No Difference in 10-Year Survivorship of Total Shoulder Arthroplasty Versus Hemiarthroplasty for Avascular Necrosis of the Humeral Head.

INTRODUCTION: Avascular necrosis of the humeral head (AVN) is characterized by osteonecrosis secondary to disrupted blood flow to the glenohumeral joint. Following collapse of the humeral head, arthroplasty, namely total shoulder arthroplasty (TSA) or humeral head arthroplasty (hemiarthroplasty) is recommended standard of care. The literature is limited to underpowered and small sample sizes in comparing arthroplasty modalities. Therefore, the aims of this study were (1) to compare the 10-year survivorship of TSA and hemiarthroplasty in the treatment of AVN of the humeral head and (2) to identify differences in their revision etiologies. METHODS: Patients who underwent primary TSA and hemiarthroplasty for AVN were identified using the PearlDiver database. TSA patients were matched by age, gender, and Charlson Comorbidity Index (CCI) to the hemiarthroplasty cohort in a 4:1 ratio since TSA patients were generally older, sicker, and more often female. The 10-year cumulative incidence rate of all-cause revision was determined using Kaplan-Meier survival analysis. Multivariable analysis was conducted using Cox Proportional Hazard modeling. Chi-squared analysis was conducted to compare the indications for revisions between matched cohorts including periprosthetic joint infection (PJI), dislocation, mechanical loosening, broken implants, periprosthetic fracture, and stiffness. RESULTS: In total, 4,825 patients undergoing TSA and 1,969 patients undergoing hemiarthroplasty for AVN were included in this study. The unmatched 10-year cumulative incidence of revision for patients who underwent TSA and hemiarthroplasty was 7.0% and 7.7%, respectively. The matched 10-year cumulative incidence of revision for patients who underwent TSA and hemiarthroplasty was 6.7% and 8.0%, respectively. When comparing the unmatched cohorts, TSA patients were at significantly higher risk of 10-year all-cause revision (HR: 1.39; P = 0.017) when compared to hemiarthroplasty patients. After matching, there was no significant difference in risk of 10-year all-cause revision (HR: 1.29; P = 0.148) and no difference in the observed etiologies for revision (P > 0.05 for all). CONCLUSION: After controlling for confounders, only 6.7% of TSA and 8.0% hemiarthroplasties for humeral head AVN were revised within 10-years of index surgery. The demonstrated high and comparable long-term survivorship for both modalities supports the utilization of either for the AVN induced humeral head collapse.

The association between cognitive ability and opioid prescribing in vulnerable older adults with chronic pain in ambulatory care: a secondary data analysis using the Medical Expenditure Panel Survey.

BACKGROUND: Vulnerable older adults living with Alzheimer's disease or Alzheimer's disease and related dementia (AD/ADRD) and chronic pain generally receive fewer pain medications than individuals without AD/ADRD, especially in nursing homes. Little is known about pain management in older adults with AD/ADRD in the community. The aim of the study was to examine opioid prescribing patterns in individuals with chronic pain by levels of cognitive ability in ambulatory care. METHODS: We used the Medical Expenditure Panel Survey (MEPS), years 2002-2017, and identified three levels of cognitive impairment: no cognitive impairment (NCI), individuals reporting cognitive impairment (CI) without an AD/ADRD diagnosis, and individuals with a diagnosis of AD/ADRD. We examined any receipt of an opioid prescription and the number of opioid prescriptions using a logistic and negative binomial regression adjusting for sociodemographic and health characteristics and stratifying by three types of chronic pain (any chronic pain, severe chronic pain, and chronic pain identified through ICD 9/10 chronic pain diagnoses). RESULTS: Among people with any chronic pain, adjusted odds of receiving an opioid for people with CI (OR 1.41, 95% confidence interval 1.31-1.52) and AD/ADRD (OR 1.23, 95% confidence interval 1.04-1.45) were higher compared to NCI. Among people with chronic pain ICD 9/10 conditions, the odds of receiving an opioid were also higher for those with CI (OR 1.43, 95% confidence interval 1.34-1.56) and AD/ADRD (OR 1.48, 95% confidence interval 1.23-1.78) compared to NCI. Among those with severe chronic pain, people with CI were more likely to receive an opioid (OR 1.17, 95% confidence interval 1.07-1.27) relative to NCI (OR 0.89, 95% confidence interval 0.75-1.06). People with AD/ADRD experiencing severe chronic pain were not more likely to receive an opioid compared to the NCI group. Adjusted predicted counts of opioid prescriptions showed more opioids in CI and AD/ADRD in all chronic pain cohorts, with the largest numbers of opioid prescriptions in the severe chronic pain and ICD 9/10 diagnoses groups. CONCLUSIONS: The results suggest increased opioid use in people living with CI and AD/ADRD in the ambulatory care setting and potentially indicate that these individuals either require more analgesics or that opioids may be overprescribed. Further research is needed to examine pain management in this vulnerable population.

Data-driven body mass index threshold associated with increased risk of 2-year periprosthetic joint infection following total shoulder arthroplasty.

BACKGROUND: Body mass index (BMI) is a modifiable risk factor for medical and infectious complications following total shoulder arthroplasty (TSA). Previous studies investigating BMI were limited to the conventional classification system, which may be outdated for modern day patients. Therefore, the purpose of this study was to identify BMI thresholds that are associated with varying risk of 90-day medical complications and 2-year prosthetic joint infection (PJI) following TSA. METHODS: A national database was utilized to identify 10,901 patients who underwent primary elective TSA from 2013 to 2022. Patients were only included if they had a BMI value recorded within 1 month prior to TSA. Separate stratum-specific likelihood ratio analyses, an adaptive technique to identify data-driven thresholds, were performed to determine data-driven BMI strata associated with varying risk of 90-day medical complications and 2-year PJI. The incidence rates of these complications were recorded for each stratum. To control for confounders, each BMI strata was propensity-score matched based on age, sex, hypertension, heart failure, chronic obstructive pulmonary disease, and diabetes mellitus to the lowest identified BMI strata for both outcomes of interest. The risk ratio (RR) and 95% confidence interval (CI) were recorded for each matched analysis. RESULTS: The average age and BMI of patients was 70.5 years (standard deviation ±9.8) and 30.7 (standard deviation ±6.2), respectively. Stratum-specific likelihood ratio analysis identified two BMI strata associated with differences in the rate of 2-year PJI: 19-39 and 40+. The same strata were identified for 90-day major complications. When compared to the matched BMI 19-39 cohort, the risk of 2-year PJI was higher in the BMI 40+ cohort (RR: 2.7; 95% CI 1.39-5.29; P = .020). After matching, there was no significant difference in the risk of 90-day major complications between identified strata (RR: 1.19, 95% CI: 0.86-1.64; P = .288). CONCLUSION: A data-driven BMI threshold of 40 was associated with a significantly increased risk of 2-year PJI following TSA. This is the first TSA study to observe BMI on a continuum and observe at what point BMI is associated with increased risk of 2-year PJI following TSA. Our identified BMI strata can be incorporated into risk-stratifying models for predicting both PJI and 90-day major complications to minimize both.

The association between anesthesia type and postoperative outcomes in patients receiving primary total shoulder arthroplasty.

PURPOSE: There has been interest to investigate optimal anesthetic techniques for primary total shoulder arthroplasty (TSA). In this study, we investigate if there are differences in postoperative complications in patients receiving (1) regional alone; (2) general alone; and (3) regional plus general anesthesia for primary TSA. METHODS: Patients undergoing primary TSA from 2014 to 2018 were identified in a national database. Patients were stratified into 3 cohorts: general anesthesia, regional anesthesia, and general anesthesia combined with regional anesthesia. Thirty-day complications were assessed using bivariate and multivariate analyses. RESULTS: Of 13,386 total patients undergoing TSA, 9079 patients (67.8%) had general anesthesia, 212 (1.6%) had regional anesthesia, and 4095 (30.6%) had general anesthesia combined with regional anesthesia. There were no significant differences in postoperative complications between the general anesthesia group and the regional anesthesia group. Following adjustment, an increased risk of extended length of hospital stay was seen in the combined general and regional anesthesia group compared to those who only had general anesthesia (p = 0.001). CONCLUSION: General versus regional versus general plus regional anesthesia have no difference in postoperative complications in patients receiving primary total shoulder arthroplasty. However, addition of regional anesthesia to general anesthesia is associated with increased length of stay. LEVEL OF EVIDENCE: III.

Comparison of 30-day complications between reverse shoulder arthroplasty and open reduction internal fixation for the treatment of proximal humerus fractures.

PURPOSE: While the use of open reduction internal fixation (ORIF) has remained stable over the last decade, there has been a significant increase in the use of reverse total shoulder arthroplasty (RTSA) for proximal humerus fractures (PHFs). This study sought to compare the complication profiles of RTSA to ORIF in a large, validated, retrospective cohort. METHODS: Patients who underwent surgical treatment for PHFs with RTSA or ORIF were identified in a national database (NSQIP) using CPT and ICD codes. Demographics and comorbidities were identified for each cohort of patients. Thirty-day complications were analyzed with univariate and multivariate analyses using Chi-square, Fischer's exact and analysis of variance testing. RESULTS: The total number of patients included in this study was 2157.522 (24.2%) underwent RTSA and 1635 (75.8%) underwent ORIF. Patients undergoing RTSA were older with an average age of 73.52 years compared with 63.84 years in those undergoing ORIF (p < 0.001). Patients with RTSA were more likely to experience any complications (p < 0.001), pulmonary complications (p = 0.029), extended length of stay > 3 days (p < 0.001), and perioperative transfusion requirement (p < 0.001) after univariate analysis. After controlling for demographic differences, the only statistically significant complication was perioperative transfusion requirement (OR 1.383). CONCLUSION: After controlling for demographic variables and comorbidities, RTSA placed patients at increased risk for perioperative blood transfusion. Patients undergoing RTSA should be counseled prior to surgery regarding the risk for transfusion and potentially optimized medically through multidisciplinary care if the surgeon elects to proceed with RTSA versus ORIF for the treatment of PHFs.

Location and Provision of Support from Migrants to Left-behind Parents in Rural Cambodia.

Cambodia is a country where labor migration has been consistently high, particularly out of rural areas. Migration increases the distance between parents and their children, which may lead to a reduction in sources of support. Based on these contemporary realities, it is important to understand the factors that impact provision of support from migrants to their parents. This study examines determinants of support provision, with a focus on migrant location. Based on family solidarity and altruism theories, other factors were considered that indicate migrant's ability to provide, the degree of parental vulnerability and degree of interaction. We hypothesized that the likelihood of migrant support provision to left-behind parents related to their location, ability to provide and needs of the household. Data were sourced from the 2011 Cambodian Rural Urban Migration Project (CRUMP) (N = 3700). In bivariate analysis, 77% of both international and rural to urban internal migrants provide monetary support. Rural to urban internal migrants are most likely, and international migrants least likely, to be providing instrumental support. When examining fully adjusted models, it is rural to urban internal migrants that are the most likely to provide both monetary and instrumental support. Both types of support are more likely to be provided by female migrants and to households headed by females. Results show that left-behind parents are not completely unsupported in rural Cambodia, but support provision may be impacted by other determinants. This study provides baseline information for policy makers to design suitable policies that may optimize the positive impact of migration for migrants and left-behind parents.

Are Religiosity and Spirituality Related to Self-Reported Health Expectancy? An Analysis of the European Values Survey.

Research on religiosity and health has generally focussed on the United States, and outcomes of health or mortality but not both. Using the European Values Survey 2008, we examined cross-sectional associations between four dimensions of religiosity/spirituality: attendance, private prayer, importance of religion, belief in God; and healthy life expectancy (HLE) based on self-reported health across 47 European countries (n = 65,303 individuals). Greater levels of private prayer, importance of religion and belief in God, at a country level, were associated with lower HLE at age 20, after adjustment for confounders, but only in women. The findings may explain HLE inequalities between European countries.

Are Older Persons in China Living More Years in an Independent Living Arrangement? Estimates Using Multistate Life Tables.

Adopting a multistate life table approach, this study estimates number of years the very old in China expect to live in an independent living arrangement (alone or with spouse only)-an estimate we term "independent living life expectancy" (ILLE)-as opposed to in coresidence with adult children or others. We also estimate how ILLE and proportion of total life expectancy (TLE) residing independently has changed over time. The backdrop for this study is a society experiencing both increasing longevity and social changes that influence the tendency to live in an independent living arrangement. The study concentrates on assessing whether changes in ILLE match or surpass gains in TLE experienced by oldest-old Chinese adults. Data are from the 2002-2014 Chinese Longitudinal Healthy Longevity Survey, and estimation is conducted using the Stochastic Population Analysis for Complex Events software. Results suggest that on balance, gains in ILLE are proportionately greater than gains in TLE, indicating an expansion of ILLE for most Chinese elders. Males, septuagenarian females, and disabled septuagenarians are the most likely to be living proportionately longer lives in an independent living arrangement. In contrast, extremely old (nonagenarian and centenarian) females and extremely old disabled individuals are least likely to have experienced dramatic changes in proportion of life residing independently. The findings imply some support for the hypothesis that given the maintenance of family solidarity in China, those in greatest need are least likely to encounter the most extreme changes toward independent living arrangements.

Pain Trends Among American Adults, 2002-2018: Patterns, Disparities, and Correlates.

Determining long-term trends in chronic pain prevalence is critical for evaluating and shaping U.S. health policies, but little research has examined such trends. This study (1) provides estimates of pain trends among U.S. adults across major population groups; (2) tests whether sociodemographic disparities in pain have widened or narrowed over time; and (3) examines socioeconomic, behavioral, psychological, and medical correlates of pain trends. Regression and decomposition analyses of joint, low back, neck, facial/jaw pain, and headache/migraine using the 2002-2018 National Health Interview Survey for adults aged 25-84 (N = 441,707) assess the trends and their correlates. We find extensive escalation of pain prevalence in all population subgroups: overall, reports of pain in at least one site increased by 10%, representing an additional 10.5 million adults experiencing pain. Socioeconomic disparities in pain are widening over time, and psychological distress and health behaviors are among the salient correlates of the trends. This study thus comprehensively documents rising pain prevalence among Americans across the adult life span and highlights socioeconomic, behavioral, and psychological factors as important correlates of the trends. Chronic pain is an important dimension of population health, and demographic research should include it when studying health and health disparities.

Needle Diagnostic Arthroscopy and Magnetic Resonance Imaging of the Shoulder Have Comparable Accuracy With Surgical Arthroscopy: A Prospective Clinical Trial.

PURPOSE: To examine the accuracy, sensitivity, and specificity of a minimally invasive needle arthroscopy device and magnetic resonance imaging (MRI) compared with diagnostic arthroscopy, the gold standard in diagnosing intra-articular shoulder pathologies. METHODS: This was a prospective, blinded clinical trial over 6 months on 50 patients with shoulder pathology requiring arthroscopy. Patients were eligible if they had an MRI and consented for surgical arthroscopy. Patients were excluded if they didn't consent. Each underwent a clinical evaluation, MRI, needle arthroscopy, and surgical arthroscopy. Videos and images were blindly reviewed postoperatively. Analysis included sensitivity, specificity, positive predictive value (PPV), negative predictive value, Cohen's kappa agreement coefficient, and the McNemar test. RESULTS: Needle arthroscopy had similar accuracy to MRI in diagnosing intra-articular shoulder pathologies when both were compared with the gold standard of diagnostic arthroscopy. It had high specificities and PPV for certain rotator cuff tears, biceps pathology, and anterior labral tears. When compared with the gold standard, specificity of needle arthroscopy for diagnosing rotator cuff tear and cartilage lesions was 1.00 and 0.97 and 0.72 and 0.86 for MRIs, respectively. Sensitivity of needle arthroscopy for rotator cuff and cartilage lesions was 0.89 and 0.74, respectively, lower than MRI. For most intra-articular pathologies, needle arthroscopy was at least equally accurate to MRI at diagnosing intra-articular shoulder pathologies, with similar or high kappa statistics when correlated with surgical arthroscopic findings. CONCLUSIONS: Needle arthroscopy is a promising diagnostic modality for intra-articular shoulder pathologies. It had comparable accuracy with MRI for diagnosing articular cartilage, labrum, rotator cuff, and biceps pathology. Across all pathologies, needle arthroscopy had better ability to "rule in" a diagnosis (high specificities and PPV), but slightly worse ability to "rule out" a diagnosis (lower sensitivities and negative predictive value) compared with MRI. LEVEL OF EVIDENCE: Level II, Development of diagnostic criteria on consecutive patients (with universally applied reference "gold" standard).

Predictors of acromial and scapular stress fracture after reverse shoulder arthroplasty: a study by the ASES Complications of RSA Multicenter Research Group.

BACKGROUND: Acromial (ASF) and scapular spine (SSF) stress fractures are well-recognized complications of reverse shoulder arthroplasty (RSA), but much of the current data are derived from single-center or single-implant studies with limited generalizability. This study from the American Shoulder and Elbow Surgeons (ASES) Complications of Reverse Shoulder Arthroplasty Multicenter Research Group determined the incidence of ASF/SSF after RSA and identified preoperative patient characteristics associated with their occurrence. METHOD: Fifteen institutions including 21 ASES members across the United States participated in this study. Patients undergoing either primary or revision RSA between January 2013 and June 2019 with a minimum 3-month follow-up were included. All definitions and inclusion criteria were determined using the Delphi method, an iterative survey process involving all primary investigators. Consensus was achieved when at least 75% of investigators agreed on each aspect of the study protocol. Only symptomatic ASF/SSF diagnosed by radiograph or computed tomography were considered. Multivariable logistic regression was performed to identify factors associated with ASF/SSF development. RESULTS: We identified 6755 RSAs with an average follow-up of 19.8 months (range, 3-94). The total stress fracture incidence rate was 3.9% (n = 264), of which 3.0% (n = 200) were ASF and 0.9% (n = 64) were SSF. Fractures occurred at an average 8.2 months (0-64) following RSA with 21.2% (n = 56) following a trauma. Patient-related factors independently predictive of ASF were chronic dislocation (odds ratio [OR] 3.67, P = .04), massive rotator cuff tear without arthritis (OR 2.51, P < .01), rotator cuff arthropathy (OR 2.14, P < .01), self-reported osteoporosis (OR 2.21, P < .01), inflammatory arthritis (OR 2.18, P < .01), female sex (OR 1.51, P = .02), and older age (OR 1.02 per 1-year increase, P = .02). Factors independently associated with the development of SSF included osteoporosis (OR 2.63, P < .01), female sex (OR 2.34, P = .01), rotator cuff arthropathy (OR 2.12, P = .03), and inflammatory arthritis (OR 2.05, P = .03). CONCLUSION: About 1 in 26 patients undergoing RSA will develop a symptomatic ASF or SSF, more frequently within the first year of surgery. Our results indicate that severe rotator cuff disease may play an important role in the occurrence of stress fractures following RSA. This information can be used to counsel patients about potential setbacks in recovery, especially among older women with suboptimal bone health. Strategies for prevention of ASF and SSF in these at-risk patients warrant further study. A follow-up study evaluating the impact of prosthetic factors on the incidence rates of ASF and SSF may prove highly valuable in the decision-making process.

Association of sleep duration with risk of all-cause mortality and poor quality of dying in oldest-old people: a community-based longitudinal study.

BACKGROUND: While sleep duration has been shown to be associated with health outcomes, few studies have been conducted among the oldest old. In addition, the impact of sleep duration on quality of dying is unknown. We aimed to evaluate how sleep duration affects all-cause mortality and quality of dying in people aged 80 + . METHODS: This community-based longitudinal study was performed by using data from 15,048 individuals aged ≥80 with information on sleep duration in the Chinese Longitudinal Healthy Longevity Survey. Cox and logistic regression models with penalized splines were applied to explore the shape of the association between sleep duration and all-cause mortality and poor quality of dying respectively and identify the interval of sleep duration resulting in the lowest risk of both. RESULTS: During a median follow-up of 3.1 years, 11,582 deaths including 4116 individuals who experienced poor quality of dying were recorded. Sleep duration showed a U-shaped association with all-cause mortality and sleeping about 8 h had the minimum risk of death; a J-shaped association was found between sleep duration and poor quality of dying. Compared with sleep duration of 7-9 h, the adjusted hazard ratio of total deaths was 1.08 (95% CI 1.03-1.13) for short duration (< 7 h) and 1.12 (95% CI 1.07-1.17) for long duration (> 9 h); the adjusted odds ratio of poor QOD was 1.10 (95% CI 1.01-1.21) for long duration, but this association was restricted to those with baseline unhealthy status (P-interaction = 0.04). CONCLUSIONS: Sleeping a little longer may be better for individuals over 80 years old, and sleep duration of 7-9 h per day is optimal for both survival and good quality of life near death.

Does Religious Activity Distinguish the Mortality Experiences of Older Taiwanese? An Analysis Using Eighteen Years of Follow-Up Data.

This paper extends investigation of religiosity and longevity to Taiwan using a 1989 survey: N = 3849, aged 60+, with 18 years of follow-up. Religious activity is measured as worship and performance of rituals. A Gompertz regression, adjusted and non-adjusted for covariates and mediating factors, shows the hazard of dying is lower for the religiously active versus the non-active. Transformed into life table functions, a 60-year-old religiously active Taiwanese female lives more than 1 year longer than her non-religious counterpart, ceteris paribus. Mainland Chinese migrants are examined carefully because of unique religious and health characteristics. They live longer, but the religiosity gap is similar.

Double-blind, randomized clinical trial assessing the efficacy and safety of early initiation of sitagliptin during metformin uptitration in the treatment of patients with type 2 diabetes: The CompoSIT-M study.

AIMS: To characterize the glycaemic efficacy and safety of initiation of the dipeptidyl peptidase-4 inhibitor sitagliptin during metformin dose escalation in people with type 2 diabetes (T2D) not at glycated haemoglobin (HbA1c) goal on a sub-maximal dose of metformin. MATERIALS AND METHODS: Study participants with HbA1c ≥58 mmol/mol and ≤97 mmol/mol (≥7.5% and ≤11.0%) while on 1000 mg/d metformin were randomized to sitagliptin 100 mg once daily or placebo. All were to uptitrate metformin to 2000 mg/d. A longitudinal data analysis model was used to test the primary hypothesis that sitagliptin is superior to placebo when initiated during uptitration of metformin in reducing HbA1c at week 20. [ClinicalTrials.gov Identifier: NCT02791490, EudraCT: 2015-004224-59] RESULTS: A total of 458 participants (mean HbA1c 71.1 mmol/mol [8.7%], T2D duration 6.3 years) were treated. After 20 weeks, the least squares (LS) mean changes from baseline in HbA1c were -12.1 mmol/mol (-14.0, -10.1) (-1.10% [-1.28, -0.93]) and -7.6 mmol/mol (-9.6, -5.6) (-0.69% [-0.88, -0.51]) with sitagliptin and placebo, respectively; the between-group difference in LS mean changes from baseline HbA1c was -4.5 mmol/mol (-6.5, -2.5) (-0.41% [-0.59, -0.23]); P < 0.001. The likelihood of having HbA1c <53 mmol/mol (<7.0%) at week 20 was higher in the sitagliptin group than in the placebo group in the overall population (relative risk 1.7, P = 0.002) and in those with a baseline HbA1c ≥69 mmol/mol (≥8.5%) (relative risk 2.4, P = 0.026). There were no notable differences between groups with regard to adverse events overall, hypoglycaemia events, changes in body weight or other safety variables. CONCLUSION: In participants not at HbA1c goal on a sub-maximal dose of metformin, addition of sitagliptin at the time of metformin dose uptitration improved glycaemic response and HbA1c goal attainment, with similar safety and tolerability, compared to metformin uptitration alone.

Design and measurement in a study of war exposure, health, and aging: protocol for the Vietnam health and aging study.

BACKGROUND: Survivors of war throughout the world experience illnesses and injuries that are crucial to understand, given the ongoing treatment and adaptation they demand. In developing countries like Vietnam, where population aging and chronic disease burdens are rapidly rising, aging populations have seen a disproportionate share of armed conflict and related casualties. This paper describes the Vietnam Health and Aging Study (VHAS), a unique resource for investigating mechanisms of association between diverse exposures to armed conflict during the Vietnam War and multiple dimensions of older adult health among survivors of that war. METHODS: The VHAS utilizes a longitudinal design, the first wave of data collection conducted in 2018 among 2447 older adults. A second wave of follow-up data collection, scheduled to take place in 2021, will examine life course, social relational and health and mortality transitions. The VHAS was conducted in four northern Vietnamese districts purposively selected to represent a spectrum of war exposure as indicated by intensity of bombings. Additionally, VHAS uses random sampling within gender and military service subdomains to permit unique gender-specific analyses of military service, trauma exposure and health. The VHAS' face-to-face interviews include modules detailing war and military service experiences; warzone stressors; and multiple dimensions of health such as chronic disease, functional limitation, disability, health behaviors, cognition and psychological health. Biomarker data collected for the full VHAS sample includes anthropometric and functional tests such as grip strength and blood pressure, hair samples for cortisol assay, and capillary blood samples to assay C-reactive protein, cholesterol, HbA1c, and other markers of interest for cardiovascular and other disease risks and for testing the impact of early life stressors on later life health. Blood samples will also permit epigenetic analysis of biological aging. DISCUSSION: Future VHAS investigations will examine dynamic linkages between war exposure, mortality and morbidity, while taking into account the selective nature of each of these processes. Longitudinal analyses will examine late-life health transitions and war-related resiliency.

Predictors of unsatisfactory patient outcomes in primary reverse total shoulder arthroplasty.

BACKGROUND: Despite favorable clinical and functional results for reverse total shoulder arthroplasty (RSA), there remains a group of patients without postoperative complications who demonstrate poor improvement and overall outcome. METHODS: Using a single surgeon shoulder arthroplasty registry, we identified patients who underwent RSA from 2013 to 2016 with minimum of 2-year postoperative follow-up. Patients with intra- and postoperative complications were excluded. Poor postoperative clinical outcome was defined as those patients within the bottom 30th percentile for American Shoulder and Elbow Surgeons (ASES) score. Poor postoperative improvement was defined as the bottom 30th percentile of ASES improvement, measured preoperatively to the 2-year postoperative mark. Multivariate logistic regression modeling was used to determine preoperative characteristics (e.g., demographics, comorbidities, preoperative ASES score) associated with poor outcome. RESULTS: A total of 137 patients met the inclusion and exclusion criteria. Multivariable logistic regression modeling found that prior shoulder surgery, the majority (75%) of which were arthroscopic, was the only independent factor associated with both poor improvement (adjusted odds ratio, 2.46 [1.03-5.83]) and outcome (adjusted odds ratio, 4.92 [1.74-14.96]). Preoperative opioid use was associated with poor outcomes only, whereas the high preoperative ASES score was associated with poor postoperative improvement. CONCLUSIONS: Prior ipsilateral shoulder surgery was strongly associated with poor clinical improvement and outcome after RSA. No other factors correlated with both poor improvement and outcome. This association is important to decision making for any shoulder surgery, given the long-term implications.

A randomized clinical trial of the efficacy and safety of sitagliptin compared with dapagliflozin in patients with type 2 diabetes mellitus and mild renal insufficiency: The CompoSIT-R study.

AIM: To compare the efficacy and safety of the dipeptidyl peptidase-4 inhibitor sitagliptin with the sodium-glucose transporter-2 inhibitor dapagliflozin in patients with type 2 diabetes and mild renal insufficiency. MATERIALS AND METHODS: Patients with HbA1c ≥7.0 to ≤9.5% (≥53 to ≤80 mmol/mol) and estimated glomerular filtration rate ≥60 to <90 mL/min/1.73m2 on metformin (≥1500 mg/d) ± sulfonylurea were randomized to sitagliptin 100 mg (n = 307) or dapagliflozin 5 mg titrated to 10 mg (n = 306) once daily for 24 weeks. A longitudinal data analysis model was used to test the primary hypothesis that sitagliptin is non-inferior to dapagliflozin in reducing HbA1c at Week 24, with superiority to be tested if non-inferiority is met. ClinicalTrials.gov NCT02532855. RESULTS: Baseline mean HbA1c (% [mmol/mol]) was 7.7 (60.9) and 7.8 (61.2), and mean eGFR (mL/min/1.73m2 ) was 79.4 and 76.9 for the sitagliptin and dapagliflozin groups, respectively. After 24 weeks, the between-group difference in least squares mean (95% CI) changes from baseline in HbA1c was -0.15% (-0.26, -0.04) (-1.67 mmol/mol [-2.86, -0.48]), P = 0.006, meeting the prespecified criteria for declaring both non-inferiority and superiority of sitagliptin versus dapagliflozin. The HbA1c goal of <7% (<53 mmol/mol) was met by 43% (sitagliptin) and 27% (dapagliflozin) of patients. No meaningful between-group difference was observed in a pre-specified analysis of 2-hour incremental postprandial glucose excursion. A review of adverse events (AEs) was notable for a lower incidence of drug-related AEs with sitagliptin compared with dapagliflozin. CONCLUSIONS: In patients with type 2 diabetes, mild renal insufficiency and inadequate glycaemic control on metformin ± sulfonylurea, sitagliptin treatment resulted in greater improvement in glycaemic control compared with dapagliflozin and was generally well tolerated.

A randomised, double-blind, trial of the safety and efficacy of omarigliptin (a once-weekly DPP-4 inhibitor) in subjects with type 2 diabetes and renal impairment.

AIMS: To assess the safety and efficacy of omarigliptin in subjects with type 2 diabetes mellitus (T2DM) and chronic renal impairment (RI). METHODS: Patients with T2DM with moderate RI (estimated glomerular filtration rate [eGFR] ≥30 to <60 mL/min/1.73 m2 ) (N=114), severe RI (eGFR <30 mL/min/1.73 m2 ) (N=55) or end-stage renal disease on dialysis (N=44), who were either not on an antihyperglycaemic agent therapy for at least 12 weeks at screening, washed-off of oral antihyperglycaemic agent monotherapy or low-dose dual combination therapy, or on insulin monotherapy, with baseline glycated haemoglobin (HbA1c) of 6.5%-10.0% were randomised to omarigliptin or to placebo for 24 weeks (primary end-point) followed by a 30-week period with subjects on placebo switched to blinded glipizide (if not on insulin). RESULTS: After 24 weeks, from a mean baseline HbA1c of 8.4% in the omarigliptin group and 8.3% in the placebo group, the least squares mean (95% CI) change from baseline in HbA1c in the overall population (all renal strata combined) was -0.77% (-1.00 to -0.54) in the omarigliptin group and -0.44% (-0.67 to -0.21) in the placebo group; between-group difference of -0.33% (-0.63 to -0.02); P=0.035. After 24 weeks, the incidences of subjects with symptomatic hypoglycaemia, one or more adverse event (AE), drug-related AE, serious AE and discontinuation due to an AE were similar in the omarigliptin and placebo groups. CONCLUSIONS: In this study in subjects with T2DM and RI, relative to placebo, omarigliptin provided clinically meaningful reductions in HbA1c, had a similar incidence of symptomatic hypoglycaemia and was generally well tolerated.

Functional limitation trajectories and their determinants among women in the Philippines.

BACKGROUND: Limited evidence exists regarding how functional limitation patterns of women in developing countries unfold through midlife and into old age, a critical period during which the tendency to develop severe problems is fomented. OBJECTIVE: Functional limitation prevalence and patterns through midlife into early old age, and their determinants, are examined among women in the Philippines. METHODS: Data from the Cebu Longitudinal Health and Nutrition Study are monitored from 1994 to 2015. Patterns are categorized using group-based trajectory modeling. Predictors of group membership are modeled. RESULTS: About half responding to all survey waves report functional limitation at least once over the study period. Movements in and out of functional limitation states are common. Between age 30 and 70, trajectories are categorized into four groups: 1) robust, 2) late onset, 3) early onset, and 4) recovery. Being married, living in a nuclear household, higher successful birth ratio, and higher education associate with favorable trajectories. More births, higher age at first birth, wealth, and urbanicity associate with less favorable trajectories. CONCLUSION: Many possible routes into and out of functional limitation exist. The manifold patterns can be grouped into common trajectories. A number of earlier life characteristics associate with these trajectories. CONTRIBUTION: This is the first analysis to ascertain common functional limitation trajectories and earlier life predictors among women as they age in a high fertility developing country setting. Recognizing these is an important step toward understanding global health given aging of the population and the likelihood of functional problems developing in women as they move into old age.

Offspring Socioeconomic Status and Parent Mortality Within a Historical Population.

Considering a network approach to health determinants, we test the hypothesis that benefits of high socioeconomic status (SES) may be transmitted up the generational ladder from offspring to parents. Studies that examine own SES and own health outcomes, or SES of parents and outcomes of young or adolescent children, are common. Those that investigate SES of offspring and their association with parental health are rare. Employing data from a historical population of individuals extracted from a comprehensive population database that links demographic and vital records across generations, this study tests the hypothesis that higher offspring SES associates with lower parental mortality after controlling for parental SES. The sample includes 29,972 individuals born between 1864 and 1883 whose offspring were born between 1886 and 1920. SES is operationalized using Nam-Powers occupational status scores divided into quartiles and a category for farmers. Models assess mortality risk after age 40. Included is a test for whether effects are proportional across parents who died younger and older. Estimated life expectancies across categories of offspring SES conditioned on parental SES are calculated to illustrate specifically how differences in SES relate to differences in years lived. Results indicate a longevity penalty for those whose offspring have low SES and a longevity dividend for those with high-SES offspring. The influence of offspring attributes on well-being of parents points to fluid and myriad linkages between generations.