difference (P=0.59) in the median (IQR) QOC of the informed consent forms provided by direct-to-consumer (DTC) aligner providers [10 (8.25, 16.25)] and non-DTC aligner providers [12 (10, 14)]. The median (IQR) SMOG score was 12.1 (10.9, 12.7) and FRES was 39.0 (36.0, 44.25). CONCLUSIONS: The QOC of the evaluated forms was incomplete and poor. The content was difficult to read and failed to reach recommended readability standards. Consent is unlikely to be valid if it is based solely on the content of the forms. Clinicians need to be aware of the limitations of informed consent forms for CAT particularly in relation to alternatives, prognosis, risks, and the need for long-term maintenance of results.

Comparison of ultrasound guidance with landmark guidance for symptomatic benefits in knee, hip and hand osteoarthritis: Systematic review and meta-analysis of randomised controlled trials.

Introduction: More than half of the patients with moderate and severe osteoarthritis (OA) report unsatisfactory pain relief, requiring consideration of intra-articular (IA) injections as the second-line management. Ultrasound-guided IA injection has proven evidence of higher accuracy in administering IA injectates into the joints than landmark-guided or blind IA injections. However, questions remain about translating higher accuracy rates of ultrasound-guided injection into better clinical improvements. Therefore, we examined the symptomatic benefits (pain, function and patient satisfaction) of ultrasound-guided injection in knee, hip and hand OA compared with blind injections by synthesising a systematic review and meta-analysis of randomised controlled trials (RCT). Methods: PubMed, Medline and Embase databases were searched for eligible studies from their inception to August 28, 2023. Results: Out of 295 records, our meta-analysis included four RCTs (338 patients with knee OA), demonstrating significant improvement in procedural pain [-0.89 (95% CI -1.25, -0.53)], pain at follow-up [-0.51 (95% CI -0.98, -0.04)] and function [1.30 (95% CI 0.86, 1.73)], favouring ultrasound guidance. One single study showed higher patient satisfaction with ultrasound guidance. Conclusion: Ultrasound-guided IA injection provided superior clinical outcomes compared with landmark-guided IA injection.