Bromelain as an adjunctive treatment for moderate-to-severe osteoarthritis of the knee: a randomized placebo-controlled pilot study

Background: Osteoarthritis (OA) of the knee is the most prevalent joint disorder. Previous studies suggest that bromelain, a pineapple extract, may be a safer alternative/adjunctive treatment for knee OA than current conventional treatment. Aim: To assess the efficacy of bromelain in treating OA of the knee. Design: Randomized, double-blind placebo-controlled trial. Methods: Subjects (n=47) with a confirmed diagnosis of moderate to severe knee OA were randomized to 12 weeks of bromelain 800 mg/day or placebo, with a 4-week follow-up. Knee (pain, stiffness and function) and quality-of-life symptoms were reported monthly in the WOMAC and SF36 questionnaires, respectively. Adverse events were also recorded. The primary outcome measure was the change in total WOMAC score from baseline to the end of treatment at week 12. Longitudinal models were used to evaluate outcome. Results: Thirty-one patients completed the trial (14 bromelain, 17 placebo). No statistically significant differences were observed between groups for the primary outcome (coefficient 11.16, p=0.27, 95%CI-8.86 to 31.18), nor the WOMAC subscales or SF36. Both treatment groups showed clinically relevant improvement in the WOMAC disability subscale only. Adverse events were generally mild in nature. Discussion: This study suggests that bromelain is not efficacious as an adjunctive treatment of moderate to severe OA, but its limitations support the need for a follow-up study.

Frost jacking of joint blocks above Cwm Idwal, in North Wales

The in situ development of ground ice is a major mechanism in rock breakdown. Where well-jointed rock has been streamlined through glacial abrasion, subsequent growth of subsurface intrusive ice may lead to the uplift of individual blocks and disruption of the ice erosional landform. This jacking' mechanism is likely to be a progressive process. Following climatic change and allied ground ice decay, the degree of subsequent settlement will be controlled by the degree to which individual blocks become wedged against their neighbours. Possibly the first example to be identified in Britain is described here. It dates from a severe phase of periglaciation occurring between the Last Glacial Maximum and the Flandrian Interglacial (c. 22-11.6 ka BP). Where identified in currently temperate regions, frost-jacked blocks may be interpreted as evidence for palaeopermafrost.

Frost jacking of joint blocks above Cwm Idwal, in North Wales

The in situ development of ground ice is a major mechanism in rock breakdown. Where well-jointed rock has been streamlined through glacial abrasion, subsequent growth of subsurface intrusive ice may lead to the uplift of individual blocks and disruption of the ice erosional landform. This jacking' mechanism is likely to be a progressive process. Following climatic change and allied ground ice decay, the degree of subsequent settlement will be controlled by the degree to which individual blocks become wedged against their neighbours. Possibly the first example to be identified in Britain is described here. It dates from a severe phase of periglaciation occurring between the Last Glacial Maximum and the Flandrian Interglacial (c. 22-11.6 ka BP). Where identified in currently temperate regions, frost-jacked blocks may be interpreted as evidence for palaeopermafrost.

Early social experience and individual differences in infants' joint attention

Fifty-nine healthy infants were filmed with their mothers and with a researcher at two, four, six and nine months in face-to-face play, and in toy-play at six and nine months. During toy-play at both ages, two indices of joint attention (JA)—infant bids for attention, and percent of time in shared attention—were assessed, along with other behavioural measures. Global ratings were made at all four ages of infants’ and mothers’ interactive style. The mothers varied in psychiatric history (e.g., half had experienced postpartum depression) and socioeconomic status, so their interactive styles were diverse. Variation in nine-month infant JA — with mother and with researcher — was predicted by variation in maternal behaviour and global ratings at six months, but not at two or four months. Concurrent adult behaviour also influenced nine-month JA, independent of infant ratings. Six-month maternal behaviours that positively predicted later JA (some of which remained important at nine months) included teaching, conjoint action on a toy, and global sensitivity. Other behaviours (e.g., entertaining) negatively predicted later JA. Findings are discussed in terms of social-learning and neurobiological accounts of JA emergence.

Fitting models for the joint action of two drugs using SAS(R)

Combinations of drugs are increasingly being used for a wide variety of diseases and conditions. A pre-clinical study may allow the investigation of the response at a large number of dose combinations. In determining the response to a drug combination, interest may lie in seeking evidence of synergism, in which the joint action is greater than the actions of the individual drugs, or of antagonism, in which it is less. Two well-known response surface models representing no interaction are Loewe additivity and Bliss independence, and Loewe or Bliss synergism or antagonism is defined relative to these. We illustrate an approach to fitting these models for the case in which the marginal single drug dose-response relationships are represented by four-parameter logistic curves with common upper and lower limits, and where the response variable is normally distributed with a common variance about the dose-response curve. When the dose-response curves are not parallel, the relative potency of the two drugs varies according to the magnitude of the desired effect and the models for Loewe additivity and synergism/antagonism cannot be explicitly expressed. We present an iterative approach to fitting these models without the assumption of parallel dose-response curves. A goodness-of-fit test based on residuals is also described. Implementation using the SAS NLIN procedure is illustrated using data from a pre-clinical study. Copyright © 2007 John Wiley & Sons, Ltd.

Joint effects of density and a growth inhibitor on the life history and population growth rate of the midge Chironomus riparius

Results of previous laboratory studies suggest that high population density often buffers the effects of chemical stressors that predominately increase mortality. Mortality stressors act to release more resources for the survivors and, therefore, produce less-than-additive effects. By contrast, growth stressors are expected to have opposite results or more-than-additive effects. We investigated the effects of a growth inhibitor (lufenuron) on larval growth and survival of Chironomus riparius and examined its joint effects with density on population growth rate (PGR). Exposure to 60 mu g/kg sediment or greater inhibited larval growth, and exposure to 88 mu g/kg or greater often resulted in mortality before reaching emergence. The effects of lufenuron, however, differed with population density. At 88 mu g/kg, mortalities and, to a lesser extent, reduced fecundity resulted in a reduction in PGR at low density. Conversely, when populations were initiated at high density, PGR was similar to that of controls, because the few survivors reached maturity sooner and started producing offspring earlier. The effect of density as a growth stressor therefore was stronger than the effect of lufenuron, which had effects similar to those of a mortality stressor and produced less-than-additive effects. Longterm studies under field conditions, however, are needed before less-than-additive effects are considered to be the norm.

Joint effects of population density and toxicant exposure on population dynamics of Capitella sp I

Very few studies have analyzed the dependence of population growth rate on population density, and even fewer have considered interaction effects of density and other stresses, such as exposure to toxic chemicals. Yet without such studies we cannot know whether chemicals harmful at low density have effects on carrying capacity or, conversely, whether chemicals reducing carrying capacity are also harmful at low density, impeding a population's capacity to recover from disturbance. This study examines the combined effects of population density and a toxicant (fluoranthene) on population growth rate (pgr) and carrying capacity using the deposit-feeding polychaete Capitella sp. I as a test organism. Populations were initiated with a stable age distribution, and population density and age/size distribution were followed during a period of 28 wk. Fluoranthene (FLU), population density, and their interaction influenced population growth rate. Population growth rate declined linearly with the logarithm of population biomass, but the slope of the relationship was steeper for the control populations than for populations exposed to 50 mug FLU/(g sediment dry mass). Populations exposed to 150 mug FLU/(g sediment dry mass) went extinct after 8 wk of exposure. Despite concerns that toxicant effects would be exacerbated at high density, we found the reverse to be the case, and effects of fluoranthene on population growth rate were much reduced in the region of carrying capacity. Fluoranthene did. reduce carrying capacity by 46%, and this could haven important implications for interacting species and/or sediment biogeochemical processes.

The joint effects of larval density and C-14-cypermethrin on the life history and population growth rate of the midge Chironomus riparius

1. Chemical effects on organisms are typically assessed using individual-level endpoints or sometimes population growth rate (PGR), but such measurements are generally made at low population densities. In contrast most natural populations are subject to density dependence and fluctuate around the environmental carrying capacity as a result of individual competition for resources. As ecotoxicology aims to make reliable population projections of chemical impacts in the field, an understanding of how high-density or resource-limited populations respond to environmental chemicals is essential. 2. Our objective was to determine the joint effects of population density and chemical stress on the life history and PGR of an important ecotoxicological indicator species, Chironomus riparius, under controlled laboratory conditions. Populations were fed the same ration but initiated at different densities and exposed to a solvent control and three concentrations of C-14-cypermethrin in a sediment-water test system for 67 days at 20 +/- 1 degreesC. 3. Density had a negative effect on all the measured life-history traits, and PGR declined with increasing density in the controls. Exposure to C-14-cypermethrin had a direct negative effect on juvenile survival, presumably within the first 24 h because the chemical rapidly dissipated from the water column. Reductions in the initial larval densities resulted in an increase in the available resources for the survivors. Subsequently, exposed populations emerged sooner and started producing offspring earlier than the controls. C-14-cypermethrin had no effect on estimated fecundity and adult body weight but interacted with density to reduce the time to first emergence and first reproduction. As a result, PGR increased with cypermethrin concentration when populations were initiated at high densities. 4. Synthesis and applications. The results showed that the effects of C-14-cypermethrin were buffered at high density, so that the joint effects of density and chemical stress on PGR were less than additive. Low levels of chemical stressors may increase carrying capacity by reducing juvenile competition for resources. More and perhaps fitter adults may be produced, similar to the effects of predators and culling; however, toxicant exposure may result in survivors that are less tolerant to changing conditions. If less than additive effects are typical in the field, standard regulatory tests carried out at low density may overestimate the effects of environmental chemicals. Further studies over a wide range of chemical stressors and organisms with contrasting life histories are needed to make general recommendations.

Joint importance of multistate systems

Importance measures in reliability engineering are used to identify weak areas of a system and signify the roles of components in either causing or contributing to proper functioning of the system. Traditional importance measures for multistate systems mainly concern reliability importance of an individual component and seldom consider the utility performance of the systems. This paper extends the joint importance concepts of two components from the binary system case to the multistate system case. A joint structural importance and a joint reliability importance are defined on the basis of the performance utility of the system. The joint structural importance measures the relationship of two components when the reliabilities of components are not available. The joint reliability importance is inferred when the reliabilities of the components are given. The properties of the importance measures are also investigated. A case study for an offshore electrical power generation system is given.

Improved arthritic knee health in a pilot RCT of phytotherapy

Although practitioner-prescribed 'western' herbal medicine (phytotherapy) is a popular complementary therapy in the UK, no clinical studies have been reported on patient-orientated outcomes. The objective of this pilot study was to investigate the effects of phytotherapy on symptoms of osteoarthritis of the knee. A previous study of Chinese herbal medicine for the treatment of irritable bowel syndrome, published in the Journal of the American Medical Association,(1) acted as a model in the development of the protocol of this investigation. Twenty adults, previously diagnosed with osteoarthritis of the knee, were recruited from two Inner London GP practices into this randomized, double-blind, placebo-controlled, pilot study carried out in a primary-care setting. All subjects were seen in consultation three times by a herbal practitioner who was blinded to the randomization coding. Each subject was prescribed treatment and given lifestyle advice according to usual practice: continuation of conventional medication where applicable, healthy-eating advice and nutrient supplementation, Individualized herbal medicine was prescribed for each patient, but only dispensed for those randomized to active treatment - the remainder were supplied with a placebo. At baseline and outcome (after ten weeks of treatment), subjects completed a food frequency questionnaire and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) knee health and Measure Yourself Outcome Profile (MYMOP) wellbeing questionnaires. Subjects completing the study per protocol (n = 14) reported an increased intake of wholegrain foods (p = 0.045) and oily fish (p = 0.039) compared to baseline, but no increase in fruit and vegetables and dairy products intakes. There was no difference in the primary outcome measure of knee health assessed as the difference in the mean response (baseline-week 10) in WOMAC score between the two treatment groups. However, there was, compared with baseline, improvement in the active group (n = 9) for the mean WOMAC stiffness sub-score at week 5 (p = 0.035) and week 10 (p = 0.060) but not in the placebo group (n = 5). Furthermore, for the active, but not the placebo group, the mean WOMAC total and sub-scores all showed clinically significant improvement (>= 20%) in knee symptoms at weeks 5 and 10 compared with baseline. Moreover, the mean MYMOP symptom 2 sub-score, mostly relating to osteoarthritis (OA), showed significant improvement at week 5 (p = 0.02) and week 10 (p = 0.008) compared with baseline for the active, but not for the placebo group. This pilot study showed that herbal medicine prescribed for the individual by a herbal practitioner resulted in improvement of symptoms of OA of the knee.