Publications of the Week, May 22

Cartilage loss and pain in knee osteoarthritis: triamcinolone vs saline injections

In patients with knee osteoarthritis, injecting the knee joint with corticosteroids has limited efficacy and may promote cartilage loss.

This study involved 140 patients with symptomatic knee osteoarthritis and ultrasound evidence of synovitis. Every 3 months for 2 years they received injections of either 40 mg of triamcinolone or saline placebo. The outcomes included symptoms (pain) and magnetic resonance imaging-measured volume of cartilage.

The study detected no clinically or statistically important effects on symptoms. The loss of cartilage was higher in the triamcinolone group (–0.11 mm difference; 95% confidence interval, –0.2 mm to –0.03 mm). The symptoms were not measured in the first month after the injections, which could have decreased the ability to detect transient beneficial effects during that time.

The authors conclude that injecting the knee with corticosteroids, a frequently performed procedure, is not supported by their findings, which suggest not only no difference in pain but also increased cartilage loss.

Position statement: optimal care of the postarrest patient. Part 2

Survival among people with out-of-hospital cardiac arrest (OHCA) is very low. These Canadian guidelines provide some directions for the management of such patients.

For the first part of our review of a number of recommendations and suggestions, see Publications of the Week, May 8.

In further sections of the guidelines, the authors suggest that post-cardiac arrest patients undergoing mechanical ventilation should have their carbon dioxide titrated to normocapnia (PaCO₂, 35 to 45 mm Hg) and oxygen therapy titrated to avoid both hypoxia and hyperoxia (suggested PaO₂ between 60 and 200 mm Hg). They also suggest that mean arterial pressure be maintained at 65 mm Hg or higher, that the hemoglobin level is maintained at least at 80 g/L, and that central venous pressure assessment as well as lactate monitoring (the latter performed every 4 to 6 hours) are part of the management. An additional weak recommendation (suggestion) advises the use of prophylactic antiarrhythmic medications in patients with recurrent episodes of ventricular fibrillation/tachycardia, nonsustained episodes of ventricular tachycardia, or a high burden of ventricular ectopy.

Lastly, from the organizational point of view, the authors recommend the adoption of institutional best-practice protocols and treatment pathways for OHCA patients from the prehospital stage through to hospital discharge.

Levothyroxine replacement for older patients with subclinical hypothyroidism

In older patients with subclinical hypothyroidism, thyroid hormone replacement had no significant benefits.

This study was designed to look at the benefits and risks of active treatment in the setting of subclinical hypothyroidism among older patients. It included over 700 patients older than 65 years of age (mean age, 74 years) with a persistent biochemical diagnosis of subclinical hypothyroidism defined as a thyrotropin elevation (from 4.60 to 19.99 mIU/L; mean, 6.40 mIU/L) and free thyroxine levels in the reference range. Consequences of thyroid hormone replacement were primarily assessed using thyroid-related quality-of-life questionnaire scores (Hypothyroid Symptoms and Tiredness scores).

Over the course of 1 year, there were no statistical or clinical differences between the groups receiving treatment or placebo. There were also no differences in symptoms and function as evaluated using secondary outcome measures, including general quality-of-life questionnaires and instruments measuring cognitive functions.

The authors conclude that levothyroxine replacement provided no apparent benefit in older persons with subclinical hypothyroidism.