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The top ten brain science and psychology studies of 2015.

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The pace of research seems to accelerate more every year, and 2015 saw its share of major studies across several categories of brain science and psychology. This Top 10 list isn’t meant to be exhaustive (and it isn't ranked in any particular order), but is rather a survey of the top research covered here at Neuropsyched along with a few additional studies that had an impact. A number of these studies also serve as prelude to research we'll see in the coming year.

1.Brain Powers Change as You Age

Science bolstered the ever-changing-brain theory in 2015 by showing that mental abilities don’t all collectively peak and begin rolling downhill at any one age, or even during one or two decades. Instead, they fluctuate across a span of ages, with a couple peaking well into our elder years. The findings came from a study that included over 50,000 people with ages ranging from the teens to their 70s. Mental abilities like brain processing speed peaked early on, around age 18, while vocabulary skills continued developing into the 60s and 70s. Remembering things we see (visual working memory) peaks around age 25, while short-term memory doesn’t take full form until around 35. One of the most interesting mental abilities the study tracked has to do with our ability to read other people – how well we identify which emotions are percolating or absent in the person across the table. The researchers found that this ability doesn’t take shape until we’re in our 40s, and continues maturing for a couple of decades well into our 60s.

Quoting study co-author Laura Germine: “The brain seems to continue to change in dynamic ways through early adulthood and middle age,” and that the current study “paints a different picture of the way we change over the lifespan than psychology and neuroscience have traditionally painted.”

2. Alzheimer’s Clues Appear Much Earlier than We Thought

A handful of studies in 2015 hinted at early clues to the development of Alzheimer’s disease. One study published in the journal Neurology showed that late middle-age memory failures can predict Alzheimer’s as much as 18 years before diagnosis. Participants were given tests of mental ability and memory every three years for 18 years. Those who scored lowest on the memory and thinking tests during the first year of the study were 10 times more likely to develop the disease.

Another study published in the journal Science used fMRI to identify early signs of the disease appearing in the brain’s internal GPS system, within a region called the  entorhinal cortex  that plays a major role in memory and navigation. Look for more studies to build on these findings in 2016.

3. Missing Link Between the Brain and Immune System Identified

How the brain rids itself of toxins has been a point of debate for some time. The prevailing theory is that the brain doesn’t use the body’s lymphatic system, but rather has its own garbage removal system that appears to come online when we sleep. A study conducted by University of Virginia researchers in 2015 found that the brain does, in fact, use the body’s lymphatic system, but with a previously unidentified network of blood vessels in the meninges (the membranes surrounding the brain and spinal cord). The study was conducted in mice but the same vessels were also identified in human samples. It’s possible that abnormalities in these vessels may play a role in various neurological diseases like multiple sclerosis and schizophrenia. If that finding is confirmed, the network of vessels could become an early treatment target for these and other diseases.  Look for additional studies to build on this one in the next year.

AFP PHOTO / MIGUEL MEDINA (Photo credit should read MIGUEL MEDINA/AFP/Getty Images)

4. Loneliness is Destructive to the Mind and Body

Two studies came out in 2015 showing a convincing link between loneliness and both mental and physical debilitation. One of the studies focused on the effects of loneliness on 8,300 adults age 65 and older who participated  in the  U.S. Health  and  Retirement  Study from 1998 to 2010. Participants in the study were assessed every two years across a range of factors, including levels of depression, loneliness, memory, cognitive function and social network status. About 1,400 of the participants (17%) reported loneliness at the start of the study, and roughly half of that group also reported clinically significant depression. Over the 12-year study, participants reporting loneliness experienced 20% faster cognitive decline than other participants. This result held true regardless of factors like demographics, socioeconomic status and the presence of other debilitating health conditions. Higher levels of depression also correlated significantly with more rapid cognitive decline.

In another study funded by the National Institutes of Health, loneliness (defined as a “perceived social isolation”) was linked to a 14% increase in premature death among older adults. More studies along these lines are set to publish in 2016.

5. Popular Over-the-Counter Drugs Linked to Increased Risk of Dementia

Researchers published a bombshell study in JAMA Internal Medicine in 2015 showing that four common medications are linked to a significantly increased risk of developing dementia in older adults. The study followed 3,434 people over the age of 65 for seven years. None of the participants showed signs of dementia at the start of the study period. During the seven years, almost 800 of the participants developed dementia (637 developed Alzheimer’s disease; the rest were afflicted with other forms of dementia). After controlling for a range of other factors, the researchers were able to link heightened risk of dementia to a daily dose of four medications: Diphenhydramine  (the active ingredient in many over-the-counter antihistamines); Chlorpheniramine  (another popular over-the-counter antihistamine); Oxybutynin (a prescription medication for bladder conditions); and Doxepin  (an older prescription antidepressant from the class of meds called tricylics).

All of the drugs in question are  anticholinergics  – meaning they block a neurotransmitter called  acetylcholine  in the nervous system. Common side effects of taking anticholinergics include drowsiness, blurred vision and memory loss. People suffering from Alzheimer’s disease typically have low brain levels of acetylcholine, and previous  research  has shown a link between taking anticholinergic drugs and increased risk of dementia in older adults. While the study didn’t prove a cause-and-effect relationship, the correlation was strong and of particular concern for older adults.

6. Middle-Age Americans Are Dying and We Don’t Know Why

While not strictly speaking a brain science or psych study, research by two economists uncovered an alarming finding with a distinctly psychological dimension. Economists Anne Case and Angus Deaton reported “a marked increase in the all-cause mortality of middle-aged white non-Hispanic men and women in the United States between 1999 and 2013. This change reversed decades of progress in mortality and was unique to the United States; no other rich country saw a similar turnaround.” The researchers focused specifically on mortality rates for 45-to-54 year olds.

The impact of this study has nothing to do with firm conclusions, because the study itself doesn’t point to specific causes for the trend. And some statisticians are still wrestling with the data to determine exactly what it tells us beyond surface-level speculation. But study co-author Angus Deaton, who was also the 2015 Nobel laureate in economics, thinks he knows at least part of what the data is telling us: “Drugs and alcohol, and suicide . . . are clearly the proximate cause.” Why those factors are increasing among this specific group is the question. More to come on this in the coming year, no doubt.

7. The More Time You Spend On Facebook, The More Likely You’ll Be Depressed

One of the biggest ironies of our time is that social media—the technology that promised to connect us to the world—may be a significant factor in elevating rates of loneliness and depression. A 2015 study published in the  Journal of Social and Clinical Psychology  added to the chorus, but also helped clarify the issue by pinpointing the lynchpin between social media use and depression – social comparison . The researchers think that the social comparisons we make between ourselves and all of our online “friends” showing off the very best parts of their lives is the heart of the matter.

The study found that people who spend the most time on Facebook, men and women, consistently showed more depressive symptoms, and social comparison with peers surfaces as the main reason why. Another way to frame the findings – the personal public relations jobs people do on Facebook are having an impact, and not the sort I think we were hoping for in the early days of the technology. Maybe in 2016 we can start ignoring more online PR and take back some of the emotional ground we’ve yielded to social media.

8. We’re Getting Closer to Blood Testing for Mental Health Disorders

While still quite preliminary, a breakthrough study in 2015 showed that biomarkers for suicidal tendencies can be identified in blood tests. Researchers from Indiana University developed a questionnaire and a blood test that together predicted with 92 percent accuracy who among a group of 108 men would develop suicidal thoughts. Considering that only about 2 percent of people suffering from depression commit suicide (and depression is the leading cause of suicide), having a method that can detect who’s most likely to go there would be immensely useful to mental health professionals. On a broader scale, tests like these may also eventually show tendencies for developing depression and other psychiatric disorders, which would put a much finer point on identifying the best treatment options earlier on. Having said that, this area of research is controversial and in its infancy, so much more to come on all of the above – but the beginnings of something potentially quite big have emerged.

9. Diet Can Influence Your Chances of Developing Depression

Each year more research comes out linking inflammation at the cellular level to a host of badness, including heart disease, diabetes, some forms of cancer, and, more recently, depression. And we’ve also found that inflammation is strongly linked to lifestyle factors, with diet high among them. While the connective details are still not entirely clear, research from 2015 indicates that changing your diet to something closer to the Mediterranean Diet (which has known anti-inflammatory effects) can lower your risk of depression. The study suggests that even moderately following the diet can cut the risk by way of, it’s thought, lowering cellular inflammation. With inflammation research exploding, we’ll hear more about this and other linkages soon.

10. We Can Stop Wasting Time Talking About Birth Order

I always like to include one study in these lists that kicks a pop psych myth squarely in its tookis. This year that honor goes to research that challenged the long-held belief that birth order has a major effect on the relative personality and intelligence of siblings. Researchers studied 377,000 high school students to find out how much birth order affected their personality development and intelligence. They found that firstborns do have slightly higher IQs than their later-born siblings, but only one point higher – a statistically significant but practically meaningless difference. Firstborns also tend to score higher on certain  personality traits  like extroversion, agreeableness and conscientiousness, but the differences between their scores and those of later-borns are, according to the researchers, “infinitesimally small.” Overall, the association between birth order and personality was statistically .02, which is well below the level of perception.

According to study co-author Brent Roberts, professor of psychology at the University of Illinois, “In some cases, if a drug saves 10 out of 10,000 lives, for example, small effects can be profound. But in terms of personality traits and how you rate them, a .02 correlation doesn’t get you anything of note. You are not going to be able to see it with the naked eye. You’re not going to be able to sit two people down next to each other and see the differences between them. It’s not noticeable by anybody.”

You can find David DiSalvo on  Twitter , Facebook ,  Google Plus , and at his website  daviddisalvo.org .

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2015 Student and Faculty Technology Research Studies

This hub contains the 2015 student and faculty studies from the EDUCAUSE Technology Research in the Academic Community research series. In 2015, ECAR collaborated with 139 institutions to collect responses from 13,276 faculty respondents across 12 countries about their technology experiences. ECAR also collaborated with 161 institutions to collect responses from 50,274 undergraduate students  across 11 countries about their technology experiences.

Study of Students and Information Technology, 2015

Authors: D. Christopher Brooks, Eden Dahlstrom, Susan Grajek, and Jamie Reeves Publication Date: December 2015

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Key Findings

Selected findings are below. See the report for a comprehensive list.

• Technology is embedded into students’ lives, and students generally have positive inclinations toward technology.
• More students own Internet-capable devices now than ever. A projected increase in connected devices could soon challenge even the most agile networks.
• Students and faculty have similarly high levels of interest in using mobile devices to enhance learning, but the actual use of these devices in academics remains low, despite their increased prevalence.
• Although students use technology extensively, we have evidence that technologies are not achieving their full potential for academic use.
• Most students support institutional use of their data to advise them on academic progress in courses and programs.

Study of Faculty and Information Technology, 2015

Authors: D. Christopher Brooks Publication Date: October 2015

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• Faculty own a variety of technologies, possess generally positive dispositions and attitudes toward technology, and use it extensively.
• Faculty have considerable experience teaching with technology, especially using digital learning environments.
• Faculty claim that they would adopt technology more if they had evidence of its impact on student learning.
• Faculty are motivated by the prospect of having release time to design or redesign their courses.
• A majority of faculty think that mobile technology can enhance student learning.

EDUCAUSE Technology Research in the Academic Community

This research can catalyze conversations among IT professionals about how to better serve their constituents; among institutional leaders about how to use technology strategically; and among faculty and students about how to articulate their technology needs and expectations.

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Related Resources

• Students and Faculty on Their IT Experience and Expectations: 2015 ECAR Findings , EDUCAUSE Live! Webinar
• Data to Drive Decisions: The 2015 ECAR Faculty and Student Technology Surveys , 2015 EDUCAUSE Annual Conference Presentation

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Education Research Highlights From 2015

A look at the research that made an impact in 2015, from the benefits of well-designed classroom spaces to the neuroscience behind exercise and math ability.

2015 was a great year for education research. fMRI technology gave us new insight into how exercise can improve math ability by changing the structure of children's brains (#13 below). We saw how Sesame Street's 40-year history has made an impact on preparing young children for school (#7). Several studies reinforced the importance of social and emotional learning for students (#2, 5, and 9). Two must-read publications were released to help educators understand how students learn (#4 and 11). Here are 15 studies published this year that every educator should know about.

1. Well-Designed Classrooms Boost Student Learning

A classroom's physical learning space makes a difference in how well students learn. In this study of 27 schools in England, researchers found that improving a primary classroom’s physical design, including lighting, layout, and decorations, can improve academic performance by as much as 16 percent (although too many decorations can be a distraction ).

• Barrett, P. S., Zhang, Y., Davies, F., & Barrett, L. C. (2015). Clever Classrooms: Summary report of the HEAD project . University of Salford, Manchester.

2. The Benefits of Being Kind Last From Kindergarten to Adulthood

Kindness matters. Kindergarten students who share, help others, and show empathy are more likely to have personal, educational, and career success as adults, finds this study that tracked 753 children from 1991 to 2010.

• Jones, D. E., Greenberg, M., Crowley, M. (2015). Early social-emotional functioning and public health: The relationship between kindergarten social competence and future wellness. American Journal of Public Health , e-View Ahead of Print.

3. Theatre Programs Help Students With Autism

Did you know that participating in theatre programs can help students with autism learn to play in groups, communicate with others, and recognize faces? These are the findings of a study by researchers from Vanderbilt University.

• Corbett, B. A., Key, A. P., Qualls, L., Fecteau, S., Newsom, C., Coke, C., & Yoder, P. (2015). Improvement in Social Competence Using a Randomized Trial of a Theatre Intervention for Children With Autism Spectrum Disorder. Journal of Autism and Developmental Disorders , 1-15.

4. The Science of Learning

If you’re looking for an excellent review of research on how students learn, check out The Science of Learning . Drawing from cognitive science, this report breaks down the research into six principles with a full reference list and teaching tips.

• Deans for Impact (2015). The Science of Learning . Austin, TX: Deans for Impact.

5. Investing $1 in Social and Emotional Learning Yields $11 in Long-Term Benefits

We know that SEL has tremendous benefits for student learning , but what are the long-term economic benefits? Researchers analyzed the economic impact of six widely-used SEL programs and found that on average, every dollar invested yields $11 in long-term benefits, ranging from reduced juvenile crime, higher lifetime earnings, and better mental and physical health.

• Belfield, C., Bowden, B., Klapp, A., Levin, H., Shand, R., & Zander, S. (2015). The Economic Value of Social and Emotional Learning . New York, NY: Center for Benefit-Cost Studies in Education.

6. Low-Income Students Now a Majority

51 percent of the students across the nation’s public schools now come from low-income families.

• A New Majority Research Bulletin: Low Income Students Now a Majority in the Nation's Public Schools

7. Sesame Street Boosts Learning for Preschool Children

Sesame Street was introduced over 40 years ago an educational program to help prepare children for school. Examining census data, researchers discovered that preschool-aged children in areas with better reception did better in school. Children living in poorer neighborhoods experienced the largest gains in school performance.

• Kearney, M. S., & Levine, P. B. (2015). Early Childhood Education by MOOC: Lessons From Sesame Street (No. w21229). National Bureau of Economic Research.

8. Don’t Assign More Than 70 Minutes of Homework

For middle school students, assigning up to 70 minutes of daily math and science homework was beneficial, but assigning more than 90-100 minutes resulted in a decline in academic performance. Read more about the research on homework .

• Fernández-Alonso, R., Suárez-Álvarez, J., & Muñiz, J. (2015). Adolescents’ Homework Performance in Mathematics and Science: Personal Factors and Teaching Practices . Journal of Educational Psychology, 107 (4), 1075–1085

9. Mindfulness Exercises Boost Math Scores

Mindfulness exercises help students feel more positive , and a new study found that it can also boost math performance. Elementary school students that participated in a mindfulness program had 15 percent better math scores, in addition to several emotional and psychological benefits.

• Schonert-Reichl, K. A., Oberle, E., Lawlor, M. S., Abbott, D., Thomson, K., Oberlander, T. F., & Diamond, A. (2015). Enhancing cognitive and social–emotional development through a simple-to-administer mindfulness-based school program for elementary school children: A randomized controlled trial . Developmental Psychology, 51 (1), 52.

10. Boys Get Higher Math Scores When Graded by Teachers Who Know Their Names

In this Israeli study, middle and high school students were randomly assigned to be graded anonymously or by teachers who knew their names. Despite performing worse than girls in math when graded anonymously, boys had better scores when teachers knew who they were.

• Lavy, V., & Sand, E. (2015). On the Origins of Gender Human Capital Gaps: Short and Long Term Consequences of Teachers’ Stereotypical Biases (No. w20909). National Bureau of Economic Research.

11. Top Psychology Principles Every Teacher Should Know

How do students think and learn? The American Psychological Association sought to answer this question with the help of experts across a wide variety of psychological fields. The result: 20 science-backed principles that explain how social and behavioral factors influence learning.

• American Psychological Association, Coalition for Psychology in Schools and Education. (2015). Top 20 Principles from Psychology for PreK–12 Teaching and Learning .

12. To Help Students With ADHD Concentrate, Let Them Fidget

Since hyperactivity can be a natural state for students with ADHD, preventing them from fidgeting can hurt their ability to stay focused. For tips on how to let students fidget quietly, check out 17 Ways to Help Students With ADHD Concentrate .

• Hartanto, T. A., Krafft, C. E., Iosif, A. M., & Schweitzer, J. B. (2015). A trial-by-trial analysis reveals more intense physical activity is associated with better cognitive control performance in attention-deficit/hyperactivity disorder. Child Neuropsychology , (ahead of print), 1-9.

13. The Neuroscience Behind Exercise and Math Ability

Research shows that exercise has a positive effect on learning , but studies generally tend to be observational. With the use of fMRI technology, however, researchers have gained new insight into how people learn. A team of scientists examined the brain structures of children and found that when young children exercise, their brains produce a thinner layer of cortical gray matter, which can lead to stronger math skills.

• Chaddock-Heyman, L., Erickson, K. I., Kienzler, C., King, M., Pontifex, M. B., Raine, L. B., Hillman, C. H., & Kramer, A. F. (2015). The Role of Aerobic Fitness in Cortical Thickness and Mathematics Achievement in Preadolescent Children. PLOS ONE, 10 (8), e0134115.

14. The Benefits of a Positive Message Home

Getting parents more involved in their child’s education is a great way to boost student learning . When teachers sent short weekly messages to parents with tips on how their kids could improve, it led to higher-quality home discussions and cut course dropout rates by almost half.

• Kraft, M. A., & Rogers, T. (2015). The underutilized potential of teacher-to-parent communication: Evidence from a field experiment . Economics of Education Review, 47 , 49-63.

15. When Teachers Collaborate, Math and Reading Scores Go Up

Teaching can feel like an isolating profession , but this new study shows that working in groups -- especially instructional teams -- can boost student learning.

• Ronfeldt, M., Farmer, S. O., McQueen, K., & Grissom, J. A. (2015). Teacher Collaboration in Instructional Teams and Student Achievement . American Educational Research Journal, 52 (3), 475-514.

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Osteoarthritis Year in Review 2015: Clinical

Leena sharma.

Northwestern University, Chicago IL

The purpose of this review is to highlight clinical research in osteoarthritis. A literature search was conducted using PubMed ( http://www.ncbi.nlm.nih.gov/pubmed/ ) with the search terms “osteoarthritis [All Fields] AND treatment [All Fields]” and the following limits activated: humans, English language, all adult 19+ years, published between April 1, 2014 and April 1, 2015. A second literature search was then conducted with the search terms “osteoarthritis [All Fields] AND epidemiology [All Fields]”, with the same limits. Reports of surgical outcome, case series, surgical technique, tissue sample or culture studies, trial protocols, and pilot studies were excluded. Of 1523, 148 were considered relevant. Among epidemiologic and observational clinical studies, themes included physical activity, early knee OA, and confidence/instability/falls. Symptom outcomes of pharmacologic treatments were reported for methotrexate, adalimumab, anti-nerve growth factor monoclonal antibodies, strontium ranelate, bisphosphonates, glucosamine, and chondroitin sulfate, and structural outcomes of pharmacologic treatments for strontium ranelate, recombinant human fibroblast growth factor 18, and glucosamine and chondroitin sulfate. Symptom outcomes of non-pharmacologic interventions were reported for: neuromuscular exercise, quadriceps strengthening, weight reduction and maintenance, TENS, therapeutic ultrasound, stepped care strategies, cognitive behavior therapy for sleep disturbance, acupuncture, gait modification, booster physical therapy, a web-based therapeutic exercise resource center for knee OA; hip physical therapy for hip OA; and joint protection and hand exercises for hand OA. Structure outcomes of non-pharmacologic interventions were reported for patellofemoral bracing.

INTRODUCTION

This is an important era in the clinical investigation of osteoarthritis (OA); a confluence of advances positions investigators to accelerate the pace of work and gains in knowledge. Towards this mission, an annual review can help to organize the large amount of work accomplished in the past year, a particularly useful task for a field as broad and heterogeneous as clinical OA. While some themes emerged, a number of studies did not fall into a theme per se. The OARSI definition of OA is: “a disorder involving movable joints characterized by cell stress and extracellular matrix degradation initiated by micro- and macro-injury that activates maladaptive repair responses including pro-inflammatory pathways of innate immunity. The disease manifests first as a molecular derangement (abnormal joint tissue metabolism) followed by anatomic, and/or physiologic derangements (characterized by cartilage degradation, bone remodeling, osteophyte formation, joint inflammation and loss of normal joint function), that can culminate in illness” ( http://oarsi.org/research/standardization-osteoarthritis-definitions ).

Among the most important concepts that emerged in this annual review of the literature is continued and further appreciation of stage of pre-disease or disease and clinical phenotype, both in terms of prognosis and suitability and likelihood of success of specific interventions. The ultimate goal of intervention that delays disease and disability progression in this heterogeneous condition will necessitate clear delineation of the phenotypes and disease stages that are encompassed by the label of OA. In recognition of this, OARSI has made the following call:

New specific and sensitive disease endpoints are critically needed to alleviate roadblocks to development of disease modifying therapeutics for OA. A key step in this process is the development of standardized definitions of OA. Standardization of OA definitions would aid communication across the field and help advance drug development for OA and research by achieving consensus on globally recognized definitions of disease and globally recognized standards for classifying the disease. We anticipate that these definitions could facilitate communication about the disease among industry and non-industry researchers, regulatory agencies, funding agencies, third party payers, and patients. We further anticipate that these definitions would be maintained by OARSI and be subjected to regular refinement as new scientific advances demand. Definitions proposed are not intended to distinguish an OA patient uniquely from patients with other forms of arthritis; but rather, they are intended to provide definitions of the disease process that supersede the many and varied OA phenotypes, to spur scientific advances, and facilitate communication with regulatory agencies. The draft definitions can be viewed as the building blocks for defining OA phenotypes. We fully acknowledge that these building blocks are likely most applicable to knee and hip OA, possibly helpful for hand OA, but will require modification for spine OA. ( http://oarsi.org/research/standardization-osteoarthritis-definitions )

The purpose of the current review is to highlight clinical research in OA, particularly in the realms of epidemiology, observational clinical studies, pharmacologic treatment, and nonpharmacologic interventions and strategies. Although an attempt to summarize clinical research in OA in the past year is valuable, it must be emphasized that this is a narrative review and that it is not feasible to summarize all of the important findings of each of these papers.

A literature search was conducted using PubMed ( http://www.ncbi.nlm.nih.gov/pubmed/ ) with the search terms “osteoarthritis [All Fields] AND treatment [All Fields]” and the following limits activated: humans, English language, all adult 19+ years, published between April 1, 2014 and April 1, 2015. A second literature search was then conducted with the search terms “osteoarthritis [All Fields] AND epidemiology [All Fields]”, with the same limits. These searches were repeated using Embase ( http://www.embase.com/ ). Reports of surgical outcome, case series, surgical technique, tissue sample or culture studies, trial protocols, pilot studies and meeting abstracts were excluded as were reports focusing on imaging, biomarkers, and rehabilitation, as these topics are being summarized within other reviews in this issue. Of 1523 papers identified, 148 were considered relevant

Papers are described under the heading (below) which corresponds with the primary goal of the reported work. However, some papers could have been included in more than one category. Table 1 lists all papers falling within a given category.

Osteoarthritis Papers Identified within Each Category

Epidemiologic and Observational Clinical Studies

Manuscripts are organized into certain themes that emerged (physical activity, early OA, confidence/instability/falls), followed by sections devoted to cross-sectional studies of prevalent knee OA, longitudinal studies dealing with incident knee OA, longitudinal studies dealing with knee OA progression, cross-sectional studies of physical functioning in knee OA, longitudinal studies of physical functioning in knee OA, hip OA, hand OA, foot OA, and pain.

Physical Activity

Papers dealing with physical activity reported on the association of activity with incident knee OA and with joint pain and stiffness, factors associated with activity avoidance, impact of sedentary activity, effect of walking on incident function limitation, qualitative analysis of symptom impact on activity, impact of time in light intensity activity on disability outcomes, and association with health-related utility.

In middle-aged women in the Australian Longitudinal Study on Women's Health, physical activity between 47 and 58 years of age was associated with lower risk of joint pain and stiffness nine years later ( 1 ). A qualitative study in Canada characterized consequences of symptoms on physical activity in persons with self-reported knee OA or symptoms ( 2 ). Meeting physical activity guidelines was not associated with incident radiographic or symptomatic knee OA in middle-aged or older adults in the Johnston County Osteoarthritis Project ( 3 ). Knee pain and lower vitality were associated with activity avoidance ( 4 ).

Being less sedentary was associated with better function in the Osteoarthritis Initiative, independent of moderate-vigorous physical activity minutes ( 5 ). More walking was associated with a lower risk of incident function limitation in persons with or at higher risk for knee OA in the Multicenter Osteoarthritis Study ( 6 ). Greater daily time in light intensity physical activity was associated with reduced onset and progression of disability in Osteoarthritis Initiative participants ( 7 ). There was a graded association between sedentary behavior and elevated systolic blood pressure, independent of moderate-vigorous physical activity minutes, in persons with or at higher risk for knee OA in the Osteoarthritis Initiative ( 8 ). In another report utilizing the Osteoarthritis Initiative, physical activity level was associated with health-related utility ( 9 ).

Papers dealing with early OA reported on the first activities to become painful in knee OA, prediction of early knee OA, significance of minor radiographic features, significance of preradiographic MRI lesions, and impact of rapid radiographic change in early OA.

In persons without radiographic OA in the Osteoarthritis Initiative, incident radiographic OA was associated with a prior trajectory of increasing knee pain, stiffness, and difficulties with functional tasks; over the 4-year study period there was no change in symptoms in the control knees which did not develop OA ( 10 ). Pain and difficulty with activities associated with higher dynamic loading were associated with longer prodromal phases ( 10 ). In persons with or at higher risk for knee OA in the Osteoarthritis Initiative, knee pain was most likely to first appear during weightbearing activities involving bending, such as using stairs ( 11 ). Questionnaire variables, genetic markers, other-site OA, and biochemical markers added only modestly to prediction of knee OA incidence using age, gender, and body mass index (BMI) in the Rotterdam Study-I; doubtful minor x-ray features strongly predicted future knee OA ( 12 ). In persons Kellgren and Lawrence radiographic grade 0 in both knees in the Osteoarthritis Initiative, baseline cartilage damage, bone marrow lesions, and meniscal tears were associated with persistent symptoms in the next 4 years ( 13 ). In persons with early symptomatic knee OA in the Osteoarthritis Initiative and in the Cohort Hip and Cohort Knee Study, rapid radiological change was associated with worsening of pain and function ( 14 ). Young and active athletes in a study in Qatar had a greater risk of manifesting early OA features ( 15 ).

Confidence/Instability/Falls

The spectrum of knee confidence, instability, and falls emerged as a theme, including manuscripts dealing with factors associated with knee confidence, consequences of knee buckling, fall risk in the setting of OA, the bone mineral density/fracture relationship in OA, and the combined impact of falls and OA on function.

Worse knee confidence was associated with pain, self-reported knee instability, weakness, and varus-valgus motion during gait in the setting of medial tibiofemoral OA in a study in Australia ( 16 ). Knee buckling and the sensation of instability without buckling was associated with fear of falling, poor balance confidence, activity limitations, and poor function in the Multicenter Osteoarthritis Study ( 17 ). In a longitudinal study with mean follow-up of 6 years from the Johnston County Osteoarthritis Project, the odds of falling increased with an increasing number of lower limb symptomatic OA joints (from 53% higher odds with 1 joint to 85% higher odds with 3-4 OA joints) ( 18 ). Fall history and knee OA (vs. neither or only one) was associated with worse KOOS-QoL and SF12 Physical Component Summary scores, in persons with or at higher risk for knee OA in the Osteoarthritis Initiative ( 19 ). Fracture risk was higher in women with OA (Dubbo Osteoporosis Epidemiology Study) than those without OA; however, the association was mainly observed in women with osteopenic BMD (for vertebral and limb fracture, but not hip fracture) and normal BMD and not in those with osteoporosis ( 20 ).

Cross-sectional Studies Dealing with Prevalent Knee OA

Type 3 finger length pattern, an indicator of prenatal androgen exposure, was associated with symptomatic (but not radiographic) knee OA, chronic pain, and hand OA in the Rotterdam Study ( 21 ). Almost half of the association between elevated BMI and knee OA was explained by serum leptin level in the Maintenance of Balance, Independent Living, Intellect, and Zest in the Elderly Boston Study ( 22 ). In the Netherlands Epidemiology of Obesity study, knee OA was associated with weight and fat-free mass, adjusting for metabolic factors, and hand OA was associated with the metabolic syndrome, adjusting for weight ( 23 ). In a study of patients undergoing total knee or hip replacement due to primary OA in Newfoundland, Canada, metabolomics analysis of synovial fluid samples demonstrated metabolically distinct subgroups ( 24 ).

Knee extensor and flexor muscle strength were associated with knee symptoms but not radiographic severity of knee OA in the Osteoarthritis Initiative ( 25 ). In the Multicenter Osteoarthritis Study, as compared to limbs without knee OA, limbs with lateral knee OA had a reduced femoral offset, an increased height of hip center, a more valgus neck-shaft angle, and an increased abductor angle, and limbs with medial knee OA had a more varus neck-shaft angle and a decreased abductor angle ( 26 ). The relationship between the external knee adduction moment and directly measured medial tibiofemoral contact forces was generally good but varied across subjects and activities in a study in the U.S., illustrating the limitations of relying solely on the adduction moment to infer medial joint loading when excessive directed cocontraction of muscles exists ( 27 ).

Patellofemoral OA was common in middle aged individuals with chronic patellofemoral pain in a study in Australia ( 28 ). In persons with predominant patellofemoral OA in a U.K. study, greater arthrogenous quadriceps muscle inhibition was associated with more severe knee pain but less severe bone marrow lesion score ( 29 ).

In a study including cases from the U.K. High Bone Mass study vs. unaffected family members and general population controls from the Chingford and Hertfordshire cohort studies, interrelationships were observed between osteophytes, enthesophytes, and high bone mass, supporting a subset of knee OA characterized by excess bone formation ( 30 ). While overall number and size of bone spurs were similar in patients with psoriatic arthritis and hand OA in a study in Germany utilizing high-resolution peripheral quantitative computer tomography, anatomic sites differed: in psoriatic arthritis, radial side; and in OA, palmar and dorsal quadrants ( 31 ).

Longitudinal Studies Dealing with Incident Knee OA

Effusion-synovitis and Hoffa-synovitis were associated with incident radiographic OA in Osteoarthritis Initiative participants ( 32 ). In another report from the Osteoarthritis Initiative, among knees without knee OA at baseline, recent knee injury was associated with accelerated development of end-stage knee OA ( 33 ). In middle aged, overweight women without knee OA in the Prevention of Knee Osteoarthritis in Overweight Females study, varus alignment was associated with incident radiographic OA; the association for valgus was borderline ( 34 ). Serum leptin at baseline was associated with MRI lesions 10 yrs later in the Michigan Study of Women's Health Across the Nation ( 35 ). A systematic review and meta-analysis showed that knee extensor muscle weakness was associated with an increased risk of developing symptomatic knee OA ( 36 ).

Longitudinal Studies Dealing with Knee OA Disease Progression

Frequent milk consumption was associated with reduced progression of knee OA in women in the Osteoarthritis Initiative (Lu). Vitamin D deficiency at 30 or 36 months was associated with 24-48 month knee OA progression in Osteoarthritis Initiative participants ( 37 ). In older adults with and without OA in the Tasmanian Older Adult Cohort study, moderate vitamin D deficiency was associated with incident or worsening knee pain over 5 years ( 38 ). In the Health, Aging and Body Composition Study, very low plasma phylloquinone (vitamin K1) was associated with progression of articular cartilage and meniscal damage in older individuals with and without OA ( 39 ).

In knees with medial meniscal tears in a study in Australia, weight gain was associated with concurrent cartilage loss and pain ( 40 ). In a 1-year ultrasound study of knee OA in The Netherlands, effusion and/or synovial hypertrophy were present in >40% at some time in the year and fluctuated; Baker's cyst and meniscal extrusion were present and stable ( 41 ). High total body BMD was associated with an increase in femoral cartilage thickness, high spine BMD with an increase in femoral and lateral tibial cartilage thickness, and high medial tibial subchondral BMD with an increase in medial tibial cartilage thickness in persons with knee OA in the Tasmanian Older Adult Cohort study ( 42 ). In the Osteoarthritis Initiative, a larger medial subchondral surface ratio (a measure of compartment-specific size mismatch) was associated with a reduced risk of incident knee symptoms; a larger lateral ratio was associated with a reduced risk of incident and progressive lateral OA ( 43 ).

Physical Functioning in Knee OA – Cross-sectional Studies

Knee OA was associated with a worse SF-36 Physical Component Summary score, as were obesity, comorbidities, and low fat free mass in The Netherlands Epidemiology of Obesity study ( 44 ). A knee-specific function measure was associated with pain status in the contralateral knee in Osteoarthritis Initiative participants; the chair stand performance measure best distinguished knee pain groups ( 45 ). Small increments of muscle strength were associated with clinically relevant differences in a knee-specific function measure in the Osteoarthritis Initiative ( 46 )

Individuals with symptomatic knee OA in a study in the U.S. had lower energetic recovery at self-selected walking speeds vs. healthy controls; findings suggested reduced effective exchange of potential and kinetic energy and increased muscular work required to control center of mass movements ( 47 ). In older adults with advanced knee OA and chronic pain in a U.S. study, age, function self-efficacy, and opioid use were associated with slower gait speed ( 48 ). In a large dataset comprising cohorts from 6 European countries, lower extremity OA at the hip or knee was associated with worse physical performance (walking speed, chair rises, balance); those at highest risk had OA at both hip and knee ( 49 ).

Physical Functioning in Knee OA – Longitudinal Studies

In the Cohort Hip and Cohort Knee study, 3-year decrease in muscle strength was associated with concurrent worsening in performance based measures of function ( 50 ). In another study of this cohort, 3 trajectories of function outcome were identified; moderate and poor outcome groups were characterized by younger age, higher BMI, greater pain, bony tenderness, reduced knee flexion, hip pain, osteophytosis, more comorbidities, and lower vitality ( 51 ). In a cohort of Chinese community-living older adults, OA was among the factors associated with worsening in frailty status ( 52 ). In persons with knee OA, baseline sleep disturbance was associated with greater increase in depression and function limitation ( 53 ).

In the Johnston County Osteoarthritis Project, variations in proximal femur shape by active shape modeling were modestly associated with incident radiographic hip OA ( 54 ). Cam-type femoroacetabular impingement and mild acetabular dysplasia were each associated with development of radiographic hip OA and total hip replacement in the Chingford 1000 Women Study ( 55 ). In the Danish working population, cumulative lifting was modestly associated with total hip replacement in men, as was high BMI at age 25 years and gain in BMI in both men and women ( 56 ). In the Australian Diabetes, Obesity and Lifestyle Study, low birth weight and preterm birth were associated with total hip replacement in adult life ( 57 ). In patients scheduled to undergo total hip replacement in a U.S. study, hip pain was associated with self-report and performance measures of function, while hip abduction strength was associated only with performance measures ( 58 ).

There were several papers dealing with hand OA, including some dealing with the association between MRI-based tissue lesions and progression and erosion development, inflammatory features and hand OA progression, hand OA and coronary heart disease events, correlates of pain in hand OA, erosive OA as a more severe form of disease, and prevalence and burden of carpometacarpal (CMC) OA.

In a study of the Oslo hand OA Cohort, MRI bone marrow lesions and synovitis were associated with radiographic joint space narrowing; synovitis, bone marrow lesions, osteophytes, and malalignment were associated with development of radiographic erosions ( 59 ). Ultrasound inflammatory features, especially when persistent, were associated with radiographic progression in clinic patients in The Netherlands who met ACR criteria for hand OA ( 60 ). In persons with radiographic hand OA in the Musculoskeletal Pain in Ullensaker Study, diabetes, lower education, female gender, familial OA, widespread pain, poor mental health, more finger joints with ultrasound-detected synovitis and radiographic OA were associated with hand pain ( 61 ). Symptomatic (but not radiographic) hand OA was associated with increased risk of coronary heart disease events in the Framingham Heart Study ( 62 ).

In 2 population-based studies in North Staffordshire, a similar frequency of joint involvement and patterning was found in erosive OA and severe non-erosive OA, suggesting that erosive OA may be a more severe form of hand OA; erosive OA (vs. non-erosive) was associated with metabolic syndrome, especially dyslipidemia ( 63 ). First CMC erosive disease was found in 2.2% of the population-based North Staffordshire cohort; 0.5% had combined 1 st CMC and interphalangeal (IP) erosive disease ( 64 ). First CMC erosive disease was associated with greater pain but similar function (vs. non-erosive OA) ( 64 ). The prevalence of doctor-diagnosed 1 st CMC OA was 1.4% (2.2% in women and 0.6% in men) in a large health care database in Sweden ( 65 ).

Studies relating to foot OA focused on factors associated with hallux valgus, factors associated with 1 st metatarsophalangeal (MTP) OA severity, prevalence of foot OA, and impact of foot pain on function.

In the Johnston County Osteoarthritis Project, hallux valgus was associated with female gender, African-American race, older age, pes planus, knee/hip OA, and inversely with higher BMI ( 66 ). In the Clinical Assessment Study of the Foot in the U.K., first MTP OA severity was associated with dorsal hallux and 1 st MTP pain, hallux valgus, 1 st IP hyperextension, and dorsal hallux and 1 st MTP keratotic lesions, and decreased 1 st MTP dorsiflexion, ankle/subtalar eversion and ankle dorsiflexion range ( 67 ). In another report from this study, population prevalence of symptomatic radiographic foot OA was reported to be 16.7%: at the 1 st MTP in 7.8%, at the 1 st cuneometatarsal joint in 3.9%, at the 2 nd cuneometatarsal in 6.8%, at the navicular first cuneiform in 5.2%, and at the talonavicular in 5.8% ( 68 ). At most sites, prevalence was greater in women, increased with age, and was higher with worse socioeconomic status. Seventy-five% with symptomatic radiographic foot OA reported disabling symptoms ( 68 ). In persons with symptomatic knee OA in the Osteoarthritis Initiative, 25% had foot pain (more often bilateral), the presence of which was associated with worse function ( 69 ).

Papers focusing on pain in OA frequently dealt with mechanisms, trajectories, and risk profiles.

In a cross-sectional study using the fifth Korean National Health and Nutrition Examination Survey, a metabolic syndrome/knee OA association was largely explained by excess weight and not insulin resistance; accumulation of metabolic syndrome components was associated with pain severity ( 70 ). In persons recruited from the community and clinic with symptomatic knee OA by ACR criteria, different quantitative sensory testing measures were associated with clinical pain in African-Americans and non-Hispanic Caucasians; reduced pain inhibition was important in all groups ( 71 ). Women in the Multicenter Osteoarthritis Study reported greater knee pain than men regardless of KL grade; differences decreased with adjustment for widespread pain ( 72 ). Higher BMI was associated with greater knee pain accounting for OA severity in persons with or at high risk for knee OA in the Osteoarthritis Initiative ( 73 ).

In the Generation of Models, Mechanism & Markers for Stratification of Osteoarthritis Patients study, 3 patterns of synovitis were identified in knee OA: 1) mainly patellar sites, associated with KOOS pain and ICOAP constant pain; 2) mostly near the ACL, not associated with pain or disease severity; 3) mainly at loose bodies, associated with disease severity ( 74 ). In another study of patients with knee OA by ACR clinical criteria, there was no association between ultrasound features and knee pain severity by KOOS pain or numeric rating scales ( 75 ).

Papers dealing with sensitivity included a report that pressure-pain threshold was associated with single and multijoint symptoms but not asymptomatic knee or hip OA in the Johnston County Osteoarthritis Project ( 76 ). A higher neuropathic pain questionnaire score was associated with widespread reduction in the pressure-pain threshold in persons with symptomatic, radiographic knee OA in the U.K. ( 77 ). Pressure-pain threshold and temporal summation were associated with pain severity but not OA presence, severity, or duration in persons with or at higher risk for knee OA in the Multicenter Osteoarthritis Study ( 78 ).

Other papers characterized pain experience and trajectories in OA. Pain flares in persons with symptomatic knee OA were described most often by quality (sharp), timing (seconds-minutes), antecedents, and consequences ( 79 ). In the Mechanical Factors in Arthritis of the Knee study in the U.S., a pain outcome measure was derived based on development of unpredictable pain; good 2-year outcome was less likely with greater catastrophizing and more likely with greater self-efficacy ( 80 ). Five WOMAC-pain trajectories over 6 years were identified in persons with symptomatic knee OA in the Osteoarthritis Initiative, none with substantial worsening; greater pain was associated with worse KL grade, obesity, depression, comorbidity, gender (female), non-Caucasian race, lower education, and younger age ( 81 ). Mild/non-progressive, progressive, moderate, improving, and severe/non-improving pain trajectories were identified in persons with symptomatic OA in the Knee Clinical Assessment Study; in Osteoarthritis Initiative participants, the progressive and improving groups were less evident ( 82 ).

Among other studies dealing with pain, nocturnal knee pain and worse sleep quality were associated with knee OA severity in participants from the Iwaki Health Promotion Project ( 83 ). More people with high knee pain/low disease burden of knee OA (vs. high pain/high OA, low pain/high OA, low pain/low OA) had widespread pain, in persons with or at higher risk for knee OA in the Multicenter Osteoarthritis Study ( 84 ). In a placebo-controlled, double-blind trial in participants with first CMC OA of the right hand, after naproxen (vs. placebo), fMRI activity was reduced in brain regions commonly associated with pain perception; changes in perceived pain intensity were associated with changes in activity in regions previously associated with pain intensity ( 85 ).

Symptom Outcome of Pharmacologic Treatments

Symptom outcomes of pharmacologic treatments were reported for methotrexate, adalimumab, anti-nerve growth factor monoclonal antibodies, strontium ranelate, bisphosphonates, glucosamine, and chondroitin sulfate. Reviews included a Cochrane review of topical rubefacients containing salicylates for chronic conditions and systematic review and network meta-analysis to analyze comparative effectiveness of pharmacologic interventions for knee OA.

In persons with symptomatic knee OA in a double-blind randomized placebo-controlled trial in Egypt, methotrexate reduced pain and improved function at 28 week follow-up ( 86 ). In a randomized, double-blind, parallel group, placebo-controlled multicenter trial in France, adalimumab was not superior to placebo to alleviate pain in hand OA not responsive to analgesics and NSAIDs ( 87 ). In persons with symptomatic knee OA by ACR clinical criteria, strontium ranelate over 3 years was associated with knee symptom and function improvement in the Strontium Ranelate Efficacy in Knee Osteoarthritis Trial ( 88 ). Bisphosphonate users with symptomatic knee OA in the Osteoarthritis Initiative had lower numeric rating scale pain scores vs. non-users (until year 4), but did not differ in WOMAC pain or function ( 89 ).

Studies of anti-nerve growth factor monoclonal antibodies included a report that individuals with knee or hip OA by ACR criteria with radiographic confirmation receiving partial symptom relief with NSAIDs may receive greater benefit with tanezumab monotherapy; adverse event frequency was higher with tanezumab than with NSAIDS, and was highest with the combination ( 90 ). Adding tanezumab to diclofenac SR improved pain, function, global assessment in patients with knee or hip OA, but higher adverse events in the combination group suggests this approach is unfavorable ( 91 ). Fasinumab, in a double-blind, placebo-controlled, parallel group, exploratory study, was generally well tolerated; all 3 doses were better than placebo for walking knee pain and WOMAC ( 92 ).

A meta-analysis of placebo-controlled trials of glucosamine for primary or secondary OA in any synovial joint revealed that most heterogeneity was explained by brand; trials using one product had better outcome but large inconsistency, and low risk of bias trials showed small effect sizes ( 93 ). In a double-blind randomized clinical trial, non-inferiority trial vs. celecoxib, combined chondroitin sulfate and glucosamine had comparable efficacy to celecoxib for symptoms, function, and joint swelling/effusion in persons with symptomatic knee OA at 6 months ( 94 ).

Studies of NSAIDS include a report that long-term NSAID use in the Osteoarthritis Initiative was associated with modest clinical (but not significant) change in stiffness, function, and structure change at the knee ( 95 ). Fixed-dose tramadol-diclofenac resulted in greater pain reduction and was well tolerated vs. tramadol-paracetamol for acute OA flare ( 96 ). There was no association between traditional NSAIDs and nonfatal acute myocardial infarction when background cardiovascular risk was low-intermediate; there was a moderate association in those at high risk or with NSAID use >365 days, in a nested case-control study using a primary care database in Spain ( 97 ). Celecoxib was as effective and safe as naproxen for knee OA in a sample of Hispanic individuals ( 98 ).

A Cochrane review concluded that evidence does not support topical rubefacients containing salicylates for chronic conditions ( 99 ). A study of comparative effectiveness of pharmacologic interventions for knee OA utilizing a systematic review and network meta-analysis revealed: for pain, all interventions outperformed oral placebo; for function, all interventions except intraarticular corticosteroids were superior to placebo; and for stiffness, treatments did not differ from each other ( 100 ). Apparent superiority of some intraarticular treatments may relate to integrated intraarticular placebo effect. Limitations of published studies included lack of long-term data, inadequate reporting of safety data, possible publication bias, and few head-to-head comparisons.

Patients taking duloxetine for knee OA or chronic low back pain who had <10% reduction in pain after 4 weeks had limited possibility for eventually achieving moderate pain reduction by the end of 12 weeks ( 101 ).

Structural Outcomes of Pharmacologic Treatments

Structural outcomes were reported for strontium ranelate, recombinant human fibroblast growth factor 18, and glucosamine and chondroitin sulfate.

Strontium ranelate, 2 g/d, was associated with a beneficial effect on cartilage volume and bone marrow lesions in some regions, in a subset of the phase III Strontium Ranelate Efficacy in Knee Osteoarthritis Trial ( 102 ). Recombinant human fibroblast growth factor 18 was not associated with an effect on medial tibiofemoral cartilage thickness (the primary outcome), but secondary end points showed dose-dependent effects in a multicenter study conducted in Europe, North America, and South Africa ( 103 ). Glucosamine and chondroitin sulfate use was associated with less cartilage volume loss in an observational study (the Osteoarthritis Initiative), albeit not in multivariable analyses ( 104 ). In another study using Osteoarthritis Initiative data, glucosamine and chondroitin sulfate use was not associated with symptom relief or modification of disease progression ( 105 ). There was no evidence of structure benefit by MRI at 6 months or urinary CTX-II excretion from glucosamine in persons with mild-to-moderate knee pain in a randomized, double-blind, placebo-controlled trial ( 106 ).

Symptom Outcomes of Non-Pharmacologic Treatments

Symptom outcomes of non-pharmacologic interventions were reported for: neuromuscular exercise, quadriceps strengthening, weight reduction and maintenance, TENS, therapeutic ultrasound, stepped care strategies, cognitive behavior therapy for sleep disturbance, acupuncture, gait modification, booster physical therapy, a web-based therapeutic exercise resource center for knee OA; physical therapy for hip OA; and joint protection and hand exercises for hand OA. Reviews included meta-analyses of exercise, valgus bracing, ginger, electrical stimulation, and continuous and pulsed ultrasound.

Exercise and Physical Therapy

An intensive diet and exercise program (vs. diabetes support/education) prevented incident knee pain at year 1, in overweight adults with diabetes in the Action for Health in Diabetes study ( 107 ). Neuromuscular and quadriceps strengthening similarly improved pain and function but did not change the external knee adduction moment in the setting of moderate-severe medial knee OA with varus alignment in Australia ( 108 ). Neuromuscular exercise was more effective for non-obese persons with a varus thrust; quadriceps strengthening was more effective for obese persons without a thrust ( 109 ). Pressure-pain sensitivity, temporal summation, and pain were reduced with exercise in patients with knee OA ( 110 ). Booster sessions with a physical therapist did not influence pain, function, or home exercise adherence in patients with knee OA ( 111 ). A systematic review and meta-regression analysis of RCTs suggested that single-type exercise programs were more efficacious than programs including different exercise types for knee OA ( 112 ). In participants with knee OA in a 12-week exercise program, among tibiofemoral and patellofemoral MRI abnormalities, severity in patellofemoral cartilage integrity was associated with less improvement in physical function and strength and severity of patellofemoral osteophyte formation with less improvement in strength ( 113 ).

A program of exercise therapy and education (vs. only education) was associated with later total hip replacement ( 114 ). Hip physical therapy did not result in pain or function improvement vs. sham treatment for painful hip OA ( 115 ). For hand OA, joint protection (vs. no protection) was effective by 6 months using OARSI/OMERACT responder criteria; hand exercise (vs. no exercise) was not effective ( 116 ). Home-based exercise for hand OA was well tolerated and improved function, grip strength, pain, and fatigue in an RCT ( 117 ). In another RCT, group exercise followed by home exercise for hand OA was well tolerated but was associated with small short-term improvement only on self-reported measures ( 118 ). Short-term night time distal interphalangeal joint splinting was associated with reduced pain and improved extension in a radiologist blinded, non-randomized, internally controlled study ( 119 ).

Behavioral Therapy

Weight reduction in obese patients with a 1-year maintenance improved knee OA symptoms, irrespective of type of maintenance program ( 120 ). In a double-blind RCT with active placebo, cognitive behavior therapy for insomnia in knee OA reduced sleep maintenance insomnia and pain ( 121 ). In a secondary analysis of data from the Lifestyles trial, short term sleep improvement predicted long term improvements for sleep, pain, and fatigue that were not attributable to psychological benefits in persons with insomnia and joint pain (likely due to OA) ( 122 ). A web-based therapeutic exercise resource center was feasible and efficacious in improving pain, function, and self-efficacy in knee OA ( 123 ). Telephone reinforcement and negotiated maintenance contracts positively affected physical activity behavior in OA ( 124 ).

Complementary and Alternative Therapy

Studies of complementary and alternative therapies included a randomized clinical trial, sham-controlled, revealing no additional benefit of TENS over education and exercise for knee OA ( 125 ). In another RCT, double-blind and sham-controlled, therapeutic ultrasound provided no additional benefit over exercise training in persons with knee OA ( 126 ). Neither laser nor needle acupuncture conferred benefit over sham intervention for pain or function in patients older than 50 years with moderate or severe chronic knee pain ( 127 ). A systematic review and network meta-analysis suggested that pulsed ultrasound is more effective than control intervention (i.e., sham or blank) for pain relief and function improvement in knee OA ( 128 ). In a meta-analysis of randomized placebo-controlled trials for OA in any joint, ginger was modestly efficacious and reasonably safe for symptomatic OA, with evidence of moderate quality based on the small number of participants and frequently inadequate intention-to-treat analyses ( 129 ).

Biomechanical Intervention

Among biomechanical interventions, a meta-analysis of RCTs suggested valgus bracing was associated with small to moderate improvement in knee pain ( 130 ). A Cochrane review concluded evidence for an effect of bracing for medial knee OA on symptoms, function, and quality of life was inconclusive; evidence was moderate for a lack of effect from lateral wedge vs. neutral insoles on symptoms and function ( 131 ).

Structural Outcomes of Non-Pharmacologic Treatments

Only one study emerged in this category. In a randomized clinical trial in persons with painful patellofemoral OA, a patellofemoral brace reduced patellofemoral but not tibiofemoral bone marrow lesion volume and pain at 6 weeks ( 132 ).

Prevalence and Impact of OA

In 2 large referral centers in Cameroon, individuals tended to present for care at later stages of disease; among 148 with knee OA, moderate to severe disease was present in 36%, bilateral and bicompartmental disease in 38.5%, and bilateral tricompartmental disease in 14.2% ( 133 ). Pain and radiographic severity did not correlate ( 133 ). Another report described the prevalence of lumbar OA in Chinese adults (approximately 9%), with no difference between urban, suburban, and rural populations; higher prevalence was linked to gender (female), age, obesity, physical work, work posture, exposure to vibration during work, and duration of sleep ( 134 ). In the Framingham Osteoarthritis Study, the age-standardized prevalence of radiographic hip OA was 19.6%; prevalence of radiographic (but not symptomatic) hip OA was higher in men ( 135 ). The prevalence of OA features by ultrasound was described in participants from the Newcastle thousand families birth cohort ( 136 ). In a large sample of residents of Malmö, Sweden, 25% had radiographic knee OA and 15% had either symptomatic or clinically defined knee OA ( 137 ).

In the Global Burden of Disease 2010 study, of 291 conditions, hip and knee OA was ranked as the 11 th highest contributor to global disability and as the 38 th highest in disability-adjusted life years. While the global age-standardized prevalence of knee and hip OA did not change from 1990 to 2010, years lived with disability increased from 10.5 million in 1990 to 17.1 million in 2010 ( 138 ).

In cardiovascular populations (U.K. family practices), the comorbid addition of OA was associated with incrementally poorer physical health (by SF-12 Physical Component Summary) but interactions were less than additive ( 139 ). Patients with symptomatic OA at multiple sites (from the Genetics Arthrosis and Progression study and the Osteoarthritis Care Clinic study) who consulted health care providers for their OA were not at higher risk of death than the general population ( 140 ).

Health Services Research

A study of national cohorts of individuals with knee OA assembled using data from the 2003, 2006, and 2009 waves of the Medicare Current Beneficiary Survey revealed an increase in opioid prescribing between 2003 and 2009 ( 141 ). Correlates of opioid use included gender (female), functional limitation, poor self-reported health status, chronic obstructive pulmonary disease, and musculoskeletal disease apart from OA ( 141 ). In patients attending outpatient medicine and specialty clinics in the U.S., 16% rejected DMOADS under all conditions, 5% did not want to perform subcutaneous injections and would only consider DMOADs under the best-case scenario, 20% were willing to take DMOADS under the best-case but would start rejecting them as risk increased, and 59% would accept DMOADs across all scenarios ( 142 ).

Duloxetine (vs. comparators celecoxib, diclofenac, naproxen, hydromorphone, and oxycodone) was cost effective for 55-year old pts with OA and more so in older patients and those at greater risk for adverse effects in Canada ( 143 ). Celecoxib with a proton pump inhibitor was cost effective for OA (vs. diclofenac with a proton pump inhibitor) in an analysis within the Swedish health system using an adaptation of the NICE OA model ( 144 ).

A systematic review revealed well-developed, feasible indicators of quality of care for OA which could be implemented in primary care ( 145 ). Sponsored by the European League Against Rheumatism and the European Community, patient-centered and consensus based standards of care for OA were developed using systematic review and a 3-round Delphi process towards a goal of harmonizing treatment and care of OA within Europe ( 146 ).

Another report demonstrated a substantial increase in OA-related costs resulting from expanding total knee replacement eligibility criteria in the U.S., suggesting the need for more effective nonoperative therapies ( 147 ).

Special Reports – Research Priorities

A EULAR ad hoc expert committee concluded that research priorities include: predictors of OA progression (especially to enable stratified intervention); better understanding of mechanisms of OA pain; improved understanding of tissue communication; developing concepts of, and consequently interventions for, early OA; and a need for new therapeutic strategies (pathology-targeted and optimal combinations) ( 148 ) The recommendations of this report are summarized in Table 2 .

OA Research Priorities, Adapted from a Report from a EULAR ad hoc Expert Committee ( 148 )

A prioritized research agenda about OA management was developed for the Patient-Centered Outcomes Research Institute; this report describes prioritized evidence gaps and top-ranked research priorities as well as recommended study designs or suggested analyses to address these gaps and priorities ( 149 ).

While much was accomplished in the past year, this review also illustrates directions for further work. Besides the obvious need to develop novel pharmacologic and non-pharmacologic interventions, future effort might include studies concerning: the relationship between physical activity and OA disease progression, modifiable determinants of physical activity behavior; interventions targeting physical activity, knee confidence, knee buckling; role of falls and fracture in OA, risk factors for falls and fracture; definitions of early OA, prevention/intervention efforts at pre- or early disease stages; identification/delineation of clinical phenotypes; the role of muscle function and quality in OA; potential disease-modifying effects of non-pharmacologic interventions; risk factors for incident and progressive hand OA, foot OA, hip OA; long-term pain outcome; and true disability outcome.

ACKNOWLEDGEMENTS

1. All searches were performed by Linda O'Dwyer, Communications Coordinator and Education Librarian, Galter Health Sciences Library, Feinberg School of Medicine, Northwestern University.

2. Funding source: NIH/NIAMS P60 AR064464

3. Study sponsors played no role in the study design, collection, analysis and interpretation of data, the writing of the manuscript, or in the decision to submit the manuscript for publication.

Support: NIH/NIAMS P60 AR064464

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AUTHOR CONTRIBUTIONS

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Students, Computers and Learning

• Education and skills
• Student performance (PISA)
• Teachers and educators
• Education equity
• Reading literacy
• Mathematics literacy
• Science literacy
• Digital divide in education
• Learning in the digital world

Cite this content as:

Are there computers in the classroom? Does it matter? Students, Computers and Learning: Making the Connection examines how students’ access to and use of information and communication technology (ICT) devices has evolved in recent years, and explores how education systems and schools are integrating ICT into students’ learning experiences. Based on results from PISA 2012, the report discusses differences in access to and use of ICT – what are collectively known as the “digital divide” – that are related to students’ socio-economic status, gender, geographic location, and the school a child attends. The report highlights the importance of bolstering students’ ability to navigate through digital texts. It also examines the relationship among computer access in schools, computer use in classrooms, and performance in the PISA assessment. As the report makes clear, all students first need to be equipped with basic literacy and numeracy skills so that they can participate fully in the hyper-connected, digitised societies of the 21st century.

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MARK H. EBELL, MD, MS, AND ROLAND GRAD, MD, MSc

Am Fam Physician. 2018;97(9):581-588

POEMs are provided by Essential Evidence Plus, a point-of-care clinical decision support system published by Wiley-Blackwell, Inc. For more information, visit http://www.essentialevidenceplus.com .

Related letter : Top 20 POEMs Should Provide Better Context of Study Quality and Scope

Author disclosure: Dr. Ebell is cofounder and editor-in-chief of Essential Evidence Plus, published by Wiley-Blackwell, Inc. Dr. Grad has no relevant financial affiliations. See Editor's Note .

Based on systematic surveillance of more than 110 medical journals, 247 studies met criteria as POEMs (patient-oriented evidence that matters) in 2017. Members of the Canadian Medical Association identified 20 of these POEMs as most relevant to practice. This article reviews the clinical questions and bottom-line answers from these studies. Blood pressure should be measured after a period of rest, using a bare arm, and orthostatic blood pressure is more predictive when measured after one minute of standing rather than three minutes. Intensive blood pressure lowering results in cardiovascular benefits but also renal harms in high-risk patients with an average age of 68 years. The initiation of a statin for primary prevention does not reduce cardiovascular events in adults 65 years or older. Sterile gloves do not reduce the risk of infection for common outpatient skin procedures, and the preferred approach to managing onychomycosis is empiric oral terbinafine. Routine home glucose monitoring is not needed in patients with type 2 diabetes mellitus, and trying to achieve an A1C target level of 6.0% rather than 7.0% to 7.9% does not improve outcomes and may be harmful. Fasting blood glucose and A1C levels have limited accuracy for identifying glucose intolerance, and patients 65 years and older with thyroid-stimulating hormone levels between 4.6 and 10.0 mIU per mL should be rechecked before considering treatment. Gabapentin and pregabalin are not effective for acute or chronic low back pain, even in patients with sciatica. Physical therapy does not provide any additional benefit over usual care in patients with acute ankle sprain, and corticosteroid injections for knee osteoarthritis are ineffective and may damage cartilage. A two-question screening test can rule out depression in older adults; a large U.S. trial continued to find no benefit to prostate cancer screening; and clinicians need to be thoughtful about how they discuss recommendations to stop screening for cancer in older patients. Finally, ibuprofen, naproxen, and celecoxib have similar risks of adverse events, and continuous positive airway pressure in patients with obstructive sleep apnea does not reduce the risk of cardiovascular events.

The volume of studies published annually has expanded greatly in recent decades. For example, 6,762 studies were indexed as randomized controlled trials in PubMed in 1990, compared with 24,434 in 2015. It is increasingly difficult for primary care physicians, who have a broad scope of practice, to remain current with the most important new research. To address this issue, for more than 20 years, a group of clinicians who are experts in evidence-based medicine has systematically reviewed more than 110 English-language research journals to identify the evidence most likely to change primary care practice. The group includes experts in family medicine, pharmacology, hospital medicine, and women's health. 1 , 2

The goal of the review process is to identify POEMs: patient-oriented evidence that matters. A POEM must report patient-oriented outcomes, such as improvement in symptoms, morbidity, or mortality; be free of important methodologic bias; and recommend a change in practice for many physicians. Adopting valid POEMs in clinical practice could therefore result in improved patient outcomes. Of more than 20,000 research studies published in 2017 in these journals, 247 met these criteria for validity, relevance, and practice change.

Since 2005, the Canadian Medical Association (CMA) has paid for a subscription to POEMs for all of its members. Each member has the option to receive the daily POEM by e-mail. When members read the POEM, they can also rate it with a validated tool called the Information Assessment Method. This tool addresses relevance to clinicians, cognitive impact, use in practice, and expected health benefits if that POEM is applied in practice. 3 For this article we identified the 20 POEMs that were rated highest for clinical relevance by CMA members in 2017. In the seventh installment of this annual series, 4 – 9 we summarize the clinical question and bottom-line answer for each of the top 20 research studies identified as POEMs, organized by topic and followed by a brief discussion. We also review the five most relevant practice guidelines.

Cardiovascular Disease and Hypertension

The first group of POEMs focuses on cardiovascular disease (CVD) and hypertension ( Table 1 ) , 10 – 14 and two of these POEMs address the proper way to measure blood pressure, a part of the care of almost every patient. Although it may be tempting to save a few seconds and measure the blood pressure through a patient's shirt or sweater, Study 1, a Japanese study, found that measuring through clothing can add 6 to 7 mm Hg to the diastolic blood pressure and 4 mm Hg to the systolic blood pressure. 10 In Study 2, Dutch patients with suspected white coat hypertension were asked to sit quietly in a room while an automated cuff measured their blood pressure every five minutes. The mean of these six measurements was 23/12 mm Hg lower than the initial office blood pressure. 11 Study 3 is a reanalysis of data from the Systolic Blood Pressure Intervention Trial (SPRINT). It concluded that for patients with hypertension but without diabetes mellitus who are at increased risk of CVD (average age = 68 years; 61% with a 10-year cardiovascular risk of 15% or greater), a more aggressive blood pressure target has cardiovascular benefits and renal harms, and requires more medications. 12 As with the Dutch study, the SPRINT trial used a similar measurement approach (i.e., the mean of three automated blood pressure measurements after the patient had rested quietly for at least five minutes), so before increasing the number of blood pressure medications that patients use to hit those targets, it is critical to measure blood pressure the same way as the SPRINT investigators. Another study of blood pressure measurement, Study 4, concluded that when evaluating a patient for possible orthostatic hypotension, it is better to measure the blood pressure one minute after standing rather than three minutes. 13

Statins are commonly prescribed to patients 65 years and older, but are they effective for primary prevention of CVD? Study 5 randomized nearly 3,000 adults 65 years and older without known CVD to receive pravastatin (Pravachol; 40 mg per day) or placebo. No reduction in coronary events or all-cause mortality was found, and a nonsignificant trend toward higher mortality in patients older than 75 years was observed in those taking the statin (hazard ratio = 1.34; 95% confidence interval, 0.98 to 1.84). 14

Two POEMs address the prevention and treatment of common infections in primary care ( Table 2 ) . 15 , 16 Study 6 is a systematic review that found no increase in infections or complications when outpatient skin procedures were performed with nonsterile gloves. 15 Study 7 questions the requirement by many insurance companies that clinicians must first test a toenail with clinically obvious onychomycosis for fungal infection before they will pay for a course of an antifungal drug. This also delays treatment unnecessarily. This cost-effectiveness analysis found that empiric therapy with oral terbinafine (Lamisil) without diagnostic testing was the most cost-effective strategy. 16

Diabetes Mellitus and Thyroid Disease

Three POEMs addressed the management of type 2 diabetes ( Table 3 ) . 17 – 20 In Study 8, a well-designed U.S. randomized trial confirmed what had been previously observed in a number of European studies: routine self-monitoring in patients with type 2 diabetes who are not taking insulin does not improve any clinical outcomes. 17 Patients should have a glucometer and can use it when they are sick or symptomatic from diabetes, but routine use is not needed. Study 9 is a long-term follow-up to the landmark ACCORD (Action to Control Cardiovascular Risk in Diabetes) trial. Like the ACCORD trial, it found that although patients randomized to tighter glycemic control had lower mean A1C levels, they also continued to have a greater risk of cardiovascular events. 18 Study 10 is a systematic review of the accuracy of A1C levels and fasting glucose levels at identifying patients with an abnormal glucose tolerance test. Neither test was sensitive (25% to 49%), although fasting glucose levels were more specific, providing moderately strong evidence for abnormal glucose tolerance when elevated. 19 The final study in this group, Study 11, provides guidance on how to treat patients with subclinical hypothyroidism. This randomized trial of patients 65 years and older with moderately elevated thyroid-stimulating hormone levels but no or minimal symptoms found that if the level is between 4.6 and 10.0 mIU per mL, it often normalizes on repeat testing, and treating this group does not improve symptoms. 20

Musculoskeletal Conditions

The next group of POEMs addresses musculoskeletal conditions ( Table 4 ) . 21 – 24 Gabapentin (Neurontin) and pregabalin (Lyrica) have become popular options for the management of acute and chronic low back pain. Study 12, a well-designed Australian randomized trial, found that in patients with moderate to severe sciatica, pregabalin did not improve any clinical outcomes. 21 Similarly, Study 13, a systematic review of gabapentin and pregabalin for chronic back pain, found at best limited evidence for benefit and consistent evidence of adverse events. 22 Unless other studies find evidence of more benefit than harm for these drugs, they should not be prescribed for patients with low back pain.

Study 14 randomized 503 adults with ankle sprain to supervised physical therapy or usual care. It found that 65% of those receiving usual care had an excellent recovery at three months compared with 56% in the physical therapy group ( P = .09). 23 Finally, a previous Cochrane review concluded that corticosteroid injections provide modest benefit for patients with osteoarthritis of the knee. 25 However, many of those studies were poorly controlled or compared injections with no treatment rather than placebo injections. Study 15 randomized 140 adults with knee osteoarthritis to regular triamcinolone, 40 mg, or saline injection every three months for two years. The authors found no benefit in pain or function and a worrisome reduction in cartilage thickness in the corticosteroid group when comparing magnetic resonance imaging studies performed before and after the study period. 24

Three POEMs address screening ( Table 5 ) . 26 – 28 Study 16 is a meta-analysis that confirms that the widely used two-question screen for depression helps rule out depression in older adults; however, as in younger patients, one or more positive responses is not diagnostic for depression and requires further confirmation. 26 Study 17 is long-term follow-up of the Prostate, Lung, Colorectal, and Ovarian Cancer Screening trial, and continues to find no mortality benefit for prostate cancer screening. 27 Current guidelines from the American College of Physicians (ACP), the American Urological Association, and the U.S. Preventive Services Task Force recommend that screening should be considered only for men 55 (age 50 for ACP) to 69 years of age after a discussion of the potential benefits (which are small) and the potential harms (which are common). Finally, discussing the decision to discontinue cancer screening can be difficult for patients and physicians. Study 18, a qualitative study, found that saying “This test will not help you live longer,” rather than focusing on the patient's limited lifespan, is the preferred approach. 28

Miscellaneous

Two studies are included as miscellaneous POEMs ( Table 6 ) . 29 , 30 Study 19 compared ibuprofen, naproxen, and celecoxib (Celebrex) and found no difference in cardiovascular events and only very small differences in gastrointestinal or renal events (less than 0.5%) among the three drugs. 29 The choice of drug should therefore be based on other factors, such as cost and patient preference, rather than the likelihood of adverse events. To round out the top 20 list, Study 20 is a systematic review of 10 randomized trials with 7,266 patients who had obstructive sleep apnea. There was no evidence that use of continuous positive airway pressure reduced the risk of cardiovascular events or death. 30 The decision to recommend continuous positive airway pressure should be based only on tolerability and effect on symptoms.

Practice Guidelines

Although most POEMs address individual research studies or systematic reviews, important practice guidelines are often summarized. The five guidelines that were rated most highly by CMA readers for relevance to practice are listed in Table 7 with their key recommendations. 14 , 31 – 35 All of these guidelines have been fully endorsed by the American Academy of Family Physicians (AAFP). They are also available on the AAFP's Clinical Practice Guidelines website at https://www.aafp.org/patient-care/browse/type.tag-clinical-practice-guidelines.html .

The authors thank Wiley-Blackwell, Inc., for giving permission to excerpt the POEMs; Drs. Allen Shaughnessy, Henry Barry, David Slawson, Nita Kulkarni, and Linda Speer for their work in selecting and writing the original POEMs; the academic family medicine fellows and faculty of the University of Missouri–Columbia for their work as peer reviewers; Pierre Pluye, PhD, for his work in codeveloping the Information Assessment Method; and Maria Vlasak for her assistance with copyediting the POEMs for the past 24 years.

A list of top POEMs from previous years is available at https://www.aafp.org/journals/afp/authors/ebm-toolkit/resources/top-poems.html .

Editor's Note: This article was cowritten by Dr. Mark Ebell, who was a member of the U.S. Preventive Services Task Force (USPSTF) from 2012 to 2015 and currently serves as a consultant to the USPSTF. This article does not necessarily represent the views and policies of the USPSTF. Dr. Ebell is deputy editor for evidence-based medicine for American Family Physician ( AFP ) and cofounder and editor-in-chief of Essential Evidence Plus, published by Wiley-Blackwell, Inc. Because of Dr. Ebell's dual roles and ties to Essential Evidence Plus, the concept for this article was independently reviewed and approved by a group of AFP 's medical editors. In addition, the article underwent peer review and editing by three of AFP 's medical editors. Dr. Ebell was not involved in the editorial decision-making process.—Sumi Sexton, MD, Editor-in-Chief, American Family Physician

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Ozone S, Shaku F, Sato M, Takayashiki A, Tsutsumi M, Maeno T. Comparison of blood pressure measurements on the bare arm, over a sleeve and over a rolled-up sleeve in the elderly. Fam Pract. 2016;33(5):517-522.

Bos MJ, Buis S. Thirty-minute office blood pressure monitoring in primary care. Ann Fam Med. 2017;15(2):120-123.

Beddhu S, Rocco MV, Toto R, et al.; SPRINT Research Group. Effects of intensive systolic blood pressure control on kidney and cardiovascular outcomes in persons without kidney disease: a secondary analysis of a randomized trial. Ann Intern Med. 2017;167(6):375-383.

Juraschek SP, Daya N, Rawlings AM, et al. Association of history of dizziness and long-term adverse outcomes with early vs later orthostatic hypotension assessment times in middle-aged adults. JAMA Intern Med. 2017;177(9):1316-1323.

Han BH, Sutin D, Williamson JD, et al.; ALLHAT Collaborative Research Group. Effect of statin treatment vs usual care on primary cardiovascular prevention among older adults. The ALLHAT-LLT randomized clinical trial. JAMA Intern Med. 2017;177(7):955-965.

Brewer JD, Gonzalez AB, Baum CL, et al. Comparison of sterile vs non-sterile gloves in cutaneous surgery and common outpatient dental procedures: a systematic review and meta-analysis. JAMA Dermatol. 2016;152(9):1008-1014.

Mikailov A, Cohen J, Joyce C, Mostaghimi A. Cost-effectiveness of confirmatory testing before treatment of onychomycosis. JAMA Dermatol. 2016;152(3):276-281.

Young LA, Buse JB, Weaver MA, et al.; Monitor Trial Group. Glucose self-monitoring in non-insulin-treated patients with type 2 diabetes in primary care settings: a randomized trial. JAMA Intern Med. 2017;177(7):920-929.

ACCORD Study Group. Nine-year effects of 3.7 years of intensive glycemic control on cardiovascular outcomes. Diabetes Care. 2016;39(5):701-708.

Barry E, Roberts S, Oke J, Vijayaraghavan S, Normansell R, Greenhalgh T. Efficacy and effectiveness of screen and treat policies in prevention of type 2 diabetes: systematic review and meta-analysis of screening tests and interventions. BMJ. 2017;356:i6538.

Stott DJ, Rodondi N, Kearney PM, et al.; TRUST Study Group. Thyroid hormone therapy for older adults with subclinical hypothyroidism. N Engl J Med. 2017;376(26):2534-2544.

Mathieson S, Maher CG, McLachlan AJ, et al. Trial of pregabalin for acute and chronic sciatica. N Engl J Med. 2017;376(12):1111-1120.

Shanthanna H, Gilron I, Rajarathinam M, et al. Benefits and safety of gabapentinoids in chronic low back pain: a systematic review and meta-analysis of randomized controlled trials. PLoS Med. 2017;14(8):e1002369.

Brison RJ, Day AG, Pelland L, et al. Effect of early supervised physiotherapy on recovery from acute ankle sprain: randomised controlled trial. BMJ. 2016;355:i5650.

McAlindon TE, LaValley MP, Harvey WF, et al. Effect of intra-articular triamcinolone vs saline on knee cartilage volume and pain in patients with knee osteoarthritis: a randomized clinical trial. JAMA. 2017;317(19):1967-1975.

Jüni P, Hari R, Rutjes AW, et al. Intra-articular corticosteroid for knee osteoarthritis. Cochrane Database Syst Rev. 2015(10):CD005328.

Tsoi KK, Chan JY, Hirai HW, Wong SY. Comparison of diagnostic performance of Two-Question Screen and 15 depression screening instruments for older adults: systematic review and meta-analysis [published correction appears in Br J Psychiatry . 2017;211(2):120]. Br J Psychiatry. 2017;210(4):255-260.

Pinsky PF, Prorok PC, Yu K, et al. Extended mortality results for prostate cancer screening in the PLCO trial with median follow-up of 15 years. Cancer. 2017;123(4):592-599.

Schoenborn NL, Lee K, Pollack CE, et al. Older adults' views and communication preferences about cancer screening cessation. JAMA Intern Med. 2017;177(8):1121-1128.

Nissen SE, Yeomans ND, Solomon DH, et al.; PRECISION Trial Investigators. Cardiovascular safety of celecoxib, naproxen, or ibuprofen for arthritis. N Engl J Med. 2016;375(26):2519-2529.

Yu J, Zhou Z, McEvoy RD, et al. Association of positive airway pressure with cardiovascular events and death in adults with sleep apnea: a systematic review and meta-analysis. JAMA. 2017;318(2):156-166.

Qaseem A, Barry MJ, Humphrey LL, Forciea MA. Oral pharmacologic treatment of type 2 diabetes mellitus: a clinical practice guideline update from the American College of Physicians. Ann Intern Med. 2017;166(4):279-290.

Qaseem A, Wilt TJ, Rich R, Humphrey LL, Frost J, Forciea MA. Pharmacologic treatment of hypertension in adults aged 60 years or older to higher versus lower blood pressure targets: a clinical practice guideline from the American College of Physicians and the American Academy of Family Physicians. Ann Intern Med. 2017;166(6):430-437.

Qaseem A, Wilt TJ, McLean RM, Forciea MA. Noninvasive treatments for acute, subacute, and chronic low back pain: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2017;166(7):514-530.

Qaseem A, Harris RP, Forciea MA. Management of acute and recurrent gout: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2017;166(1):58-68.

Bibbins-Domingo K, Grossman DC, Curry SJ, et al. Statin use for the primary prevention of cardiovascular disease in adults. US Preventive Services Task Force recommendation statement. JAMA. 2016;316(19):1997-2007.

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Charpignon M , Ontiveros J , Sundaresan S, et al. Evaluation of Suicides Among US Adolescents During the COVID-19 Pandemic. JAMA Pediatr. 2022;176(7):724–726. doi:10.1001/jamapediatrics.2022.0515

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Evaluation of Suicides Among US Adolescents During the COVID-19 Pandemic

• 1 Institute for Data, Systems, and Society, Massachusetts Institute of Technology, Cambridge
• 2 Harvard College, Harvard University, Cambridge, Massachusetts
• 3 Computational Health Informatics Program, Boston Children’s Hospital, Boston, Massachusetts

In 2021, the American Academy of Pediatrics declared a state of emergency regarding child and adolescent mental health. 1 During the COVID-19 pandemic, US adolescents have been affected by the widespread loss of primary caregivers. Suicide-risk screenings have yielded higher positive rates than during the prepandemic period 2 ; thus, we sought to measure suicide-related mortality in this population.

Through partnerships with 14 state departments of public health, we collected data from 2015 through 2020 for 85 102 decedents with suicide as the cause of death. MIT COUHES approved the conduct of this research and waived ethical review and the informed consent requirement because the study was not human participant research and used death certificates from deceased individuals.

To assess pandemic-period changes in suicide, we first compared counts of suicides between the prepandemic (2015-2019) and pandemic (2020) periods. Counts were collated for adolescents aged 10 to 19 years 3 and across all ages (overall). We then computed the yearly proportion of overall suicides among adolescents to examine how the burden of suicide has shifted across age groups throughout the pandemic. To measure the change in adolescent suicidality between the prepandemic and pandemic periods, we investigated the absolute count of adolescent suicides and proportion of overall suicides that occurred among adolescents. Reflecting the relative burden for adolescents rather than absolute suicidality, the second outcome was chosen to inform resource reallocation decisions in this age group, particularly about mental health, psychiatric services, and emergency care. Additional study details are provided in the eMethods in the Supplement .

Georgia, Indiana, New Jersey, Oklahoma, and Virginia had an increase in absolute count of adolescent suicides during the pandemic. These states, along with California, also had an increase in the proportion of overall suicides among adolescents. In contrast, Montana had a decrease in both absolute count and proportion of adolescent suicides during the pandemic, whereas Alaska had a decrease in proportion only. When data were aggregated across all 14 states, the proportion of overall suicides among adolescents increased during the pandemic. No other pandemic-period changes in adolescent outcomes were statistically significant ( Table ).

Proportion of suicides among adolescents has shifted markedly and heterogeneously across the 14 participating states. Although the study was limited to states with available data, this 14-state cohort included representation from all 10 Department of Health and Human Services regions and comprised 32% of all US residents (33% adolescents). Future research is needed to expand this analysis to the remaining US states. The format of data available from each state varies greatly, but any existing aberrations are unlikely to change the directionality of the findings because of standardization of International Classification of Diseases coding across states.

In accordance with previous work on excess mortality during the pandemic, 4 we treated the full year of 2020 as the pandemic period. Although previous studies reported that suicide-related deaths in the broader population decreased during the pandemic, 5 we found that adolescents have not experienced the same patterns as adults in the participating 14 states in the same period; specifically, suicides among adults 35 years or older have followed a downward pattern, 5 although there is undoubtedly variation across geographic areas and subpopulations. Stratification by age group and geography will be necessary to expose these heterogeneities in mental health outcomes associated with the pandemic. Moreover, given recent evidence that pandemic-period suicidality may be differentially affected by race and ethnicity, especially among youth, future work is needed to capture variability across ethnoracial subpopulations. 6

These findings highlight the importance of alleviating the downstream consequences of the pandemic for adolescent well-being. Examples of interventions that may address shifting suicidality among young people in the US include expanding bereavement counseling to cope with the loss of caregivers and implementing more readily available suicide risk assessment solutions.

Accepted for Publication: December 7, 2021.

Published Online: April 25, 2022. doi:10.1001/jamapediatrics.2022.0515

Corresponding Authors: Marie-Laure Charpignon, MSc, Institute for Data, Systems, and Society, 50 Ames St, Cambridge, MA 02142 ( [email protected] ); Maimuna Shahnaz Majumder, PhD, Boston Children’s Hospital, 300 Longwood Ave, Boston, MA 02115 ( [email protected] ).

Author Contributions : Ms Charpignon and Mr Ontiveros had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Ms Charpignon and Mr Ontiveros contributed equally to the manuscript. Drs Mandl and Majumder are senior authors.

Concept and design: Charpignon, Sundaresan, Puri, Mandl, Majumder.

Acquisition, analysis, or interpretation of data: Charpignon, Ontiveros, Sundaresan, Puri, Chandra, Majumder.

Drafting of the manuscript: All authors.

Critical revision of the manuscript for important intellectual content: Charpignon, Ontiveros, Sundaresan, Puri, Chandra, Majumder.

Statistical analysis: Charpignon, Ontiveros, Sundaresan, Puri, Chandra.

Obtained funding: Majumder.

Supervision: Mandl, Majumder.

Conflict of Interest Disclosures: None reported.

Funding/Support: This study was supported by National Institutes of Health award T32HD040128 from the Eunice Kennedy Shriver National Institute of Child Health and Human Development and National Center for Advancing Translational Sciences award KL2 TR002542 from the Harvard Catalyst of The Harvard Clinical and Translational Science Center.

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Additional Information: Representatives from the state departments of public health from which we obtained data directly via data use agreements reviewed the data analysis and validated the results of this study. We are bound by our data use agreements with the vital statistics division at each individual state department of health.

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ETA launched the American Apprenticeship Initiative (AAI) in October 2015 and provided five-year grants to 46 grantees to expand registered apprenticeship into new sectors and to populations historically underrepresented in apprenticeships. Some AAI grantees received no-cost extensions of their periods of performance through September 2021. In April 2016, ETA commissioned an evaluation of the AAI to build evidence about the effectiveness of registered apprenticeship for apprentices and employers. The evaluation included four sub-studies (an implementation study, an outcomes study, an employer return-on-investment (ROI) study, and an assessment of a demonstration to encourage employers to adopt apprenticeship). Three reports comprised the implementation sub-study. In addition to the sub-study reports, the AAI Evaluation included five topical issue briefs.

This brief examines the costs to AAI grantees, along with the number of apprenticeships they helped create, to derive the government cost per added apprentice. The key data source for the analysis is the Department of Labor’s Apprenticeship Quarterly Performance Reports, or Apprenticeship QPR, supplemented with information from the AAI Grantee Survey to understand how the costs of apprenticeship expansion vary with grantee characteristics. By the last quarter of the AAI grants (ending September 2021), average cost per apprentice for all grantees declined to $5,171; for the median grantee, the figure was $6,407 per apprentice. The median AAI grantee with prior experience spent about $4,867, far less than the $8,702 per apprentice spent by the median AAI grantee with no apprenticeship experience. Ultimately, the costs per apprentice of individual grantees are lower as AAI grantees generate more apprenticeships. The implications of this research are that funding grantees based on the targets they propose is likely to yield a wide variation in the cost per added apprentice and paying only for the apprenticeships generated could increase the number of apprenticeships for a given budget.

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Civil registration and vital statistics are key for a country’s planning and the distribution of resources and services. Birth certificates are essential to access government services in most countries. According to the Kenya Vital Statistics Report (2021), about 92% of births in Kenya are registered.  Children who do not have birth certificates may be disadvantaged in accessing government services, including healthcare through the National Health Insurance Fund (NHIF). As outlined by the Huduma Kenya Service Delivery Programme (HKSDP) , one needs a birth certificate to register for national examinations and apply for a national identification card and passport. In turn, one requires a national identity card to register a cell phone sim card, open an account, access government offices and engage in many other aspects of life.

However, there seems to be a lack of awareness of the importance of these documents, particularly in low-income households. The sometimes tedious application process and the transport cost to and from government offices, especially for those living in far-flung villages, have also been cited as reasons for failing to apply for these documents. As a result, already vulnerable and disadvantaged households are further excluded from essential government and digital financial services.

Between 2019 and 2021, the African Medical and Research Foundation (AMREF) and PharmAccess Foundation implemented the Innovative Partnership for Universal Sustainable Healthcare ( i -PUSH) program in Kenya’s Kakamega County. The intervention was geared towards the training of community health volunteers (CHVs), improving quality of care at the health facility level, and providing partly subsidized, mobile phone-based access to the National Health Insurance Fund (NHIF)* for low-income households.

A team of researchers from the African Population and Health Research Center (APHRC) and the Amsterdam Institute for Global Health and Development (AIGHD) evaluated the program to provide insights into the motivations, drivers, and challenges that hinder women and their families’ access to good-quality health care. The study also evaluated the impact of the intervention on health insurance enrolment and utilization of reproductive, maternal, newborn, and child health (RMNCH) services. The evaluation study covered 240 households in 24 villages, where women between the ages of 18 and 49 were randomly assigned to the control or treatment group. The study participants were either expectant or mothers with children under four years of age. All the women were interviewed at baseline, and the treatment group was subsequently offered support in enrolling for NHIF through a subsidized package offered by i-PUSH.

The project also required the mothers in the study to have access to mobile phones, which were used to enroll them into NHIF and to save on NHIF premiums. During the COVID-19 period, the i-PUSH research team purchased low-cost phones for the participants who did not own phones. Access to mobile phones doubled as an asset for remote data collection.

The challenge

While recruiting participants for the study, the research team realized that some households did not fulfill NHIF documentation criteria. The team noted that 37% of the children did not have birth certificates, while 21% of mothers did not have identity cards.  “ Some of the mothers did not have national identification cards. We also discovered that some children did not have birth certificates ,” said Caroline Wainaina (APHRC), the research coordinator on the project. The reasons for lacking these important documents included misplaced birth notifications or identification cards; the impression of some parents that the children were still young and thus did not need a birth certificate; parents being unsure of the birth certification process; and financial and time constraints in accessing the civil registrar’s office and documentation required for the process. “I went to apply for a national identification card, and when I reached the stage of taking a passport photo, they referred me to a studio at Khwisero [a local town] where they were asking for 200 shillings, which I did not have. I asked my husband, and he said I should wait until he gets money,” said one of the study participants.

The lack of documentation meant fewer people were eligible for the NHIF health insurance subsidy from the i-PUSH program. This proved a challenge that the implementing partners and evaluation team had not foreseen.

The process

The research team proactively mitigated the challenges encountered through community and policy engagement. The team liaised with the civil registrar’s office, which engaged the community in raising awareness of the importance of having identification documents. “We facilitated a visit for the registration officials to sensitize the participants on the information required to acquire IDs and birth certificates,” said Bernard Kosgei, formerly of PharmAccess. Through community health workers, the research team helped households gather the documents required to facilitate the registration process. The team also helped mothers obtain documentation from health facilities and area chiefs required to obtain birth notification and birth certificates. The project facilitated the birth certificate process by paying the required fees. Through persistent follow-up, most of the women could get the birth certificates for their children and thereby ensure all their family members were covered under NHIF.

This collaborative effort resulted in a shorter turnaround time for families to obtain birth certificates. It ensured they incurred no transport costs when the registration team visited the communities. This was an essential benefit as some participants were not financially stable and thus could not afford the KES 200 – KES 300 bodaboda (motorbike) taxi fees to get to the registration offices.

Impact on the local communities

The efforts to increase registration and provide birth certificates for young children produced two longer-term benefits for the local communities. First, the certificates would be life-long assets to the children and enable their eligibility or access to a range of other essential services. Second, the challenges encountered in the community awakened local government officials to the extent of the problem after the field- team met with them and explained the challenges encountered.

These unexpected findings were unrelated to the academic and evaluation outcomes of the i-PUSH project.

Recommendations

Though this process was helpful in enhancing the registration of the study participants, it is neither scalable nor sustainable. There is a need for better strategies to ensure that all children have birth certificates, independent of external interventions through programs such as i-PUSH. The thrust to implement Universal Health Coverage (UHC) countrywide would strongly benefit from sensitization of the public is on the importance of obtaining identification documents.

Therefore, the team recommends the following:

• To further strengthen linkages between local registration and health officials, health facilities should sensitize parents and caregivers on the importance of acquiring the birth certificate beyond processing the birth notification.
• Local administration should sensitize the public on the process of obtaining identification documents.
• It is crucial to bring civil registration services closer to communities. This can be done through mobile/portable camps and partnering with non-state actors.
• Stakeholder mapping is critical in understanding who fits where, thus ensuring that all key actors in implementation are engaged at community and policy levels.
• As the country prepares to roll out the Social Health Insurance Fund (SHIF), we recommend that the government consider assisting the marginalized and disenfranchised to acquire the necessary identification documents to enable them to access insurance benefits.

  *As the government works towards attaining universal health coverage, it has now transitioned from NHIF to the Social Health Insurance Fund (SHIF).

This blog was drafted by Florence Sipalla, Caroline Wainaina, Amanuel Abajobir, and Wendy Janssens

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• Main Findings

The following analysis discusses the demographic characteristics of each of the five social media platforms in the survey.

Facebook — 72% of adult internet users/62% of entire adult population

Fully 72% of online American adults use Facebook, a proportion unchanged from September 2014. Usage continues to be especially popular among online women, 77% of whom are users. In addition, 82% of online adults ages 18 to 29 use Facebook, along with 79% of those ages 30 to 49, 64% of those ages 50 to 64 and 48% of those 65 and older.

Pinterest — 31% of adult internet users/26% of entire adult population

Some 31% of online adults use Pinterest, a proportion that is unchanged from the 28% of online adults who did so in September 2014. Women continue to dominate Pinterest – 44% of online women use the site, compared with 16% of online men. Those under the age of 50 are also more likely to be Pinterest users – 37% do so, compared with 22% of those ages 50 and older.

Instagram — 28% of adult internet users/24% of entire adult population

Some 28% of online adults use Instagram, a proportion that is unchanged from the 26% of online adults who did so in September 2014. Instagram continues to be popular with non-whites and young adults: 55% of online adults ages 18 to 29 use Instagram, as do 47% of African Americans and 38% of Hispanics. Additionally, online women continue to be more likely than online men to be Instagram users (31% vs. 24%).

LinkedIn — 25% of adult internet users/22% of entire adult population

A quarter of online adults use LinkedIn, a proportion that is unchanged from the 28% of online adults who did so in September 2014. As was true in previous surveys of LinkedIn usage, the platform is especially popular among working-age adults as well as college graduates and those with relatively high household incomes. LinkedIn is the only major social media platform for which usage rates are higher among 30- to 49-year-olds than among 18- to 29-year-olds. Fully 46% of online adults who have graduated from college are LinkedIn users, compared with just 9% of online adults with a high school diploma or less. The site continues to be popular among the employed – 32% are LinkedIn users, compared with 14% of online adults who are not employed.

Twitter — 23% of all internet users/20% of entire adult population

Some 23% of all online adults use Twitter, a proportion that is identical to the 23% of online adults who did so in September 2014. Internet users living in urban areas are more likely than their suburban or rural counterparts to use Twitter. Three-in-ten online urban residents use the site, compared with 21% of suburbanites and 15% of those living in rural areas. Twitter is more popular among younger adults — 30% of online adults under 50 use Twitter, compared with 11% of online adults ages 50 and older.

Frequency of Use on Social Media Sites

While there were no changes in overall usership on any site when comparing data from the fall of 2014 and the spring of 2015, a few social media platforms did see an increase in user engagement. The proportion of daily users on Instagram, Pinterest and LinkedIn increased significantly from 2014.

Today, 59% of Instagram users are on the platform daily, including 35% who visit several times a day. This 59% figure reflects a 10-point increase from September 2014 when 49% of Instagram users reported visiting the site on a daily basis. Similarly, the proportion of Pinterest users who visit the platform daily rose from 17% in September 2014 to 27% in April 2015, while the proportion of daily users on LinkedIn increased from 13% to 22% over the same time period.

Twitter saw no significant changes in its proportion of daily users. Some 38% of those on Twitter use the site daily, a figure that is statistically unchanged from the 36% who did in 2014.

Facebook continues to have the most engaged users – 70% log on daily, including 43% who do so several times a day. This overall proportion of daily users, however, is unchanged from the 70% who used Facebook daily in 2014.

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