Intra-articular hyaluronic acid for the treatment of osteoarthritis of the knee: systematic review and meta-analysis

Background

Osteoarthritis of the knee affects up to 10% of the elderly population. The condition is frequently treated by intra-articular injection of hyaluronic acid. We performed a systematic review and meta-analysis of randomized controlled trials to assess the effectiveness of this treatment.

Methods

We searched MEDLINE, EMBASE, CINAHL, BIOSIS and the Cochrane Controlled Trial Register from inception until April 2004 using a combination of search terms for knee osteoarthritis and hyaluronic acid and a filter for randomized controlled trials. We extracted data on pain at rest, pain during or immediately after movement, joint function and adverse events.

Results

Twenty-two trials that reported usable quantitative information on any of the predefined end points were identified and included in the systematic review. Even though pain at rest may be improved by hyaluronic acid, the data available from these studies did not allow an appropriate assessment of this end point. Patients who received the intervention experienced a reduction in pain during movement: the mean difference on a 100-mm visual analogue scale was –3.8 mm (95% confidence interval [CI] –9.1 to 1.4 mm) after 2–6 weeks, –4.3 mm (95% CI –7.6 to –0.9 mm) after 10–14 weeks and –7.1 mm (95% CI –11.8 to –2.4 mm) after 22–30 weeks. However, this effect was not compatible with a clinically meaningful difference (expected to be about 15 mm on the visual analogue scale). Furthermore, the effect was exaggerated by trials not reporting an intention-to-treat analysis. No improvement in knee function was observed at any time point. Even so, the effect of hyaluronic acid on knee function was more favourable when allocation was not concealed. Adverse events occurred slightly more often among patients who received the intervention (relative risk 1.08, 95% CI 1.01 to 1.15). Only 4 trials explicitly reported allocation concealment, had blinded outcome assessment and presented intention-to-treat data.

Interpretation

According to the currently available evidence, intra-articular hyaluronic acid has not been proven clinically effective and may be associated with a greater risk of adverse events. Large trials with clinically relevant and uniform end points are necessary to clarify the benefit–risk ratio.Osteoarthritis affects about 10% of the population over 55 years of age. Of those, one-quarter are severely disabled.¹ The condition is characterized by degeneration of the articular cartilage and subsequent subchondral bone changes. The underlying mechanisms remain unknown, but the glycosaminoglycan–proteoglycan matrix may play a major role.²Hyaluronic acid, a glycosaminoglycan, is widely used for the treatment of osteoarthritis of the knee. A survey of 2 general practices in the United Kingdom showed that about 15% of patients with osteoarthritis received intra-articular treatment with glucosamine sulfates.³ The costs of such treatment are significant. At present, 1 syringe of hyaluronic acid costs at least Can$130 (US$110). The treatment of knee osteoarthritis is covered by the US Medicare program but not by provincial formularies in Canada. In Austria (which has 8 million inhabitants) more than 10 million euros (approximately US$12 million or Can$15 million) is spent by social insurance programs annually for hyaluronic acid preparations (excluding the cost of application).Hyaluronic acid has beneficial effects in vitro.⁴ Because of its viscoelastic quality, it may replace synovial fluid. Furthermore, it may reduce the perception of pain. Beneficial molecular and cellular effects have also been reported.^2,4 Hyaluronic acid is frequently applied by intra-articular injection, but the evidence concerning its clinical relevance is conflicting. The European League against Rheumatism (EULAR) recommends the intra-articular application of hyaluronic acid as “category 2” evidence (at least 1 controlled study without randomization).⁵ The American College of Rheumatology recommends intra-articular hyaluron therapy for patients with no response to nonpharmacologic therapy and simple analgesics.⁶ In contrast, other specialists have concluded that “hyaluronate sodium is not efficacious” in the treatment of osteoarthritis.⁷ The first state-of-the-art systematic review and meta-analysis was published recently,⁸ and its authors concluded “that intra-articular hyaluronic acid, at best, has a small effect.” We performed a systematic review and meta-analysis of the effect of intra-articular hyaluronic acid for the treatment of osteoarthritis of the knee. In contrast to 2 previous meta-analyses on this subject,^8,9 we used a different approach to data synthesis and interpretation: instead of analyzing a composite effect size over time, we allocated trial data, when possible, to 3 outcome groups that we assumed would be relevant for patients with osteoarthritis. We specifically looked at pain at rest, pain during exercise and joint function as distinct outcomes, measured repeatedly over time. In addition, we assessed adverse events and the impact of both trial quality and molecular mass of the product. This analysis allows us to provide important additional insight into the effects of intra-articular administration of hyaluronic acid for the treatment of osteoarthritis of the knee.     

Identification of a chemically induced point mutation mediating herbicide tolerance in annual medics (Medicago spp.)

Background and Aims: Sulfonylurea (SU) herbicides are used extensively in cereal–livestockfarming zones as effective and cheap herbicides with usefullevels of residual activity. These residues can persist beyondthe cropping year, severely affecting legumes in general, andannual medics in particular, resulting in reduced dry matterproduction, lower seed yields and decreased nitrogen fixation.A strand medic cultivar, Medicago littoralis ‘Angel’,has been developed via chemical mutagenesis with tolerance toSU soil residues. Identifying the molecular basis of the observedtolerance was the aim of this study. Methods: Two F₂ populations were generated from crosses between ‘Angel’and varieties of intolerant M. truncatula, the male-sterilemutant tap and the cultivar ‘Caliph’. Genetic mappingwith SSR (single sequence repeat) and gene-based markers allowedidentification of the trait-defining gene. Quantitative geneexpression studies showed the activity of the respective alleles. Key Results: Segregation ratios indicated the control of SU-herbicide toleranceby a single dominant gene. SU herbicides inhibit the biosynthesisof the branched-chain amino acids by targeting the acetolactatesynthase enzyme, allowing the choice of a mapping approach usingacetolactate synthase (ALS) gene homologues as candidates. SSR-markeranalysis suggested the ALS-gene homologue on chromosome 3 inM. truncatula. The ALS-gene sequences from ‘Angel’and intolerant genotypes were sequenced. In ‘Angel’,a single point mutation from C to T translating into an aminoacid change from proline to leucine was identified. The polymorphismwas used to develop a diagnostic marker for the tolerance trait.Expression of the mutant ALS allele was confirmed by quantitativeRT-PCR and showed no differences at various seedling stagesand treatments to the corresponding wild-type allele. Conclusions: The identification of the trait-defining gene and the developmentof a diagnostic marker enable efficient introgression of thiseconomically important trait in annual medic improvement programs.     

Evaluating vaccinia virus cytokine co-expression in TLR GKO mice

Using Toll-like receptor (TLR) and MyD88 gene knock-out (GKO) mice the effect of TLRs and MyD88 on virus replication, interferon (IFN)-β production, natural killer (NK) cell and CD8T cell responses were assessed following ectromelia virus (ECTV) and recombinant vaccinia virus (rVV) infection. The capacity for rVVs encoding cytokines to restore immune function in MyD88(-/-) mice was clearly demonstrated. Results showed that TLR2(-/-), TLR4(-/-)and TLR7(-/-) mice survived ECTV infection whereas MyD88(-/-) and TLR9(-/-)mice, in contrast, were highly susceptible. Next, following infection with rVV, MyD88(-/-) mice elicited reduced serum IFN-β, NK cell and CD8T cell responses compared with wild-type mice, whereas TLR9(-/-) mice showed elevated CD8T cell responses. When MyD88(-/-)mice were infected with rVV co-expressing IFN-β these mice were able to restore IFN-β levels and CD8T cell responses but not NK cell activation. Interestingly, even though rVV co-expressing interleukin (IL)-2 enhanced NK cell activation in MyD88(-/-) mice, this was not associated with an antiviral effect, as observed in normal mice. Surprisingly, co-infection with rVV IL-2/rVV IL-12, but not rVV IL-2/rVV IFN-β, restored the attenuated phenotype of rVV IL-2 in MyD88(-/-) mice indicating that the IL-2/IL-12 combination promotes antiviral responses. Our results clearly show that the CD8T cell defect observed in MyD88(-/-) mice to vaccinia virus infection can be restored by rVV-encoding IFN-β demonstrating the critical role of this cytokine in T cell mediated immunity and illustrates that the model can provide an effective platform for the elucidation of cytokine immunobiology.     

Unlocking the barley genome by chromosomal and comparative genomics

We used a novel approach that incorporated chromosome sorting, next-generation sequencing, array hybridization, and systematic exploitation of conserved synteny with model grasses to assign ~86% of the estimated ~32,000 barley (Hordeum vulgare) genes to individual chromosome arms. Using a series of bioinformatically constructed genome zippers that integrate gene indices of rice (Oryza sativa), sorghum (Sorghum bicolor), and Brachypodium distachyon in a conserved synteny model, we were able to assemble 21,766 barley genes in a putative linear order. We show that the barley (H) genome displays a mosaic of structural similarity to hexaploid bread wheat (Triticum aestivum) A, B, and D subgenomes and that orthologous genes in different grasses exhibit signatures of positive selection in different lineages. We present an ordered, information-rich scaffold of the barley genome that provides a valuable and robust framework for the development of novel strategies in cereal breeding.     

New Insights to Self‐Aggregation in Ionic Liquid Electrolytes for High‐Energy Electrochemical Devices

Some cations of ionic liquids (ILs) of interest for high‐energy electrochemical storage devices, such as lithium batteries and supercapacitors, have a structure similar to that of surfactants. For such, it is very important to understand if these IL cations tend to aggregate like surfactants since this would affect the ion mobility and thus the ionic conductivity. The aggregation behaviour of ILs consisting of the bis(trifluoromethanesulfonyl)imide anion and different N‐alkyl‐N‐methyl‐pyrrolidinium cations, with the alkyl chain varied from C₃H₇ to C₈H₁₇, was extensively studied with NMR and Raman methods, also in the presence of Li⁺ cations. ²H NMR spin‐lattice and spin‐spin relaxation rates were analyzed by applying the “two step” model of surfactant dynamics. Here we show that, indeed, the cations in these ILs tend to form aggregates surrounded by the anions. The effect is even more pronounced in the presence of dissolved lithium cations.     

Molecular phylogenetics ofCochlearia (Brassicaceae) and allied genera based on nuclear ribosomal ITS DNA sequence analysis contradict traditional concepts of their evolutionary relationship

The systematics and phylogeny of the genusCochlearia and allied genera are unsettled. There are no clearly defined genera and subtribal structures to determine subtribeCochleariinae in respect to subtribeThlaspidinae. The use of morphological data, such as fruit form or embryo characters have resulted in contradictory taxonomic concepts in the past due to their homoplastic nature. We investigated all sections of genusCochlearia recognised in the most common concepts, as well as some genera such asIonopsidium, Bivonaea, Pastorea andThlaspi s. l. pro parte. Previous studies based on molecular data and morphological studies have shown close relationships between taxa from subtribeCochleariinae andThlaspidinae. The Internal Transcribed Spacer regions of the nuclear encoded ribosomal DNA operon and the plastidictrnL intron were sequenced from a number of genera. A molecular phylogeny was derived and compared to traditional classification systems. These data grouped sections ofCochlearia outside theCochlearial Ionopsidium core group and integrated them either closely to genusNoccaea in subtribeThlaspidinae (sect.Pseudosempervivum) or positioned them outside both theCochlearia core group and theThlaspi s. l. clade (sect.Hilliella). The molecular data indicate that subtribal arrangements in tribeLepidieae are artificial and do not reflect evolutionary history. The genusCochlearia is represented by sectionsCochlearia andGlaucocochlearia and the genusIonopsidium should be integrated intoCochlearia.     

Action of Pasteurella multocida toxin depends on the helical domain of Galphaq

Pasteurella multocida produces a 146-kDa protein toxin (PMT), which activates multiple cellular signal transduction pathways, resulting in the activation of phospholipase Cbeta, RhoA, Jun kinase, and extracellular signal-regulated kinase. Using Galpha(q)/Galpha(11) -deficient cells, it was shown that the PMT-induced pleiotropic effects are mediated by Galpha(q) but not by the highly related Galpha(11) protein (Zywietz, A., Gohla, A., Schmelz, M., Schultz, G., and Offermanns, S. (2001) J. Biol. Chem. 276, 3840-3845). Here we studied the molecular basis of the unique specificity of PMT to distinguish between Galpha(q) and/or Galpha(11). Infection of Galpha(q) -deficient cells with retrovirus-encoding Galpha(q) caused reconstitution of PMT-induced activation of phospholipase Cbeta, whereas Galpha(11) -encoding virus did not reconstitute PMT activity. Chimeras between Galpha(q) and/or Galpha(11) revealed that a peptide region of Galpha(q), covering amino acid residues 105-113, is essential for the action of PMT to activate phospholipase Cbeta. Exchange of glutamine 105 or asparagine 109 of Galpha(11), which are located in the all-helical domain of the Galpha subunit, with the equally positioned histidines of Galpha(q), renders Galpha(11) capable of transmission PMT-induced phospholipase Cbeta activation. The data indicate that the all-helical domain of Galpha(q) is essential for the action of PMT and suggest an essential functional role of this domain in signal transduction via G(q) proteins.     

Stomatal movement in Zea mays: Shuttle of potassium and chloride between guard cells and subsidiary cells

Summary When stomates of Zea mays open K and Cl migrate from the subsidiary cells into the guard cells; when the stomates close both elements return to the subsidiary cells. Subsidiary cells function as reservoirs for K and Cl. Import of K and Cl into the guard cells and loss of both elements from the guard cells become observable 1 or 2 min after light is turned on or off, both when histochemical methods and the electron-probe microanalyzer are used for detection. Each stomatal complex of maize contains on the average 10±3×10^-13 gram equivalents (eq) of K and 4±1×10^-13 eq of Cl. Guard cells accumulate K in the light and CO₂-free air at an average rate of 10×10^-15 eq K per minute, and Cl at approximately half that rate.