Vijay Shetty

BACKGROUND: Guidelines recommending various nonoperative treatments for patients with knee osteoarthritis remain inconsistent. Much of this controversy relates to what constitutes a clinically important effect. The purposes of the present study were to compare treatment effect sizes from recent meta-analyses evaluating pharmacological or medical device interventions for the treatment of knee osteoarthritis and to further assess the clinical impact that the intra-articular placebo effect may have on intra-articular injection therapies. METHODS: A search of PubMed, MEDLINE, and Embase from the inception date of each database through May 30, 2017 was conducted for all articles involving meta-analyses of pharmacological or medical device knee osteoarthritis treatments compared with controls. Two reviewers independently screened articles for eligibility and extracted data for analysis. We present effect estimates on a standardized mean difference (SMD) scale and compare them all against a threshold for clinical importance of 0.50 standard deviation (SD) unit. RESULTS: Ten meta-analyses (sample size range, 110 to 39,814) providing a total of 19 different effect sizes for pain were included in this review. SMD estimates ranged from 0.08 to 0.79 for various electrical modalities, orthotic devices, topical and oral nonsteroidal anti-inflammatory drugs (NSAIDs), dietary supplements, and intra-articular injection therapies. Seventeen treatments demonstrated significant improvements in terms of pain when patients who had received treatment were compared with controls. After accounting for the intra-articular placebo effect, the greatest effect estimates were those of intra-articular platelet-rich plasma and high molecular weight hyaluronic acid. When these were judged according to our threshold for clinical importance, high molecular weight intra-articular hyaluronic acid was found to have the most precise effect estimate that surpassed this threshold. Platelet-rich plasma was found to provide the greatest point estimate of the treatment effect, but the precision around this estimate had the largest amount of uncertainty across all treatments. CONCLUSIONS: While many nonoperative treatments demonstrated significant improvements in pain, we found the greatest effect estimates for intra-articular treatments. While platelet-rich plasma provided the greatest point estimate of the treatment effect, variability among studies suggests that future research into optimal formulations is required. The strongest current evidence supports clinically important and significant treatment effects with intra-articular hyaluronic acid formulations between 1,500 and >6,000 kDa. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Nanomedicine is one of the most promising therapeutic modalities researchers are working on. It involves development of drugs and devices that work at the nanoscale (10-9m). Coronary artery disease (CAD) is responsible for more than a third of all deaths in age group >35 years. With such a huge burden of mortality, CAD is one of the diseases where nanomedicine is being employed for preventive and therapeutic interventions. Nanomedicine can effectively deliver focused drug payload at sites of local plaque formation. Non-invasive strategies include thwarting angiogenesis, intra-arterial thrombosis and local inflammation. Invasive strategies following percutaneous coronary intervention (PCI) include anti-restenosis and healing enhancement. However, before practical application becomes widespread, many challenges need to be dealt with. These include manufacturing at the nanoscale, direct nanomaterial cellular toxicity and visualization.

Introduction: To compare pain scores at rest and ambulation and to assess patient satisfaction between the different modalities of pain management at different time points after surgery. Settings and Design: The ASSIST (Patient Satisfaction Survey: Pain Management) was an investigator-initiated, prospective, multicenter survey conducted among 1046 postoperative patients from India. Material and Methods: Pain scores, patient's and caregiver's satisfaction toward postoperative pain treatment, and overall pain management at the hospital were captured at three different time points through a specially designed questionnaire. The survey assessed if the presence of acute pain services (APSs) leads to better pain scores and patient satisfaction scores. Statistical Analysis: One-way ANOVA was used to evaluate the statistical significance between different modalities of pain management, and paired t-test was used to compare pain and patient satisfaction scores between the APS and non-APS groups. Results: The results indicated that about 88.4% of patients reported postoperative pain during the first 24 h after surgery. The mean pain score at rest on a scale of 1–10 was 2.3 ± 1.8 during the first 24 h after surgery and 1.1 ± 1.5 at 72 h; the patient satisfaction was 7.9/10. Significant pain relief from all pain treatment was reported by patients in the non-APS group (81.6%) compared with those in the APS (77.8%) group (P < 0.0016). Conclusion: This investigator-initiated survey from the Indian subcontinent demonstrates that current standards of care in postoperative pain management remain suboptimal and that APS service, wherever it exists, is yet to reach its full potential.