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Dahai Yu,1 Matthew Missen,1 Kelvin P Jordan,1 John J Edwards,1 James Bailey,1 Ross Wilkie,1 Justine Fitzpatrick,2 Nuzhat Ali,2 Paul Niblett,2 George Peat1 1Primary Care Centre versus Arthritis, School of Medicine, Keele University, Keele, Staffordshire, UK; 2Office for Health Improvement and Disparities, Department of Health and Social Care, London, UKCorrespondence: Dahai Yu, Email d.yu@keele.ac.ukPurpose: To compare estimates of annual person-consulting incidence and prevalence of low back pain (LBP) and osteoarthritis for two national English electronic health record databases (Clinical Practice Research Datalink (CPRD) Aurum and CPRD GOLD).Patients and Methods: Retrospective, population-based, longitudinal cohort study. LBP and osteoarthritis cases were defined using established codelists in people aged ≥ 15 and ≥ 45 years, respectively. Incident cases were new recorded cases in a given calendar year with no relevant consultation in the previous 3 years (denominator = exact person-time in the same calendar year for the at-risk population). Prevalent cases were individuals with ≥ 1 consultation for the condition of interest recorded in a given calendar year, irrespective of prior consultations for the same condition (denominator = all patients with complete registration history in the previous 3 years). We estimated age-sex standardised incidence and annual (12-month period) prevalence for both conditions in 2000– 2019, overall, and by sex, age group, and region.Results: Standardised incidence and prevalence of LBP from Aurum were lower than those from GOLD until 2014, after which estimates were similar. Both databases showed recent declines in incidence and prevalence of LBP: declines began earlier in GOLD (after 2012– 2014) than Aurum (after 2014– 2015). Standardised incidence (after 2011) and prevalence of osteoarthritis (after 2003) were higher in Aurum than GOLD and showed different trends: incidence and prevalence were stable or increasing in Aurum, decreasing in GOLD. Stratified estimates in CPRD Aurum suggested consistently higher occurrence among women, older age groups, and those living in the north of England.Conclusion: Comparative analyses of two English databases produced conflicting estimates and trends for two common musculoskeletal conditions. Aurum estimates appeared more consistent with external sources and may be useful for monitoring population musculoskeletal health and healthcare demand, but they remain sensitive to analytic decisions and data quality.Keywords: musculoskeletal, electronic health records, epidemiologic methods, osteoarthritis, low back pain, primary care

Georgia Carney,1,2 Andrew Harrison,3 Jane Fitzpatrick1,2,4 1Joint Health Institute, Melbourne, Victoria, Australia; 2Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Parkville, Victoria, Australia; 3Bioventus International, Hoofddorp, 2131 LS, Netherlands; 4Australasian College of Sport and Exercise Physicians, Melbourne, Victoria, AustraliaCorrespondence: Jane Fitzpatrick Level 7, Alan Gilbert Building 161 Barry Street University of Melbourne, Parkville, Victoria, 3010, AustraliaTel +61 3 9429 6444Email jane.fitzpatrick@unimelb.edu.au Twitter @sportsdocPurpose: To determine the duration of symptom relief following repeated administration of hyaluronic acid injections for osteoarthritis.Patients and Methods: This was a 6-year observational study with 623 consecutive patients who had received hyaluronic acid injections. The primary outcome measure was the mean time between injections measured in days. Classical one-sample 2-sided t-tests, one-way analysis of variances and post-hoc analyses were performed to determine if there were statistically significant differences between age, gender, radiographic severity and the type of joints injected. All patients were invited to complete an online post-treatment experience and satisfaction survey.Results: The analysis included 727 joints (mean Kellgren-Lawrence grade, 2.9 ± 0.8 (range 2– 4)) in 623 patients (297 (47.7%) male; mean age at first injection, 57.8 ± 12.7 years (range 21.2– 92.1)). Patients ranged from having 1– 8 injections per joint. The mean time between injections in days was 466.8 ± 321.7 (2nd injection, 157 joints), 400.5 ± 164.7 (3rd injection, 58 joints), 378.2 ± 223.1 (4th injection, 27 joints), 405.3 ± 216.3 (5th injection, 7 joints), 268.4 ± 104.4 (6th injection, 5 joints), 289.8 ± 99.4 (7th injection, 4 joints), and 272.5 ± 33.2 (8th injection, 2 joints). Patients with grades 2 and 3 compared to grade 4 osteoarthritis experienced a longer time between injections (F (2, 154) = 3.53, p = 0.0316). No statistically significant differences were observed between age, gender, or joint groups. The survey included 233 participants (109 (46.8% male)). A total of 144 respondents (64.9%) recommended hyaluronic acid injections for osteoarthritis.Conclusion: Pain relief from hyaluronic acid injections was sustained for on average 466.8 days post initial treatment. Patients who received subsequent 3rd, 4th, and 5th injections also experienced extended duration of benefit. Patients with grades 2 or 3 osteoarthritis are more likely to experience a longer duration of relief.Keywords: biological treatment, joint, hyaluronic acid, intra-articular injection, long-term, pain relief

Jane Fitzpatrick,1,2 Christen Richardson,3 Ianiv Klaber,4 Martin D Richardson1 1Centre for Health and Exercise Sports Medicine, School of Health Sciences, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Parkville, VIC, Australia; 2Joint Health Institute, Melbourne, VIC, Australia; 3Medical School, College of Health and Medicine, Australian National University, Acton, ACT, Australia; 4Orthopaedic Surgery Department, School of Medicine, Pontifical Catholic University of Chile, Santiago, ChileCorrespondence: Jane FitzpatrickCentre for Health and Exercise Sports Medicine, School of Health Sciences, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Level 7, Allan Gilbert Building, 161 Barry Street, Melbourne, VIC, AustraliaEmail jane.fitzpatrick@unimelb.edu.auBackground/Hypothesis: Adhesive capsulitis of the shoulder results in pain and restricted movement of the glenohumeral joint. Hypothesis: There would be a difference in active range of movement in the affected shoulder of patients with adhesive capsulitis after receiving a series of injections of collagenase Clostridium histolyticum (CCH) compared to placebo.Methods: This study reports the results from a single site that was part of a 321-participant, multicenter, double-blind, prospective parallel-group, randomized controlled clinical trial. Inclusion criteria: over 18 years of age, unilateral idiopathic adhesive capsulitis for > 3 months, but < 12 months. Exclusion criteria: recent physical therapy, injections, subacromial impingement, calcific tendonitis or glenohumeral joint arthritis in the affected shoulder. Subjects were randomized 3:1 to receive CCH 0.58 mg or placebo under ultrasound guidance. Injections were on days 1, 22, and 43. The primary outcome measure was a functional assessment of active range of movement.Results: Overall, 37 patients were screened, 26 subjects were excluded, and 11 subjects were randomly assigned to the treatment group (n=9) or the control group (n=2). Both control and treatment groups showed improvement in ROM between baseline and day 95. In the treatment group, AROM improved from the baseline of 272.89° (SD 86.25) to 462.11° (SD 96.89) and the control group from 246.00° (SD 5.66) to 451.50° (SD 50.20) at day 95 with no statistical difference between groups p=0.78. Site data were in line with the whole study findings. Treatment-related adverse events at the injection site, including haematoma (bruising) and localised pain and swelling, were common.Conclusion: Although the participants showed improvement in function, statistical significance was neither reached in the site nor the overall study cohort. Given the adverse events and the potential risks of the procedure, we would not recommend this drug for the treatment of adhesive capsulitis of the shoulder.Level of Evidence: 2, cohort from one site of RCT.Keywords: adhesive capsulitis, frozen shoulder, collagenase

Ross Leighton,1 Jane Fitzpatrick,2,3 Helen Smith,4 Daniela Crandall,4 Carl R Flannery,4 Thierry Conrozier5 1Department of Surgery, Dalhousie University, Halifax, NS, Canada; 2Sports Medicine Professionals Pty Ltd, Richmond, VIC, Australia; 3University of Western Australia, Perth, WA, Australia; 4Bioventus LLC, Durham, NC, USA; 5Department of Rheumatology, Hospital Nord Franche-Comte, Belfort, France Background: Pain and limitations in joint mobility associated with knee osteoarthritis (OA) are clinically challenging to manage, and advanced progression of disease can often lead to total knee arthroplasty. Intra-articular injection of hyaluronic acid (HA), also referred to as viscosupplementation, is a non-surgical treatment approach for OA, the effectiveness of which may depend on the HA composition, and the length of time over which it resides in the joint. One of the available options for such therapies includes NASHA (Durolane HA), a non-animal, biofermentation-derived product, which is manufactured using a process that stabilizes the HA molecules to slow down their rate of degradation and produce a unique formulation with a terminal half-life of ~1 month. The objectives of the current review were to assess, in patients with OA of the knee, the efficacy and safety of intra-articular treatment with NASHA relative to control (saline) injections, other HA products, and other injectables (corticosteroids, platelet-rich plasma, mesenchymal stem cells).Methods: This systematic evidence review examines patient outcomes following NASHA treatment as described in published data from studies conducted in subjects with knee OA. A Preferred Reporting Items for Systematic Reviews and Meta-analyses-compliant literature search strategy yielded 11 eligible clinical studies with a variety of comparator arms. Outcomes assessed at various time points following intra-articular treatment included measures of pain, function, quality of life, and incidence of treatment-related adverse events (AEs).Results: The available evidence reported for the clinical studies assessed demonstrates sustained and effective relief of knee OA symptoms following a single injection of NASHA. In addition, an excellent biocompatibility profile is observed for NASHA as an intra-articular therapy for OA, as reflected by the low rate of AEs associated with treatment.Conclusion: Treatment with NASHA is an effective and safe single-injection procedure, which can be beneficial in the clinical management of knee OA. Keywords: osteoarthritis, viscosupplementation, intra-articular, hyaluronic acid, NASHA, Durolane, residence time, symptomatic relief, clinical outcomes

Building on the various works of theorists pertaining to curriculum negotiation, the Negotiated Integrated Curriculum (NIC) initiative detailed in this article attempts to redress the imbalance within curricular decision-making whereby student voice and learner agency is largely absent. The NIC initiative enquires into students' concerns about life and constructs a curriculum to address these concerns as a mechanism that can be shaped to make learning more meaningful through agentic engagement. Based on a longitudinal study of two primary schools, this small scale, exploratory research details the influence of this process on learners and educators and the challenges that were faced during its implementation. The findings of this study examine two main issues: the first is how student voice, particularly around the decision-making of pedagogical activities, can be practically implemented to enhance the perceived relevance of a curriculum; and secondly the process of negotiation between teachers and students to achieve this. Recommendations for the promotion of learner agency and further research are discussed in the context of Irish curriculum reform.

Summertime solar heating of near-surface snow in central Greenland causes mass loss and grain growth. These depth hoar layers become seasonal markers which are observed in ice cores and snow pits. Mass redistribution associated with depth-hoar formation can change concentrations of immobile chemicals by as much as a factor of two in the depth hoar, altering atmospheric signals prior to archival in ice. For methanesulfonic acid (MSA) this effect is not significant because the summer maximum does not coincide with the density minimum, and the amplitude of the annual (MSA) signal is more than a factor of ten.

A case study was conducted on a group of undergraduate chemical engineering students to assess the relevance of attending lectures from a student perspective and to understand why these students attend and do not attend lectures with a view to developing approaches to teaching, which are of greater interest and benefit to student learning. The students were surveyed by means of a questionnaire-type survey, which collected both quantitative and qualitative data from them. The majority of students stated that lectures are still very beneficial to their learning and are not an out-of-date mode of education. The major reasons for lecture non-attendance were time priority and curriculum overload issues with other scholarly activities and poor quality teaching. The students provided a number of suggestions to improve lectures and lecture attendance, including the incorporation of active learning in lectures, linking lectures to assessment and adding extra value to what is already in the notes. (Contains 3 tables and 7 figures.)