Length of Stay and Discharge Disposition after Total Hip Arthroplasty: A Large Multi-Center Propensity Matched Comparison of Robotic-Assisted and Manual Techniques.

BACKGROUND: Robotic-arm assistance continues to gain popularity in total hip arthroplasty (THA) for its potential to improve component placement accuracy and patient outcomes. Nonetheless, there is limited data on the impact of robotic-assisted THA (RA-THA) on hospital length of stay (LOS) and discharge location. This study thus aimed to compare LOS, discharge location, and readmission rate for propensity-matched cohorts of RA-THA versus manual THA (M-THA). METHODS: A retrospective review of a multi-hospital database was performed to identify patients who underwent THA between January 2016 and December 2021 from surgeons who performed both RA-THA and M-THA at 77 geographically diverse hospitals. The RA-THA and M-THA cohorts were 1-to-1 matched based on patient sex, age, and body mass index, resulting in 8,536 patients per cohort. Insurance type, LOS, same-day discharge, discharge disposition, and 90-day all-cause readmission rate were compared using Mann-Whitney U and Chi-square tests. RESULTS: Average LOS was significantly shorter for RA-THA patients (1.39 ± 0.85 days) than for M-THA patients (1.48 ± 0.91 days, P < 0.001). Compared to 5.6% of M-THA patients, 5.3% of RA-THA patients underwent same-day discharge (P = 0.38). There were statistically significant differences in discharge disposition between cohorts, with more RA-THA cases discharged home without home healthcare compared to M-THA (47.9 versus 45.5%, P = 0.001) and fewer RA-THA cases discharged to a skilled nursing facility (SNF) compared to M-THA (5.6 versus 6.9%, P = 0.001). The 90-day all-cause readmission rate for RA-THA cases was 3.0%, compared to 3.4% for M-THA cases (P = 0.26). CONCLUSION: Compared to M-THA, RA-THA had a shorter average LOS, a similar percentage of patients with same-day discharge, fewer patients who had SNF discharge, and a similar all-cause 90-day readmission rate. These results may be of interest to surgeons participating in bundled payment programs and engaging in cost savings.

The Gap in Knowledge about Tapering Targeted Therapy being used as Monotherapy in Rheumatoid Arthritis: A Systematic Review.

BACKGROUND: Up to 30% of patients with RA are being treated with biologic (b)-disease modifying anti-rheumatic drugs (DMARDs) as monotherapy. Monotherapy with Interleukin (IL)-6 inhibitors(i) and Janus-kinase (JAK)-i has been shown to be effective. Whether patients can taper targeted therapy (bDMARDs and JAK-i) used as monotherapy (targeted monotherapy) is unknown. OBJECTIVE: To determine the feasibility of tapering of targeted monotherapy in patients with controlled RA. METHODS: We conducted a literature search in Medline, Embase and Cochrane Library for prospective studies reporting remission outcomes after tapering targeted monotherapy in RA patients, from 1/2014 - 8 /2021. RESULTS: 5 randomized studies which met our inclusion criteria, evaluating tapering of monotherapy with tumor necrosis factor-inhibitors, tocilizumab, abatacept and baricitinib in RA. Studies were heterogeneous. Three trials studied early RA. Three studies gradually tapered therapy, including 1 dose reduction study. Three studies tapered both biological and conventional-synthetic (cs)-DMARDs. No study compared stopping targeted monotherapy to continuing it. Remission rates were low 14-28% across all studies that stopped targeted monotherapy. The highest remission rate of 72% was reported by the dose reduction study. Trials that studied early RA reported remission rates after tapering ranging 27-72%. Trials tapering therapy in established RA reported rates of remission from 14-20%. CONCLUSION: There is a crucial gap in published literature to inform on tapering targeted monotherapy in patients with RA. Stopping targeted monotherapy is unlikely to maintain disease control in RA. Dose reduction strategies and early treatment of disease may be associated with more successful tapering, and warrant future study.

Anticitrullinated peptide antibody epitope expansion and the HLA DRB1 'shared epitope' are less common in seropositive checkpoint inhibitor-induced inflammatory arthritis than in longstanding rheumatoid arthritis.

BACKGROUND: Immune checkpoint inhibitors (ICI) can potentially cause ICI-inflammatory arthritis (ICI-IA), which often resembles rheumatoid arthritis (RA). In this study, we examined the degree of anticitrullinated peptide antibodies (ACPA) epitope expansion in CCP+ICI-IA and patients with RA. METHODS: We used clinical data and serum from ICI-IA and patients with RA with early disease as well as longstanding disease. A custom, bead-based antigen array was used to identify IgG ACPA reactivities to 18 putative RA-associated citrullinated proteins. Hierarchical clustering software was used to create a heatmap to identify ACPA levels. Additionally, HLA DRB1 typing was performed on ICI-IA patients as well as controls of patients treated with ICI that did not develop ICI-IA (ICI controls). RESULTS: Compared to patients with CCP+RA, patients with CCP+ICI-IA were older (p<0.001), less likely to have positive rheumatoid factor (p<0.001) and had a shorter duration of symptoms (p<0.001). There were less ACPA levels and a lower number of distinct ACPA epitopes in the serum of patients with ICI-IA compared with longstanding patients with RA (p<0.001). Among those tested for HLA DRB1, there were no differences in the frequency of the shared epitope between those with ICI-IA and ICI controls. CONCLUSION: Patients with ICI-IA had lower ACPA titres and targeted fewer ACPA epitopes than longstanding patients with RA, and there were no significant differences in the presence of the shared epitope between those that developed ICI-IA and ICI controls. It remains to be determined if ICI-IA represents an accelerated model of RA pathogenesis with ICI triggering a transition from preclinical to clinical disease.

Can Patients With Controlled Rheumatoid Arthritis Taper Methotrexate From Targeted Therapy and Sustain Remission? A Systematic Review and Metaanalysis.

OBJECTIVE: To determine the risk of not being able to sustain remission after tapering methotrexate (MTX) from targeted therapy in patients with controlled rheumatoid arthritis (RA). METHODS: A systematic literature search was conducted in MEDLINE, Embase, and the Cochrane Library for studies reporting remission outcomes after tapering MTX from targeted therapies in RA. Full-text articles and abstracts reported in English were included. Metaanalyses were conducted using random-effects models. Forest and funnel plots were created. RESULTS: A total of 10 articles were included. Studies evaluated MTX being tapered from combination treatment with tumor necrosis factor inhibitors, tocilizumab, abatacept, and tofacitinib. A total of 9 studies used a randomized design and 1 was observational. Out of 10 studies, 3 focused on early RA (ie, < 1 yr). The MTX-tapering strategy was gradual in 2 studies and rapid in 8 studies. Follow-up ranged from 3 to 18 months in randomized trials and up to 3 years in the observational study. Our metaanalysis, which included 2000 participants with RA from 10 studies, showed that patients who tapered MTX from targeted therapy had a 10% reduction in the ability to sustain remission and an overall pooled risk ratio of 0.90 (95% CI 0.84-0.97). There was no heterogeneity (I 2 = 0%, P = 0.94). Our funnel plot indicated minimal publication bias. CONCLUSION: Patients with controlled RA may taper MTX from targeted therapy with a 10% reduction in the ability to sustain remission for up to 18 months. Longer follow-up studies with attention to radiographic, functional, and patient-reported outcomes are needed. The risk of disease worsening should be discussed with the patient with careful follow-up and prompt retreatment of disease worsening.

Role of Sonic Hedgehog Signaling Pathway in Intervertebral Disc Formation and Maintenance.

A PURPOSE OF REVIEW: The intervertebral discs (IVD) are an essential component of the spine. Degeneration of the discs, commonly due to age or injury, is a leading cause of chronic lower back pain. Despite its high prevalence, there is no effective treatment for disc disease due to limited understanding of disc at the cellular and molecular level. B RECENT FINDINGS: Recent research has demonstrated the importance of the intracellular developmental pathway sonic hedgehog (Shh) during the formation and postnatal maintenance of the IVD. Recent studies corroborate that the down-regulation of SHH expression is associated with pathological changes in the IVDs and demonstrate the reactivation of the hedgehog pathway as a promising avenue for rescuing health disc structure and function. C SUMMARY: Understanding the role of developmental signaling pathways that regulate disc formation and maintenance may help develop strategies to recapitulate the same mechanism for disc treatment and hence improve the quality and longevity of patient lives.