OARSI guidelines for the non-surgical management of knee, hip, and polyarticular osteoarthritis

To update and expand upon prior Osteoarthritis Research Society International (OARSI) guidelines by developing patient-focused treatment recommendations for individuals with Knee, Hip, and Polyarticular osteoarthritis (OA) that are derived from expert consensus and based on objective review of high-quality meta-analytic data. We sought evidence for 60 unique interventions. A systematic search of all relevant databases was conducted from inception through July 2018. After abstract and full-text screening by two independent reviewers, eligible studies were matched to PICO questions. Data were extracted and meta-analyses were conducted using RevMan software. Grading of Recommendations Assessment, Development, and Evaluation (GRADE) Evidence Profiles were compiled using the GRADEpro web application. Voting for Core Treatments took place first. Four subsequent voting sessions took place via anonymous online survey, during which Panel members were tasked with voting to produce recommendations for all joint locations and comorbidity classes. We designated non-Core treatments to Level 1A, 1B, 2, 3, 4A, 4B, or 5, based on the percentage of votes in favor, in addition to the strength of the recommendation. Core Treatments for Knee OA included arthritis education and structured land-based exercise programs with or without dietary weight management. Core Treatments for Hip and Polyarticular OA included arthritis education and structured land-based exercise programs. Topical non-steroidal anti-inflammatory drugs (NSAIDs) were strongly recommended for individuals with Knee OA (Level 1A). For individuals with gastrointestinal comorbidities, COX-2 inhibitors were Level 1B and NSAIDs with proton pump inhibitors Level 2. For individuals with cardiovascular comorbidities or frailty, use of any oral NSAID was not recommended. Intra-articular (IA) corticosteroids, IA hyaluronic acid, and aquatic exercise were Level 1B/Level 2 treatments for Knee OA, dependent upon comorbidity status, but were not recommended for individuals with Hip or Polyarticular OA. The use of Acetaminophen/Paracetamol (APAP) was conditionally not recommended (Level 4A and 4B), and the use of oral and transdermal opioids was strongly not recommended (Level 5). A treatment algorithm was constructed in order to guide clinical decision-making for a variety of patient profiles, using recommended treatments as input for each decision node. These guidelines offer comprehensive and patient-centered treatment profiles for individuals with Knee, Hip, and Polyarticular OA. The treatment algorithm will facilitate individualized treatment decisions regarding the management of OA.

Factors associated with health-related quality of life, hip function, and health utility after operative management of femoral neck fractures.

Aims: The primary aim of this prognostic study was to identify baseline factors associated with physical health-related quality of life (HRQL) in patients after a femoral neck fracture. The secondary aims were to identify baseline factors associated with mental HRQL, hip function, and health utility. Patients and Methods: Patients who were enrolled in the Fixation using Alternative Implants for the Treatment of Hip Fractures (FAITH) trial completed the 12-item Short Form Health Survey (SF-12), Western Ontario and McMaster Universities Arthritis Index, and EuroQol 5-Dimension at regular intervals for 24 months. We conducted multilevel mixed models to identify factors potentially associated with HRQL. Results: The following were associated with lower physical HRQL: older age (-1.42 for every ten-year increase, 95% confidence interval (CI) -2.17 to -0.67, p < 0.001); female gender (-1.52, 95% CI -3.00 to -0.05, p = 0.04); higher body mass index (-0.69 for every five-point increase, 95% CI -1.36 to -0.02, p = 0.04); American Society of Anesthesiologists class III ( versus class I) (-3.19, 95% CI -5.73 to -0.66, p = 0.01); and sustaining a displaced fracture (-2.18, 95% CI -3.88 to -0.49, p = 0.01). Additional factors were associated with mental HRQL, hip function, and health utility. Conclusion: We identified several baseline factors associated with lower HRQL, hip function, and utility after a femoral neck fracture. These findings may be used by clinicians to inform treatment and outcomes. Cite this article: Bone Joint J 2018;100-B:361-9.

Characterization of Porcine Epidemic Diarrhea Virus Isolate US/Iowa/18984/2013 Infection in 1-Day-Old Cesarean-Derived Colostrum-Deprived Piglets.

Porcine epidemic diarrhea virus (PEDV) was first recognized in North America in April 2013 and has since caused devastating disease. The objective of this study was to characterize disease and viral detection associated with an original North American PEDV isolate inoculated in neonatal piglets. Thirty-six 1-day-old cesarean-derived and colostrum-deprived piglets were randomly assigned to the control (n = 16) or challenged group (n = 20); the latter were orogastrically inoculated with 1 ml of US/Iowa/18984/2013 PEDV isolate titered at 1 × 10(3) plaque-forming units per milliliter. Rectal swabs were collected from all piglets prior to inoculation and every 12 hours postinoculation (hpi) thereafter, with 4 control and 5 challenged piglets euthanized at 12, 24, 48, and 72 hpi. One piglet had a positive real-time quantitative polymerase chain reaction test on rectal swab at 12 hpi, and all remaining piglets were positive thereafter, with highest viral quantities detected at 24 and 36 hpi. Diarrhea was evident in 30% and 100% of challenged piglets at 18 and 24 hpi, respectively. Viral antigen was detected in enterocytes by immunohistochemistry in the duodenum and ileum of piglets euthanized at 12 hpi and was apparent throughout the small intestine of all piglets thereafter, with villus height:crypt depth ratios consistently below 4:1. Viremia was confirmed in 18 of 20 pigs at euthanasia. Clinical disease was severe and developed rapidly following infection with an original North American PEDV isolate, with lesions, viremia, and antigen detection possible by 12 hpi.

Epidural analgesia for pain relief following hip or knee replacement.

BACKGROUND: Hip and knee replacement are common operative procedures to improve mobility and quality of life. Adequate pain relief is essential in the postoperative period to enable ambulation and initiation of physiotherapy. Lumbar epidural analgesia is a common modality for pain relief following these procedures. However, there is no systematic review of the evidence comparing the efficacy of epidural analgesia with other postoperative analgesic modalities. As the use of epidural analgesia may delay the initiation of anticoagulant thromboprophylaxis due to the potential risk of epidural hematoma, a synthesis of the evidence is necessary to determine whether or not alternative analgesic modalities are worse, equivalent, or better than epidural analgesia. OBJECTIVES: Our objective is to answer the question: "Is lumbar epidural analgesia more efficacious than systemic analgesia or long-acting spinal analgesia for postoperative pain relief in patients after elective hip or knee replacement?" SEARCH STRATEGY: MEDLINE, EMBASE, CINAHL, LILACS, and the Cochrane Controlled Trials Register were searched from their inception to June 2001. Reference lists of review articles and included studies were also reviewed for additional citations. SELECTION CRITERIA: A study was included if it was a randomized or pseudo randomized controlled clinical trial of patients undergoing hip or knee replacement, in which postoperative lumbar epidural analgesia was compared to other methods for pain relief. Study selection was performed unblinded in duplicate. DATA COLLECTION AND ANALYSIS: Data were collected unblinded in duplicate. Information on the patients, methods, interventions, outcomes (pain relief, postoperative function, length of stay) and adverse events were recorded. Methodological quality was assessed using a validated 5-point scale. Meta-analysis was conducted when sufficient data existed from two or more studies. Heterogeneity testing was performed using the Breslow-Day method. The fixed effects model was used unless heterogeneity was present, in which case, a random effects model was used. Continuous data were summarized as weighted mean differences (WMD) or standardized mean differences (SMD) with 95% confidence intervals (CI). Dichotomous data were summarized as odds ratios (OR) and numbers-needed-to-treat (NNT) or numbers-needed-to-harm (NNH) with their respective 95% CI. Graphical representation of continuous data used the MetaView program. MAIN RESULTS: In the first four to six hours after surgery, patients receiving epidural analgesia had less pain at rest, based on visual analog scores (VAS), than patients receiving systemic analgesia (SMD -0.77; 95% CI -1.24 to -0.31). This effect was not statistically significant by 18 to 24 hours (SMD -0.29; 95% CI -0.73 to 0.16). These observations were based only on studies evaluating populations consisting of total knee replacements alone or mixed populations of total hip or total knee replacements. For pain relief with movement after surgery, patients receiving epidural analgesia reported lower pain scores than patients receiving systemic analgesia in all four studies examining these outcomes. The choice of epidural agents may also influence the extent to which epidural analgesia differs from systemic analgesia. The differences between epidural analgesia and systemic analgesia in the frequency of nausea and vomiting (OR 0.95; 95% CI 0.60 to 1.49) or depression of breathing (OR 1.07; 95% CI 0.45 to 2.54) were not statistically significant. Sedation occurred less frequently with epidural analgesia (OR 0.30; 95% CI 0.09 to 0.97) with a number-needed-to-harm of 7.7 (95% CI 3.5 to 42.0) patients for the systemic analgesia group. Retention of urine (OR 3.50, 95% CI 1.63 to 7.51; NNH 4.5, 95% CI 2.3 to 12.2), itching (OR 4.74, 95% CI 1.76 to 12.78; NNH 6.8, 95% CI 4.4 to 15.8), and low blood pressure (OR 2.78, 95% CI 1.15 to 6.72; NNH 6.7, 95% CI 3.5 to 103) were more frequent with epidural analgesia compared to systemic analgesia. There were insufficient numbers to draw conclusions on the edural analgesia compared to systemic analgesia. There were insufficient numbers to draw conclusions on the effect of epidural analgesia on serious postoperative complications, functional outcomes, or length of hospital stay. REVIEWER'S CONCLUSIONS: Epidural analgesia may be useful for postoperative pain relief following major lower limb joint replacements. However, the benefits may be limited to the early (four to six hours) postoperative period. An epidural infusion of local anesthetic or local anesthetic-narcotic mixture may be better than epidural narcotic alone. The magnitude of pain relief must be weighed against the frequency of adverse events. The current evidence is insufficient to draw conclusions on the frequency of rare complications from epidural analgesia, postoperative morbidity or mortality, functional outcomes, or length of hospital stay.

Medico-ethno botany of Mount Abu, Rajasthan, India.

Mount Abu, a beautiful hill station on the Aravalli ranges, is bestowed with the richest flora in Western India. Though studies on the flora and vegetation of this area have been completed, ethnobotanical aspects were neglected until the present studies were undertaken. Many unknown or little known uses of 69 species of plants belonging to 63 genera of 37 families have been recorded.