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Topic:Osteoarthritis

Osteoarthritis (OA) in horses is a degenerative joint disease characterized by the progressive deterioration of articular cartilage, subchondral bone changes, and synovial inflammation. This condition can result in pain, reduced mobility, and impaired performance in affected animals. Osteoarthritis is commonly observed in athletic horses due to repetitive joint stress, but it can also occur in older horses as part of the natural aging process. Diagnosis typically involves clinical examination, imaging techniques such as radiography or MRI, and sometimes synovial fluid analysis. Management strategies focus on alleviating pain, reducing inflammation, and slowing disease progression through pharmacological treatments, physical therapy, and sometimes surgical interventions. This page compiles peer-reviewed research studies and scholarly articles that explore the pathophysiology, diagnosis, and management of osteoarthritis in equine patients.
Histopathologic features of distal tarsal joint cartilage and subchondral bone in ridden and pasture-exercised horses.
American journal of veterinary research    January 5, 2011   Volume 72, Issue 1 33-41 doi: 10.2460/ajvr.72.1.33
Tranquille CA, Dyson SJ, Blunden AS, Collins SN, Parkin TD, Goodship AE, Murray RC.To determine whether histopathologic characteristics of the osteochondral units of equine distal tarsal joints were associated with exercise history in horses without lameness. Methods: 30 cadaver tarsi from horses without lameness and with known exercise history were separated into 3 groups: nonridden, pasture exercise (group P); low-intensity, ridden exercise (group L); and high-intensity, elite competition exercise (group E). Methods: Standardized sites from the centrodistal and tarsometatarsal joints under went histologic preparation. A grading system was adapted to describe location, dept...
Determination of firocoxib in equine plasma using high performance liquid chromatography.
Journal of chromatography. B, Analytical technologies in the biomedical and life sciences    December 3, 2010   Volume 879, Issue 2 205-208 doi: 10.1016/j.jchromb.2010.11.026
Cox S, Yarbrough J.A new method of analysis has been developed and validated for the determination of firocoxib, a new nonsteroidal anti-inflammatory drug (NSAID) approved for use in horses and dogs to control pain and inflammation associated with osteoarthritis. Following a liquid extraction using ethyl acetate:hexane (40:60), samples were separated by isocratic reversed-phase HPLC on a Sunfire C(18) column and quantified using UV detection at 290 nm. The mobile phase was a mixture of water with 0.025% trifluoroacetic acid and acetonitrile, with a flow-rate of 1.1 ml/min. The procedure produced a linear curve o...
Effects of high mobility group box protein-1, interleukin-1β, and interleukin-6 on cartilage matrix metabolism in three-dimensional equine chondrocyte cultures.
Connective tissue research    November 30, 2010   Volume 52, Issue 4 290-300 doi: 10.3109/03008207.2010.523803
Ley C, Svala E, Nilton A, Lindahl A, Eloranta ML, Ekman S, Skiöldebrand E.The effects of high mobility group box protein (HMGB)-1, interleukin (IL)-1β, and IL-6 on equine articular chondrocytes were investigated, with emphasis on detecting differences between anatomical sites exposed to different loading in vivo, using three-dimensional (3D) cell cultures established with chondrocytes from dorsal radial facet (DRF, highly loaded) and palmar condyle (PC, less loaded) of the third carpal bone (C3). Expression of important genes involved in cartilage metabolism, presence of glycosaminoglycans and cartilage oligomeric matrix protein (COMP) in pellets, and concentration...
Septic arthritis in adult horses.
Polish journal of veterinary sciences    November 17, 2010   Volume 13, Issue 1 201-212 
Carstanjen B, Boehart S, Cislakova M.Septic arthritis in horses is a serious disease which can become life-threatening. In case the infection can be eliminated before irreversible joint damage occurs, complete recovery is possible. This article gives an overview of the literature concerning etiology, diagnosis and strategies of therapy in cases of septic arthritis in adult horses, with special reference to novel options of treatment.
Pain in osteoarthritis.
The Veterinary clinics of North America. Equine practice    November 9, 2010   Volume 26, Issue 3 619-642 doi: 10.1016/j.cveq.2010.07.007
van Weeren PR, de Grauw JC.This article focuses on pain associated with osteoarthritis (OA). It first describes the basic biology of articular cartilage and other joint structures and the defining features of the osteoarthritic disease process. Subsequently, the possible origins of pain in OA are discussed before embarking on how to manage this clinical entity. The emphasis is on the pharmacologic management of joint pain, and attention is paid to systemic therapeutic strategies as well as to local (intra-articular) treatment modalities. Nonmedical ways of modulating joint pain are briefly mentioned, but not extensively...
Determination of the prevalence and severity of metacarpophalangeal joint osteoarthritis in Thoroughbred racehorses via quantitative macroscopic evaluation.
American journal of veterinary research    November 3, 2010   Volume 71, Issue 11 1284-1293 doi: 10.2460/ajvr.71.11.1284
Neundorf RH, Lowerison MB, Cruz AM, Thomason JJ, McEwen BJ, Hurtig MB.To determine the prevalence and severity of osteoarthritis in the metacarpophalangeal joints of Thoroughbred racehorses via development and validation of a quantitative macroscopic evaluation system. Methods: Metacarpophalangeal joints from 50 Thoroughbred racehorses. Methods: Joints were collected from horses that died or were euthanized within 60 days of racing. Metacarpophalangeal joints were assessed for osteoarthritic degeneration by use of macroscopic and histologic scoring systems, polarized light microscopy, and cartilage biochemical analysis. The global macroscopic score for the entir...
Evaluation of the osteogenic and chondrogenic differentiation capacities of equine adipose tissue-derived mesenchymal stem cells.
American journal of veterinary research    October 6, 2010   Volume 71, Issue 10 1228-1236 doi: 10.2460/ajvr.71.10.1228
Braun J, Hack A, Weis-Klemm M, Conrad S, Treml S, Kohler K, Walliser U, Skutella T, Aicher WK.To evaluate the proliferative behavior, telomere length, immunophenotype, and differentiation capacity of equine adipose tissue-derived mesenchymal stem cells (AT-MSCs). Methods: 6 adult racing horses treated for articular Injury but otherwise healthy. Methods: AT-MSCs were Isolated from horses and expanded In Dulbecco modified Eagle medium enriched with fetal bovine serum and antimicrobials. Expression of cell surface antigens and telomere length were Investigated via flow cytometry Differentiation of MSCs Into chondrocytes, osteoblasts, and adipocytes was Induced In vitro by specific stimuli...
The OARSI histopathology initiative – recommendations for histological assessments of osteoarthritis in the horse.
Osteoarthritis and cartilage    October 1, 2010   Volume 18 Suppl 3 S93-S105 doi: 10.1016/j.joca.2010.05.031
McIlwraith CW, Frisbie DD, Kawcak CE, Fuller CJ, Hurtig M, Cruz A.Equine models of osteoarthritis (OA) have been used to investigate pathogenic pathways of OA and evaluate therapeutic candidates for naturally occurring equine OA which is a significant clinical disease in the horse. This review focuses on the macroscopic and microscopic criteria for assessing naturally occurring OA in the equine metacarpophalangeal joint as well as the osteochondral fragment-exercise model of OA in the equine middle carpal joint. Methods: A review was conducted of all published OA studies using horses and the most common macroscopic and microscopic scoring systems were summar...
Effects of age and loading rate on equine cortical bone failure.
Journal of the mechanical behavior of biomedical materials    September 21, 2010   Volume 4, Issue 1 57-75 doi: 10.1016/j.jmbbm.2010.09.006
Kulin RM, Jiang F, Vecchio KS.Although clinical bone fractures occur predominantly under impact loading (as occurs during sporting accidents, falls, high-speed impacts or other catastrophic events), experimentally validated studies on the dynamic fracture behavior of bone, at the loading rates associated with such events, remain limited. In this study, a series of tests were performed on femoral specimens obtained post-mortem from equine donors ranging in age from 6 months to 28 years. Fracture toughness and compressive tests were performed under both quasi-static and dynamic loading conditions in order to determine the ef...
Clinical significance of osseous spurs on the dorsoproximal aspect of the third metatarsal bone.
Equine veterinary journal    September 16, 2010   Volume 42, Issue 7 591-599 doi: 10.1111/j.2042-3306.2010.00097.x
Fairburn A, Dyson S, Murray R.Osseous spurs on the dorsoproximal aspect of the third metatarsal bone (MtIII) are common, but their clinical significance is unknown. Objective: To verify the sites of insertion of the dorsal metatarsal ligament and the tendons of tibialis cranialis and fibularis tertius in order to determine if periarticular osteophytes and entheseophytes could be differentiated radiologically; and to determine the frequency of occurrence of osseous spurs on the dorsoproximal aspect of MtIII. Objective: The frequency of osseous spurs on the dorsoproximal aspect of MtIII would be higher in lame than in clinic...
Cytokine and catabolic enzyme expression in synovium, synovial fluid and articular cartilage of naturally osteoarthritic equine carpi.
Equine veterinary journal    September 14, 2010   Volume 42, Issue 8 693-699 doi: 10.1111/j.2042-3306.2010.00140.x
Kamm JL, Nixon AJ, Witte TH.Understanding the expression of catabolic and anabolic genes during osteoarthritis progression should help to identify the major mediators of the disease. Objective: To compare the cytokine and anabolic marker concentrations in synovium, synovial fluid and cartilage between normal and osteoarthritic joints. Methods: Carpi from horses age 2-11 years were used. Tissues were harvested at the time of surgery or euthanasia, and RNA was isolated for RT-PCR analysis. Tumour necrosis factor alpha (TNFα), interleukin-1beta (IL-1β), aggrecanase 1 (ADAMTS-4), aggrecanase 2 (ADAMTS-5), matrix metallopro...
Regulation of SOX9 in normal and osteoarthritic equine articular chondrocytes by hyperosmotic loading.
Osteoarthritis and cartilage    August 26, 2010   Volume 18, Issue 11 1502-1508 doi: 10.1016/j.joca.2010.08.011
Peffers MJ, Milner PI, Tew SR, Clegg PD.SOX9 is a transcription factor that is essential for cartilage extracellular matrix (ECM) formation. Osteoarthritis (OA) is characterised by a loss of cartilage ECM. In chondrocytes SOX9 gene expression is regulated by osmotic loading. Here we characterise SOX9 mRNA regulation through static and cyclical application of hyperosmotic conditions in normal and OA monolayer equine chondrocytes. Furthermore, we investigate whether extracellular signal-regulated protein kinase (ERK)1/2 mitogen-activated protein kinases (MAPK) pathways have a role in this regulation of SOX9. Methods: Equine chondrocyt...
The use of intra-articular corticosteroids in the horse: what is known on a scientific basis?
Equine veterinary journal    August 19, 2010   Volume 42, Issue 6 563-571 doi: 10.1111/j.2042-3306.2010.00095.x
McIlwraith CW.Intra-articular use of corticosteroids has become a recent focus (or re-focus) of attention in the Thoroughbred racing industry. This manuscript reviews the clinical use and scientific basis of intra-articular corticosteroid administration including catastrophic injury, articular cartilage degradation and the development of osteoarthritis (OA), as well as the timing of injection relative to racing.
Tiludronate infusion in the treatment of bone spavin: a double blind placebo-controlled trial.
Equine veterinary journal    July 20, 2010   Volume 42, Issue 5 381-387 doi: 10.1111/j.2042-3306.2010.00120.x
Gough MR, Thibaud D, Smith RK.Tiludronate regulates bone remodelling through a decrease of the resorptive process and should therefore ameliorate the remodelling processes active in osteoarthritis of the distal tarsal joints ('bone spavin') and alleviate pain associated with abnormal bone lysis. Objective: To confirm the efficacy of tiludronate, administered as a single infusion at a dose of 1 mg/kg bwt, in the treatment of bone spavin in the horse. Methods: A double blind placebo controlled trial on 108 clinical cases of bone spavin was undertaken. The lameness score of the lamest limb was assessed following distal tarsal...
Age-related differences in prostaglandin E2 synthesis by equine cartilage explants and synoviocytes.
Journal of veterinary pharmacology and therapeutics    June 19, 2010   Volume 33, Issue 3 268-276 doi: 10.1111/j.1365-2885.2009.01131.x
Briston L, Dudhia J, Lees P.Time- and concentration-related actions of lipopolysaccharide (LPS) on the synthesis of prostaglandin E(2) (PGE(2)) were investigated in cartilage explants and synoviocytes harvested from 3 age groups of horses, all with clinically normal joint function: group A 20 years. Cartilage explants from group A horses were least and those from group C were most sensitive to LPS. Significant increases in PGE(2) concentration (P <or= 0.01) were obtained in group C horses in response to LPS concentrations of 1.0 microg/mL (and higher) after exposure for 24, 36 and 48 h, whereas explants from group A h...
Identification, validation and qualification of biomarkers for osteoarthritis in humans and companion animals: mission for the next decade.
Veterinary journal (London, England : 1997)    June 15, 2010   Volume 185, Issue 2 95-97 doi: 10.1016/j.tvjl.2010.05.026
Mobasheri A, Henrotin Y.No abstract available
In vitro expression of receptor activator of nuclear factor-kappaB ligand and osteoprotegerin in cultured equine articular cells.
American journal of veterinary research    June 2, 2010   Volume 71, Issue 6 615-622 doi: 10.2460/ajvr.71.6.615
Byron CR, Barger AM, Stewart AA, Pondenis HC, Fan TM.To determine concentrations of receptor activator of nuclear factor-kappaB ligand (RANKL) and osteoprotegerin (OPG) in equine chondrocytes and synoviocytes and to quantify changes in the OPG:RANKL ratio in response to exogenous factors. Methods: Samples of articular cartilage and synovium with grossly normal appearance obtained from metacarpophalangeal and metatarsophalangeal joints of 5 adult (1- to 8-year-old) horses. Methods: Cell cultures of chondrocytes and synoviocytes were incubated with human recombinant interleukin-1beta (hrIL-1beta; 10 ng/mL), lipopolysaccharide (LPS; 10 microg/mL), ...
Comparison of magnetic resonance imaging, computed tomography, and radiography for assessment of noncartilaginous changes in equine metacarpophalangeal osteoarthritis. Olive J, D'Anjou MA, Alexander K, Laverty S, Theoret C.We compared the ability of 1.5 T magnetic resonance imaging (MRI), computed tomography (CT), and computed radiography (CR) to evaluate noncartilaginous structures of the equine metacarpophalangeal joint (MCP), and the association of imaging changes with gross cartilage damage in the context of osteoarthritis. Four CR projections, helical single-slice CT, and MRI (Ti-weighted gradient recalled echo [GRE], T2*-weighted GRE with fast imaging employing steady-state acquisition [FIESTA], T2-weighted fast spin echo with fat saturation, and spoiled gradient recalled echo with fat saturation ISPGR-FS]...
Therapeutic efficacy of undenatured type-II collagen (UC-II) in comparison to glucosamine and chondroitin in arthritic horses.
Journal of veterinary pharmacology and therapeutics    May 7, 2010   Volume 32, Issue 6 577-584 doi: 10.1111/j.1365-2885.2009.01079.x
Gupta RC, Canerdy TD, Skaggs P, Stocker A, Zyrkowski G, Burke R, Wegford K, Goad JT, Rohde K, Barnett D, DeWees W, Bagchi M, Bagchi D.The present investigation evaluated arthritic pain in horses receiving daily placebo, undenatured type II collagen (UC-II) at 320, 480, or 640 mg (providing 80, 120, and 160 mg active UC-II, respectively), and glucosamine and chondroitin (5.4 and 1.8 g, respectively, bid for the first month, and thereafter once daily) for 150 days. Horses were evaluated for overall pain, pain upon limb manipulation, physical examination, and liver and kidney functions. Evaluation of overall pain was based upon a consistent observation of all subjects during a walk and a trot in the same pattern on the same sur...
Fat-suppressed spoiled gradient-recalled imaging of equine metacarpophalangeal articular cartilage. Olive J, D'Anjou MA, Girard C, Laverty S, Theoret C.The purpose was to evaluate the capacity of 1.5 T magnetic resonance (MR) imaging to assess articular cartilage in racehorses with naturally occurring metacarpophalangeal joint osteoarthritis. A sagittal, three-dimensional spoiled gradient-recalled echo (SPGR) with fat saturation (FS) sequence was acquired ex vivo on 20 joints. Following joint dissection, specific areas on the third metacarpal condyle were designated for subsequent sampling for histologic cartilage thickness measurement and modified Mankin scoring. Cartilage thickness was measured and cartilage signal intensity was also graded...
Variations in chondrocyte apoptosis may explain the increased prevalence of osteoarthritis in some joints.
Rheumatology international    April 16, 2010   Volume 31, Issue 10 1341-1348 doi: 10.1007/s00296-010-1471-9
Thomas CM, Whittles CE, Fuller CJ, Sharif M.To investigate whether there are any variations in chondrocyte susceptibility to an apoptotic stimulus between cells of articular cartilage (AC) from equine joints that differ in prevalence of osteoarthritis (OA). Methods: Cartilage from macroscopically normal equine metacarpophalangeal (MCP), proximal interphalangeal (PIP) and distal interphalangeal (DIP) joints was used. Prior to culture, chondrocyte viability was assessed using the fluorescein diacetate (FDA) and propidium iodide paravital staining method. AC explants were subsequently treated with tumour necrosis factor-α (TNF-α) in comb...
Imaging and histological features of central subchondral osteophytes in racehorses with metacarpophalangeal joint osteoarthritis.
Equine veterinary journal    April 14, 2010   Volume 41, Issue 9 859-864 doi: 10.2746/042516409x448481
Olive J, D'Anjou MA, Girard C, Laverty S, Theoret CL.Marginal osteophytes represent a well known component of osteoarthritis in man and animals. Conversely, central subchondral osteophytes (COs), which are commonly present in human knees with osteoarthritis, have not been reported in horses. Objective: To describe and compare computed radiography (CR), single-slice computed tomography (CT), 1.5 Tesla magnetic resonance imaging (MRI), and histological features of COs in equine metacarpophalangeal joints with macroscopic evidence of naturally-occurring osteoarthritis. Methods: MRI sequences (sagittal spoiled gradient recalled echo [SPGR] with fat ...
Osteogenic comparison of expanded and uncultured adipose stromal cells.
Cytotherapy    April 8, 2010   Volume 12, Issue 4 554-562 doi: 10.3109/14653241003709694
Cheung WK, Working DM, Galuppo LD, Leach JK.Adipose stromal cells (ASC) are a promising alternative to progenitor cells from other tissue compartments because of their multipotential and capacity to retrieve significantly more progenitor cells. Initial cell samples are heterogeneous, containing a collection of cells that may contribute to tissue repair, but the sample becomes more homogeneous with each passage. Therefore, we hypothesized that the osteogenic potential of culture-expanded ASC would differ from uncultured ASC. Methods: Adipose tissue was collected from a yearling colt, and ASC were isolated and expanded using standard prot...
Correlation of signal attenuation-based quantitative magnetic resonance imaging with quantitative computed tomographic measurements of subchondral bone mineral density in metacarpophalangeal joints of horses.
American journal of veterinary research    April 7, 2010   Volume 71, Issue 4 412-420 doi: 10.2460/ajvr.71.4.412
Olive J, d'Anjou MA, Alexander K, Beauchamp G, Theoret CL.To evaluate the ability of signal attenuation-based quantitative magnetic resonance imaging (QMRI) to estimate subchondral bone mineral density (BMD) as assessed via quantitative computed tomography (QCT) in osteoarthritic joints of horses. Methods: 20 metacarpophalangeal joints from 10 horse cadavers. Methods: Magnetic resonance (MR) images (dorsal and transverse T1-weighted gradient recalled echo [GRE] and dorsal T2*-weighted GRE fast imaging employing steady-state acquisition [T2*-FIESTA]) and transverse single-slice computed tomographic (CT) images of the joints were acquired. Magnetic res...
A technique for laser-facilitated equine pastern arthrodesis using parallel screws inserted in lag fashion.
Veterinary surgery : VS    March 10, 2010   Volume 39, Issue 2 244-253 doi: 10.1111/j.1532-950X.2009.00627.x
Watts AE, Fortier LA, Nixon AJ, Ducharme NG.To report a technique for laser-facilitated, minimally invasive proximal interphalangeal joint (PIJ) arthrodesis in horses. Methods: Case series. Methods: Horses (n=6); 5 thoracic and 2 pelvic limb PIJ. Methods: PIJ osteoarthritis (OA) diagnosis was confirmed by radiography. A diode laser was used to apply 2000 J of energy to the joint followed by insertion of 3 parallel 5.5 mm screws in lag fashion through stab incisions to achieve PIJ arthrodesis. After anesthetic recovery, limbs were maintained in bandages (n=2) or bandage casts (5) for 3 weeks. Horses were allowed exercise or turnout by 3 ...
Treatment of carpometacarpal osteoarthritis by arthrodesis in 12 horses.
Veterinary surgery : VS    December 19, 2009   Volume 38, Issue 8 1006-1011 doi: 10.1111/j.1532-950X.2009.00590.x
Barber SM, Panizzi L, Lang HM.To evaluate arthrodesis as a treatment for carpometacarpal joint osteoarthritis (CMC-OA). Methods: Case series. Methods: Horses (n=12) with CMC-OA. Methods: Arthrodesis was facilitated by insertion and fanning of a drill bit into the CMC joint at several (3-5) locations in 15 limbs. Follow-up radiographs were obtained for 7 horses (9 limbs). Outcome was determined by telephone survey of owners based on postoperative pain, return to use, appearance of the limb, and success of treatment. Results: Postoperative pain was slight or moderate in 10 of 12 (83%) horses during the first 30 days, and 11 ...
Carpometacarpal osteoarthritis in thirty-three horses.
Veterinary surgery : VS    December 19, 2009   Volume 38, Issue 8 998-1005 doi: 10.1111/j.1532-950X.2009.00589.x
Panizzi L, Barber SM, Lang HM, Carmalt JL.To describe signalment, clinical, and radiographic changes associated with carpometacarpal osteoarthritis (CMC-OA) and to report long-term outcome. Methods: Case series. Methods: Horses (n=33) with CMC-OA. Methods: Medical records (1992-2007) of horses diagnosed with CMC-OA were reviewed and signalment, clinical, and radiographic findings retrieved. Owners were contacted for information on the impact of lameness on intended use, response to treatment, progression of lameness, outcome, and owner satisfaction with response to treatment. Results: CMC-OA identified in 39 limbs, occurred predominan...
In vivo evaluation of autologous cartilage fragment-loaded scaffolds implanted into equine articular defects and compared with autologous chondrocyte implantation.
The American journal of sports medicine    December 16, 2009   Volume 37 Suppl 1 71S-80S doi: 10.1177/0363546509348478
Frisbie DD, Lu Y, Kawcak CE, DiCarlo EF, Binette F, McIlwraith CW.Current autologous chondrocyte implantation (ACI) techniques require 2 surgical procedures: 1 for cell harvest and 1 for reimplantation of cultured cells. A 1-step procedure is more desirable. Objective: A 1-step surgical procedure using autologous cartilage fragments on a polydioxanone scaffold, or CAIS (cartilage autograft implantation system), in a clinically relevant defect (15-mm diameter) within equine femoral trochlea was compared with a 2-step ACI technique as well as with empty defects and defects with polydioxanone foam scaffolds alone. Methods: Controlled laboratory study. Methods: ...
Effect of exercise on thicknesses of mature hyaline cartilage, calcified cartilage, and subchondral bone of equine tarsi.
American journal of veterinary research    December 3, 2009   Volume 70, Issue 12 1477-1483 doi: 10.2460/ajvr.70.12.1477
Tranquille CA, Blunden AS, Dyson SJ, Parkin TD, Goodship AE, Murray RC.OBJECTIVE-To investigate effects of exercise on hyaline cartilage (HC), calcified cartilage (CC), and subchondral bone (SCB) thickness patterns of equine tarsi. SAMPLE POPULATION-30 tarsi from cadavers of horses with known exercise history. PROCEDURES-Tarsi were assigned to 3 groups according to known exercise history as follows: pasture exercise only (PE tarsi), low-intensity general-purpose riding exercise (LE tarsi), and high-intensity elite competition riding exercise (EE tarsi). Osteochondral tissue from distal tarsal joints underwent histologic preparation. Hyaline cartilage, CC, and SCB...
Low quality of evidence for glucosamine-based nutraceuticals in equine joint disease: review of in vivo studies.
Equine veterinary journal    November 26, 2009   Volume 41, Issue 7 706-712 doi: 10.2746/042516409x424153
Pearson W, Lindinger M.Nutraceuticals are increasingly applied to the management of equine arthritis and joint disease, particularly those based upon glucosamine and chondroitin sulphate. While the first report of using glucosamine in horses appeared more than 25 years ago, it was not until 1992 that isolated studies began to be reported. Since that time, 15 in vivo papers have been published in the equine literature, usually on products already commercially available and often seeking evidence for efficacy. These studies demonstrate an encouraging trend to manufacturers of these products investing in research, but ...
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