Patients with systemic lupus erythematosus have a higher incidence of cardiovascular disease than the general population. Antihypertensive drugs that modify the renin-angiotensin system (RAS) are ...used to protect renal function in lupus nephritis and may also have extrarenal effects that lower cardiovascular disease risk due to their anti-inflammatory properties. In this study, we compared the effects of RAS vs non-RAS antihypertensive drugs on cardiovascular disease incidence in patients with lupus.
Using a medical insurance claims dataset, 220,168 patients with lupus were identified, of which 31,647 patients (4018 patients prescribed RAS drugs, 27,629 patients prescribed non-RAS drugs) were eligible for the study. Patients had a mean age of 46.1 years, were 93.0% female, and healthy (96.9% Charlson Comorbidity Index score 0-4). Patients in the 2 drug groups were propensity score matched using demographic data, risk factors, and comorbidities.
Use of RAS vs non-RAS drugs lowered the relative risk (RR) of diagnosis of cardiovascular disease (RR 0.80; 95% confidence interval CI, 0.74-0.87), which was more pronounced after propensity score matching (RR 0.62; 95% CI, 0.57-0.68). The decreased risk in cardiovascular disease occurred regardless of lupus nephritis status (with lupus nephritis: RR 0.51; 95% CI, 0.39-0.65; without lupus nephritis: RR 0.65; 95% CI, 0.59-0.72). RAS-modifying therapies significantly increased cardiovascular disease-free survival probability over a 5-year period (86.0% vs 78.3% probability).
RAS-modifying drugs reduced the risk of cardiovascular disease in patients with systemic lupus erythematosus in this dataset. These findings have the potential to impact clinical decision-making with regards to hypertension management in patients with lupus.
While opioids are known to cause unintended adverse effects, they are being utilized by a number of patients with osteoarthritis (OA). The aim of this study was to evaluate the association of patient ...familiarity and perceptions regarding efficacy and risks with opioid medication use for OA.
A total of 362 adults with knee and/or hip OA were surveyed in this cross-sectional study. Patients' familiarity with and perceptions of benefits/risks of opioid medications were measured to evaluate potential associations with the utilization of opioid medications for OA within the last 6 months. Logistic regression models were adjusted for sociodemographic and clinical variables.
In this sample, 28.7% (100/349) reported use of an opioid medication for OA-related symptoms in the last 6 months. Those who were on an opioid medication, compared to those who were not, were younger (mean age 62.5 vs 64.8 yrs), were more likely to have a high school education or lower (48.0% vs 35.3%), and had higher mean depression (Patient Health Questionnaire PHQ-8 7.2 vs 4.9) and OA-related pain (Western Ontario and McMaster Universities Arthritis Index WOMAC 54.8 vs 46.8) scores. After adjustment for sociodemographic and clinical variables, the following were associated with opioid medication use: higher perception of medication benefit (OR 1.68, 95% CI 1.18-2.41), lower perception of medication risk (OR 0.67, 95% CI 0.51-0.88), and having family or friends who received the medication for OA (OR 3.88, 95% CI 1.88-8.02).
Among adults with knee/hip OA, opioid use was associated with being familiar with the treatment, as well as believing that the medication was beneficial and low-risk.
When conservative treatments do not work, TKA may be the best option for patients with knee osteoarthritis, although a relatively large proportion of individuals do not have clinically important ...improvement after TKA. Evidence also suggests that women are less likely to benefit from TKA than men, but the reasons are unclear. Widespread pain disproportionately affects women and has been associated with worse outcomes after joint arthroplasty, yet it is unknown if the effect of widespread pain on TKA outcomes differs by patient gender.
(1) Does the association between widespread pain and no clinically important improvement in osteoarthritis-related pain and disability 2 years after TKA differ between men and women? (2) Does the use of pain medications 2 years after TKA differ between those with widespread pain and those without widespread pain before surgery?
Osteoarthritis Initiative (https://nda.nih.gov/oai/) study participants were followed annually from March 2005 until October 2015. Participants who underwent TKA up to the 7-year follow-up visit with pain/disability assessment at the protocol-planned visit before TKA and at the second planned annual visit after surgery were included in the analysis. Among 4796 study participants, 391 had a confirmed TKA, including 315 with pain/disability assessment at the protocol-planned visit before TKA. Overall, 95% of participants (298) had the required follow-up assessment; 5% (17) did not have follow-up data. Widespread pain was defined based on the modified American College of Rheumatology criteria. Symptoms were assessed using the WOMAC pain (range 0 to 20; higher score, more pain) and disability (range 0 to 68; higher score, more disability) scores, and the Knee Injury and Osteoarthritis Outcome Score for pain (range 0 to 100; higher score, less pain). Improvements in pain and disability were classified based on improvement from established clinically important differences (decrease in WOMAC pain ≥ 1.5; decrease in WOMAC disability ≥ 6.0; increase in Knee Injury and Osteoarthritis Outcome Score for pain ≥ 9). At baseline, more women presented with widespread pain than men (45% 84 of 184 versus 32% 36 of 114). Probability and the relative risk (RR) of no clinically important improvement were estimated using a logistic regression analysis in which participants with widespread pain and those without were compared. The analyses were done for men and women separately, then adjusted for depression and baseline outcome scores.
Among women, preoperative widespread pain was associated with an increased risk of no clinically important improvement 2 years after TKA, based on WOMAC pain scores (13.5% versus 4.6%; RR 2.93 95% CI 1.18 to 7.30; p = 0.02) and the Knee Injury and Osteoarthritis Outcome Score for pain (16.5% versus 4.9%; RR 3.39 95% CI 1.34 to 8.59; p = 0.02). Given the lower and upper limits of the confidence intervals, our data are compatible with a broad range of disparate associations between widespread pain and lack of clinically important improvement in WOMAC pain scores (RR 0.77 95% CI 0.22 to 2.70; p = 0.68) and the Knee Injury and Osteoarthritis Outcome Score for pain (RR 1.37 95% CI 0.47 to 4.00; p = 0.57) among men, as well as clinically important improvement in WOMAC disability scores among men (RR 0.72 95% CI 0.20 to 2.55; p = 0.61) and women (RR 1.98 95% CI 0.92 to 4.26; p = 0.08). Participants presenting with widespread pain before TKA were more likely than those without widespread pain to use medication for symptoms of knee osteoarthritis most days for at least 1 month 2 years after TKA (51% 61 of 120 versus 32% 57 of 178; mean difference, 18.8 95% CI 7.3 to 30.1; p < 0.01).
Widespread pain before TKA was associated with an increased risk of no clinically important improvement in knee pain 2 years postoperatively among women. Because of the small number of men with widespread pain in the sample, the results for men were inconclusive. In clinical practice, screening TKA candidates for widespread pain may be useful, and expectations of surgical outcomes may need to be tempered if patients have a concurrent diagnosis of widespread pain. Future studies should include more men with widespread pain and investigate if treatment of widespread pain before or concurrent with TKA surgery may improve surgical outcomes.
Level III, therapeutic study.
Objective
This study sought to determine the extent to which physical activity confounds the relation between race and the incidence of osteoarthritis (OA)‐related functional limitation.
Methods
OA ...Initiative study participants with or at increased risk of knee OA who wore an accelerometer were included. Race was self‐reported. Average time spent in moderate to vigorous physical activity (minutes per day) based on ActiGraph uniaxial accelerometer data was assessed. Functional limitation was based on the following: (1) inability to achieve a community walking speed (1.2 m/s) standard, (2) slow walking speed (<1.0 m/s), and (3) low physical functioning based on a Western Ontario and McMaster Universities OA Index (WOMAC) physical function score greater than 28 of 68.
Results
African American (AA) participants (n = 226), compared with White participants (n = 1348), had a higher likelihood of developing functional limitation based on various measures. When adjusted for time in moderate to vigorous physical activity, the association between AA race and inability to walk a community walking speed slightly decreased (from relative risk RR 2.15, 95% confidence interval 95% CI 1.64–2.81, to RR 1.99, 95% CI 1.51–2.61). Association between AA race and other measures of functional limitation mildly decreased (slow walking speed: from RR 2.06, 95% CI 1.40–3.01, to RR 1.82, 95% CI 1.25–2.63; low physical functioning: from RR 3.44, 95% CI 1.96–6.03, to RR 3.10, 95% CI 1.79–5.39). When further adjusted for demographic and other clinical variables, only the association between race and low physical functioning (WOMAC) significantly decreased and no longer met statistical significance.
Conclusion
Greater physical activity is unlikely to completely make up for race differences in OA‐related functional limitation, and other barriers to health equity need to be addressed.
Abstract Objective To determine whether changes in preoperative osteoarthritis (OA) symptoms are associated with improvement after total knee replacement (TKR) and to identify predictors of ...clinically significant improvement. Methods Data on Osteoarthritis Initiative participants who were annually assessed and underwent TKR were included. T0 was the assessment prior to TKR while T−1 was the assessment prior to that. T+2 was the second assessment after TKR. We compiled data on the Western Ontario and McMaster Universities OA Index (WOMAC), OA-related symptoms, and radiographic severity. We defined clinically significant improvement as improvement in WOMAC total score ≥ to the minimal important difference (MID) (0.5 SD of mean change) between T0 and T+2 and also considered other definitions of improvement. Logistic regression models were performed to evaluate the relationship between improvement and preoperative measures. Results Improved ( n = 211) compared to unimproved ( n = 58) patients had greater worsening of their WOMAC pain ( p = 0.002) and disability ( p < 0.001) from T−1 to T0. Preoperative measures as predictors of improvement included higher WOMAC disability (OR = 1.08, p < 0.001), presence of chronic OA symptoms in the surgical knee (OR = 5.77, p = 0.033), absence of OA-related symptoms in the contralateral knee (OR = 9.25, p < 0.001), exposure to frequent knee bending (OR = 3.46, p = 0.040), and having a Kellgren–Lawrence x-ray grade of ≥2 in the contralateral knee (OR = 4.71, p = 0.010). Conclusions More than 75% of participants had improvement after TKR. Improved patients were more likely to have escalation of OA pain and disability prior to surgery than unimproved patients. Other preoperative measures predicted improvement after TKR.
Patient preferences contribute to marked racial disparities in the utilization of total knee replacement (TKR). The objectives of this study were to identify the determinants of knee osteoarthritis ...(OA) patients' preferences regarding TKR by race and to identify the variables that may mediate racial differences in willingness to undergo TKR.
Five hundred fourteen White (WH) and 285 African-American (AA) patients with chronic knee pain and radiographic evidence of OA participated in the study. Participants were recruited from the community, an academic medical center, and a Veterans Affairs hospital. Structured interviews were conducted to collect socio-demographics, disease severity, socio-cultural determinants, and treatment preferences. Logistic regression was performed, stratified by race, to identify determinants of preferences. Clinical and socio-cultural factors were entered simultaneously into the models. Stepwise selection identified factors for inclusion in the final models (p < 0.20).
Compared to WHs, AAs were less willing to undergo TKR (80 % vs. 62 %, respectively). Better expectations regarding TKR surgery outcomes determined willingness to undergo surgery in both AAs (odds ratio (OR) 2.08, 95 % confidence interval (CI) 0.91-4.79 for 4(th) vs. 1(st) quartile) and WHs (OR 5.11, 95 % CI 2.31-11.30 for 4(th) vs. 1(st) quartile). Among AAs, better understanding of the procedure (OR 1.80, 95 % CI 0.97-3.35), perceiving a short hospital course (OR 0.81, 95 % CI 0.58-1.13), and believing in less post-surgical pain (OR 0.73, 95 % CI 0.39-1.35) and walking difficulties (OR 0.66, 95 % CI 0.37-1.16) also determined willingness. Among WHs, having surgical discussion with a physician (OR 1.96, 95 % CI 1.05-3.68), not ever receiving surgical referral (OR 0.56, 95 % CI 0.32-0.99), and higher trust in the healthcare system (OR 1.58, 95 % CI 0.75-3.31 for 4(th) vs. 1(st) quartile) additionally determined willingness. Among the variables considered, only knowledge-related matters pertaining to TKR attenuated the racial difference in knee OA patients' treatment preference.
Expectations of surgical outcomes influence preference for TKR in all patients, but clinical and socio-cultural factors exist that shape marked racial differences in preferences for TKR. Interventions to reduce or eliminate racial disparities in the utilization of TKR should consider and target these factors.
Characterize radiographic worsening in knee osteoarthritis (KOA) by race and sex over 4 years and evaluate the role of established risk factors in observed race/sex differences.
Whites (WHs) (694 ...males and 929 females) and African-Americans (AAs) (92 males and 167 females) at risk for radiographic KOA were eligible. Cox shared frailty models were used to estimate race and sex group differences in radiographic worsening, defined by Kellgren-Lawrence (K-L) and OARSI joint space narrowing (JSN). Mixed effect models for repeated measures were used to estimate race- and sex-specific mean medial and lateral fixed joint space width (fJSW) over 4 years of follow-up, as well as annual loss of fJSW.
Risk of OARSI medial JSN grade worsening was higher among AA males than WH females HR = 2.28, (95% CI: 1.14–4.57), though adjustment for KOA risk factors attenuated the association. Compared to WH females, WH males had lower risk of K-L grade worsening adjusted HR = 0.75 (95% CI: 0.58–0.96).
Mean baseline medial fJSW (mm) was 6.49 in WH and AA males, 5.42 in WH females, and 5.41 in AA females. Annual change in mean medial fJSW was greater in AA males (−0.19mm/year) than in other subgroups (−0.09 WH males, −0.07 WH females, −0.10 AA females, p < 0.0001). Compared to WHs, AAs had less lateral fJSW at baseline and throughout follow-up.
Compared to WHs and AA females, AA males experienced higher risk of medial joint space loss. Controlling for established risk factors attenuated associations between race/sex and disease worsening, suggesting that risk factors such as obesity, history of knee injury, and bony finger joint enlargements largely explain race/sex variations in rates of KOA development and progression.
Our objective was to determine if there are ethnic differences in the use of over-the-counter (OTC) and prescription oral nonsteroidal anti-inflammatory drugs (NSAIDs) and if observed ethnic ...differences persist after adjustment for sociodemographic and clinical factors.
Knee and hip osteoarthritis study participants were identified. Surveys were administered to collect sociodemographics, clinical information, and oral treatment methods for arthritis. Multivariable logistic regression models were created using a fully conditional method.
Hispanics (n = 130), compared to non-Hispanic whites (n = 204), were less likely to have a high school education (26.9% vs 63.2%, P <0.001), less likely to have private medical insurance (P <0.001), and more likely to have worse health (P = 0.004). OTC oral NSAID use was less common (52.9% vs 66.3%, P = 0.019), whereas prescription oral NSAID use was more common (43.4% vs 31.7%, P = 0.042) among Hispanics than non-Hispanic whites in the last 6 months. The ethnic difference in using an OTC NSAID instead of not using any oral NSAID was attenuated and no longer significant when adjusted for age, sex, education, and medical insurance (odds ratio OR 0.54 95% confidence interval CI: 0.28-1.02). The odds of using a prescription instead of an OTC NSAID remained significantly higher among Hispanics than non-Hispanic whites when adjusted for the same variables (odds ratio 2.17 95% confidence interval: 1.16-4.05).
Among patients with osteoarthritis, OTC NSAIDs were less commonly used but prescription NSAIDs were more commonly used by Hispanics than non-Hispanic whites. Sociodemographic factors partially mediate ethnic differences in the use of oral NSAIDs.
Gout, a crystalline arthropathy caused by the deposition of monosodium urate crystals in the articular and periarticular soft tissues, is a frequent cause of painful arthropathy. Imaging has an ...important role in the initial evaluation as well as the treatment and follow up of gouty arthropathy. The imaging findings of gouty arthropathy on radiography, ultrasonography, computed tomography, dual energy computed tomography, and magnetic resonance imaging are described to include findings of the early, acute and chronic phases of gout. These findings include early monosodium urate deposits, osseous erosions, and tophi, which may involve periarticular tissues, tendons, and bursae. Treatment of gout includes non-steroidal anti-inflammatories, colchicine, glucocorticoids, interleukin-1 inhibitors, xanthine oxidase inhibitors, uricosuric drugs, and recombinant uricase. Imaging is critical in monitoring response to therapy; clinical management can be modulated based on imaging findings. This review article describes the current standard of care in imaging and treatment of gouty arthropathy.
Objective
To determine the extent of ethnic differences in the use of exercise for therapy and identify relevant modifiable determinants of exercise use among patients with knee/hip osteoarthritis ...(OA).
Methods
Knee/hip OA study participants were identified. Surveys were administered to collect patient sociodemographic and clinical information, and beliefs and attitudes about providers and treatments. Final multivariable logistic regression models were created using a fully conditional method.
Results
Hispanic participants (n = 130), compared to non‐Hispanic participants (n = 232), were less likely to have private medical insurance (9.2% versus 31.0%) or to report having excellent/very good health (40.7% versus 52.6%). They were also less likely to report using exercise for OA treatment in the last 6 months (56% versus 73%; P = 0.003). When adjusted for age and disease severity, the difference in exercise use among ethnicities remained significant (odds ratio OR 0.59 95% confidence interval (95% CI) 0.36–0.99). In a multivariable logistic regression model designed to determine the most important determinants of exercise use for OA treatment, in the last 6 months the following were all associated with exercise use: having knee instead of hip OA (OR 2.83 95% CI 1.51–5.29), having family/friends who exercise (OR 3.20 95% CI 1.76–5.84), having a good understanding of what happens after exercise (OR 2.19 95 CI 1.15–4.19), and higher perceived benefit of exercise (OR 2.24 95% CI 1.64–3.04).
Conclusion
Among patients with knee/hip OA, Hispanics were less likely to exercise for OA treatment. Increased knowledge about the benefits of exercise for treatment and improved familiarity with exercise as treatment for OA may increase exercise use.
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