Comorbidity clusters in people with gout: an observational cohort study with linked medical record review.

Objective: To investigate how comorbid conditions cluster in patients with gout in a UK primary care population. Methods: A cross-sectional study was performed using baseline data from a primary-care-based prospective observational cohort of people aged ⩾18 years with gout. Participants with gout were identified through primary care medical records. Factor analysis was performed to obtain distinct clusters of comorbidity variables including obesity, hypertension, diabetes mellitus, hyperlipidaemia, coronary heart disease, heart failure, chronic kidney disease (CKD) and cancer. Hierarchical cluster analysis of patient observations was also performed to identify homogenous subgroups of patients based on combinations of their comorbidities. Results: Four distinct comorbidity clusters (C1-C4) were identified in 1079 participants [mean (s.d.) age 65.5 years (12.5); 909 (84%) male]. Cluster C1 (n = 197, 18%) was the oldest group and had the most frequent attacks of gout; 97% had CKD. Participants in C2 (n = 393, 36%) had isolated gout with few comorbidities but drank alcohol more frequently. In cluster C3 (n = 296, 27%), hypertension, diabetes mellitus, hyperlipidaemia, coronary heart disease and/or CKD were prevalent, and urate-lowering therapy was prescribed more frequently than in other clusters. All patients in C4 (193, 18%) had hypertension and were more likely to be obese than other clusters. Conclusion: Four distinct comorbidity clusters were identified. People with multiple comorbidities were more likely to receive allopurinol. Tailoring of treatments depending on cluster and comorbidities should be considered.

Impact of musculoskeletal pain on insomnia onset: a prospective cohort study.

OBJECTIVE: Pain, the most common manifestation of rheumatological conditions, is highly prevalent among older adults, with worse health outcomes found in those with co-morbid insomnia. Proactive prevention of insomnia may reduce the overall disease burden of pain and rheumatological conditions. To inform such development, this study examined the role of pain, physical limitation and reduced social participation in predicting and mediating insomnia onset. METHODS: A prospective cohort study was conducted involving 6676 individuals ≥50 years of age who completed questionnaires at baseline and a 3-year follow-up. Participants were classified into none, some and widespread pain according to the ACR criteria. Logistic regression was used to examine the relationship between baseline pain and insomnia onset at 3 years. Path analysis was used to test for the mediating role of physical limitation and social participation restriction. RESULTS: Some [adjusted odds ratio (AOR) 1.57 (95% CI 1.15, 2.13)] and widespread [2.13 (1.66, 3.20)] pain increased the risk of insomnia onset at 3 years, after adjusting for age, gender, socio-economic class, education, anxiety, depression, sleep and co-morbidity at baseline. The combination of physical limitation and reduced social participation explained up to 68% of the effect of some pain on insomnia onset and 66% of the effect of widespread pain on insomnia onset. CONCLUSION: There was a dose-response association between the extent of pain at baseline and insomnia onset at 3 years that was substantially mediated by physical limitation and reduced social participation. Targeting physical limitation and social participation in older people with pain may buffer co-morbid insomnia, reducing the overall disease burden.

Repeated primary care consultations for non-specific physical symptoms in children in UK: a cohort study.

BACKGROUND: Non-specific physical symptoms (NSPS), such as headache and abdominal pain, are common reasons for children to consult primary care. NSPS represent a significant burden not only on society, but also on health care services, through frequent physician consultations and referrals to secondary care. Research evidence suggests a positive relationship between health and consulting behavior of parents and their children, but research on whether repeated physician consultations for NSPS in children is influenced by parental consultations for NSPS is lacking. The aim was to measure the frequency of repeated physician consultations for NSPS in children, and investigate whether this is influenced by maternal consultations for NSPS. METHODS: A cohort study of children registered with primary care practices contributing to the Consultation in Primary Care Archive database. Participants were child-mother pairs registered between January 2007 and December 2010. The cohort comprised all children (n = 1437) aged 2 to 16 years who consulted a physician for NSPS in 2009. Mothers' consultations for NSPS were measured between 2007 and 2008. Main outcome measures were repetition and frequency of consultations for NSPS in children (consultations for NSPS in both 2009 and 2010). RESULTS: Overall, 27% of children had repeated consultations for NSPS. The three most common repeated consultations were for back pain, constipation and abdominal pain. Exposure to maternal consultation for NSPS was associated with 21% increase in consultation frequency for NSPS (adjusted incidence rate ratio 1.21; 95% CI 1.12, 1.31). After adjusting for child age and maternal age, maternal consultation for NSPS was associated with an increased risk of repeated consultations for NSPS in children (relative risk 1.41; 95% CI 1.16, 1.73). This association was also significant for specific NSPS groups including painful, gastrointestinal, and neurologic symptoms. CONCLUSIONS: Repeated consultation for NSPS is common among children. It is important for primary care physicians and secondary care clinicians, managing children referred from primary care for NSPS, to be aware that consultation for NSPS in mothers is a risk factor for repeated consultations for NSPS among children. More research is needed to uncover exactly how parental health influences health and consulting behavior of children.

Incidence of prostate, breast, lung and colorectal cancer following new consultation for musculoskeletal pain: a cohort study among UK primary care patients.

Musculoskeletal pain has been linked with subsequent cancer. The objective was to investigate associations between pain sites and specific cancers, and investigate the hypothesis that musculoskeletal pain is an early marker, rather than cause, of cancer. This was a cohort study in the General Practice Research Database. From a cohort of 46,656 people aged ≥50 years with a recorded musculoskeletal problem in 1996 but not during the previous 2 years, patients with a new consultation for back, neck, shoulder or hip pain in 1996 were selected and compared with 39,253 persons who had had no musculoskeletal consultation between 1994 and 1996. Outcome was incidence of prostate, breast, lung and colorectal cancer up to 10 years after baseline consultation. Strongest associations with prostate cancer were in the first year of follow-up for males consulting initially with back (adjusted hazard ratio 5.42; 95% CI 3.31, 8.88), hip (6.08; 2.87, 12.85) or neck problems (3.46; 1.58, 7.58). These associations remained for back and neck problems over 10 years. Significant associations existed with breast cancer up to 5 years after consultation in females with hip problems, and with breast and lung cancer in the first year after presentation with back problems. Previously observed links between pain and cancer reflect specific associations between pain sites and certain cancers. One explanation is liability for bony metastases from primary sites, and that pain represents a potential early marker of cancer. However, older patients with uncomplicated musculoskeletal pain seen in clinical practice have a low absolute excess cancer risk.

Onset of work restriction in employed adults with lower limb joint pain: individual factors and area-level socioeconomic conditions.

PURPOSE: To examine individual and area-level socioeconomic factors that predict the onset of work restriction in employed persons with lower limb joint pain. METHODS: Population-based prospective cohort study. Adults were aged 50-59, reported hip, knee, foot pain or a combination and maintained employment through 3 year follow-up (n = 716). Work restriction was measured as inability to participate in work as desired. Multi-level logistic regression was used to assess the associations of work restriction onset with baseline factors: health (severity of knee pain/functional limitation, comorbidity, anxiety, depression, cognitive impairment, abnormal weight), demographic socio-economic, environment and area-level employment deprivation. RESULTS: 108 (15.1 %) reported the onset of work restriction over 3 years. Severe lower limb joint pain and functional limitation, number of affected body sites and area employment deprivation were independently associated with onset. Significant interactions indicated a greater effect of area employment deprivation on older and more depressed workers. CONCLUSIONS: Results suggest that effectively preventing work disability in those with OA will require both condition-specific interventions to decrease pain and maintain function, and providing alternative employment opportunities for those with progressive functional limitations. Results in older workers are particularly concerning, as retirement ages are expected to increase in the general population.

Diabetes as a Prognostic Factor in Frozen Shoulder: A Systematic Review.

OBJECTIVE: To summarize evidence from longitudinal observational studies to determine whether diabetes (types 1 and 2) is associated with the course of symptoms in people with frozen shoulder. DATA SOURCES: A systematic literature search of 11 bibliographic databases (published through June 2021), reference screening, and emailing professional contacts. STUDY SELECTION: Studies were selected if they had a longitudinal observational design that included people diagnosed with frozen shoulder at baseline and compared outcomes at follow-up (>2wk) among those with and without diabetes at baseline. DATA EXTRACTION: Data extraction was completed by 1 reviewer using a predefined extraction sheet and was checked by another reviewer. Two reviewers independently judged risk of bias using the Quality in Prognostic Factor Studies tool. DATA SYNTHESIS: A narrative synthesis, including inspection of forest plots and use of the prognostic factor Grading of Recommendations, Assessment, Development and Evaluations framework. Twenty-eight studies satisfied the inclusion criteria. Seven studies were judged to be at a moderate risk of bias and 21 at a high risk of bias. Diabetes was associated with worse multidimensional clinical scores (moderate certainty in evidence), worse pain (low certainty in evidence), and worse range of motion (very low certainty in evidence). CONCLUSIONS: This review provides preliminary evidence to suggest that people with diabetes may experience worse outcomes from frozen shoulder than those without diabetes. If high-quality studies can confirm the findings of this review, then clinicians should monitor patients with frozen shoulder with diabetes more closely and offer further treatment if pain or lack of function persists long-term.

Health-related quality of life in gout in primary care: Baseline findings from a cohort study.

OBJECTIVES: To examine gout-related, comorbid, and sociodemographic characteristics associated with generic and disease-specific health-related quality of life (HRQOL) in gout. METHODS: Adults with gout from 20 general practices were mailed a questionnaire containing the Health Assessment Questionnaire-Disability Index (HAQ-DI), Short-Form-36 Physical Function subscale (PF-10), Gout Impact Scale (GIS), and questions about gout-specific, comorbid and sociodemographic characteristics. Variables associated with HRQOL were examined using multivariable linear regression models. RESULTS: A total of 1184 completed questionnaires were received (response 65.9%). Worse generic and gout-specific HRQOL was associated with frequent gout attacks (≥5 attacks PF-10 ß = -4.90, HAQ-DI ß = 0.14, GIS subscales ß = 8.94, 33.26), current attack (HAQ-DI ß = 0.15, GIS ß = -1.94, 18.89), oligo/polyarticular attacks (HAQ-DI ß = 0.11, GIS ß = 0.78, 7.86), body pain (PF-10 ß = -10.68, HAQ-DI ß = 0.29, GIS ß = 2.61, 11.89), anxiety (PF-10 ß = -1.81, HAQ-DI ß = 0.06, GIS ß = 0.38, 1.70), depression (PF-10 ß = -1.98, HAQ-DI ß = 0.06, GIS 0.42, 1.47) and alcohol non-consumption (PF-10 ß = -16.10, HAQ-DI ß = 0.45). Gout-specific HRQOL was better in Caucasians than non-Caucasians (GIS ß = -13.05, -13.48). Poorer generic HRQOL was associated with diabetes mellitus (PF-10 ß = -4.33, HAQ-DI ß = 0.14), stroke (PF-10 ß = -12.21, HAQ-DI ß = 0.37), renal failure (PF-10 ß = -9.43, HAQ-DI ß = 0.21), myocardial infarction (HAQ-DI ß = 0.17), female gender (PF-10 ß = -17.26, HAQ-DI ß = 0.43), deprivation (PF-10 ß = -7.80, HAQ-DI ß = 0.19), and body mass index ≥35kg/m2 (PF-10 ß = -6.10, HAQ-DI ß = 0.21). CONCLUSIONS: HRQOL in gout is impaired by gout-specific, comorbid, and sociodemographic characteristics, highlighting the importance of comorbidity screening and early urate-lowering therapy. Both gout-specific and generic questionnaires identify the impact of disease-specific features on HRQOL but studies focusing on comorbidity should include generic instruments.

Incident acute pseudogout and prior bisphosphonate use: Matched case-control study in the UK-Clinical Practice Research Datalink.

Oral bisphosphonates are the most commonly used drugs to treat postmenopausal osteoporosis. Acute pseudogout is anecdotally reported to occur following bisphosphonate initiation but empirical data are lacking. We investigated whether treatment with oral bisphosphonates is a risk factor for incident acute pseudogout.A matched case-control study was undertaken using data from the UK-Clinical Practice Research Datalink. Adults who consulted for incident acute pseudogout between 1987 and 2012 were each matched for gender, age at pseudogout diagnosis, and general practice to up to 4 control subjects without pseudogout. The exposure of interest was a prescription for an oral bisphosphonate issued within the 60-day period prior to the date of incident acute pseudogout. Associations between incident acute pseudogout and prior bisphosphonate prescription were examined using conditional logistic regression, adjusting for hyperparathyroidism, osteoarthritis, rheumatoid arthritis, hemochromatosis, hypophosphatasia, and prescriptions for diuretics and oral corticosteroids.Two thousand eleven acute pseudogout cases were compared with 8013 matched controls without acute pseudogout (mean age [standard deviation] 72 years [14]; 52% male). One hundred twenty-three cases (6.1%) had received an oral bisphosphonate prescription in the 60-day exposure period compared with 305 controls (3.8%) (adjusted incidence rate ratio [IRR] 1.33; 95% confidence interval [CI] 1.05-1.69). This association was stronger in females (adjusted IRR 1.49; 95% CI 1.15-1.94) and was nonsignificant in males (0.83; 0.48-1.44).Incident acute pseudogout was associated with prescription of an oral bisphosphonate in the preceding 60 days. Prescribers should be aware of acute pseudogout as a possible side effect of bisphosphonate treatment. Further research is needed to explore the risks conferred by different bisphosphonates and the mechanism underlying this association.

Widespread pain and depression are key modifiable risk factors associated with reduced social participation in older adults: A prospective cohort study in primary care.

In older adults, reduced social participation increases the risk of poor health-related quality of life, increased levels of inflammatory markers and cardiovascular disease, and increased mortality. Older adults frequently present to primary care, which offers the potential to deliver interventions at the point of care to increase social participation. The aim of this prospective study was to identify the key modifiable exposures that were associated with reduced social participation in a primary care population of older adults.The study was a population-based prospective cohort study. Participants (n = 1991) were those aged ≥65 years who had completed questionnaires at baseline, and 3 and 6-year follow-ups. Generalized linear mixed modeling framework was used to test for associations between exposures and decreasing social participation over 6 years.At baseline, 44% of participants reported reduced social participation, increasing to 49% and 55% at 3 and 6-year follow-up. Widespread pain and depression had the strongest independent association with reduced social participation over the 6-year follow-up period. The prevalence of reduced social participation for those with widespread pain was 106% (adjusted incidence rate ratio 2.06, 95% confidence interval 1.72, 2.46), higher than for those with no pain. Those with depression had an increased prevalence of 82% (adjusted incidence rate ratio 1.82, 95% confidence interval 1.62, 2.06). These associations persisted in multivariate analysis.Population ageing will be accompanied by increasing numbers of older adults with pain and depression. Future trials should assess whether screening for widespread pain and depression, and targeting appropriate treatment in primary care, increase social participation in older people.

Foot problems in people with gout in primary care: baseline findings from a prospective cohort study.

BACKGROUND: Foot problems are common in people with gout yet the prevalence of current foot problems in people with gout and the burden they present to healthcare systems is not known. This cross-sectional study aimed to determine the prevalence and associations of hallux valgus, foot pain and disability in people with gout, and to assess the frequency with which foot problems lead to consultation with healthcare professionals. METHODS: Adults registered with 20 general practices who had consulted their GP about gout or been prescribed allopurinol or colchicine in the preceding two years were mailed a questionnaire. Prevalence of hallux valgus, foot pain in the last month, and disabling foot pain in the mailed population were ascertained using validated instruments and estimated by inverse-weighted logistic regression. Associations with socio-demographic, comorbid and gout-specific factors were examined using logistic regression. Participants were asked if they had seen health care professionals for foot problems within the preceding 12 months. RESULTS: One thousand one hundred eighty-four questionnaires were received (response 66 %). Prevalence of hallux valgus was 36.3 %, foot pain in the last month 22.3 % and disabling foot pain 14.5 %. Hallux valgus associated with age (adjusted OR 1.47 per 10-year increase, 95 % CI 1.26, 1.72) and female gender (2.03; 1.31, 3.15). Foot pain in the last month associated with age (1.24; 1.00, 1.55), obesity (BMI 30.0-34.9 2.67; 1.32, 5.38; BMI ≥ 35.0 3.16; 1.44, 6.93), mild depression (2.04; 1.09, 3.81) and polyarticular gout attacks (1.86; 1.18, 2.95). Disabling foot pain associated with age (1.42; 1.08, 1.87), obesity (BMI 30.0-34.9 3.73; 1.54, 9.09; BMI ≥ 35.0 4.36; 1.64, 11.64), depression (mild 2.63; 1.25, 5.53; moderate 3.53; 1.11, 11.26) and ischaemic heart disease (2.45; 1.32, 4.53). In the previous 12 months, 495 (42.8 %) reported consulting their GP about their feet and 281 (23.7 %) a podiatrist/chiropodist. CONCLUSIONS: Foot problems are common in people with gout and frequently lead to healthcare consultation. Hallux valgus has similar associations to those seen in the general population, whereas foot pain associates with obesity and gout characteristics, and disabling foot pain with obesity and comorbidity. Patient assessment should consider foot problems and offer specific treatment where relevant.

The association between GP consultations for non-specific physical symptoms in children and parents: a case-control study.

BACKGROUND: Non-specific physical symptoms (NSPS) such as abdominal pain, headache and musculoskeletal pain are widespread in the community, and are common reasons for visiting a general practitioner (GP). Causes of NSPS are multifactorial, but may include parental influences. OBJECTIVE: To investigate associations between GP consultations for NSPS in parents and their children. METHODS: Matched case-control study using GP consultation data from 12 GP practices in the United Kingdom. Participants were 1328 children who consulted a GP for NSPS in 2009 (cases), 3980 controls who consulted a GP in 2009 but not for NSPS, plus parents of cases and controls (n = 8354). PRIMARY OUTCOME MEASURE: child consultation status for NSPS. RESULTS: Maternal consultation for NSPS was associated with significantly increased odds of their child consulting for NSPS (odds ratio (OR) 1.51, 95% confidence intervals (CI) 1.33, 1.73); there was no significant association with paternal consultations (OR 0.87, 95% CI 0.71, 1.08). Each additional maternal consultation for NSPS was associated with an increase in the rate ratio for number of consultations for NSPS in the child by 1.03 (95% CI 1.01, 1.05). This overall association was clearest in maternal-child consultations for painful NSPS and for specific bodily systems including gastrointestinal, musculoskeletal and neurologic symptoms. CONCLUSIONS: Maternal GP consultation for NSPS is associated with increased odds of GP consultations for NSPS in children. This study included a large sample of children and parents and used medical records data which is not subject to recall bias. However, analysis was based on medical records, thus the presence of NSPS not leading to consultations is unknown. Medical practitioners managing children with NSPS need to be aware of this association.

Reasons why multimorbidity increases the risk of participation restriction in older adults with lower extremity osteoarthritis: a prospective cohort study in primary care.

OBJECTIVE: To determine why multimorbidity causes participation restriction in adults ages ≥50 years who consult primary care with lower extremity osteoarthritis (OA). METHODS: This was a population-based prospective cohort study of 1,053 consulters for lower extremity OA who were free of participation restriction at baseline. Path analysis was used to test proposed mechanisms by examining for mediation of the association between multimorbidity at baseline, defined by self-report and consultation data separately, and incident participation restriction at 3 years by lower extremity pain severity, obesity, locomotor disability, and depression. RESULTS: Multimorbidity was associated with incident participation restriction (adjusted odds ratio [OR] 2.83, 95% confidence interval [95% CI] 2.03-3.94 for multimorbidity [self-report]; OR 1.59, 95% CI 1.15-2.21 for multimorbidity [consultation data]). The extent of mediation of the association of baseline multimorbidity, defined by self-report, and incident participation restriction was greater for severe lower extremity pain than obesity (standardized beta coefficients for indirect effect 0.032 [SE 0.015] and 0.020 [SE 0.019], respectively). The addition of depression and locomotor disability increased the amount of mediation (0.115 [SE 0.028]) and reduced the proportion explained by severe lower extremity pain (0.014 [SE 0.015]) and obesity (0.006 [SE 0.010]). Locomotor disability was the strongest mediator. CONCLUSION: The additional impact on participation in social and domestic life that multimorbidity places on individuals with lower extremity OA appears to be mediated through further restriction of locomotor disability, as well as through depression. The results suggest that the effect of multimorbidity on the daily lives of people with lower extremity OA will be ameliorated by active management of depression and locomotor disability.