"You don't put it down to arthritis": A qualitative study of the first symptoms recalled by individuals with knee osteoarthritis.

Objective: As part of the first phase of the OARSI Early-stage Symptomatic Knee Osteoarthritis (EsSKOA) initiative, we explored the first symptoms and experiences recalled by individuals with knee osteoarthritis (OA). Design: This qualitative study, informed by qualitative description, was a secondary analysis of focus groups (n â€‹= â€‹17 groups) and one-on-one interviews (n â€‹= â€‹3) conducted in 91 individuals living with knee OA as part of an international study to better understand the OA pain experience. In each focus group or interview, participants were asked to describe their first symptoms of knee OA. We inductively coded these transcripts and conducted thematic analysis. Results: Mean age of participants was 70 years (range 47-92) and 68 â€‹% were female. We developed four overarching themes: Insidious and Episodic Onset, Diverse Early Symptoms, Must be Something Else, and Adjustments. Participants described the gradual and intermittent way in which symptoms of knee OA developed over many years; many could not identify a specific starting point. Participants described diverse initial knee symptoms, including activity-exacerbated joint pain, stiffness and crepitus. Most participants dismissed early symptoms or rationalized their presence, employing various strategies to enable continued participation in recreational and daily activities. Few sought medical attention until physical functioning was demonstrably impacted. Conclusions: The earliest symptoms of knee OA are frequently insidious in onset, episodic and present long before individuals present to health professionals. These results highlight challenges to identifying people with knee OA early and support the development of specific classification criteria for EsSKOA to capture individuals at an early stage.

Development and validation of the Flare-OA questionnaire for measuring flare in knee and hip osteoarthritis.

OBJECTIVE: Ability to assess flares in osteoarthritis (OA) of the knee and hip (KHOA) is important in clinical care and research. Using mixed methods, we developed a self-reported instrument measuring flare and assessed its psychometric properties. METHODS: We constructed questionnaire items from semi-structured interviews and a focus group (patients, clinicians) by using a dual-language (English-French) approach. A Delphi consensus method was used to select the most relevant items. Patients with OA from Australia, France and the United States completed the preliminary Flare-OA, HOOS, KOOS and Mini-OAKHQOL questionnaires online. We used a factor analysis and content approach to reduce items and determine structural validity. We tested the resulting questionnaire (score 0-100) for internal consistency, convergent and known-groups validity. RESULTS: Initially, 180 statements were generated and reduced to 33 items in five domains (response 0 = not at all, to 10 = absolutely) by Delphi consensus (50 patients, 116 professionals) and an expert meeting. After 398 patients (mean [SD] age 64 [8.5] years, 70.4% female, 86.7% knee OA) completed the questionnaire, it was reduced to 19 items by factor analysis and a content approach (RMSEA = 0.06; CFI = 0.96; TLI = 0.94). The Cronbach's alpha was >0.9 for the five domains and the whole questionnaire. Correlation coefficients between Flare-OA and other instrument scores were as predicted, supporting construct validity. The difference in Flare-OA score between patients with and without flare (31.8) largely exceeded 2 SEM (10.2). CONCLUSION: Flare-OA is a valid and reliable patient-reported instrument for assessing the occurrence and severity of flare in patients with KHOA in clinical research.

Fundamentals of osteoarthritis: outcome evaluation with patient-reported measures and functional tests.

Evaluating outcome in osteoarthritis (OA) clinical research and practice requires reliable, valid and responsive patient-reported outcome measures (PROMs) and functional tests that reflect important problems experienced by people with OA. The goal of this work is to provide information to start to guide the reader in selecting measures for people with OA. In this narrative review, we begin by providing an overview of measurement properties that can help clinicians and researchers in making decisions about whether a measure might be appropriate for use in their research or clinical context. We then report evidence supporting the use of measures of pain (e.g., Pain Visual Analogue (VAS), Numeric Pain Rating Scale (NPRS), Intermittent and Constant Osteoarthritis Pain, PROMIS Pain Interference, and, for screening in research, the painDETECT and the Self-report Leeds Assessment of Neuropathic Symptoms and Signs) and fatigue (e.g., PROMIS-Fatigue) at a group level in clinical research. Several multi-dimensional joint-specific measures (e.g., Western Ontario McMaster Universities' Osteoarthritis Outcomes Scale, Knee/Hip Injury and Osteoarthritis Outcome Score, Oxford Hip/Knee Scale) also have evidence for group-level use. Functional tests (e.g., timed walk tests, 30 Second Chair Stand, Timed Up and Go, etc.) have measurement properties supporting their use at the group level in clinical research and at the individual patient level as do the pain VAS and NPRS. Other generic and disease-specific PROMs have been used in or could be used in OA studies but their measurement properties require further evaluation in people with OA.

Are medical comorbidities contributing to the use of opioid analgesics in patients with knee osteoarthritis?

BACKGROUND: Although opioid analgesics are not generally recommended for treatment of knee osteoarthritis (OA), they are frequently used. We sought to determine the association between medical comorbidities and self-reported opioid analgesic use in these patients. METHODS: This cross-sectional study recruited patients referred to two provincial hip and knee clinics in Alberta, Canada for consideration of total knee arthroplasty. Standardized questionnaires assessed demographic (age, gender, income, education, social support, smoking status) and clinical (pain, function, total number of troublesome joints) characteristics, comorbid medical conditions, and non-surgical OA management participants had ever used or were currently using. Multivariable Poisson regression with robust estimate of the standard errors assessed the association between comorbid medical conditions and current opioid use, controlling for potential confounders. RESULTS: 2,127 patients were included: mean age 65.4 (SD 9.1) years and 59.2% female. Currently used treatments for knee OA were: 57.6% exercise and/or physiotherapy, 61.1% NSAIDs, and 29.8% opioid analgesics. In multivariable regression, controlling for potential confounders, comorbid hypertension (RR 1.18, 95% CI 1.02-1.37), gastrointestinal disease (RR 1.31, 95% CI 1.07-1.60), depressed mood (RR 1.25, 95% CI 1.05-1.48) and a higher number of troublesome joints (RR 1.04 per joint, 95% CI 1.00-1.09) were associated with opioid use, with no association found with having ever used recommended non-opioid pharmacological or non-pharmacological treatments. CONCLUSIONS: In a large cohort of patients with knee OA, of 12 comorbidities assessed, comorbid hypertension, gastrointestinal disease, and depressed mood were associated with current use of opioid analgesics, in addition to total burden of troublesome joints. Improved guidance on the management of painful OA in the setting of common comorbidities is warranted.

The longitudinal relationship between hand, hip and knee osteoarthritis and cardiovascular events: a population-based cohort study.

OBJECTIVE: In this population-based cohort study, we examined the association between the presence of symptomatic osteoarthritis (OA) and risk for cardiovascular (CV) events. METHOD: A cohort aged ≥55 years recruited from 1996 to 98 was followed through provincial health administrative data to 2014. Demographics, joint complaints and functional limitations were collected. Hip, knee and hand OA were defined using a validated definition. Using Cox-regressions, the relationship between OA and a composite CV outcome (myocardial infarction (MI), stroke, angina, heart failure, revascularization) was assessed controlling for age, body mass index (BMI), sex, pre-existing metabolic factors, comorbidities, income status, primary care exposure and functional limitations. RESULTS: 18,490 participants were included: median age was 68 years, 60.3% were female; 24.4% met criteria for OA (10.0% hip, 15.3% knee, 16.0% hand), 16.3% self-reported limitation in grip and 25.4% in walking. Over a median 13.4 years, 31.9% experienced a CV event. Controlling for all but walking limitation, a dose-response relationship was observed between number of joints affected by knee/hip OA and CV risk (HR 2 hips/knees vs none: 1.13, 95% CI 1.03-1.23; 3+ hips/knees: 1.22, 95% CI 1.09-1.36). This relationship became non-significant additionally controlling for difficulty walking. Self-reported difficulty walking was associated with a 30% increased hazard for CV events. The effect of hand OA was not significant. CONCLUSION: In a large population cohort, a greater burden of hip/knee OA was associated with higher CV risk; the relationship was explained by OA-related difficulty walking. Increased attention to management of OA with a view to improving mobility has potential to reduce CV events.

Osteoarthritis-related difficulty walking and risk for diabetes complications.

OBJECTIVES: To examine the effect of Osteoarthritis (OA)-related difficulty walking on risk for diabetes complications in persons with diabetes and OA. DESIGN: A population cohort aged 55+ years with symptomatic hip and knee OA was recruited 1996-98 and followed through provincial administrative data to 2015 (n = 2,225). In those with confirmed OA (examination and radiographs) and self-reported diabetes at baseline (n = 359), multivariate Cox regression modeling was used to examine the relationship between baseline difficulty walking (Health Assessment Questionnaire (HAQ) difficulty walking score; use of walking aid) and time to first diabetes-specific complication (hospitalization for hypo- or hyperglycemia, infection, amputation, retinopathy, or initiation of chronic renal dialysis) and cardiovascular (CV) events. RESULTS: Participants' mean baseline age was 71.4 years; 66.9% were female, 77.7% had hypertension, 54.0% had pre-existing CV disease, 42.9% were obese and 15.3% were smokers. Median HAQ difficulty walking score was 2/3 indicating moderate to severe walking disability; 54.9% used a walking aid. Over a median 6.1 years, 184 (51.3%) experienced one or more diabetes-specific complications; 191 (53.2%) experienced a CV event over a median 5.7 years. Greater baseline difficulty walking was associated with shorter time to the first diabetes-specific complication (adjusted HR per unit increase in HAQ walking 1.24, 95% CI 1.04-1.47, P = 0.02) and CV event (adjusted HR for those using a walking aid 1.35, 95% CI 1.00-1.83, P = 0.04). CONCLUSIONS: In a population cohort with OA and diabetes, OA-related difficulty walking was a significant - and potentially modifiable - risk factor for diabetes complications.

Association of adipokines and joint biomarkers with cartilage-modifying effects of weight loss in obese subjects.

OBJECTIVES: To determine (1) the effects of weight loss in obese subjects on six adipokines and joint biomarkers; and (2) the relationship between changes in these markers with changes in cartilage outcomes. DESIGN: Plasma levels of adiponectin, leptin, IL-6, COMP, MMP-3 and urine levels of CTX-II were measured at baseline and 12 months from 75 obese subjects enrolled in two weight-loss programs. Magnetic resonance imaging (MRI) was used to assess cartilage volume and thickness. Associations between weight loss, cartilage outcomes and markers were adjusted for age, gender, baseline BMI, presence of clinical knee OA, with and without weight loss percent. RESULTS: Mean weight loss was 13.0 ± 9.5%. Greater weight loss percentage was associated with an increase in adiponectin (ß = 0.019, 95% CI 0.012 to 0.026,) and a decrease in leptin (ß = -1.09, 95% CI -1.37 to -0.82). Multiple regression analysis saw an increase in adiponectin associated with reduced loss of medial tibial cartilage volume (ß = 14.4, CI 2.6 to 26.3) and medial femoral cartilage volume (ß = 18.1, 95% CI 4.4 to 31.8). Decrease in leptin was associated with reduced loss of medial femoral volume (ß = -4.1, 95% CI -6.8 to -1.4) and lateral femoral volume (ß = -1.8, 95% CI -3.7 to 0.0). When weight loss percent was included in the model, only the relationships between COMP and cartilage volume remained statistically significant. CONCLUSIONS: Adiponectin and leptin may be associated with cartilage loss. Further work will determine the relative contributions of metabolic and mechanical factors in the obesity-related joint changes.

Use of biological disease-modifying anti-rheumatic drugs in patients with concurrent rheumatic disease and hepatitis B.

BACKGROUND: Biological disease-modifying anti-rheumatic drugs (bDMARDs) are effective in the management of inflammatory arthritides. Reactivation of hepatitis B virus (HBV) is a potential adverse outcome in patients treated with bDMARDs. There is currently no consensus on the approach to identifying and treating these patients with underlying HBV infection. AIM: The aims of this study were to assess the risk of HBV reactivation in patients treated with bDMARDs, and to determine whether HBV screening should be carried out in all patients prior to commencing bDMARDs. METHODS: A literature search was undertaken to identify all reports of patients with inflammatory arthritides and concurrent HBV infection being treated with bDMARDs. RESULTS: Forty-three patients with HBV infection were identified, of whom eight patients developed HBV reactivation after exposure to bDMARDs. Of the patients who experienced reactivation, two had unknown infection that surfaced during bDMARD therapy. Patients who experienced reactivation were promptly treated with antiviral therapy and saw clinical improvement. There are no long-term data on these patients. CONCLUSIONS: HBV reactivation may result in serious consequences, including death. Tuberculosis screening prior to bDMARD treatment is already standard practice, as is HBV screening for patients undergoing cancer chemotherapy. Implementing HBV screening for all patients prior to bDMARD treatment can identify patients with chronic HBV who may require antiviral therapy.

An assessment of the safety of street foods in the Ga district, of Ghana; implications for the spread of zoonoses.

Street food refers to food and beverages prepared and sold by vendors in streets and other public places for immediate consumption. In Ghana street foods are sold at small eating places popularly known as 'chop bars'. Food safety studies were conducted on the premises of 160 'chop bars' in the Ga District of Ghana in July 1998. Only three (1.8%) of the proprietors met all the requirements (based on a five-point checklist) for basic hygiene. Twenty-four (15%) out of the 160 proprietors had access to potable water while the other 136 (85%) proprietors purchased water from vendors and six used pond water. These two latter sources of water were of poor microbiological quality (as shown by faecal coliform values which ranged from 1.0x10(2)-1.9x10(5) cfu/ml). One hundred and five proprietors (65.6%) did not obtain their meat supply from an approved source. Factors influencing the purchase of meat from an approved source included the proximity of a chop bar to a slaughter facility, the conduct of meat inspection personnel and affordable user fees.

Comparison of the efficacy cost and complication rate of APD and CAPD as long-term outpatient treatments for renal failure.

We compared 10 patients treated with overnight APD in their homes with a parallel group of 30 patients having CAPD (Freeline II) over two years 1990 and 1991. Our aim was to discover if APD was an efficient and cost effective alternative to CAPD. The average amount of dialysate used per day in APD patients was 11 litres (range 9 to 14 litres) compared to 6.8 litres (range 6 to 10 litres) for CAPD. The average plasma creatinine was 920 umol/L, plasma urea of 21 mmol/L on APD and 825 umol/L and 24 mmol/L respectively on CAPD. In 1990 there were 2 incidences of peritonitis (2 in 1991) in the APD patients compared to 24 incidences (24 in 1991) in the CAPD patients with 6 recurrences (5 in 1991) and 19 exist site infections (24 in 1991). The average fluid costs plus disposables were comparable. However the cost of treating complications per patient for APD was for 1990 32 pounds (108 pounds in 1991) and for CAPD 832 pounds (1308 pounds in 1991). All the APD patients who had previously experienced CAPD preferred this treatment for its convenience and social acceptability. APD is a cost-effective alternative to CAPD and has advantages in some patients.

A simple, rapid method for enumerating total viable and metabolically active bacteria in groundwater.

We report here a new staining procedure which uses both the enzymatic dehydrogenation of 2-(p-iodophenyl)-3-p-(nitrophenyl)-5 phenyltetrazolium chloride to a pink intracellular formazan and the DNA-specific fluorochrome 4',6'-diamidino-2-phenylindole. Application of this staining procedure to cells concentrated on filters and then transferred to microscope slides by the filter-transfer-freeze technique has proven valuable for statistically accurate enumeration of the total viable and metabolically active cells in groundwaters.