Using hip measures to avoid misdiagnosing early rapid onset osteoarthritis for osteonecrosis.

In the early phases, subchondral insufficiency fractures and rapidly destructive osteoarthritis of the hip are often mistaken for osteonecrosis of the hip. Three hip measures were used comparing combined subchondral insufficiency fractures and rapidly destructive 18 osteoarthritis patients to 18 osteonecrosis patients. Due to the rarity of these conditions there was no statistical power. Initial diagnoses for the osteoarthritis patients were recorded. The osteoarthritis group had significantly higher means for Tönnis angle (P < 0.001), lateral center edge angle (P = 0.006), and acetabular extrusion index (P = 0.014). Only 7 of the 18 patients were initially diagnosed without reservation as subchondral insufficiency fracture or rapidly destructive osteoarthritis. Using hip measures will reduce the misdiagnosis of rapid onset osteoarthritis of the hip for osteonecrosis.

The contribution of community-based conservation models to conserving large herbivore populations.

In East Africa, community-based conservation models (CBCMs) have been established to support the conservation of wildlife in fragmented landscapes like the Tarangire Ecosystem, Tanzania. To assess how different management approaches maintained large herbivore populations, we conducted line distance surveys and estimated seasonal densities of elephant, giraffe, zebra, and wildebeest in six management units, including three CBCMs, two national parks (positive controls), and one area with little conservation interventions (negative control). Using a Monte-Carlo approach to propagate uncertainties from the density estimates and trend analysis, we analyzed the resulting time series (2011-2019). Densities of the target species were consistently low in the site with little conservation interventions. In contrast, densities of zebra and wildebeest in CBCMs were similar to national parks, providing evidence that CBCMs contributed to the stabilization of these migratory populations in the central part of the ecosystem. CBCMs also supported giraffe and elephant densities similar to those found in national parks. In contrast, the functional connectivity of Lake Manyara National Park has not been augmented by CBCMs. Our analysis suggests that CBCMs can effectively conserve large herbivores, and that maintaining connectivity through CBCMs should be prioritized.

Non-invasive electromagnetic field therapy produces rapid and substantial pain reduction in early knee osteoarthritis: a randomized double-blind pilot study.

This study examined whether a non-thermal, non-invasive, pulsed electromagnetic field (PEMF), known to modulate the calmodulin (CaM)-dependent nitric oxide (NO)/cyclic guanosine monophosphate (cGMP) signaling pathway, could reduce pain in early knee OA. This randomized, placebo-controlled, double-blind pilot clinical study enrolled 34 patients. Patient selection required initial VAS ≥4, 2 h of standing activity per day, and no recent interventions such as cortisone injections or surgery. Results showed VAS pain score decreased in the active cohort by 50 ± 11% versus baseline starting at day 1 and persisting to day 42 (P < 0.001). There was no significant decrease in VAS versus baseline at any time point in the sham cohort (P = 0.227). The overall decrease in mean VAS score for the active cohort was nearly threefold that of the sham cohort (P < 0.001). The results suggest that non-thermal, non-invasive PEMF therapy can have a significant and rapid impact on pain from early knee OA and that larger clinical trials are warranted.

What's on the horizon for community-based conservation? Emerging threats and opportunities.

Community-based conservation can support livelihoods and biodiversity, while reinforcing local and Indigenous values, cultures, and institutions. Its delivery can help address cross-cutting global challenges, such as climate change, conservation, poverty, and food security. Therefore, understanding trends in community-based conservation is pertinent to setting and implementing global goals. We undertook a horizon scan to prioritize 15 emerging threats and opportunities expected to impact the future effectiveness of community-based conservation. Topics relate to global biodiversity policy; human rights; shifting human geography; inclusion, diversity, equity, and access; conservation finance and income; and economic reforms. Our findings offer guidance on strengthening community-based conservation to achieve global environmental and development goals.

The paths of musculoskeletal scaffold research leading to long-term effects.

BACKGROUND AND PURPOSE: Developing successful musculoskeletal scaffolds for specific tissue replacement has many challenges. Ideal scaffolds support the physiologic needs of the ingrowth tissue until new cells establish a matrix approximating the biomechanical properties of the original tissue or organ construct. Short- and long-term effects on matrix formation and surrounding tissue are critical for clinical applications. METHOD: This is a review of scaffold development of alginate, fibrin, and poly glycolic and polylactic acid scaffolds by three laboratories. RESULTS: Varied chain structures of alginate modified with an RGD-containing peptide sequence (G4RGDY) promotes cell multiplication. Given the proper mix of chain size and radiation used to reduce chain size, the adjusted rate of degradation showed no long-term effect at 21 weeks in vitro. To date, there are no long-term fibrin-based scaffold constructs. Plasmid DNA-laden 75:25 PLGA microspheres were able to have the microsphere incorporated into the polymer solution, resulting in sustained plasmid DNA release for more than 70 days without significant surrounding tissue effects. CONCLUSION: Years of research on the same construct are required before long-term effects of tissue engineering scaffolds can be determined.

Age and BMI variations in bone, muscle, and fat on AP mid-thigh radiographs.

BACKGROUND: Body mass index (BMI) uses height and weight to determine relative fat content. BMI is used in numerous epidemiologic and mechanical studies of hip and knee osteoarthritis (OA). There are more precise, but cumbersome and expensive, measurements of the contribution of body fat to BMI. Our hypotheses were that there would be a large variation in relative mid-thigh bone, muscle, and fat width within specific BMI range and that relative widths change with age and sex. METHODS: The hospital IRB approved a retrospective review of 340 patients who had a recent knee radiograph for knee OA. Using 5.08-cm (2-inch) increments, six groups were created. At height-adjusted reference points on the lower mid-thigh total thigh diameter (TD), muscle diameter (MD), bone diameter (BD), and nonfat diameter (NFD) were measured. Relative widths within BMI groups (<25, 25-30, 30-40, >40) were compared to age and sex. RESULTS: MD, BD, and NFD ratios showed a wide variation in all BMI groups. As would be expected MD, BD, and NFD ratios decreased with increasing BMI. These ratios did not significantly change with age. However, the MD ratio remains similar for each BMI in men, in women it decreases with BMI. CONCLUSION: Adding relative thigh measurements to BMI data could enhance mechanical and epidemiologic studies.

The Biological Basis for Surface-dependent Regulation of Osteogenesis and Implant Osseointegration.

Bone marrow stromal cells are regulated by the chemical and physical features of a biomaterial surface. When grown on titanium (Ti) and Ti alloy surfaces, such as titanium-aluminum-vanadium, with specific topographies that mimic the microscale, mesoscale, and nanoscale features of an osteoclast resorption pit, they undergo a rapid change in cell shape to assume a columnar morphology typical of a secretory osteoblast. These cells exhibit markers associated with an osteoblast phenotype, including osteocalcin and osteopontin, and they secrete factors associated with osteogenesis, including bone morphogenetic protein 2, vascular endothelial growth factor, and neurotrophic semaphorins. The pathway involves a shift in integrin expression from α5ß1 to α2ß1 and signaling by Wnt5a rather than Wnt3a. Conditioned media from these cultures can stimulate vasculogenesis by human endothelial cells and osteoblastic differentiation of marrow stromal cells not grown on the biomimetic substrate, suggesting that the surface could promote osteogenesis in vivo through similar mechanisms. In vivo studies using a variety of animal models confirm that implants with biomimetic surfaces result in improved osseointegration compared with Ti implants with smooth surfaces, as do meta-analyses comparing clinical performance of implant surface topographies.

Payments for ecosystem services as a framework for community-based conservation in northern Tanzania.

Payments for ecosystem services (PES) are an increasingly promoted approach to conservation. These approaches seek to develop financial mechanisms that create economic incentives for the maintenance of ecosystems and associated biodiversity by rewarding those who are responsible for provision of ecological services. There are, however, few cases in which such schemes have been used as a strategy for conserving wildlife in developing countries and very few operational examples of such schemes of any sort in sub-Saharan Africa. In savannah ecosystems, large mammal populations generally depend on seasonal use of extensive areas and are widely declining as a result of habitat loss, overexploitation, and policies that limit local benefits from wildlife. Community-based conservation strategies seek to create local incentives for conserving wildlife, but often have limited impact as a result of persistent institutional barriers that limit local rights and economic benefits. In northern Tanzania, a consortium of tourism operators is attempting to address these challenges through an agreement with a village that possesses part of a key wildlife dispersal area outside Tarangire National Park. The operators pay the community to enforce voluntary restrictions on agricultural cultivation and permanent settlement in a defined area of land. The initiative represents a potentially cost-effective framework for community-based conservation in an ecologically important area and is helping to reconcile historically conflicting local and national interests relative to land tenure, pastoralist livelihoods, and conservation. Wider adaptation of payments for ecosystem services approaches to settings where sustaining wildlife populations depends on local stewardship may help address current challenges facing conservation outside state-protected areas in savannah ecosystems in sub-Saharan Africa and other parts of the world.

Creating social work competencies for practice in hospice palliative care.

Social workers play an important role in the delivery of Hospice Palliative Care in many diverse settings. The profession brings a unique perspective to end-of-life care that reflects and supports the holistic philosophy of Hospice Palliative Care. Despite the prominent and longstanding position of social work in this area, the role and functions of social workers had not been clearly defined. A Canadian task group of social work practitioners and educators utilized a modified Delphi process to consult front line clinicians nationally, and thereby achieved consensus regarding the identification and description of eleven core competencies in Hospice Palliative Care. These competencies are relevant for social workers at different experience levels across care settings. They can be used to inform social work practice, as well as professional development and educational curricula in this area.

Conservation and aid: designing more effective investments in natural resource governance reform.

Biodiversity conservation outcomes are closely related to the rules and institutions governing resource use. Creating local incentives for conservation through more secure resource tenure is central to conservation outcomes on private and communal lands, where the preponderance of biodiversity occurs. Conservation efforts in sub-Saharan Africa are therefore centrally concerned with governance dynamics and institutional reform processes, such as the decentralization of property rights, and how best to achieve such reforms. Traditional mechanisms for financing conservation efforts in Africa rely heavily on funds channeled through multilateral and bilateral aid agencies. The history of development aid highlights a range of constraints these aid agencies face in terms of working toward more effective resource governance arrangements and promoting reforms. Government aid agencies possess incentives for promoting large-scale and short-term projects that maximize expenditure volumes and tend to define issues in technical rather than political terms. The history of development aid suggests that these and other characteristics of aid agencies impedes their ability to influence governance reform processes and that aid funding may discourage the adoption of reforms. Greater emphasis in African conservation financing needs to be placed on flexible, small-scale investments aligned to local interests and constituencies that prioritize innovation, learning, and experimentation. Additionally, more research is required that explores the linkages between conservation funding, donor decision-making processes, and governance reforms.

Evaluation of an Organizational Intervention to Improve Osteoarthritis.

BACKGROUND: Osteoarthritis (OA) is a serious public health problem that affects millions in the United States (Hootman & Helmick, 2006). National health objectives indicate an urgent need to increase the number of people educated about the causes, prevention, and treatment of OA (Sleath, Cahoon, Sloane, & Callahan, 2008). The most effective OA reduction strategies include health education, health promotion, and self-management education (Schulz, et al., 2015). Studies examining the design and implementation of education are limited. Researchers have established the a link between improving knowledge and improved health outcomes; reduced pain, increased mobility, improved joint health, and delayed surgery (Szychlinska, Leonardi, Al-Qahtani, M., Mobasheri, & Musumeci, 2016). Beneficial interventions may decrease the disability associated with OA and the need for more invasive treatments (Sharma, 2016). In our previous article titled Components of an Effective Osteoarthritis Self-Management Program, provided components needed for program implementation and how to measure the program's success by using the nursing Health Belief Model. OBJECTIVE: The purpose of this program evaluation is to improve program information and increase patient knowledge. METHOD: This evaluation used two mixed methods: (a) standardized survey (Figure 1), (b) instructor interview (Figure 2). Both evaluations were conducted by the authors with defined methods and conditions discussed under sections Participant Survey Method and Instructor Interview Method. RESULTS: The program evaluation goal was met with positive reviews from all 67 participants who attended the program. Instructor interviews uncovered reasons for volunteering and gathered data used for future recommendations. CONCLUSION: This program evaluation will provide tools for program implementation and evaluation by health organizations with the long-term aim of reducing the burden of OA and healthcare costs.

Ethical safeguards for industry-funded research in an academic setting.

The shrinking economy has driven many investigators to seek industrial funding for both clinical and bench research. This has resulted in four concerns for the clinician scientist: (1) research that results in effective clinical application; (2) research design that meets evidence medicine requirements and has clinical significance; (3) adherence to clinical competencies; and (4) research records that are open and reflect both the scientific and economic path to the results of the investigation. This paper reports on how one institution protects the interests of all four stakeholders in any research study in academic centers: the investigator, the institution, patients, and industry. The process makes it possible for the investigator to concentrate on research methodology and to remain secure about the ethical conduct of their research. At our institution, all industrial-funded research is arranged on an institution-to-sponsor basis. Contract language is generated by the institution, not the investigator. This protects the investigator and includes freedom to publish regardless of the results. Issues of intellectual property, patient protection, and the institutions needs, such as intellectual property and compliance with the federal/state guidelines, and indemnification are incorporated into the pre- and post-award applications. Concurrently, Institutional Review Board (IRB) proposals are prepared and submitted. This process leaves a paper trail that provides a transparency acceptable to all stakeholders.

The Value of Phenotypes in Knee Osteoarthritis Research.

BACKGROUND: Over the past decade, phenotypes have been used to help categorize knee osteoarthritis patients relative to being subject to disease, disease progression, and treatment response. A review of potential phenotype selection is now appropriate. The appeal of using phenotypes is that they most rely on simple physical examination, clinically routine imaging, and demographics. The purpose of this review is to describe the panoply of phenotypes that can be potentially used in osteoarthritis research. METHODS: A search of PubMed was used singularly to review the literature on knee osteoarthritis phenotypes. RESULTS: Four phenotype assembly groups were based on physical features and noninvasive imaging. Demographics included metabolic syndrome (dyslipidemia, hypertension, obesity, and diabetes). Mechanical characteristics included joint morphology, alignment, the effect of injury, and past and present history. Associated musculoskeletal disorder characteristics included multiple joint involvement, spine disorders, neuromuscular diseases, and osteoporosis. With the knee as an organ, tissue characteristics were used to focus on synovium, meniscus, articular cartilage, patella fat pad, bone sclerosis, bone cysts, and location of pain. DISCUSSION: Many of these phenotype clusters require further validation studies. There is special emphasis on knee osteoarthritis phenotypes due to its predominance in osteoarthritic disorders and the variety of tissues in that joint. More research will be required to determine the most productive phenotypes for future studies. CONCLUSION: The selection and assignment of phenotypes will take on an increasing role in osteoarthritis research in the future.

Thinking about complexity in health: A systematic review of the key systems thinking and complexity ideas in health.

RATIONALE, AIMS, AND OBJECTIVES: As the Sustainable Development Goals are rolled out worldwide, development leaders will be looking to the experiences of the past to improve implementation in the future. Systems thinking and complexity science (ST/CS) propose that health and the health system are composed of dynamic actors constantly evolving in response to each other and their context. While offering practical guidance for steering the next development agenda, there is no consensus as to how these important ideas are discussed in relation to health. This systematic review sought to identify and describe some of the key terms, concepts, and methods in recent ST/CS literature. METHOD: Using the search terms "systems thinkin * AND health OR complexity theor* AND health OR complex adaptive system* AND health," we identified 516 relevant full texts out of 3982 titles across the search period (2002-2015). RESULTS: The peak number of articles were published in 2014 (83) with journals specifically focused on medicine/healthcare (265) and particularly the Journal of Evaluation in Clinical Practice (37) representing the largest number by volume. Dynamic/dynamical systems (n = 332), emergence (n = 294), complex adaptive system(s) (n = 270), and interdependent/interconnected (n = 263) were the most common terms with systems dynamic modelling (58) and agent-based modelling (43) as the most common methods. CONCLUSIONS: The review offered several important conclusions. First, while there was no core ST/CS "canon," certain terms appeared frequently across the reviewed texts. Second, even as these ideas are gaining traction in academic and practitioner communities, most are concentrated in a few journals. Finally, articles on ST/CS remain largely theoretical illustrating the need for further study and practical application. Given the challenge posed by the next phase of development, gaining a better understanding of ST/CS ideas and their use may lead to improvements in the implementation and practice of the Sustainable Development Goals.

The Use of Tomosynthesis in the Global Study of Knee Subchondral Insufficiency Fractures.

RATIONALE AND OBJECTIVES: Subchondral insufficiency fractures (SIF), previously termed spontaneous osteonecrosis of the knee, are marked by a sudden onset of severe pain. Other than the size of the lesion, prediction for progression to joint replacement is difficult. The objective was to determine if quantitative analysis of bone texture using digital tomosynthesis imaging would be useful in predicting more rapid progression to joint replacement. MATERIALS AND METHODS: Tomosynthesis studies of 30 knees with documented SIF were quantified by fractal, mean intercept length (MIL), and line fraction deviation analyses. Fractal dimension, lacunarity, MIL, and line fraction deviation variables measured from these analyses were then correlated to short interval progression to joint replacement surgery. RESULTS: Higher odds for joint replacement were related to higher values of the standard deviation of slope lacunarity and to morphometric measures (eg, MIL). CONCLUSIONS: Using digital tomosynthesis images for bone texture assessment may help distinguish condylar bone response in SIF, potentially acting as a clinically relevant predictive tool. In the future, contrasting SIF to the more gradual long-term process of osteoarthritis, there may be a better understanding of the different mechanisms for the two conditions.

Parental experiences of adult child death from cancer.

BACKGROUND: Although parents experience the death of adult children diagnosed with cancer, most of the literature on adult child death has examined the issues of violent death or suicide. Where death from cancer has been studied, the focus has been mainly on psychological outcomes. Little is known about parents' experiences with this phenomenon. OBJECTIVE: To understand parents' experience of having an adult child die from cancer. DESIGN: Descriptive-exploratory study utilizing semistructured interviews with parents of 10 adult children who had died of cancer. SETTING: Parents who had lost a child to cancer were interviewed in their own home or in the interviewer's office. ANALYSIS: Interviews were recorded, transcribed, and analyzed. Latent content analysis and constant comparison techniques were used to develop coding labels, which were then classified into categories and subcategories. RESULTS: Parents experienced a tension between their strong desire to "parent" their child, and their recognition that their child was an autonomous adult, sometimes with a spouse and family who took precedence over them. Parents of a dying child felt helpless, and sometimes were excluded/unacknowledged by health care professionals. To cope, they reconfigured their parent role using various strategies. After the death of their child further reconfiguring takes place, including preserving memories of the child, and talking about him/her. Continuing family and social relationships influence this stage. CONCLUSION: The conflict of wishing to "parent" a dying adult child while recognizing the child's autonomy creates uncertainty for parents at an already stressful time. Facilitating parent-child communication during the illness is important. After the death of the adult child parents may continue to face difficulty with their perceived role in society (parent and/or bereaved person), and sometimes within their family. Health care professionals should make greater efforts to include the parents of the dying adult in the circle of care. The bereavement experience of these parents is intense and long-lasting. Further research is needed regarding the ways in which health care providers can best assist parents to successfully integrate this profound loss.