Objective
To develop updated guidelines for the pharmacologic management of rheumatoid arthritis.
Methods
We developed clinically relevant population, intervention, comparator, and outcomes (PICO) ...questions. After conducting a systematic literature review, the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to rate the certainty of evidence. A voting panel comprising clinicians and patients achieved consensus on the direction (for or against) and strength (strong or conditional) of recommendations.
Results
The guideline addresses treatment with disease‐modifying antirheumatic drugs (DMARDs), including conventional synthetic DMARDs, biologic DMARDs, and targeted synthetic DMARDs, use of glucocorticoids, and use of DMARDs in certain high‐risk populations (i.e., those with liver disease, heart failure, lymphoproliferative disorders, previous serious infections, and nontuberculous mycobacterial lung disease). The guideline includes 44 recommendations (7 strong and 37 conditional).
Conclusion
This clinical practice guideline is intended to serve as a tool to support clinician and patient decision‐making. Recommendations are not prescriptive, and individual treatment decisions should be made through a shared decision‐making process based on patients’ values, goals, preferences, and comorbidities.
Given that the number of total joint arthroplasties (TJAs) performed worldwide is expected to continue to increase, and there are significant costs associated with these procedures, selecting ...candidates for same-day or 23-hour discharge is important in lowering costs and providing greater access. Younger, healthier patients are excellent candidates for same-day discharge after TJA. Preoperative medical assessment can help exclude patients who may not be candidates, such as patients with 1 or more comorbidities that increase the risk of intra- and postoperative complications and who may require a longer period of monitoring
Management of difficult osteoporosis Russell, Linda A.
Best practice & research. Clinical rheumatology,
December 2018, 2018-Dec, 2018-12-00, 20181201, Letnik:
32, Številka:
6
Journal Article
Recenzirano
Osteoporosis and associated low-impact fractures are common. There is associated morbidity and mortality with low-impact fractures. It is critical to identify which patients would benefit from ...therapy. General treatment considerations are reviewed. Currently available treatment options are discussed. Certain patient populations pose challenges in the treatment of osteoporosis. An in-depth review of clinically challenging scenarios is presented: Treatment of patients with severe osteoporosis, Treatment of Premenopausal women with low bone density, Treatment of osteoporosis in patients with kidney disease, Treatment of Osteoporosis in patients on glucocorticoid therapy, Treatment of osteoporosis in patients with a fracture.
Osteoporosis is a common condition. As the population ages, more patients with osteoporosis will require orthopedic procedures, including arthroplasty. Adverse outcomes are more likely for patients ...with osteoporosis requiring orthopedic procedures, for example those with intraoperative fractures, periprosthetic osteolysis with implant migration, and postoperative periprosthetic fractures. Cemented prosthetic hip replacements may be more successful among patients with poor bone quality. Femoral neck fracture is a concern during hip resurfacing among patients with osteoporosis. Vitamin D deficiency is common among patients undergoing joint arthroplasty and the ideal vitamin D level for joint arthroplasty has yet to be determined. Both bisphosphonates and teriparatide may aide successful osteointegration among patients undergoing noncemented joint arthroplasty. Focusing on bone health perioperatively should result in better outcomes for orthopedic procedures.
Objective
To develop updated guidelines for the pharmacologic management of rheumatoid arthritis.
Methods
We developed clinically relevant population, intervention, comparator, and outcomes (PICO) ...questions. After conducting a systematic literature review, the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to rate the certainty of evidence. A voting panel comprising clinicians and patients achieved consensus on the direction (for or against) and strength (strong or conditional) of recommendations.
Results
The guideline addresses treatment with disease‐modifying antirheumatic drugs (DMARDs), including conventional synthetic DMARDs, biologic DMARDs, and targeted synthetic DMARDs, use of glucocorticoids, and use of DMARDs in certain high‐risk populations (i.e., those with liver disease, heart failure, lymphoproliferative disorders, previous serious infections, and nontuberculous mycobacterial lung disease). The guideline includes 44 recommendations (7 strong and 37 conditional).
Conclusion
This clinical practice guideline is intended to serve as a tool to support clinician and patient decision‐making. Recommendations are not prescriptive, and individual treatment decisions should be made through a shared decision‐making process based on patients’ values, goals, preferences, and comorbidities.
Summary Background The immunopathogenesis of type 1 diabetes mellitus is associated with T-cell autoimmunity. To be fully active, immune T cells need a co-stimulatory signal in addition to the main ...antigen-driven signal. Abatacept modulates co-stimulation and prevents full T-cell activation. We evaluated the effect of abatacept in recent-onset type 1 diabetes. Methods In this multicentre, double-blind, randomised controlled trial, patients aged 6–45 years recently diagnosed with type 1 diabetes were randomly assigned (2:1) to receive abatacept (10 mg/kg, maximum 1000 mg per dose) or placebo infusions intravenously on days 1, 14, 28, and monthly for a total of 27 infusions over 2 years. Computer-generated permuted block randomisation was used, with a block size of 3 and stratified by participating site. Neither patients nor research personnel were aware of treatment assignments. The primary outcome was baseline-adjusted geometric mean 2-h area-under-the-curve (AUC) serum C-peptide concentration after a mixed-meal tolerance test at 2 years' follow-up. Analysis was by intention to treat for all patients for whom data were available. This trial is registered at ClinicalTrials.gov , NCT00505375. Findings 112 patients were assigned to treatment groups (77 abatacept, 35 placebo). Adjusted C-peptide AUC was 59% (95% CI 6·1–112) higher at 2 years with abatacept (n=73, 0·378 nmol/L) than with placebo (n=30, 0·238 nmol/L; p=0·0029). The difference between groups was present throughout the trial, with an estimated 9·6 months' delay (95% CI 3·47–15·6) in C-peptide reduction with abatacept. There were few infusion-related adverse events (36 reactions occurred in 17 22% patients on abatacept and 11 reactions in six 17% on placebo). There was no increase in infections (32 42% patients on abatacept vs 15 43% on placebo) or neutropenia (seven 9% vs five 14%). Interpretation Co-stimulation modulation with abatacept slowed reduction in β-cell function over 2 years. The beneficial effect suggests that T-cell activation still occurs around the time of clinical diagnosis of type 1 diabetes. Yet, despite continued administration of abatacept over 24 months, the decrease in β-cell function with abatacept was parallel to that with placebo after 6 months of treatment, causing us to speculate that T-cell activation lessens with time. Further observation will establish whether the beneficial effect continues after cessation of abatacept infusions. Funding US National Institutes of Health.
Abstract There is a paucity of data available on perioperative outcomes of patients undergoing total knee arthroplasty (TKA) for rheumatoid arthritis (RA). We determined differences in demographics ...and risk for perioperative adverse events between patients suffering from osteoarthritis (OA) versus RA using a population-based approach. Of 351,103 entries for patients who underwent TKA, 3.4% had a diagnosis of RA. RA patients were on average younger RA: 64.3 years vs OA: 66.6 years; P < 0.001 and more likely female RA: 79.2% vs OA: 63.2%; P < 0. 001. The unadjusted rates of mortality and most major perioperative adverse events were similar in both groups, with the exception of infection RA: 4.5% vs. OA: 3.8%; P < 0.001. RA was not associated with increased adjusted odds for combined adverse events.
Updated night atomic oxygen concentration (O) profiles from the Sounding of the Atmosphere using Broadband Emission Radiometry (SABER) instrument on the National Aeronautics and Space Administration ...TIMED satellite are presented. These are derived from measurements of the OH(υ = 9 + 8) volume emission rates and photochemical balance relationships. The new night O concentrations are smaller than those originally derived in 2013 and yield physically realistic global annual mean energy budgets in the upper mesosphere and lower thermosphere. The update to the night O atom profiles is motivated by recent discovery and verification of large rates of collisional quenching of OH(υ) by atomic oxygen. The kinetic model relating the SABER‐observed OH emission rates to atomic oxygen is now consistent with these larger quenching rates and other literature values. The new, smaller SABER night O also confirms that SABER daytime ozone is too large. The new night O and OH(υ) model impacts the inference of day and night atomic hydrogen.
Plain Language Summary
An updated data set of night atomic oxygen in the terrestrial mesosphere is presented. The atomic oxygen is derived from measurements made by the Sounding of the Atmosphere using Broadband Emission Radiometry (SABER) instrument on the National Aeronautics and Space Administration TIMED satellite. Atomic oxygen is a critical component of the chemistry and energy budget of the mesosphere and lower thermosphere. The data set is a 16‐year record intended to replace a prior data set published in 2013. The new atomic oxygen data set covers the mesopause region, approximately 80 to 100 km in altitude. The major change is that the new atomic oxygen concentrations are significantly smaller than the original data set. The new data yield a physically realistic global annual mean energy budget, in contrast to the original data set. A significant consequence of the new night data set is that the SABER daytime ozone concentrations (derived from measurements of 9.6 μm emission) are too large, confirming previous suggestions published in the literature. The results also impact the atomic hydrogen derived from SABER, both day and night.
Key Points
Updated SABER night atomic oxygen data sets for all 16 years of mission and concentrations are approximately 25% smaller at peak than baseline data set
Daytime SABER upper mesospheric ozone is confirmed to be large by ~25% as a consequence
New data yield physically realistic energy budget that has approximate balance between heating and cooling on global annual mean basis
Objective
Expected outcomes (e.g., expected survivorship after a cancer treatment) have improved decision‐making around treatment options in many clinical fields. Our objective was to evaluate the ...effect of expected values of 3 widely available total knee arthroplasty (TKA) outcomes (risk of serious complications, time to revision, and improvement in pain and function at 2 years after surgery) on clinical recommendation of TKA.
Methods
The RAND/University of California Los Angeles appropriateness criteria method was used to evaluate the role of the 3 expected outcomes in clinical recommendation of TKA. The expected outcomes were added to 5 established preoperative factors from the modified Escobar appropriateness criteria. The 8 indication factors were used to develop 279 clinical scenarios, and a panel of 9 clinicians rated the appropriateness of TKA for each scenario as inappropriate, inconclusive, and appropriate. Classification tree analysis was applied to these ratings to identify the most influential of the 8 factors in discriminating TKA appropriateness classifications.
Results
Ratings for the 279 appropriateness scenarios deemed 34.4% of the scenarios as appropriate, 40.1% as inconclusive, and 25.5% as inappropriate. Classification tree analyses showed that expected improvement in pain and function and expected time to revision were the most influential factors that discriminated among the TKA appropriateness classification categories.
Conclusion
Our results showed that clinicians would use expected postoperative outcome factors in determining appropriateness for TKA. These results call for further work in this area to incorporate estimates of expected pain/function and revision outcomes into clinical practice to improve decision‐making for TKA.
Background
Race is an important predictor of TKA outcomes in the United States; however, analyses of race can be confounded by socioeconomic factors, which can result in difficulty determining the ...root cause of disparate outcomes after TKA.
Questions/purposes
We asked: (1) Are race and socioeconomic factors at the individual level associated with patient-reported pain and function 2 years after TKA? (2) What is the interaction between race and community poverty and patient-reported pain and function 2 years after TKA?
Methods
We identified all patients undergoing TKA enrolled in a hospital-based registry between 2007 and 2011 who provided 2-year outcomes and lived in New York, Connecticut, or New Jersey. Of patients approached to participate in the registry, more than 82% consented and provided baseline data, and of these patients, 72% provided 2-year data. Proportions of patients with complete followup at 2 years were lower among blacks (57%) than whites (74%), among patients with Medicaid insurance (51%) compared with patients without Medicaid insurance (72%), and among patients without a college education (67%) compared with those with a college education (71%). Our final study cohort consisted of 4035 patients, 3841 (95%) of whom were white and 194 (5%) of whom were black. Using geocoding, we linked individual-level registry data to US census tracts data through patient addresses. We constructed a multivariate linear mixed-effect model in multilevel frameworks to assess the interaction between race and census tract poverty on WOMAC pain and function scores 2 years after TKA. We defined a clinically important effect as 10 points on the WOMAC (which is scaled from 1 to 100 points, with higher scores being better).
Results
Race, education, patient expectations, and baseline WOMAC scores are all associated with 2-year WOMAC pain and function; however, the effect sizes were small, and below the threshold of clinical importance. Whites and blacks from census tracts with less than 10% poverty have similar levels of pain and function 2 years after TKA (WOMAC pain, 1.01 ± 1.59 points lower for blacks than for whites, p = 0.53; WOMAC function, 2.32 ± 1.56 lower for blacks than for whites, p = 0.14). WOMAC pain and function scores 2 years after TKA worsen with increasing levels of community poverty, but do so to a greater extent among blacks than whites. Disparities in pain and function between blacks and whites are evident only in the poorest communities; decreasing in a linear fashion as poverty increases. In census tracts with greater than 40% poverty, blacks score 6 ± 3 points lower (worse) than whites for WOMAC pain (p = 0.03) and 7 ± 3 points lower than whites for WOMAC function (p = 0.01).
Conclusions
Blacks and whites living in communities with little poverty have similar patient-reported TKA outcomes, whereas in communities with high levels of poverty, there are important racial disparities. Efforts to improve TKA outcomes among blacks will need to address individual- and community-level socioeconomic factors.
Level of Evidence
Level III, therapeutic study.
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