Rheumatology: What You May Have Missed in 2023.

Many patients with rheumatologic conditions receive care from physicians other than rheumatologists. Here we note key findings from 6 studies in rheumatology published in 2023 that offer valuable insights for internal medicine specialists and subspecialists outside of rheumatology. The first study investigated the effect of low-dose glucocorticoids on patients with rheumatoid arthritis (RA) over 2 years and challenged existing perceptions about the risks of glucocorticoids in this setting. The second study focused on the updated guideline for preventing and treating glucocorticoid-induced osteoporosis. With the chronic and widespread use of glucocorticoids, the American College of Rheumatology emphasized the importance of assessing fracture risk and initiating pharmacologic therapy when appropriate. The third study explored the potential use of methotrexate in treating inflammatory hand osteoarthritis, suggesting a novel approach to managing this challenging and common condition. The results of the fourth article we highlight suggest that sarilumab has promise as an adjunct treatment of polymyalgia rheumatica relapse during glucocorticoid dosage tapering. The fifth study evaluated sublingual cyclobenzaprine for fibromyalgia treatment, noting both potential benefits and risks. Finally, the sixth article is a systematic review and meta-analysis that assessed the therapeutic equivalence of biosimilars and reference biologics in the treatment of patients with RA. Knowledge of this recent literature will be useful to clinicians regardless of specialty who care for patients with these commonly encountered conditions.

Causal relationships between pain, medical treatments, and knee osteoarthritis: A graphical causal model to guide analyses.

OBJECTIVE: Randomized controlled trials (RCTs) are a gold standard for estimating the benefits of clinical interventions, but their decision-making utility can be limited by relatively short follow-up time. Longer-term follow-up of RCT participants is essential to support treatment decisions. However, as time from randomization accrues, loss to follow-up and competing events can introduce biases and require covariate adjustment even for intention-to-treat effects. We describe a process for synthesizing expert knowledge and apply this to long-term follow-up of an RCT of treatments for meniscal tears in patients with knee osteoarthritis (OA). METHODS: We identified 2 post-randomization events likely to impact accurate assessment of pain outcomes beyond 5 years in trial participants: loss to follow-up and total knee replacement (TKR). We conducted literature searches for covariates related to pain and TKR in individuals with knee OA and combined these with expert input. We synthesized the evidence into graphical models. RESULTS: We identified 94 potential covariates potentially related to pain and/or TKR among individuals with knee OA. Of these, 46 were identified in the literature review and 48 by expert panelists. We determined that adjustment for 50 covariates may be required to estimate the long-term effects of knee OA treatments on pain. CONCLUSION: We present a process for combining literature reviews with expert input to synthesize existing knowledge and improve covariate selection. We apply this process to the long-term follow-up of a randomized trial and show that expert input provides additional information not obtainable from literature reviews alone.

Is Preoperative Weight Reduction in Patients Who Have Body Mass Index ≥ 40 Associated With Lower Complication Rates After Primary Total Hip Arthroplasty?

BACKGROUND: Given the heightened risk of postoperative complications associated with obesity, delaying total hip arthroplasty (THA) in patients who have a body mass index (BMI) > 40 to maximize preoperative weight loss has been advocated by professional societies and orthopaedic surgeons. While the benefits of this strategy are not well-understood, previous studies have suggested that a 5% reduction in weight or BMI may be associated with reduced complications after THA. METHODS: We identified 613 patients who underwent primary THA in a single institution during a 7-year period and who had a BMI >40 recorded from 9 to 12 months prior to surgery. Subjects were stratified into 3 cohorts based on whether their baseline BMI decreased by >5% (147 patients, 24%), was unchanged ( ± 5%) (336 patients, 55%), or increased by >5% (130 patients, 21%) on the day of surgery. The frequency of 90-days Hip Society and Centers for Medicare & Medicaid Services complications was compared between these cohorts. There were significant baseline differences between the cohorts with respect to baseline American Society of Anesthesiologists class (P < .001) and hemoglobin A1C (P = .011), which were accounted for in a multivariate regression analysis. RESULTS: In univariate analysis, there was a lower incidence of readmission (P = .025) and total complications (P = .005) in the increased BMI cohort. The overall complication rate was 18.4% in the decreased BMI cohort, 17.6% in the unchanged cohort, and 6.2% in the increased cohort. However, multivariable regression analysis controlling for potential confounders did not find that preoperative change in BMI was associated with differences in 90-days complications between cohorts (P > .05). CONCLUSIONS: Patients who have a BMI >40 and achieved a clinically significant (>5%) BMI reduction prior to THA did not have a lower risk of 90-days complications or readmissions. Thus, delaying THA in these patients to encourage weight loss may result in restricting access to a beneficial surgery without an appreciable safety benefit.

Substantial Weight Loss May Not Improve Early Outcomes of Total Knee Arthroplasty in the Morbidly Obese.

BACKGROUND: Body mass index (BMI) cutoffs for morbidly obese patients otherwise indicated for total knee arthroplasty (TKA) have been widely proposed and implemented, though they remain controversial. Previous studies suggested that a 5% reduction in BMI may be associated with fewer postoperative complications. Thus, the purpose of this study was to determine whether a substantial reduction in preoperative BMI in morbidly obese patients improved 90-day outcomes after TKA. METHODS: There were 1,270 patients who underwent primary TKA at a single institution and had a BMI > 40 recorded during the year prior to surgery. Patients were stratified into three cohorts based on whether their BMI within 3 months to 1 year preoperatively had decreased by ≥ 5% (228 patients [18%]); increased by ≥ 5% (310 [24%]); or remained unchanged (within 5%) (732 [58%]) on the day of surgery. There were several baseline differences between the cohorts with respect to medical comorbidities. The rate of 90-day complications and six-week patient-reported outcome measures were compared via univariate and multivariable analyses. RESULTS: On univariate analysis, individual and total complication rates were similar between the cohorts (P > .05). On multivariable logistic regression, the risk of complications was similar in patients who had decreased versus unchanged BMI (OR [odds ratio] 1.0; P = .898). However, there was a higher risk of complications in the increased BMI cohort compared to those patients who had an unchanged BMI (OR 1.5; P = .039). The six-week patient-reported outcome measures were similar between the cohorts. CONCLUSIONS: Patients who have a BMI > 40 who achieved a meaningful reduction in BMI prior to TKA did not have a lower rate of 90-day complications than those whose BMI remained unchanged. Furthermore, considering that nearly one in four patients experienced a significant increase in BMI while awaiting surgery, postponing TKA may actually be detrimental.

Obesity Severity Does Not Associate With Rate, Timing, or Invasiveness of Early Reinterventions After Total Knee Arthroplasty.

BACKGROUND: The use of body mass index (BMI) cutoff values has been suggested for proceeding with total knee arthroplasty (TKA) in obese patients. However, the relationship between obesity severity and early reoperations after TKA is poorly defined. This study evaluated whether increased World Health Organization (WHO) obesity class was associated with risk, severity, and timing of reintervention within one year after TKA. METHODS: There were 8,674 patients from our institution who had a BMI ≥ 30 and underwent unilateral TKA for primary osteoarthritis between 2016 and 2021. Patients were grouped by WHO obesity class: 4,456 class I (51.5%), 2,527 class II (29.2%), and 1,677 class III (19.4%). A chart review was performed to determine patient characteristics and identify patients who underwent any closed or open reintervention requiring anesthesia within the first postoperative year. Regression analyses were performed to identify variables associated with increased odds ratios (ORs) for requiring a reintervention, its timing, and invasiveness. RESULTS: There were 158 patients (1.8%) who required at least one reintervention, and 15 patients (0.2%) required at least 2 reinterventions. Reintervention rates for obesity classes I, II, and III were 1.8% (n = 81), 2.0% (n = 51), and 1.4% (n = 23), respectively. There were 65 closed procedures (41.1%), 47 minor procedures (29.7%), 34 open with or without liner exchange (21.5%), and 12 revisions with component exchange (7.6%). Obesity class was not associated with reintervention rate (P = .3), timing (P = .36), or invasiveness (P = .93). Diabetes (odds ratio [OR] = 2.47; P = .008) was associated with a need for reintervention. Non-Caucasian race (OR = 1.7; P = .01) and Charlson comorbidity index (OR = 2.1; P = .008) were associated with earlier reintervention. No factors were associated with the invasiveness of reintervention. CONCLUSIONS: The WHO obesity class did not associate with rate, timing, or invasiveness of reintervention after TKA in obese patients. These findings suggest that policies that restrict the indication for elective TKA based only on a BMI limit have limited efficacy in reducing early reintervention after TKA in obese patients. LEVEL OF EVIDENCE: III.

Factors Associated With COVID-19 Vaccine Hesitancy in Rheumatology Outpatients in New York City.

OBJECTIVE: The aim of this study was to measure COVID-19 vaccine hesitancy among rheumatology outpatients from an early COVID-19 "hotspot" during the initial period of vaccine availability. METHODS: In March 2021, a Web-based survey was sent to 7505 adults seen at a Rheumatology Division in New York City. We evaluated characteristics associated with 3 categories of COVID-19 vaccination status: declined, undecided, and willing/already received. We used multinomial logistic regression models to calculate relative risk ratios assessing predictors of vaccination status. RESULTS: Among 2384 (32%) respondents (80% female, 87% White, 59% with systemic rheumatic disease), 2240 (94.0%) were willing/already received COVID-19 vaccination, 88 (3.7%) were undecided, and 56 (2.3%) declined. Compared with those willing/already vaccinated, those declining or undecided were younger, more likely identified as Black or Hispanic/Latinx, and had lower household income and educational attainment. Immunosuppressive medication use did not differ among groups. After multivariable adjustment, every 1-year increase in age was associated with a 0.96 lower relative risk of declining or being undecided versus willing/already vaccinated. Respondents identifying as Black versus White had a higher relative risk ratio of being undecided (4.29 [95% confidence interval, 1.96-9.36]), as did those identifying as Hispanic/Latinx versus non-Hispanic/non-Latinx (2.81 [95% confidence interval, 1.29-6.09]). Those declining vaccination were least likely to believe in general vaccine importance or the safety and efficacy of the COVID-19 vaccine. CONCLUSIONS: Among rheumatology patients in New York City with and without systemic rheumatic disease, COVID-19 vaccine uptake was high after its initial availability. Sociodemographic but not medication-related factors were associated with vaccine hesitancy; these findings can inform future rheumatology vaccination programs.

Comparison of two frailty definitions in women with systemic lupus erythematosus.

OBJECTIVES: Frailty is a risk factor for adverse health in systemic lupus erythematosus (SLE). The Fried phenotype (FP) and the Systemic Lupus International Collaborating Clinics Frailty Index (SLICC-FI) are common frailty metrics reflecting distinct approaches to frailty assessment. We aimed to 1) compare frailty prevalence according to both metrics in women with SLE and describe differences between frail and non-frail participants using each method and 2) evaluate for cross-sectional associations between each metric and self-report disability. METHODS: Women aged 18-70 years with SLE were enrolled. FP and SLICC-FI were measured, and agreement calculated using a kappa statistic. Physician-reported disease activity and damage, Patient Reported Outcome Measurement Information System (PROMIS) computerized adaptive tests, and Valued Life Activities (VLA) self-report disability were assessed. Differences between frail and non-frail participants were evaluated cross-sectionally, and the association of frailty with disability was determined for both metrics. RESULTS: Of 67 participants, 17.9% (FP) and 26.9% (SLICC-FI) were frail according to each metric (kappa = 0.41, p< 0.01). Compared with non-frail women, frail women had greater disease damage, worse PROMIS scores, and greater disability (all p< 0.01 for FP and SLICC-FI). After age adjustment, frailty remained associated with a greater odds of disability (FP: odds ratio [OR] 4.7, 95% confidence interval [CI] 1.2-18.8; SLICC-FI: OR 4.6, 95% CI 1.3-15.8). CONCLUSION: Frailty is present in 17.9-26.9% of women with SLE. These metrics identified a similar, but non-identical group of women as frail. Further studies are needed to explore which metric is most informative in this population.

Measuring What Matters: A Qualitative Study of the Relevance and Clinical Utility of PROMIS Surveys in Systemic Lupus Erythematosus.

OBJECTIVE: To evaluate the relevance and clinical utility of the Patient-Reported Outcomes Measurement Information System (PROMIS) surveys in patients with systemic lupus erythematosus (SLE). METHODS: Adults with SLE receiving routine outpatient care at a tertiary care academic medical center participated in a qualitative study. Patients completed PROMIS computerized adaptive tests (CATs) in 12 selected domains and rated the relevance of each domain to their experience with SLE. Focus groups and interviews were conducted to elucidate the relevance of the PROMIS surveys, identify additional domains of importance, and explore the utility of the surveys in clinical care. Focus group and interview transcripts were coded, and a thematic analysis was performed using an iterative inductive process. RESULTS: Twenty-eight women and 4 men participated in 4 focus groups and 4 interviews, respectively. Participants endorsed the relevance and comprehensiveness of the selected PROMIS domains in capturing the effect of SLE on their lives. They ranked fatigue, pain interference, sleep disturbance, physical function, and applied cognition abilities as the most salient health-related quality of life (HRQOL) domains. They suggested that the disease-agnostic PROMIS questions holistically captured their lived experience of SLE and its common comorbidities. Participants were enthusiastic about using PROMIS surveys in clinical care and described potential benefits in enabling disease monitoring and management, facilitating communication, and empowering patients. CONCLUSION: PROMIS includes the HRQOL domains that are of most importance to individuals with SLE. Patients suggest that these universal tools can holistically capture the impact of SLE and enhance routine clinical care.

Outcomes of COVID-19 and Factors Associated With Its Severity Among Hospitalized Patients With and Without Systemic Rheumatic Disease During the First Wave of the Pandemic in New York City.

BACKGROUND/OBJECTIVE: Conflicting data exist regarding whether patients with systemic rheumatic disease (SRD) experience more severe outcomes related to COVID-19. Using data from adult patients hospitalized with COVID-19 in New York City during the first wave of the pandemic, we evaluated whether patients with SRD were at an increased risk for severe outcomes. METHODS: We conducted a medical records review study including patients aged ≥18 years with confirmed SARS-CoV-2 infection hospitalized at 3 NewYork-Presbyterian sites, March 3-May 15, 2020. Inverse probability of treatment weighting was applied to a multivariable logistic regression model to assess the association between SRD status and the composite of mechanical ventilation, intensive care unit admission, or death. RESULTS: Of 3710 patients hospitalized with COVID-19 (mean [SD] age, 63.7 [17.0] years; 41% female, 29% White, and 34% Hispanic/Latinx), 92 (2.5%) had SRD. Patients with SRD had similar age and body mass index but were more likely to be female, ever smokers, and White or Black, compared with those without SRD. A higher proportion of patients with versus without SRD had hypertension and pulmonary disease, and used hydroxychloroquine, corticosteroids, and immunomodulatory/immunosuppressive medications before admission. In the weighted multivariable analysis, patients with SRD had an odds ratio of 1.24 (95% confidence interval, 1.10-1.41; p < 0.01) for the composite of mechanical ventilation, intensive care unit admission, or death, compared with patients without SRD. CONCLUSIONS: During the initial peak of the pandemic in New York City, patients with versus without SRD hospitalized with COVID-19 had a 24% increased likelihood of having severe COVID-19 after multivariable adjustment.

Prevalence of frailty in patients with polymyalgia rheumatica and association with health-related quality of life, cognition and sarcopenia.

OBJECTIVE: To describe the prevalence of frailty in a single-centre cohort of patients with PMR and describe its association with health-related quality of life (HRQoL), cognition and sarcopenia. METHODS: This was a cross-sectional study of patients with PMR, according to 2012 EULAR/ACR Classification Criteria, presenting within 12 months of diagnosis and on treatment with glucocorticoids. Frailty was defined according to the Fried frailty criteria. HRQoL was assessed using Patient-Reported Outcomes Measurement Information System Computerized Adaptive Test (PROMIS-CAT) and cognition was assessed using the Mini-Mental State Examination. Sarcopenia was measured by DXA. RESULTS: Forty-one patients were enrolled. Prevalence of frailty and pre-frailty was 17% and 59%, respectively. Frail patients had higher inflammatory markers at diagnosis compared with pre-frail and robust patients. Of 27 patients with DXA results, 26% were sarcopenic. Frail patients had worse physical function, and more pain behaviour and interference compared with pre-frail and robust patients. In univariable analyses, frail patients were more likely to have worse physical function, and more pain behaviour and pain interference, which remained significant after adjusting for age. There were no significant associations between cognition or sarcopenia and frailty. CONCLUSIONS: In this cohort of PMR patients, there was a higher prevalence of frailty and pre-frailty compared with that reported in community-dwelling elderly. Frailty was associated with worse physical function, and increased pain behaviour and pain interference, differences that were also clinically meaningful. Larger prospective studies are needed to confirm these findings and analyse the association of frailty with other PMR disease outcomes.

Clinical integration of patient-reported outcome measures to enhance the care of patients with SLE: a multi-centre prospective cohort study.

OBJECTIVE: To assess the feasibility and impact of integrating electronic patient-reported outcome measures (PROMs) into the routine outpatient care of patients with SLE. METHODS: We conducted a prospective cohort study, utilizing a mixed-methods sequential explanatory design, of SLE outpatients receiving rheumatology care at two academic medical centres. Participants completed electronic PROMs at enrolment and then prior to their next two routine rheumatology visits. PROM score reports were shared with patients and rheumatologists before visits. Patients and rheumatologists completed post-visit surveys evaluating the utility of PROMs in the clinical encounters. Focus groups of patients and interviews with treating rheumatologists were conducted to further explore their experience utilizing PROMs. RESULTS: A total of 105 SLE patients and 17 rheumatologists participated in the study. Patients completed PROMs in 159 of 184 encounters (86%), with 93% of surveys completed remotely. Patients reported that PROMs were 'quite a bit' or 'very' useful (55% of encounters) and beneficial to communication (55% of encounters). In contrast, physicians found PROMs useful (20%) and beneficial to communication (17%) less frequently. There was no significant change in visit length, health-related quality of life or disease activity after implementation of PROMs; however, patient satisfaction improved slightly. Qualitative analyses revealed that patients felt PROMs provided utility primarily by facilitating communication, particularly when physicians discussed the surveys. CONCLUSION: The remote capture and integration of electronic PROMs into clinical care was feasible in a diverse cohort of SLE outpatients. PROMs were useful to patients and enhanced their clinical experience primarily by facilitating communication.

Predicting Post-Discharge Opioid Consumption After Total Hip and Knee Arthroplasty in the Opioid-Naïve Patient.

BACKGROUND: Pain catastrophizing, anxiety, and depression are associated with poor outcomes after total hip (THA) and total knee (TKA) arthroplasty. The goal of this study is to determine the relationship between post-operative pain scores and opioid consumption; and the association among pre-operative measures of anxiety, depression, and pain catastrophizing and post-operative opioid consumption in patients undergoing THA and TKA. METHODS: This is a single-institution prospective cohort study of 243 opioid-naïve patients undergoing elective, primary THA (n = 123) or TKA (n = 120) for osteoarthritis. Pre-operatively, patients completed the PROMIS-29 (Patient-Reported Outcomes Measures Information System; physical function/anxiety/depression/fatigue/sleep disturbance/social activities/pain interference/pain intensity) and Pain Catastrophizing Scale. Post-operatively, patients completed a weekly survey for 12 weeks determining morphine-milligram-equivalent (MME) opioid consumption, opioid cessation, and visual analog scale pain scores. Multivariable regression models determined the association between pre-operative scores and post-operative opioid consumption. RESULTS: Mean (±standard deviation) total opioid consumption and duration was 75.1 ± 112.0 MME and 1.7 ± 1.7 weeks in THA and 384.7 ± 473.3 MME and 4.3 ± 3.5 weeks in TKA. Visual analog scale pain scores (0-100) after opioid cessation were 28.0 ± 22.9 in THA and 30.7 ± 25.8 in TKA. Multivariable regression showed that each unit increase in PROMIS-29 fatigue T-score was associated with 8.4 hours longer opioid usage in THA (P = .008) and 15.1 hours longer in TKA (P = .036), as well as 12.7 MME additional opioids in TKA (P = .027). There were no significant associations with other PROMIS-29 domains or the Pain Catastrophizing Scale. CONCLUSION: Opioid use duration is different for THA and TKA and may correlate with pain scores. Only pre-operative fatigue was associated with post-operative opioid consumption. These findings should inform THA and TKA post-operative pain management pathways.

2022 American College of Rheumatology/American Association of Hip and Knee Surgeons Guideline for the Perioperative Management of Antirheumatic Medication in Patients With Rheumatic Diseases Undergoing Elective Total Hip or Total Knee Arthroplasty.

OBJECTIVE: To develop updated American College of Rheumatology/American Association of Hip and Knee Surgeons 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.

Current Medication Practices and Preferences Among Patients With Psoriatic Arthritis.

OBJECTIVE: The aim of this study was to evaluate real-world psoriatic arthritis (PsA) medication use and patient medication preferences. METHODS: This is a cross-sectional survey of Classification for Psoriatic Arthritis criteria defined PsA patients recruited from a single-center PsA registry from June to September 2020. Preferences were ranked on a 5-point Likert scale ranging from "not at all important" to "extremely important." RESULTS: One hundred thirty-seven patients (29%) responded. The median duration (years) of PsA skin and joint symptoms was 19 (interquartile range, 10-34) and 12 (interquartile range, 8-21), respectively. The most common initial immunomodulatory medications were anti-tumor necrosis factor α (35%), methotrexate (19%), and anti-phosphodiesterase 4 (anti-PDE4) (12.4%). At survey administration, the most common immunomodulatory therapies were anti-tumor necrosis factor α (30%), anti-interleukin 17 (IL-17) (20.4%), and methotrexate (10.2%). After 2018, when updated guidelines from the American College of Rheumatology/National Psoriasis Foundation were published, a significantly higher percentage of patients' first medication was an anti-IL-17 compared with 2018 or earlier (30% vs 3.5%, p < 0.001), a pattern also seen with anti-PDE4 (40% vs 11.5%, p < 0.012). Medication preferences most ranked as "extremely" important were prevention of joint damage (80%), ability to perform daily activities (71%), prevention of pain (70.1%), rheumatologist recommendation (63%), and medication adverse effects (62%). CONCLUSIONS: The significant increase of anti-IL-17 and anti-PDE4 medications as initial treatment after 2018 may reflect their inclusion as potential initial therapy in updated guidelines, along with the importance placed by patients on medication adverse effects. Given the expanding armamentarium of PsA medications, it is increasingly important to align patient preferences and therapeutic options to ensure durable use of effective therapy.

Impact of the first wave of the COVID-19 pandemic on systemic lupus erythematosus patients: Results from a multi-center prospective cohort.

OBJECTIVE: The aim of this study was to evaluate the initial impact of the COVID-19 pandemic on individuals with systemic lupus erythematosus (SLE). METHODS: Patients with SLE participating in a multi-center longitudinal cohort study in New York and Boston were invited to complete a supplemental web-based questionnaire in the summer of 2020. Participants completed standardized patient-reported outcome (PRO) measures and a combination of Likert scale and open-ended questions exploring the impact of the COVID-19 pandemic on their health and access to health care. Changes in PROs were evaluated with paired t-tests and frequencies of worsened symptoms were calculated. A thematic qualitative analysis was conducted on free text responses. RESULTS: Of 97 patients invited, 63 (65%) completed a supplemental questionnaire. Nearly 50% of respondents exhibited increases in anxiety (47.5%) and depression (48.3%) and over 40% scored worse in measures of pain interference, fatigue, and cognitive abilities. Respondents with pre-existing diagnoses of anxiety did not differ from other participants in PRO scores, but were more than three times as likely to report worsened health status. Patients denied difficulties accessing medications (85%) or medical care (84%) and over 50% participated in telehealth visits. Anxiety and increased health risks due to immunosuppression were recurring themes in free text responses. CONCLUSIONS: SLE patients experienced a significant physical and emotional toll in the initial months of the COVID-19 pandemic. Comprehensive patient-centered care, including monitoring and addressing anxiety and health-related quality of life, is critical to improving health outcomes in this population during the ongoing health crisis.

Genicular Artery Embolization for Refractory Hemarthrosis following Total Knee Arthroplasty: Technique, Safety, Efficacy, and Patient-Reported Outcomes.

PURPOSE: To investigate the safety and efficacy of genicular artery embolization for treatment of refractory hemarthrosis following total knee arthroplasty. MATERIAL AND METHODS: Patients who underwent genicular artery embolization with spherical embolics between January 2010 and March 2020 at a single institution were included if they had undergone total knee arthroplasty and subsequently experienced recurrent hemarthrosis. Technical success was defined as the significant reduction or elimination of the hyperemic blush. Clinical success was defined as the absence of clinical evidence of further hemarthrosis. Clinical follow-up was performed 7-14 days after the procedure and at 3-month intervals thereafter via a telephone interview. A total of 117 embolizations, comprising 82 initial, 28 first repeat, and 7 second repeat, were performed. RESULTS: An average of 2.5 arteries was treated per procedure. The superior lateral genicular artery was the most frequently embolized. The most utilized embolic size was 100-300 µm. Follow-up was available for all patients, with a median duration of 21.5 months. 65.9%, 25.6%, and 8.5% of patients underwent 1, 2, and 3 treatments, respectively. Complications occurred following 12.8% of treatments, of which the most common was transient cutaneous ischemia. Technical success was achieved in all cases. Clinical success was achieved in 56%, 79%, and 85% of patients following the first, second, and third treatment, respectively. 83% of patients reported being either satisfied or very satisfied with the overall result. CONCLUSIONS: Targeted genicular artery embolization with spherical embolics is an effective treatment for recurrent hemarthrosis with infrequent serious complications. Repeat embolization should be considered in cases of recurrence following initial therapy.

Use of Total Hip Arthroplasty in Patients Under 21 Years Old: A US Population Analysis.

BACKGROUND: The purpose of this study is to evaluate trends in the use of total hip arthroplasty (THA) in the United States in patients under 21 years of age. Specifically, we examined the frequency of THA in this patient population over the past 2 decades, the epidemiologic characteristics of patients under 21 who underwent THA, and the characteristics of the hospitals where these procedures were performed. METHODS: We retrospectively reviewed the Kids' Inpatient Database, an inpatient US national weighted sample of hospital admissions in patients under 21 from approximately 4200 hospitals in 46 states. We queried the database using Current Procedural Terminology codes for elective and non-elective primary THA for the years 2000-2016. We utilized the International Classification of Diseases, Ninth Revision and International Classification of Diseases, Tenth Revision codes to determine primary diagnoses. RESULTS: The weighted total number of THAs performed in patients under 21 in the Kids' Inpatient Database increased from 347 in 2000 to 551 in 2016. The most common diagnoses were osteonecrosis, osteoarthritis, and inflammatory arthritis. The frequency of THA for osteonecrosis increased from 24% in 2000 to 38% in 2016, while the frequency of THA for inflammatory arthritis decreased from 27% in 2000 to 4% in 2016. CONCLUSION: The number of THAs in patients under 21 in the United States has increased over the past 2 decades and these procedures are increasingly performed in urban teaching hospitals. The decrease in THA for inflammatory arthritis in this population likely reflects improvements in medical management during the study period.

Variables Associated With Perceived Risk of Contracting SARS-CoV-2 Infection During the COVID-19 Pandemic Among Patients With Systemic Rheumatic Diseases.

OBJECTIVE: The aim of this study was to assess patients' perceived risk of contracting SARS-CoV-2 at the peak of the pandemic in NYC in terms of their systemic rheumatic disease and medications. METHODS: With the approval of their rheumatologists, patients were interviewed by telephone and were asked about their perceived risk of contracting SARS-CoV-2 considering their rheumatic condition and whether medications increased this risk. Patients also completed surveys assessing beliefs about medication and multidimensions of physical/mental well-being. Information about current medications and rheumatologist-initiated changes in medications during the pandemic were reported by patients and verified from medical records. RESULTS: One hundred twelve patients (86% women; mean age, 50 years; 81% White, 15% Latino) with diverse diagnoses were enrolled. Fifty-four percent thought they were at "very much greater risk" of COVID-19 because of their rheumatic condition, and 57% thought medications "definitely" put them at greater risk. In multivariable analysis, the perception of "very much greater risk" was associated with greater belief that rheumatic disease medications were necessary, worse physical function, chronic pulmonary comorbidity, and more anxiety. In a separate model, the perception that medications "definitely" caused greater risk was associated with White race, not taking hydroxychloroquine, rheumatologists initiating change in medications, more anxiety, and taking biologics and corticosteroids. CONCLUSIONS: Patients' perceived increased risk of contracting SARS-CoV-2 was associated with beliefs about their rheumatic disease, medications, comorbidity, and anxiety. Clinicians should be aware of patients' perceptions and foster self-management practices that will alleviate anxiety, minimize exposure to the virus, and optimize systemic rheumatic disease outcomes.

Procalcitonin Differs in Children With Infection and Children With Disease Flares in Juvenile Idiopathic Arthritis.

BACKGROUND/OBJECTIVE: Patients with juvenile idiopathic arthritis (JIA) often present with signs and symptoms suggestive of serious bacterial infection (SBI). Procalcitonin (PCT) is a biomarker that is elevated in SBI. We conducted a comparative cohort study to test the hypothesis that PCT levels will differ between active JIA, quiescent JIA, and bacteremic patients and healthy controls. METHODS: From October 2016 to May2018, consecutive children 6 months to 18 years of age with (a) active untreated JIA, (b) quiescent JIA, and (c) healthy elective presurgical candidates were recruited from clinics at a musculoskeletal specialty hospital. Juvenile idiopathic arthritis was defined according to the International League of Associations for Rheumatology criteria. Clinical data and serum samples meeting the same criteria were included from a prior study. Consecutive bacteremic patients were identified over the same period. Procalcitonin and other common measures of inflammation were measured. Descriptive statistics and univariate logistic analyses were performed. RESULTS: Ninety-two study subjects were recruited. Erythrocyte sedimentation rate, C-reactive protein (CRP), and PCT levels were all elevated in bacteremic patients in comparison to the other groups. Erythrocyte sedimentation rate and CRP both had wide ranges that overlapped between groups; however, the PCT concentration was 0.15 µg/mL or greater in 1 of 59 patients with JIA, whereas it was 0.15 µg/mL or less in only 1 bacteremic patient. CONCLUSIONS: Our study indicates that serum erythrocyte sedimentation rate, CRP, and PCT levels are all biomarkers that can be used to distinguish SBI versus active JIA at presentation. However, PCT is the most accurate, with the least overlap between patients with infection and noninfectious inflammatory arthritis. This finding can help clinicians direct therapy.

PROMIS Computer Adaptive Tests and Their Correlation With Disease Activity in Juvenile Idiopathic Arthritis.

BACKGROUND/OBJECTIVE: The importance of patient-reported outcomes, like the Patient-Reported Outcomes Measurement Information System (PROMIS) measures, is increasingly recognized both in clinical care and in research. While "short forms" have been studied in juvenile idiopathic arthritis (JIA), study of PROMIS computer adaptive tests (CATs) in JIA is limited. This cross-sectional study evaluates whether PROMIS CATs correlate with disease activity in patients with JIA. METHODS: A convenience sample of patients with JIA (N = 44) was recruited from a single center. Patients and parents completed pediatric and parent proxy PROMIS CATs. Disease activity was evaluated using the Juvenile Arthritis Disease Activity Score in 71 joints (JADAS-71) and the Childhood Health Assessment Questionnaire (CHAQ). Correlation of the CAT T scores with disease activity was assessed using Spearman correlation coefficients. RESULTS: Forty-four of 80 eligible subjects (29 patients and 15 parents) completed all or some PROMIS CATs. Pain interference and mobility CATs correlated moderately with JADAS-71. Nearly all correlations with the JADAS-71 were weakened when the patient global was removed. Pain interference, mobility, and fatigue were strongly correlated with the CHAQ. Among parent proxy CATs, only mobility and depressive symptoms correlated strongly with the CHAQ. CONCLUSIONS: Only pain interference and mobility PROMIS CATs showed strong correlation with standard disease activity measures in JIA, and nearly all correlations were weakened when the patient global was removed. Correlations of the CATs with the CHAQ were stronger than correlations with the JADAS-71, indicating that although the CHAQ is no longer routinely used it may be a better measure of health-related quality of life in routine clinical care.