Racial and ethnic disparities in arthroplasty utilization are evident, but the reasons are not known. We aimed to identify concerns that may contribute to barriers to arthroplasty from the patient's ...perspective.
We identified patients' concerns about arthroplasty by performing a mixed methods study. Themes identified during semi-structured interviews with Black and Hispanic patients with advanced symptomatic hip or knee arthritis were used to develop a questionnaire to quantify and prioritize their concerns. Multiple linear and logistic regression analyses were conducted to determine the association between race/ethnicity and the importance of each theme. Models were adjusted for sex, insurance, education, HOOS, JR/KOOS, JR, and discussion of joint replacement with a doctor.
Interviews with eight participants reached saturation and provided five themes used to develop a survey answered by 738 (24%) participants; 75.5% White, 10.3% Black, 8.7% Hispanic, 3.9% Asian/Other. Responses were significantly different between groups (p < 0.05). Themes identified were "Trust in the surgeon" "Recovery", "Cost/Insurance", "Surgical outcome", and "Personal suitability/timing". Compared to Whites, Blacks were two-fold, Hispanics four-fold more likely to rate "Trust in the surgeon" as very/extremely important. Blacks were almost three times and Hispanics over six times more likely to rate "Recovery" as very/extremely important.
We identified factors of importance to patients that may contribute to barriers to arthroplasty, with marked differences between Blacks, Hispanics, and Whites.
Objective
Morning stiffness is a hallmark symptom of rheumatoid arthritis (RA), but its etiology is poorly understood. This study was undertaken to determine whether any histologic features of ...synovium are associated with this symptom.
Methods
Data on patient‐reported morning stiffness duration and severity, and Disease Activity Score in 28 joints (DAS28) were collected from 176 patients with RA undergoing arthroplasty. Synovium was scored for 10 histopathologic features: synovial lining hyperplasia, lymphocytes, plasma cells, Russell bodies, binucleate plasma cells, fibrin, synovial giant cells, detritus, neutrophils, and mucin. Fibrinolysis of clots seeded with various cell types was measured in turbidimetric lysis assays.
Results
Stiffness severity and morning stiffness duration were both significantly associated with DAS28 (P = 0.0001 and P = 0.001, respectively). None of the synovial features examined were associated with patient‐reported stiffness severity. The presence of neutrophils and fibrin in RA synovial tissue were significantly associated (P < 0.0001) with patient‐reported morning stiffness of ≥1 hour, such that 73% of patients with both synovial fibrin and neutrophils reported morning stiffness of ≥1 hour. Further, neutrophils and fibrin deposits colocalized along the synovial lining. In in vitro analyses, fibrin clots seeded with necrotic neutrophils were more resistant to fibrinolysis than those seeded with living neutrophils or no cells (P = 0.008). DNase I treatment of necrotic neutrophils abrogated the delay in fibrinolysis.
Conclusion
In RA, prolonged morning stiffness may be related to impaired fibrinolysis of neutrophil‐enmeshed fibrin deposits along the synovial membrane. Our findings also suggest that morning stiffness severity and duration may reflect distinct pathophysiologic phenomena.
Objective
To develop updated guidelines for the perioperative management of disease‐modifying medications for patients with rheumatic diseases, specifically those with inflammatory arthritis (IA) and ...those with systemic lupus erythematosus (SLE), undergoing elective total hip arthroplasty (THA) or elective total knee arthroplasty (TKA).
Methods
We convened a panel of rheumatologists, orthopedic surgeons, and infectious disease specialists, updated the systematic literature review, and included currently available medications for the clinically relevant population, intervention, comparator, and outcomes (PICO) questions. We used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology to rate the quality of evidence and the strength of recommendations using a group consensus process.
Results
This guideline updates the 2017 recommendations for perioperative use of disease‐modifying antirheumatic therapy, including traditional disease‐modifying antirheumatic drugs, biologic agents, targeted synthetic small‐molecule drugs, and glucocorticoids used for adults with rheumatic diseases, specifically for the treatment of patients with IA, including rheumatoid arthritis and spondyloarthritis, those with juvenile idiopathic arthritis, or those with SLE who are undergoing elective THA or TKA. It updates recommendations regarding when to continue, when to withhold, and when to restart these medications and the optimal perioperative dosing of glucocorticoids.
Conclusion
This updated guideline includes recently introduced immunosuppressive medications to help decision‐making by clinicians and patients regarding perioperative disease‐modifying medication management for patients with IA and SLE at the time of elective THA or TKA.
INTRODUCTION:Socioeconomic factors such as poverty may mediate racial disparities in health outcomes after total hip arthroplasty (THA) and confound analyses of differences between blacks and whites.
...METHODS:Using a large institutional THA registry, we built models incorporating individual and census tract data and analyzed interactions between race and percent of population with Medicaid coverage and its association with 2-year patient-reported outcomes.
RESULTS:Black patients undergoing THA had worse baseline and 2-year pain and function scores compared with whites. We observed strong positive correlations between census tract Medicaid coverage and percent living below poverty (rho = 0.69; P < 0.001). Disparities in 2-year Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain and function were magnified in communities with high census tract Medicaid coverage. For blacks in these communities, 2-year WOMAC function scores were predicted to be −5.54 points lower (80.42 versus 85.96) compared with blacks in less deprived communities, a difference not observed among whites.
CONCLUSION:WOMAC pain and function 2 years after THA are similar among blacks and whites in communities with little deprivation (low percent census tract Medicaid coverage). WOMAC function at 2 years is worse among blacks in areas of higher deprivation but is not seen among whites.
LEVEL OF EVIDENCE:Level II - Cohort Study
Objective
To determine whether racial disparities in total knee replacement (TKR) failure are explained by poverty.
Methods
Black and white New York state residents, enrolled in a prospective ...single‐institution TKR registry January 1, 2008 to February 6, 2012, who underwent primary unilateral TKR (n = 4,062) were linked to the New York Statewide Planning and Research Cooperative System database (January 1, 2008 to December 31, 2014) to capture revisions performed at outside institutions. Patients were linked by geocoded addresses to residential census tracts. Multivariable Cox regression was used to assess predictors of TKR revision. Multivariable logistic regression was used to analyze predictors of TKR failure, defined as TKR revision in New York state ≤2 years after surgery, or as Hospital for Special Surgery (HSS) TKR quality of life score “not improved” or “worsened” 2 years after surgery.
Results
The mean ± SD age was 68.4 ± 10 years, 64% of patients were female, 8% lived in census tracts with >20% of the population under the poverty line, and 9% were black. Median follow‐up time was 5.3 years. A total of 3% of patients (122 of 4,062) required revision a median 454 days (interquartile range 215–829) after surgery. TKR revision risk was higher in blacks than whites, with a hazard ratio of 1.69 (95% confidence interval 1.01–2.81), but in multivariable analysis, only younger age, male sex, and constrained prosthesis were predictors of TKR revision. TKR failure occurred in 200 of 2,832 cases (7%) with 2‐year surveys. Risk factors for TKR failure were non‐osteoarthritis TKR indication, low surgeon volume, and low HSS Expectations Survey score, but not black race. Community poverty was not associated with TKR revision or failure.
Conclusion
There was a trend toward higher TKR revision risk in blacks, but poverty did not modify the relationship between race and TKR revision or failure.
The Outcome Measures in Rheumatology (OMERACT) Glucocorticoid (GC) Impact Working Group has been working to develop a core domain set to measure the impact of GCs on patients living with rheumatic ...and musculoskeletal diseases. The mandatory domains previously identified for inclusion in all clinical trials measuring the GC effects include infection, bone fragility, mood disturbance, hypertension, diabetes, weight, fatigue, and mortality. Before progressing to instrument selection, the Working Group sought to establish precise definitions of all mandatory domains within the core domain set.
OMERACT methodology was applied with the use of evidence and consensus-based decision making of all stakeholder groups (patient research partners, health care professionals, clinician researchers, industry members and methodologists) to develop detailed definitions for the broad domain, target domain and domain components, taking into consideration sources of variability that could affect measurement of the domain. The working group synthesized prior qualitative studies, quantitative work, and results from Delphi rounds, to develop a rich definition of 'what' is to be measured.
Between 2021 and 2023, the OMERACT Working Group on GC Impact conducted virtual meetings to establish domain definitions. First, we mapped each domain onto an OMERACT Core Area. All domains were primarily represented within the Pathophysiological Manifestations Core Area, except from Fatigue which was primarily Life Impact and Weight which spanned both Core Areas. Sources of variability included cultural factors, age, gender, education level, socioeconomic status, personal experiences, emotional state, and language barriers. The domain definitions will form the foundation for instrument selection and the initial step of domain / concept match and content validity in the OMERACT pillar of 'truth' before moving on to feasibility and discrimination.
The OMERACT GC Impact Working Group has developed and agreed upon detailed domain definitions for core domains. Future steps of the working group are to select instruments and develop the core outcome measurement set for clinical trials measuring the impact of GC on patients with rheumatic and musculoskeletal diseases.
Introduction. Glucocorticoids (GCs) remain widely used. However, the impact of GCs from the perspective of the patient, rather than of the clinician, remains relatively unexplored. Additionally, no ...general patient reported outcome measure has been developed to assess the effects of GCs across rheumatological conditions. The aim of this literature review was to identify the adverse effects of systemic GC use that are of importance to patients.
Methods. OVID EMBASE, OVID MEDLINE, PsycINFO and CINAHL was searched relating to three concepts: GCs, the patient perspective and adverse effects. A meta-synthesis of the qualitative data was performed separately by two independent researchers before qualitative metasummary was utilized to quantitatively aggregate the findings (combining quantitative and qualitative results), including the derivation of frequency and intensity effect sizes to identify those outcomes most prominently featured across all reviewed articles.
Results. The initial search retrieved 1,356 articles, of which 25 (18 quantitative, 7 qualitative) were deemed suitable for quality assessment and data extraction. Four major themes emerged amongst the 71 discrete outcomes: physical symptoms (44), psychological symptoms (18), effect on participation (6) and contextual factors (3).
Conclusions. Patients with a broad range of inflammatory diseases and demographic features describe key cross-cutting themes in relation to GCs and their impact on health-related quality of life. This work will inform the development of a core domain set for clinical trials involving GCs and a patient reported outcome to measure impact of GCs from the patient's perspective.
Objective
To develop updated guidelines for the perioperative management of disease‐modifying medications for patients with rheumatic diseases, specifically those with inflammatory arthritis (IA) and ...those with systemic lupus erythematosus (SLE), undergoing elective total hip arthroplasty (THA) or elective total knee arthroplasty (TKA).
Methods
We convened a panel of rheumatologists, orthopedic surgeons, and infectious disease specialists, updated the systematic literature review, and included currently available medications for the clinically relevant population, intervention, comparator, and outcomes (PICO) questions. We used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology to rate the quality of evidence and the strength of recommendations using a group consensus process.
Results
This guideline updates the 2017 recommendations for perioperative use of disease‐modifying antirheumatic therapy, including traditional disease‐modifying antirheumatic drugs, biologic agents, targeted synthetic small‐molecule drugs, and glucocorticoids used for adults with rheumatic diseases, specifically for the treatment of patients with IA, including rheumatoid arthritis and spondyloarthritis, those with juvenile idiopathic arthritis, or those with SLE who are undergoing elective THA or TKA. It updates recommendations regarding when to continue, when to withhold, and when to restart these medications and the optimal perioperative dosing of glucocorticoids.
Conclusion
This updated guideline includes recently introduced immunosuppressive medications to help decision‐making by clinicians and patients regarding perioperative disease‐modifying medication management for patients with IA and SLE at the time of elective THA or TKA.
Abstract Patients with rheumatoid arthritis (RA) continue to undergo arthroplasty to relieve pain and restore lost function caused by joint damage, despite improvements in disease-modifying therapy. ...The widespread use of potent immunosuppressant medications by RA patients implies that they frequently receive these drugs at the time of surgery. In addition to the medical challenges of medication and disease management at the time of surgery, there are surgical complexities related to complex deformities, osteoporotic bone, and ligament laxity. This paper discusses the current state of the art regarding arthroplasty utilization, outcomes, and perioperative management from a medical and surgical perspective, and highlights the clinical challenges to achieve optimal outcomes.
Context: Increased oxidant stress and inflammation (OS/infl) are linked to both aging-related diseases and advanced glycation end products (AGEs). Whereas AGE receptor-1 (AGER1) reduces OS/infl in ...animals, this has not been assessed in normal humans.
Objective: The objectives of the study were to determine whether AGER1 correlates with AGEs and OS/infl and a reduction of dietary AGEs (dAGEs) lowers OS/infl in healthy adults and chronic kidney disease (CKD-3) patients.
Design: This study was cross-sectional with 2-yr follow-up studies of healthy adults and CKD-3 patients, a subset of which received a reduced AGE or regular diet.
Setting: The study was conducted at general community and renal clinics.
Participants: Participants included 325 healthy adults (18–45 and >60 yr old) and 66 CKD-3 patients.
Intervention: An isocaloric low-AGE (30–50% reduction) or regular diet was given to 40 healthy subjects for 4 months and to nine CKD-3 patients for 4 wk.
Main Outcome: Relationships between age, dAGEs, serum AGEs, peripheral mononuclear cell AGE-receptors, and OS/Infl before and after reduction of dAGE intake were measured.
Results: AGEs, oxidant stress, receptor for AGE, and TNFα were reduced in normal and CKD-3 patients after the low-AGE diet, independently of age. AGER1 levels in CKD-3 patients on the low-AGE diet resembled 18- to 45-yr-old normal subjects. Dietary, serum, and urine AGEs correlated positively with peripheral mononuclear cell AGER1 levels in healthy participants. AGER1 was suppressed in CKD-3 subjects, whereas receptor for AGE and TNFα were increased.
Conclusions: Reduction of AGEs in normal diets may lower oxidant stress/inflammation and restore levels of AGER1, an antioxidant, in healthy and aging subjects and CKD-3 patients. AGE intake has implications for health outcomes and costs and warrants further testing.
Reduction of advanced glycation endproducts (AGE) in normal diets lowers oxidant stress/inflammation, and restores levels of AGE receptor-1 in healthy, aging, and chronic kidney disease-3 patients.
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