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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.
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Artroplastia de Quadril , Índice de Massa Corporal , Complicações Pós-Operatórias , Redução de Peso , Humanos , Artroplastia de Quadril/efeitos adversos , Masculino , Feminino , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/epidemiologia , Idoso , Pessoa de Meia-Idade , Estudos Retrospectivos , Obesidade/complicações , Período Pré-OperatórioRESUMO
BACKGROUND: Physical activity levels remain suboptimal in older adults. Exploration of potentially modifiable factors such as social support is needed to inform the development and implementation of patient-oriented physical activity interventions for older adults. The impact of general health on the relationship between social support and physical activity is not well understood. We aimed to determine the association between social support and self-reported physical activity in a study of community-dwelling older adults. In addition, we examined whether self-reported general health mediates the relationship between social support and self-reported physical activity. METHOD: This cross-sectional study analyzed baseline data collected as part of a randomized controlled trial comparing a digital physical activity intervention, which included social support features, with a tablet-based educational control. Adults ≥ 60 years of age were enrolled at 2 sites. Self-reported general health, social support, physical activity, and sociodemographic characteristics and comorbid conditions were assessed. Pearson and point-biserial correlations were computed to evaluate the relationship between physical activity and general health, social support, and sociodemographic features. Social support (exposure), general health (mediator), and physical activity (outcome) were incorporated into a mediation model. RESULTS: Among 181 participants (mean age of 70.1 years), significant correlations were found between physical activity and both general health and social support (r = -0.19 and r = 0.21, respectively; both p < 0.01). General health significantly mediated the relationship between social support and physical activity (unstandardized ß coefficient 416.9; 95% confidence interval 96.4, 842.0). CONCLUSIONS: Augmentation of social support, particularly when coupled with other modes of health promotion to improve personal wellbeing, may be a valuable component of physical activity promotion programs. Further longitudinal research is needed to clarify the potential mechanistic pathways linking social support, general health, and physical activity to inform development of evidence-based physical activity interventions for older adults and improve downstream health-related outcomes. TRIAL REGISTRATION: ClinicalTrials.gov, ClinicalTrials.gov identifier NCT03538158 . Registered May 25, 2018.
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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.
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Artroplastia do Joelho , Índice de Massa Corporal , Obesidade Mórbida , Complicações Pós-Operatórias , Redução de Peso , Humanos , Obesidade Mórbida/cirurgia , Obesidade Mórbida/complicações , Masculino , Feminino , Pessoa de Meia-Idade , Idoso , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/epidemiologia , Resultado do Tratamento , Estudos Retrospectivos , Medidas de Resultados Relatados pelo Paciente , Osteoartrite do Joelho/cirurgiaRESUMO
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.
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Glucocorticoides , Humanos , Glucocorticoides/uso terapêutico , Glucocorticoides/efeitos adversos , Glucocorticoides/administração & dosagem , Osteoporose/tratamento farmacológico , Artrite Reumatoide/tratamento farmacológico , Antirreumáticos/uso terapêutico , Antirreumáticos/efeitos adversos , Metotrexato/uso terapêutico , Metotrexato/efeitos adversos , Reumatologia/normas , Doenças Reumáticas/tratamento farmacológico , Doenças Reumáticas/complicações , Medicamentos Biossimilares/uso terapêutico , Medicamentos Biossimilares/efeitos adversos , Polimialgia Reumática/tratamento farmacológico , Fibromialgia/tratamento farmacológicoRESUMO
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.
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Artroplastia do Joelho , Índice de Massa Corporal , Obesidade , Osteoartrite do Joelho , Reoperação , Humanos , Masculino , Feminino , Idoso , Reoperação/estatística & dados numéricos , Obesidade/complicações , Pessoa de Meia-Idade , Osteoartrite do Joelho/cirurgia , Estudos Retrospectivos , Índice de Gravidade de Doença , Fatores de Tempo , Complicações Pós-Operatórias/etiologia , Fatores de Risco , Idoso de 80 Anos ou maisRESUMO
OBJECTIVE: Frailty and objective hand grip strength (one of the components of the frailty phenotype) are both risk factors for worse health outcomes in SLE. Whether telomere length, an established cellular senescence marker, is a biologic correlate of the frailty phenotype and hand grip strength in patients with SLE is not clear. First, we aimed to evaluate differences in telomere length between frail and non-frail women with SLE and then assessed whether frailty or hand grip strength is differentially associated with telomere length after adjusting for relevant confounders. METHODS: Women ≥18 years of age with validated SLE enrolled at a single medical centre. Fried frailty status (which includes hand grip strength), clinical characteristics and telomere length were assessed cross-sectionally. Differences between frail and non-frail participants were evaluated using Fisher's exact or Wilcoxon rank-sum tests. The associations between frailty and hand grip strength and telomere length were determined using linear regression. RESULTS: Of the 150 enrolled participants, 131 had sufficient data for determination of frailty classification; 26% were frail with a median age of 45 years. There was a non-significant trend towards shorter telomere length in frail versus non-frail participants (p=0.07). Hand grip strength was significantly associated with telomere length (beta coefficient 0.02, 95% CI 0.004, 0.04), including after adjustment for age, SLE disease activity and organ damage, and comorbidity (beta coefficient 0.02, 95% CI 0.002, 0.04). CONCLUSIONS: Decreased hand grip strength, but not frailty, was independently associated with shortened telomere length in a cohort of non-elderly women with SLE. Frailty in this middle-aged cohort may be multifactorial rather than strictly a manifestation of accelerated ageing.
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Fragilidade , Lúpus Eritematoso Sistêmico , Idoso , Pessoa de Meia-Idade , Humanos , Feminino , Idoso Fragilizado , Força da Mão , Encurtamento do Telômero , Telômero , Lúpus Eritematoso Sistêmico/genética , FenótipoRESUMO
Sulfasalazine is a prodrug known to be effective for the treatment of inflammatory bowel disease (IBD)-associated peripheral spondyloarthritis (pSpA), but the mechanistic role for the gut microbiome in regulating its clinical efficacy is not well understood. Here, treatment of 22 IBD-pSpA subjects with sulfasalazine identifies clinical responders with a gut microbiome enriched in Faecalibacterium prausnitzii and the capacity for butyrate production. Sulfapyridine promotes butyrate production and transcription of the butyrate synthesis gene but in F. prausnitzii in vitro, which is suppressed by excess folate. Sulfasalazine therapy enhances fecal butyrate production and limits colitis in wild-type and gnotobiotic mice colonized with responder, but not non-responder, microbiomes. F. prausnitzii is sufficient to restore sulfasalazine protection from colitis in gnotobiotic mice colonized with non-responder microbiomes. These findings reveal a mechanistic link between the efficacy of sulfasalazine therapy and the gut microbiome with the potential to guide diagnostic and therapeutic approaches for IBD-pSpA.
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Colite , Microbioma Gastrointestinal , Doenças Inflamatórias Intestinais , Humanos , Camundongos , Animais , Sulfassalazina/farmacologia , Sulfassalazina/uso terapêutico , Doenças Inflamatórias Intestinais/tratamento farmacológico , Resultado do Tratamento , ButiratosRESUMO
OBJECTIVE: We aimed to determine the association of COVID-19 vaccination with flares of systemic rheumatic disease (SRD). METHODS: Adults with systemic rheumatic disease (SRD) in a single-center COVID-19 Rheumatology Registry were invited to enroll in a study of flares. COVID-19 vaccine information from March 5, 2021, to September 6, 2022, was obtained from chart review and self-report. Participants self-reported periods of SRD flare and periods without SRD flare. "Hazard periods" were defined as the time before a self-report of flare and "control periods" as the time before a self-report of no flare. The association between flare and COVID-19 vaccination was evaluated during hazard and control periods through univariate conditional logistic regression stratified by participant, using lookback windows of 2, 7, and 14 days. RESULTS: A total of 434 participants (mean ± SD age 59 ± 13 years, 84.1% female, 81.8% White, 64.5% with inflammatory arthritis, and 27.0% with connective tissue diseases) contributed to both the hazard and control periods and were included in analysis. A total of 1,316 COVID-19 vaccinations were identified (58.5% Pfizer-BioNTech, 39.5% Moderna, and 1.4% Johnson & Johnson); 96.1% of participants received at least one dose and 93.1% at least two doses. There was no association between COVID-19 vaccination and flares in the subsequent 2, 7, or 14 days (odds ratio [OR] 1.46, 95% confidence interval [CI] 0.86-2.46; OR 1.09, 95% CI 0.76-1.55; and OR 0.85, 95% CI 0.64-1.13, respectively). Analyses stratified on sex, age, SRD subtype, and vaccine manufacturer similarly showed no association between vaccination and flare. CONCLUSION: COVID-19 vaccination was not associated with flares in this cohort of participants with SRD. These data are reassuring and can inform shared decision-making on COVID-19 immunization.
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BACKGROUND: Chronic knee pain after total knee arthroplasty (TKA) is a common complication that is difficult to treat. This report aims to highlight the benefit of combining embolotherapy and neurolysis intervention for symptomatic relief of post-TKA pain in a patient with long-standing pain refractory to conservative management. CASE PRESENTATION: A 77-year-old man who had previously undergone left knee arthroplasty has been grappling with worsening knee effusion and debilitating pain, resulting in limited mobility and progressive musculature deconditioning over a 20-year period. Diagnostic arteriography showed marked diffuse periarticular hyperemia around the medial and lateral joint spaces of the left knee, along with capsular distention. The patient initially underwent microsphere embolization to selectively target multiple branches of the genicular arteries, achieving a 50% reduction in pain at the one-month follow-up. Subsequently, the patient underwent image-guided genicular nerve neurolysis, targeting multiple branches of the genicular nerves, which led to further pain reduction (80% compared to the initial presentation or 60% compared to post-embolization) at the one-month follow-up. This improvement facilitated weight-bearing and enabled participation in physical therapy, with sustained pain relief over the 10-month follow-up period. CONCLUSION: The combination of genicular artery embolization and genicular nerve block may be a technically safe and effective option for alleviating chronic pain after total knee arthroplasty.
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OBJECTIVES: To evaluate whether social isolation or loneliness is associated with outcomes 1 year after low-energy hip fracture. DESIGN: Prospective inception cohort study. SETTING: Academic level I trauma center. PATIENT SELECTION CRITERIA: Participants were 65 years or older and enrolled 2-4 days after surgery for a first low-energy hip fracture. Exclusion criteria were bilateral or periprosthetic hip fracture, previous hip fracture, non-English speaking, international address, active cancer, stage 4 cancer in the past 5 years, radiation to the hip region, and cognitive impairment. Participants were followed longitudinally for 1 year. OUTCOME MEASURES AND COMPARISONS: The patient-reported outcomes measurement information system (PROMIS)-29 was elicited 2-4 days postoperatively and 1 year later. Patient-reported risk factors included the Lubben Social Networks Scale and the University of California, Los Angeles Loneliness Scale, which were compared with the lower extremity activity scale and PROMIS-29 domains. RESULTS: Three hundred and twenty-five patients were enrolled. Participants had a median age of 81.7 years, were 70.9% female, and were 85.9% White. In total, 31.6% of patients were socially isolated at the time of fracture. At 1 year, 222 of the 291 subjects who were confirmed alive at 1 year provided data. Multivariable linear models were performed separately for each outcome, including lower extremity activity scale and PROMIS-29 domains. Controlling for age, sex, education, and body mass index, those who were socially isolated at the time of fracture had worse PROMIS-29 function (ß = -3.83; P = 0.02) and ability to participate in social roles (ß = -4.17; P = 0.01) at 1 year. Secondary analyses found that prefracture loneliness was associated with clinically meaningfully worse function, anxiety, depression, fatigue, sleep, pain, and ability to participate in social roles at 1 year (all P < 0.01). CONCLUSIONS: Prefracture social isolation was associated with worse outcomes 1 year after surgical repair of low-energy hip fracture. These data suggest loneliness may be more strongly associated with important patient-centric metrics than prefracture social isolation. Given the dearth of modifiable risk factors in this population, future studies are needed to evaluate whether improving social connections could affect outcomes in this rapidly growing demographic. LEVEL OF EVIDENCE: Prognostic Level I. See Instructions for Authors for a complete description of levels of evidence.
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Fraturas do Quadril , Neoplasias , Humanos , Feminino , Idoso de 80 Anos ou mais , Masculino , Estudos de Coortes , Estudos Prospectivos , Fraturas do Quadril/cirurgia , Isolamento SocialRESUMO
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.
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COVID-19 , Doenças Reumáticas , Reumatologia , Adulto , Humanos , Feminino , Masculino , Pacientes Ambulatoriais , Vacinas contra COVID-19 , Cidade de Nova Iorque/epidemiologia , COVID-19/epidemiologia , COVID-19/prevenção & controle , VacinaçãoRESUMO
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.
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Traumatismos do Joelho , Osteoartrite do Joelho , Humanos , Osteoartrite do Joelho/complicações , Osteoartrite do Joelho/terapia , Dor/etiologia , Modalidades de FisioterapiaRESUMO
OBJECTIVE: Primary care practitioners (PCPs) care for the majority of patients with knee osteoarthritis (KOA). Despite the existing evidence-based guidelines, PCPs often feel unequipped to evaluate and effectively treat patients with KOA. To address this need, we designed and implemented a free internet-based program focusing on the diagnosis and treatment of KOA. We assessed whether the program led to improvements in participants' confidence in their knowledge and skills related to effectively recognizing and caring for patients with or at risk of KOA. METHODS: We used Caffarella's integrative model to develop a program aligned with the American College of Rheumatology 2019 Guideline for the treatment of KOA. The program incorporated 18 case-based questions to provide retrieval practice and mastery experiences. We assessed changes in participants' confidence in their KOA knowledge and skills after program completion. RESULTS: Of the first 353 learners completing the program, 53.8% were women, 41.9% had a clinical focus in primary care, and 69.1% were nonphysicians. Overall confidence in KOA knowledge and skills improved after program completion (P < 0.001; effect size = 1.28, 95% confidence interval 1.12-1.45), with largest improvements among participants with lower pre-program confidence. A total of 95.8% of participants indicated they would recommend the program to others. CONCLUSION: A free online program focusing on the effective care for patients with KOA attracted a wide range of learners, even though it targeted PCPs. Participants overwhelmingly endorsed it as highly relevant and would recommend it to others. Whether improvements in confidence translate into better patient outcomes is an important area for future research.
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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.
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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.
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OBJECTIVE: Meniscal tear in persons aged ≥45 years is typically managed with physical therapy (PT), and arthroscopic partial meniscectomy (APM) is offered to those who do not respond. Prior studies suggest APM may be associated with greater progression of radiographic changes. METHODS: We assessed changes between baseline and 60 months in the Kellgren-Lawrence (KL) grade and OARSI radiographic score (including subscores for joint space narrowing and osteophytes) in subjects aged 45-85 years enrolled into a seven-center randomized trial comparing outcomes of APM with PT for meniscal tear, osteoarthritis changes, and knee pain. The primary analysis classified subjects according to treatment received. To balance APM and PT groups, we developed a propensity score and used inverse probability weighting (IPW). We imputed a 60-month change in the OARSI score for subjects who underwent total knee replacement (TKR). In a sensitivity analysis, we classified subjects by randomization group. RESULTS: We analyzed data from 142 subjects (100 APM, 42 PT). The mean ± SD weighted baseline OARSI radiographic score was 3.8 ± 3.5 in the APM group and 4.0 ± 4.9 in the PT group. OARSI scores increased by a mean of 4.1 (95% confidence interval [95% CI] 3.5-4.7) in the APM group and 2.4 (95% CI 1.7-3.2) in the PT group (P < 0.001) due to changes in the osteophyte component. We did not observe statistically significant differences in the KL grade. Sensitivity analyses yielded similar findings to the primary analysis. CONCLUSION: Subjects treated with APM had greater progression in the OARSI score because of osteophyte progression but not in the KL grade. The clinical implications of these findings require investigation.
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OBJECTIVE: Frailty is a risk factor for adverse health in adults with SLE, including those <65 years. Emergency department (ED) utilisation is high in adults with SLE, but to our knowledge, whether frailty is associated with ED use is unknown. In a large administrative claims dataset, we assessed risk of ED utilisation among frail adults with SLE ≤65 years of age relative to non-frail adults ≤65 years of age with SLE. METHODS: Using the MarketScan Medicaid subset from 2011 to 2015, we identified beneficiaries 18-65 years with SLE (≥3 SLE International Classification of Diseases, Ninth Revision codes ≥30 days apart). Comparators without a systemic rheumatic disease (SRD) were matched 4:1 on age and gender. Frailty status in 2011 was determined using two claims-based frailty indices (CFIs). We compared risk of recurrent ED utilisation among frail and non-frail beneficiaries with SLE using an extension of the Cox proportional hazard model for recurrent events data. RESULTS: Of 2262 beneficiaries with SLE and 9048 non-SRD comparators, 28.8% and 11.6% were frail, respectively, according to both CFIs. Compared with non-frail beneficiaries with SLE, frail beneficiaries with SLE had significantly higher hazard of recurrent ED use (HR 1.75, 95% CI 1.48 to 2.08). CONCLUSION: Frailty increased hazard of recurrent ED visits in frail adults ≤65 years of age with SLE relative to comparable non-frail adults with SLE. Frailty is a potential target for efforts to improve quality of care in SLE.
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Fragilidade , Lúpus Eritematoso Sistêmico , Estados Unidos/epidemiologia , Adulto , Humanos , Idoso , Lúpus Eritematoso Sistêmico/complicações , Lúpus Eritematoso Sistêmico/epidemiologia , Fragilidade/complicações , Fragilidade/epidemiologia , Medicaid , Serviço Hospitalar de Emergência , Análise de DadosRESUMO
OBJECTIVE: Expected outcomes (e.g., expected survivorship after a cancer treatment) have improved decision-making around treatment options in many clinical fields. Our objective was to evaluate the effect of expected values of 3 widely available total knee arthroplasty (TKA) outcomes (risk of serious complications, time to revision, and improvement in pain and function at 2 years after surgery) on clinical recommendation of TKA. METHODS: The RAND/University of California Los Angeles appropriateness criteria method was used to evaluate the role of the 3 expected outcomes in clinical recommendation of TKA. The expected outcomes were added to 5 established preoperative factors from the modified Escobar appropriateness criteria. The 8 indication factors were used to develop 279 clinical scenarios, and a panel of 9 clinicians rated the appropriateness of TKA for each scenario as inappropriate, inconclusive, and appropriate. Classification tree analysis was applied to these ratings to identify the most influential of the 8 factors in discriminating TKA appropriateness classifications. RESULTS: Ratings for the 279 appropriateness scenarios deemed 34.4% of the scenarios as appropriate, 40.1% as inconclusive, and 25.5% as inappropriate. Classification tree analyses showed that expected improvement in pain and function and expected time to revision were the most influential factors that discriminated among the TKA appropriateness classification categories. CONCLUSION: Our results showed that clinicians would use expected postoperative outcome factors in determining appropriateness for TKA. These results call for further work in this area to incorporate estimates of expected pain/function and revision outcomes into clinical practice to improve decision-making for TKA.
Assuntos
Artroplastia do Joelho , Osteoartrite do Joelho , Humanos , Tomada de Decisão Clínica , Dor , Articulação do Joelho , Resultado do TratamentoRESUMO
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.