Osteoarthritis is a debilitating condition that can become extremely painful and significantly affect a patient’s mobility, sleep, and ability to work. As it reduces physical activity and sleep quality, the disease is also associated with many mental and physical health conditions, including depression, anxiety, cardiovascular disease and diabetes.

Knee and hip osteoarthritis currently affect more than 300 million people worldwide. Around one in five women over the age of 60 live with the condition, and this prevalence is expected to rise as our life-expectancy increases.

In osteoarthritis, there is a disturbance in the balance between build-up and degradation processes in the joint. When these processes become unbalanced, more cartilage is destroyed than is produced. The result is the incurable and progressive break-down of cartilage, as well as inflammatory and painful changes in the synovial membrane and the adjacent bone structures.

At present, treatments for osteoarthritis remain limited. General medical recommendations centre around exercise and drugs, which work to reduce inflammation and relieve pain. However, there are currently no treatments available that can stop the disease from progressing or repair the damaged structure of the joints. According to the American College of Rheumatology and the Arthritis Foundation, the search for a treatment that can reduce the pain of osteoarthritis and treat the affected tissues and joint structures remains a ‘substantial unmet medical need’.

Growth and Differentiation Factor 5, or ‘GDF5’ for short, is a protein known to be associated with susceptibility to osteoarthritis. It is involved in the development of bones and joints in humans and other mammals. If this protein is under-expressed, individuals are more likely to develop the disease. In fact, studies have revealed that supplementation with GDF5 could be a beneficial treatment for osteoarthritis.

Dr Kerstin Kleinschmidt-Doerr of Merck Healthcare and her colleagues have built on this research. To mitigate the undesirable bone-activating effects of this protein, the team used molecular-based tools to create modified forms of GDF5. They investigated different variants of the protein and ultimately chose the one that performed best in various tests. They named this modified protein molecule R399E.

The researchers characterised the protein in detail in isolated cells and tissues, as well as in animals. They first tested the effects of R399E on joint tissues they had collected from osteoarthritis patients. Interestingly, the protein had measurable effects on the biochemical processes within these samples.

For instance, R399E reduced the production of cartilage-destroying enzymes and therefore decreased the degradation of cartilage. Surprisingly, it also reduced the release of inflammatory mediators and pain messengers. At the same time, treatment with R399E for only one week per month in cartilage cultures resulted in an increase in the number of cartilage cells and cartilage matrix formation. The researchers also discovered an accumulation of the protein in cartilage cultures, which raised their hope that the effect would last long enough in a patient’s knee after injection.

Dr Kleinschmidt-Doerr and her colleagues then tested R399E on rabbits with osteoarthritis for its effect on the altered joint tissue and pain caused by the disease. However, unlike human patients, knee pain in rabbits cannot be measured using questionnaires. Therefore, the researchers needed to devise a method for measuring the comparatively weak knee pain experienced by the animals in a reliable and reproducible way.

When osteoarthritis is triggered only in the right knee, as in this study, the animals put less weight on this limb and more weight on the left limb. Therefore, the team developed a method to objectively measure how much weight a rabbit puts on each knee voluntarily. The bigger the difference between right and left, the more pain the rabbits feel, which is a fair assumption.

Dr Kleinschmidt-Doerr’s team showed that rabbits who received R399E injections into the diseased knee put significantly more weight on that limb compared to animals who received a placebo injection. This result indicates that the treatment reduces osteoarthritis-related knee pain in rabbits. Importantly, the pain reduction was observed as early as six hours after the first injection of R399E. In their rabbit study, the pain-relieving effect was greater and longer lasting than when the team administered triamcinolone – a common pain medication for osteoarthritis.

The team is particularly proud of their knee pain examination method, which was only possible thanks to the particularly species-appropriate and stress-free handling of the animals. The animals, which were very relaxed during the measurement, could be reliably tested without being influenced by the observer. This makes the results particularly meaningful and robust.

Finally, examination of the tissues of the knee after 13 weeks showed that structural damage was also significantly less in the treated knees than in those of the placebo control groups.

Dr Kleinschmidt-Doerr and her colleagues then confirmed the pain-relieving and tissue-protective effects of the same doses of R399E in sheep with osteoarthritis.

The team’s experiments with sheep, rabbits and human patient tissue samples clearly demonstrate the potential of R399E in both relieving pain and reducing damage to joint tissues. Based on these data, it appears justified to test effectiveness and safety of R399E in human patients.

If clinical studies were to prove the assumed potential of R339E, it could become the first treatment that both reduces the debilitating pain of osteoarthritis while actually rebuilding damaged joints. Given that there are over 300 million people suffering with the condition worldwide, the impact of such a treatment on global health and wellbeing would be revolutionary.

However, people with type 2 diabetes either cannot produce enough insulin or their bodies are not responsive enough to the hormone – a phenomenon known as insulin resistance. As their cells cannot effectively absorb sugar, people with this condition typically have high blood sugar levels.

The risk of developing type 2 diabetes is linked to high blood pressure and obesity, which can often be reduced with healthy lifestyle choices. However, the risk also increases with age, and some ethnicities have a higher risk of developing the condition. For example, according Diabetes UK, people of South Asian descent are up to four times more likely to develop type 2 diabetes.

High blood sugar levels can cause symptoms such as fatigue, excessive thirst, and blurred vision. Having high blood sugar for long periods of time can also lead to permanent damage to the eyes, kidneys, nerves and cardiovascular system. According to the World Health Organization, diabetes is a major cause of heart attacks, strokes, kidney failure, blindness, and lower limb amputation.

Early diagnosis, regular monitoring and treatment are vital for avoiding these serious complications, but sadly the number of people with diabetes is increasing across the globe. In 2017, there were about 451 million adult patients globally, and this number is expected to increase to 693 million by 2045.

Dr Xiaomu Li’s team at Zhongshan Hospital at Fudan University in Shanghai, China, works to unravel the relationships between high blood pressure, insulin resistance, and the risk of developing type 2 diabetes. Individuals with high blood pressure are at much higher risk of developing diabetes, and around half of people with diabetes also suffer from high blood pressure. In addition, the risk of cardiovascular disease in these patients is about four times that of people with diabetes who have normal blood pressure.

Dr Li and her colleagues recently carried out a study to investigate the relationships between blood pressure and varying degrees of insulin resistance, and how these two factors were linked with new diagnoses of diabetes. This was the first study to investigate whether high blood pressure and insulin resistance could predict a person’s risk of developing type 2 diabetes. The team hypothesised that high blood pressure and insulin resistance may lead to a dangerous feedback loop, resulting in the development of diabetes.

To conduct their study, Dr Li and her team investigated the records of 1251 adults with no history of diabetes, who had been reviewed in the Physical Examination Centre of Zhongshan Hospital in 2015. They collected data on a number of factors, including blood pressure, blood sugar levels, and cholesterol levels. From the patient records, the researchers also calculated the HOMA-IR value. This stands for ‘Homeostatic Model Assessment of Insulin Resistance’ and describes the level of insulin resistance in the body. The team then analysed the data while taking into account individual differences, such as gender and age.

Out of the 1251 study participants, Dr Li’s team found 166 new cases of diabetes, which is a total detection rate of just over 13%. The rate of newly diagnosed diabetes was about four times higher in the adults who had high blood pressure compared to those with normal blood pressure. Even participants whose blood pressure was at the higher end of the normal range had an increased rate of new diabetes diagnosis. In terms of insulin resistance, the researchers found that higher HOMA-IR scores were correlated with higher rates of diabetes.

The team then combined the blood pressure data with the HOMA-IR values that indicated higher levels of insulin resistance, and performed further statistical analysis. They discovered that the risk of diabetes was a staggering 38 times higher in these individuals compared to those with low HOMA-IR scores and normal blood pressure.

Dr Li and her colleagues conclude that higher blood pressure and insulin resistance levels combine to exponentially increase a person’s risk of developing type 2 diabetes. Armed with this knowledge, doctors and other healthcare workers can more easily identify individuals who are at particularly high risk of developing this often-irreversible condition.

For instance, screening programs that assess the HOMA-IR scores of patients with high blood pressure would enable healthcare providers to identify the most at-risk patients, allowing them to devise targeted intervention strategies that prevent or delay the onset of diabetes. For those who have already developed the condition, such screening programs would enable earlier diagnoses, allowing patients to begin treatments that can prevent the often life-changing complications of diabetes.

Acute vestibular syndrome – or AVS for short – is the onset of sudden and intense feelings of spinning or dizziness, often accompanied by nausea, balance problems, and involuntary eye movements known as nystagmus.

These symptoms can all be caused by damage or disease in the vestibular system – the network responsible for maintaining our sense of balance and spatial awareness. AVS can either be central, which is related to the brain, or peripheral, which is related to the inner ear. Knowing the location of the damage helps doctors identify which patients may be suffering from a potentially life-threatening medical condition. This is because central AVS is associated with severe morbidity. In contrast, peripheral AVS is a common condition of the inner ear or eighth cranial nerve, which is not lethal.

Diagnosing AVS and categorising the cause as either central or peripheral can be achieved by gathering a medical history, conducting physical and neurological examinations, and using complex diagnostic technology such as video oculography.

Doctors and healthcare workers can perform a HINTS examination to differentiate between central and peripheral AVS. The HINTS examination consists of three components: a head impulse test, a nystagmus test, and a test of skew.

The head impulse test involves rapid horizontal movements of the patient’s head while the patient focuses on a fixed point. Nystagmus are involuntary eye movements. Factors such as the presence or absence and direction of these movements can indicate whether AVS is central or peripheral. The test of skew analyses the alignment of the eyes. In central AVS, imbalances in the eye muscles can lead to one eye appearing higher than the other.

The original HINTS examination was established in 2009. Since then, variations have been released, including the HINTS-PLUS, which includes a hearing test, and the so-called STANDING algorithm.

Video oculography uses video goggles or a specialised camera to track a patient’s eye movements. It is highly accurate and may capture subtle abnormalities that would be missed by a physical examination. It is also a highly specialised piece of equipment requiring trained healthcare staff to perform the tests and interpret the results.

A recent review paper found that less than 20% of patients who came to hospital with severe dizziness underwent a HINTS examination. Several studies have suggested that only doctors specialising in eye or ear problems relating to the nervous system are able to correctly conduct and interpret physical and neurological examinations such as the HINTS examination, which is better than an early MRI for identifying stroke. The findings of these studies are particularly concerning when we think about the care of patients attending rural or remote hospitals, who may not have access to specialist doctors or video-oculography technology.

Dr Millie Nakatsuka of the University of Sydney in Australia is an expert in neuro-ophthalmology and has a particular interest in health inequality in regional and rural hospitals. Working with a multidisciplinary team, Dr Nakatsuka conducted a large-scale review to evaluate whether appropriate training and education can allow emergency doctors to use the HINTS examination and STANDING algorithm to effectively distinguish between central and peripheral AVS.

The team began by looking at 1,757 results from all the major clinical journals and clinical trial records. Of these, 27 were deemed appropriate for further consideration. Articles were screened against multiple factors to ensure they met the stated criteria for clinician education and did not contain significant bias. After being screened, five studies were available for qualitative analysis and two for quantitative analysis.

More information was available on the STANDING algorithm than the traditional HINTS examination and its variations. Data supported the proposal that emergency doctors who are well-trained and educated can use the STANDING algorithm to identify central AVS in comparison to AVS with a peripheral cause. When administered by trained emergency doctors, the STANDING algorithm offered high levels of sensitivity, as 96% of cases of central AVS were accurately detected. It also showed high specificity, as 88% of non-central AVS cases were ruled out.

The researchers did not find enough evidence to fully support emergency doctors’ use of the original HINTS examination. However, they did report that two separate research studies are currently being conducted to assess the reliability of HINTS when performed by trained emergency doctors.

Dr Nakatsuka’s study provides the first high-quality evidence supporting the diagnostic accuracy of the STANDING algorithm when conducted by trained emergency doctors. As such, the team’s findings contradict previous reports concluding that bedside physical examinations for AVS should only be conducted by specialist doctors.

In Australia, only 25% of public hospitals are in major cities, with rural and regional hospitals facing large disparities in access to medical specialities and diagnostic technology such as video-oculography. Dr Nakatsuka’s work shows that if staff are given adequate education and training, patients will be able to be rapidly and accurately classified as having central or peripheral AVS without needing to travel to a large well-resourced city hospital.

Increasing interest in the use of smartphones to record eye movements to aid AVS diagnosis also emerged in Dr Nakatsuka’s work, illustrating the useful application of technology and clinical skills. She hopes to build upon this current work by conducting further research on the education and training needed by point-of-care healthcare professionals to provide robust AVS differential diagnoses.

Like many countries in the Global North, Canada has an ageing population. Currently, its medical system is not equipped to ensure that seniors can age healthily and within the community. Healthy ageing, defined as the maintenance of functional ability in older age, is a key priority for the World Health Organization. Those who don’t age healthily become frail, with reduced function and health.

Currently, Canadian medical practitioners evaluate elderly patients using antiquated assessment methods which tend to focus solely on frailty, medical conditions, weaknesses, risks and loss. Anne Summach, Titus Chan and Tammy O’Rourke argue that an alternative approach is needed.

Firstly, they explain that more attention should be paid to strengths, capacities, and resilience, rather than focusing entirely on deficits. It is also imperative to highlight the factors that lead to frailty. If these factors are neglected, healthy ageing can be impeded, increasing the risk that seniors will need to be moved to long-term care.

Assessments should also identify complex comorbidities, which are a key factor in increased healthcare use for older people, who require targeted interventions from a range of services. Addressing this complexity and risk can help to improve people’s quality of life. Finally, the assessment should facilitate an integrated, holistic approach, incorporating community organisations as well as primary care practitioners.

To fulfil these needs, Summach, Chan and O’Rourke have developed the Healthy Ageing Asset Index. This can be used to assess seniors’ risk factors for functional decline, which may worsen their frailty. It can also be used to suggest interventions for improving resilience and for meeting their social and medical needs.

In developing the index, it was important for the researchers to consider a range of factors. The team conducted a study to identify issues particularly relevant for older people, such as chronic conditions, last medical appointment, substance use, and attachment to a primary provider. As pre-existing assessment tools tended to lack social assessment indicators, highlight weaknesses, and focus on hospital discharge, the researchers adjusted these tools before using them as the basis for the Healthy Ageing Asset Index.

Summach, Chan and O’Rourke released a first draft of the index in a senior-serving community organisation in Western Canada, which was based on a new, community-based model for social care.

Within this organisation, primary care is codeveloped by seniors and staff and the clinic director is a nurse practitioner. The clinical staff are embedded, providing care within the social service organisation, partnered with social workers, community navigators, and volunteers. On site, seniors are able to complete financial resource and housing applications requirements, and access referrals to community-based organisations. This type of support has never been experienced by older adults in the city.

The Healthy Ageing Asset Index was implemented as a component of all new-client visits to a primary care centre on the site. Nurses, nurse practitioners, and student nurse practitioners conducted the assessments. The research team then made changes to the index in response to feedback from users.

For example, feedback from students highlighted the need for standardised questions to ensure clarity for both the assessor and patient. Furthermore, due to a lack of NPs, the researchers adjusted the index to make it accessible to a range of assessors, including alternative clinical team members, social workers, and non-medical personnel. This ultimately led to a greater breadth of perspectives and more robust community and social services approach to implementation.

The final product needed to be usable by a range of community organisations, not just medical professionals. It had to take a strength-based approach, which concentrated on optimising patient capacity through support. Because of the COVID-19 pandemic, it was vital that the tool could be used both in-person and via telehealth. Finally, it had to foster inclusion, validation and empowerment.

The final version of the Healthy Ageing Asset Index incorporates seven categories, which align with the Healthy Ageing Framework and the World Health Organization’s determinants of healthy ageing.

Each section is scored from one to three, with zero indicating low complexity. Scores one and above in a subcategory suggest vulnerability factors and trigger clinical and social prescriptions. Clinical prescribing focuses on traditional medical needs, such as referrals to specialists and prescription optimisation, while social prescribing refers to programs that address diet, exercise, housing, transport, community engagement, and financial and substance use supports.

The use and results of the Healthy Ageing Asset Index are promising. Seventy-three seniors identified as moderately frail completed the index with a Community Connector in Social Work, leading to an intervention planning exercise. They were then reassessed at three, six, and twelve months of the intervention. This allowed for scores to be tracked over time, and for the index’s effectiveness to be assessed.

Summach, Chan and O’Rourke noticed a significant reduction in index scores for seniors at the twelve-month assessment when compared to their intake score. This occurred over a longer period of time than anticipated, potentially due to the time it takes for a relationship to build between the patient and medical professional. However, the index generally succeeded in expanding the capacity to assess and address complex needs relating to frailty.

These index scores were used to individualise interventions, which were optimised to align with the seniors’ capacities and goals. The scores were also integrated into electronic medical records for easy data extraction and reporting.

Enhancing our capacity to screen seniors and address their complex medical needs is important given Canada’s changing demographics. Summach, Chan and O’Rourke have created a tool that has the potential to improve wellbeing, reduce costs, improve workforce stability, reduce institutionalisation, and lessen pressure on facilities that provide higher levels of care. The Healthy Ageing Asset Index could help to shift Canadian healthcare away from reactionary medical care and towards a programme of long-term wellness and prevention.

Full-time therapy dogs are increasingly being incorporated into patient care, especially in children’s hospitals. Research has shown that these dogs can provide several benefits to young patients, such as reducing fear, anxiety, and perceptions of pain. Dogs who work alongside healthcare workers in hospital settings are referred to as facility dogs.

Facility dogs receive more intensive training than therapy dogs, similar to service dogs (such as guide dogs who assist with navigation). However, rather than supporting one specific individual with a disability, facility dogs support multiple individuals in a community with varying needs. In paediatric medicine, these dogs are trained to offer distraction, comfort, and motivation to children receiving medical treatment.

Whilst the main goal of a facility dog is to support patients, they also have a high level of interaction with the healthcare professionals they work alongside. Little research has focused on the impact these dogs may have on the healthcare workers themselves. Medical professionals are at risk of experiencing poor mental health and work-related burnout due to the distressing nature of their job and caring for ill children and their families.

When healthcare workers experience poor mental health and burnout, it can affect their professional functioning and put a strain on hospital resources. There is limited research to address this issue, something Clare Jensen and her colleagues from Purdue University and the University of Arizona in the USA noted. As such, these researchers wanted to better understand the impact of facility dogs on the mental health of paediatric healthcare professionals.

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Previous research suggests many benefits to having support from a dog. For example, studies have found that having a dog present during a stressful task can be better at reducing anxiety compared to having a human friend present. One reason for this may be that dogs can offer unique support that comes without judgement. Research also suggests that dogs can reduce stress. One study found that emergency healthcare workers experienced less stress after spending 5 minutes with a therapy dog compared to doing a relaxing task. Finally, being in the company of a dog can increase social interaction and help to establish closer connections with others.

Despite some promising initial research, no previous studies have specifically focused on the effects of facility dogs on the mental health of paediatric healthcare workers. Jensen and her colleagues aimed to fill this knowledge gap by undertaking a study to measure the impact of facility dogs on paediatric healthcare workers’ mental health and professional well-being. The researchers predicted that workplace interactions with a facility dog would be associated with better mental health, less burnout, and better job perceptions.

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The study involved 130 paediatric healthcare professionals working in children’s hospitals across the USA. Half of the participants worked with facility dogs and the other half did not. Most of the participants were white females with job roles ranging from nurses, social workers, physicians, and child-life specialists. All facility dogs in the study came from the non-profit organisation Canine Assistants. Facility dogs were mostly golden retrievers, labrador retrievers, and goldendoodles that were specifically bred and trained for their jobs. To measure the impact of partnering with a facility dog, participants completed an online survey to report on their burnout, job perceptions and mental health.

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Findings suggest that working with a facility dog had many benefits for paediatric healthcare professionals. Working with a facility dog was associated with less job-related burnout and greater feelings of accomplishment in the workplace. Facility dogs also benefited job perceptions. Professionals who worked with a facility dog were more positive about their job, had greater work-related enthusiasm, and had lower levels of work-related depression. Facility dogs also helped with job retention. Professionals working with facility dogs were more likely to want to stay in their current roles than those who didn’t work with a facility dog.

Interestingly, facility dogs did not impact burnout in terms of emotional exhaustion and were not associated with reduced anxiety, as expected from previous research. Ms Jensen and her colleagues explain that this might be related to the challenges faced when working with a facility dog. These dogs are often in high demand and the professionals must juggle their workload as well as the dog’s well-being.

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In conclusion, the researchers from Purdue University and the University of Arizona provide strong evidence for the benefits of incorporating facility dogs into paediatric healthcare settings, suggesting a positive impact on the mental well-being of healthcare professionals, as well as patients. They hope the outcomes of this study will help provide hospitals with a realistic view of what can be expected from incorporating facility dogs, as well as provide encouragement to explore the implementation of such programmes.