Examining racial disparities in utilization rate and perioperative outcomes following knee and hip arthroplasty.

BACKGROUND: Previous arthroplasty utilization research predominantly examined Black and White populations within the US. This is the first known study to examine utilization and complications in poorly studied minority racial groups such as Asians and Native Hawaiian/Pacific-Islanders (NHPI) as compared to Whites. RESULTS: Data from 3304 primary total hip and knee arthroplasty patients (2011 to 2019) were retrospectively collected, involving 1789 Asians (52.2%), 1164 Whites (34%) and 320 Native Hawaiians/Pacific Islanders (NHPI) (9.3%). The 2012 arthroplasty utilization rates for Asian, White, and NHPI increased by 32.5%, 11.2%, and 86.5%, respectively, by 2019. Compared to Asians, Whites more often underwent hip arthroplasty compared to knee arthroplasty (odds ratio (OR) 1.755; p < 0.001). Compared to Asians, Whites and NHPI more often received total knee compared to unicompartmental knee arthroplasty (White: OR 1.499; NHPI: OR 2.013; p < 0.001). White patients had longer hospitalizations (2.66 days) compared to Asians (2.19 days) (p = 0.005) following bilateral procedures. Medicare was the most common insurance for Asians (66.2%) and Whites (54.2%) while private insurance was most common for NHPI (49.4%). Compared to Asians, economic status was higher for Whites (White OR 0.695; p < 0.001) but lower for NHPI (OR 1.456; p < 0.001). After controlling for bilateral procedures, NHPI had a lower risk of transfusion compared to Asians (OR 0.478; p < 0.001) and Whites had increased risk of wound or systemic complications compared to Asians (OR 2.086; p = 0.045). CONCLUSIONS: Despite NHPI demonstrating a significantly poorer health profile and lower socioeconomic status, contrary to previous literature involving minority racial groups, no significant overall differences in arthroplasty utilization rates or perioperative complications could be demonstrated amongst the racial groups examined.

Nontuberculous mycobacterial skin and soft tissue infection in Hawai'i.

BACKGROUND: Hawai'i has the highest nontuberculous mycobacterial (NTM) lung infection prevalence in the United States. Limited data regarding skin and soft tissue infections (SSTI) due to NTM in Hawai'i exists. This study describes patient demographics, clinical courses of infection, treatment patterns, and clinical outcomes of NTM SSTIs in Hawai'i. METHODS: A retrospective chart review (n = 50) of patients diagnosed and treated at Hawai'i Pacific Health facilities for NTM SSTIs between January 2010 and July 2021 was conducted. Patient demographics, clinical course, and treatment data were collected from electronic medical records. RESULTS: Half of the patient population consisted of females, and the average age of patients during infection was 49 years (SD = 25.6). The majority of cases (80%) were caused by rapidly growing mycobacteria (RGM), most commonly Mycobacterium abscessus. NTM SSTI by race were Asian (48%), White (28%), and Native Hawaiian and Other Pacific Islanders (16%). Almost all Asian patients with NTM SSTI were Filipino or Japanese. Diagnosis was frequently delayed. The average time to diagnosis was 116 days. Most patients achieved complete resolution (72%) following a prolonged course of antimicrobial treatment (mean = 196 days) with surgical debridement. CONCLUSION: Increased awareness among physicians and the community of non-mycobacterial skin infections is essential in Hawai'i due to the high prevalence of NTM and the high percentage of predisposed populations. Increased awareness of NTM could reduce delayed diagnosis and improve patient care. Further studies are required to inform optimal treatment and diagnostic strategies, improve patient outcomes, and aid public health surveillance efforts.

Current approaches to osteoporosis treatment.

PURPOSE OF REVIEW: Osteoporosis is a skeletal disorder in which bone strength is decreased leading to an increased risk of fracture. In line with advances in knowledge of bone biology, the past several years have held major therapeutic advances in osteoporosis treatment. In this article, we review the current approaches to osteoporosis treatment with a focus on issues of interest to the practicing rheumatologist. RECENT FINDINGS: In addition to the bisphosphonates, the introduction of denosumab, teriparatide and selective oestrogen-receptor modulators, as well as the development of new therapeutic agents (romosozumab and odanacatib) has opened the door to new approaches, including individualization of treatment in different clinical circumstances based on patient comorbidities and preference; combination therapy to optimize treatment effect; and consideration of goal-based treatment. Postmarketing surveillance of bisphosphonates has revealed several safety concerns including osteonecrosis of the jaw and atypical femoral fractures. Bisphosphonate drug holidays should be considered in patients on bisphosphonate therapy because prolonged treatment may be associated with adverse events. SUMMARY: Substantial progress has been made in the past several years in the understanding and modification of osteoporosis management. Many conditions encountered by rheumatologists are associated with bone loss; therefore, the rheumatologist needs to be aware of the current approaches in osteoporosis management.

Septic arthritis in gout patients: a population-based cohort study.

OBJECTIVE: To evaluate the association of incident gout with the risk of incident septic arthritis in a general population context. METHODS: We investigated the association of incident gout with the risk of incident septic arthritis using the Health Improvement Network, a computerized medical record database from general practices in the UK. We conducted a cohort analysis of the risk of an incident septic arthritis diagnosis among adults with incident gout compared with up to five non-gout individuals matched by age, sex, date of study entry and enrolment year. We performed Cox proportional hazard regression models to adjust for lifestyle variables, physician visits, comorbidities and medication use. RESULTS: We identified 72 073 incident gout patients and 358 342 matched non-gout patients. The incidence rates of a septic arthritis diagnosis were 0.24 cases and 0.09 cases per 1000 person-years in the gout and comparison cohorts, respectively. Matched univariate and multivariate hazard ratios of a septic arthritis diagnosis were 2.82 (95% CI 2.15, 3.71) and 2.60 (95% CI 1.93, 3.51), respectively. The association persisted among subgroups stratified by sex, age group (<75 and ≥75) and socio-economic deprivation level. CONCLUSION: This general population-based study suggests that gout is associated with an increased likelihood of septic arthritis.

A retrospective study of septic arthritis in a tertiary hospital in West Texas with high rates of methicillin-resistant Staphylococcus aureus infection.

Septic arthritis is an important concern for rheumatologists in the evaluation of joint disease. Very few studies have addressed the microbiologic epidemiology and outcomes of septic arthritis in the USA since the year 2000. We performed a retrospective study of septic arthritis in a tertiary hospital in West Texas from the year 2000 to 2013. We recorded data on patient demographics, microbiologic etiology, treatment patterns, and outcomes. The most common causative organisms were Staphylococcus aureus and Streptococcus spp. Methicillin-resistant Staphylococcus aureus (MRSA) caused septic arthritis in 22.6 % of the cases. MRSA septic arthritis was associated with low rates of adequate empiric antimicrobial therapy. The mortality due to sepsis in our study was 5.5 %. Patients with septic arthritis had a mean length of stay of 13.5 ± 12.1 days and required 2.1 ± 1.4 joint operations. Many patients (29.2 %) had readmissions due to complications, and these patients had high rates of home health utilization and transfers to other facilities post hospital discharge. In our logistic regression analysis model, factors associated with poor outcomes in septic arthritis were MRSA, older age, and prosthetic joint infection. Septic arthritis is associated with significant mortality, morbidity, and health care costs, and more studies are needed to improve outcomes, especially considering the increasing rates of MRSA as the pathogen.

Upper-extremity digital ischemia in granulomatosis with polyangiitis.

We report a case of granulomatosis with polyangiitis (GPA) in a 48-year-old man that was complicated by upper-extremity digital ischemia. Our patient initially presented with acute kidney injury, nasal and sinus symptoms, and bilateral lower-extremity swelling. He was diagnosed with GPA based on clinical features, findings on renal biopsy, and positive antineutrophilic cytoplasmic antibodies. He was treated with immunosuppression, but during the course of the disease, he developed cyanosis in his bilateral upper extremities. In our case, middle-/large-size arteries (Chapel Hill Consensus Conference nomenclature) in the upper extremities were occluded, and this caused the digital ischemia. Despite treatment with immunosuppression, plasmapheresis, and antithrombotic therapy, our patient's digital ischemia progressed leading to autoamputation of his fingers. Because of the rarity of digital ischemia in GPA, this case presented with many diagnostic and therapeutic challenges.

Gout in Native Hawaiian Patients in Hawai'i: Clinical Characteristics and Disparities.

OBJECTIVE: The purpose of this study was to investigate differences in clinical characteristics and health care use of Native Hawaiian and White patients with gout. METHODS: We performed a retrospective chart review of Native Hawaiian and White patients with gout treated from 2011 to 2017 within a large health care system in Hawai'i. We compared demographic characteristics, clinical outcomes, and risk factors for gout. We used multivariable logistic regression to identify predictive factors of emergency department visits. RESULTS: We identified 270 Native Hawaiian patients with gout and 239 White patients with gout. The Native Hawaiian patients were younger on average (54.0 vs 64.0 years; P < 0.0001) and had an earlier onset of disease (50.0 vs 57.0 years; P < 0.0001). Native Hawaiian patients with gout had higher mean (7.58 vs 6.87 mg/dL; P < 0.0001) and maximum (10.30 vs 9.50 mg/dL; P < 0.0001) serum urate levels compared to White patients with gout. Native Hawaiian patients with gout also had a greater number of tophi (median 2.00 vs 1.00; P < 0.0001). Native Hawaiians patients with gout were 2.7 times more likely to have frequent (≥1) emergency department visits than White patients with gout. Native Hawaiian patients with gout were less likely to have a therapeutic serum urate ≤6.0 mg/dL and had lower rates of rheumatology specialty care. CONCLUSION: Native Hawaiian patients have a higher disease burden of gout, with earlier disease onset and more tophi. Native Hawaiian patients with gout are more likely to use emergency services for gout and have lower rates of rheumatology specialty care compared to White patients. Future studies are needed to promote culturally appropriate preventive care and management of gout in Native Hawaiians.

2023 American College of Rheumatology (ACR)/American College of Chest Physicians (CHEST) Guideline for the Treatment of Interstitial Lung Disease in People with Systemic Autoimmune Rheumatic Diseases.

OBJECTIVE: We provide evidence-based recommendations regarding the treatment of interstitial lung disease (ILD) in adults with systemic autoimmune rheumatic diseases (SARDs). METHODS: We developed clinically relevant population, intervention, comparator, and outcomes questions. A systematic literature review was then performed, and the available evidence was rated using the Grading of Recommendations, Assessment, Development, and Evaluation methodology. A panel of clinicians and patients reached consensus on the direction and strength of the recommendations. RESULTS: Thirty-five recommendations were generated (including two strong recommendations) for first-line SARD-ILD treatment, treatment of SARD-ILD progression despite first-line ILD therapy, and treatment of rapidly progressive ILD. The strong recommendations were against using glucocorticoids in systemic sclerosis-ILD as a first-line ILD therapy and after ILD progression. Otherwise, glucocorticoids are conditionally recommended for first-line ILD treatment in all other SARDs. CONCLUSION: This clinical practice guideline presents the first recommendations endorsed by the American College of Rheumatology and American College of Chest Physicians for the treatment of ILD in people with SARDs.

2023 American College of Rheumatology (ACR)/American College of Chest Physicians (CHEST) Guideline for the Screening and Monitoring of Interstitial Lung Disease in People with Systemic Autoimmune Rheumatic Diseases.

OBJECTIVE: We provide evidence-based recommendations regarding screening for interstitial lung disease (ILD) and the monitoring for ILD progression in people with systemic autoimmune rheumatic diseases (SARDs), specifically rheumatoid arthritis, systemic sclerosis, idiopathic inflammatory myopathies, mixed connective tissue disease, and Sjögren disease. METHODS: We developed clinically relevant population, intervention, comparator, and outcomes questions related to screening and monitoring for ILD in patients with SARDs. A systematic literature review was performed, and the available evidence was rated using the Grading of Recommendations, Assessment, Development, and Evaluation methodology. A Voting Panel of interdisciplinary clinician experts and patients achieved consensus on the direction and strength of each recommendation. RESULTS: Fifteen recommendations were developed. For screening people with these SARDs at risk for ILD, we conditionally recommend pulmonary function tests (PFTs) and high-resolution computed tomography of the chest (HRCT chest); conditionally recommend against screening with 6-minute walk test distance (6MWD), chest radiography, ambulatory desaturation testing, or bronchoscopy; and strongly recommend against screening with surgical lung biopsy. We conditionally recommend monitoring ILD with PFTs, HRCT chest, and ambulatory desaturation testing and conditionally recommend against monitoring with 6MWD, chest radiography, or bronchoscopy. We provide guidance on ILD risk factors and suggestions on frequency of testing to evaluate for the development of ILD in people with SARDs. CONCLUSION: This clinical practice guideline presents the first recommendations endorsed by the American College of Rheumatology and American College of Chest Physicians for the screening and monitoring of ILD in people with SARDs.

2023 American College of Rheumatology (ACR)/American College of Chest Physicians (CHEST) Guideline for the Screening and Monitoring of Interstitial Lung Disease in People with Systemic Autoimmune Rheumatic Diseases.

OBJECTIVE: We provide evidence-based recommendations regarding screening for interstitial lung disease (ILD) and the monitoring for ILD progression in people with systemic autoimmune rheumatic diseases (SARDs), specifically rheumatoid arthritis, systemic sclerosis, idiopathic inflammatory myopathies, mixed connective tissue disease, and Sjögren disease. METHODS: We developed clinically relevant population, intervention, comparator, and outcomes questions related to screening and monitoring for ILD in patients with SARDs. A systematic literature review was performed, and the available evidence was rated using the Grading of Recommendations, Assessment, Development, and Evaluation methodology. A Voting Panel of interdisciplinary clinician experts and patients achieved consensus on the direction and strength of each recommendation. RESULTS: Fifteen recommendations were developed. For screening people with these SARDs at risk for ILD, we conditionally recommend pulmonary function tests (PFTs) and high-resolution computed tomography of the chest (HRCT chest); conditionally recommend against screening with 6-minute walk test distance (6MWD), chest radiography, ambulatory desaturation testing, or bronchoscopy; and strongly recommend against screening with surgical lung biopsy. We conditionally recommend monitoring ILD with PFTs, HRCT chest, and ambulatory desaturation testing and conditionally recommend against monitoring with 6MWD, chest radiography, or bronchoscopy. We provide guidance on ILD risk factors and suggestions on frequency of testing to evaluate for the development of ILD in people with SARDs. CONCLUSION: This clinical practice guideline presents the first recommendations endorsed by the American College of Rheumatology and American College of Chest Physicians for the screening and monitoring of ILD in people with SARDs.

2023 American College of Rheumatology (ACR)/American College of Chest Physicians (CHEST) Guideline for the Treatment of Interstitial Lung Disease in People with Systemic Autoimmune Rheumatic Diseases.

OBJECTIVE: We provide evidence-based recommendations regarding the treatment of interstitial lung disease (ILD) in adults with systemic autoimmune rheumatic diseases (SARDs). METHODS: We developed clinically relevant population, intervention, comparator, and outcomes questions. A systematic literature review was then performed, and the available evidence was rated using the Grading of Recommendations, Assessment, Development, and Evaluation methodology. A panel of clinicians and patients reached consensus on the direction and strength of the recommendations. RESULTS: Thirty-five recommendations were generated (including two strong recommendations) for first-line SARD-ILD treatment, treatment of SARD-ILD progression despite first-line ILD therapy, and treatment of rapidly progressive ILD. The strong recommendations were against using glucocorticoids in systemic sclerosis-ILD as a first-line ILD therapy and after ILD progression. Otherwise, glucocorticoids are conditionally recommended for first-line ILD treatment in all other SARDs. CONCLUSION: This clinical practice guideline presents the first recommendations endorsed by the American College of Rheumatology and American College of Chest Physicians for the treatment of ILD in people with SARDs.

Romosozumab for the treatment of osteoporosis in women: Efficacy, safety, and cardiovascular risk.

Increased understanding of the Wnt signaling pathway has led to the development of romosozumab, one of the most potent osteoanabolic agents to date for osteoporosis treatment. Romosozumab is a monoclonal antibody that inhibits sclerostin, a natural inhibitor of the Wnt signaling pathway. Romosozumab, by inhibiting sclerostin activates the Wnt signaling pathway, leading to increased bone formation and decreased bone resorption. The pivotal ARCH and FRAME studies established romosozumab's fracture reduction efficacy. Romosozumab was superior to alendronate in fracture reduction and bone mineral density gain in the ARCH study. Romosozumab treatment should be followed sequentially with a potent antiresorptive agent. The antifracture efficacy gained from romosozumab is maintained or improved after transitioning to an antiresorptive agent. As one of the most potent osteoanabolic agents, the introduction of romosozumab has significantly increased our ability to treat osteoporosis. Studies have provided important information on using romosozumab with other osteoporosis medications to optimize osteoporosis treatment. Romosozumab used before antiresorptive medications is associated with more significant bone mineral density increases than when an antiresorptive agent is used before romosozumab. Romosozumab is recommended for osteoporosis treatment in patients at very high risk for fracture with low cardiovascular risk. Romosozumab is generally well tolerated, with 4%-5% of patients having injection site reactions. The ARCH trial showed a higher risk of cardiovascular events in patients receiving romosozumab. Romosozumab carries a black box warning that romosozumab should not be initiated in patients with myocardial infarction or stroke in the preceding year. However, the information on romosozumab and increased cardiovascular risk is conflicting. The risk of cardiovascular disease with romosozumab is unclear. While romosozumab has demonstrated significant osteoanabolic effect and antifracture efficacy and will benefit high fracture risk patients, further studies are needed to investigate the cardiovascular safety of romosozumab.

Clinical Utility of Romosozumab in the Management of Osteoporosis: Focus on Patient Selection and Perspectives.

As one of the most potent osteoanabolic agents with a unique mechanism of action, romosozumab has high efficacy for osteoporosis treatment. It is a monoclonal antibody against sclerostin, a natural inhibitor of the Wnt signaling pathway, and by inhibiting sclerostin, activation of Wnt signaling occurs with a cascade of changes ultimately leading to bone mineral density (BMD) gains. Romosozumab stimulates bone modeling and has a dual effect of activating bone formation while inhibiting bone resorption. With this unique mechanism of action, treatment with romosozumab leads to a rapid and significant gain in BMD; these gains are higher than seen with bisphosphonates, denosumab, or parathyroid hormone (PTH) analogs. The FRAME and ARCH studies represent two pivotal trials demonstrating the efficacy of romosozumab in treating osteoporosis. Treatment with romosozumab should be followed by an antiresorptive agent, as this approach has demonstrated maintenance of or greater increases in BMD and reduced fracture risk even after finishing romosozumab treatment. As an osteoanabolic agent, romosozumab has shown superiority to alendronate in reducing fracture risk, increasing bone density, and potentially more rapid fracture risk reduction. Recent data have suggested that romosozumab prior to antiresorptive therapy may be the ideal treatment sequence, especially in high-risk patients and patients at imminent risk of fracture. Carrying a black box warning, romosozumab should be avoided in patients who have had myocardial infarction or stroke in the past year. Further studies are needed to clarify the increased cardiovascular risk attributed to this drug. Romosozumab has expanded our osteoporosis armamentarium and has enabled novel approaches, including "treat to target." Future studies are needed to evaluate the optimal use sequence and to assess its safety, especially in patients with cardiovascular risk factors.

Subcutaneous immunoglobulin therapy in statin-induced necrotizing autoimmune myopathy.

We report a case of statin-associated necrotising autoimmune myopathy successfully treated with subcutaneous immunoglobulin therapy (SCIG) monotherapy without corticosteroids. This is a 51-year old female with seronegative rheumatoid arthritis, who had been on statins for several years, who developed proximal muscle weakness and elevated creatine kinase after resuming her statin post sleeve gastrectomy for weight loss. Our patient had a history of severe side effects to prednisone. She did not respond to mycophenolate, cyclophosphamide, and rituximab treatment. She had responded to partial treatment with intravenous immunoglobulin (IVIG) but had a severe headache after IVIG infusion. IVIG treatment was discontinued. We tried SCIG treatment, and she was able to tolerate the SCIG treatment with intermittent headaches that were less intense. After treatment with SCIG, creatine kinase levels decreased significantly, with an improvement of muscle strength. She continues to do well on SCIG treatment. To our knowledge, no other cases of statin-associated necrotising autoimmune myopathy treated with SCIG have been reported in the literature. More studies and reports are needed to confirm the utility and efficacy of SCIG in statin-associated necrotising autoimmune myopathy, as well as to provide information about dosing, tolerability, and durability of SCIG in the treatment of statin-associated necrotising autoimmune myopathy.

Septic arthritis of native joints due to Mycobacterium avium complex: A systematic review of case reports.

INTRODUCTION: While MAC native joint septic arthritis is historically considered a rare entity, the number of reported cases have increased in recent decades. However, no comprehensive review of this topic has been conducted. OBJECTIVES: To conduct a systematic review of cases of MAC native joint septic arthritis reported in the literature and summarize the presentations, baseline characteristics, risk factors, diagnosis, treatment, and treatment outcomes. METHODS: A systematic review was conducted by performing an extensive literature search through Medline, Google Scholar, and Web of Science, starting from their inception. Screening of articles, assessment of eligibility, and data synthesis from eligible articles were independently performed by two reviewers with input from a third reviewer to achieve consensus. Inclusion criteria to determine eligibility included articles in English, case reports/case series, adult patients who presented with MAC/MA/MI septic arthritis of a native joint. Statistical analyses were performed using Statistical Package for the Social Sciences. RESULTS: Thirty-three cases of MAC native joint septic arthritis were reported since 1976. MAC septic arthritis affects immunocompetent and immunocompromised patients, most frequently as a monoarthritis involving the knees and wrist. MAC septic arthritis may present in the context of disseminated MAC infection and primary MAC septic arthritis. The average time to diagnosis from onset of symptoms was 20 months, where the majority of cases were initially misdiagnosed. Although arthrocentesis can be used to make the diagnosis, a synovial biopsy is necessary in many cases to confirm the diagnosis. A combination of surgery and antimycobacterial drug treatment has the highest chance of achieving complete resolution. CONCLUSION: The diagnosis of septic arthritis of native joints due to MAC can be challenging and/or delayed. A high level of suspicion is needed in high-risk patients and also when atypical presentations occur. Therefore, understanding the presentation, risk factors, and pitfalls in diagnosing MAC septic arthritis are essential. MAC septic arthritis literature is scarce, necessitating further research of this rare condition to increase awareness, diagnostic accuracy and determine the optimal treatment strategy to improve patient outcomes.

Septic Arthritis of the Right Wrist Due to Mycobacterium avium Complex in an Immunocompetent Patient.

Septic arthritis due to Mycobacterium avium complex (MAC) is extremely rare. While MAC infection is classically associated with HIV/AIDS and immunosuppressed states, it may occur in immunocompetent individuals. We report a case of MAC septic arthritis of a native wrist joint in an immunocompetent host. The diagnosis of septic arthritis due to MAC is commonly delayed and initially misdiagnosed, warranting a high level of suspicion to make an accurate and timely diagnosis. Suspecting the diagnosis when there are atypical features present in the clinical history may be crucial in identifying affected patients.

Osteoporosis treatment rates after hip fracture 2011-2019 in Hawaii: Undertreatment of men after hip fractures.

OBJECTIVES: To investigate trends of osteoporosis treatment rates, and factors affecting osteoporosis treatment after hip fracture admission within a single health care system in Hawaii. METHODS: A retrospective chart review was conducted of patients aged 50 years or older and hospitalized for hip fractures between January 1, 2011 and December 31, 2019 at Hawaii Pacific Health, a large health care system in Hawaii. We collected data on basic demographics and osteoporosis medication prescription from electronic medical records. We evaluated trends of osteoporosis treatment rates and performed logistic regression to determine factors associated with osteoporosis treatment. RESULTS: The mean for treatment rates for osteoporosis from 2011 to 2019 was 17.2% (range 8.8%-26.0%). From 2011 to 2019 there was a small increase in treatment rates from 16.3% in 2011 to 24.1% in 2019. Men were less likely to receive osteoporosis treatment after admission for hip fracture. Patients discharged to a facility were more likely to receive osteoporosis treatment. As compared to women, men who had a hip fracture were less likely to receive dual-energy X-ray absorptiometry scan, and osteoporosis medication before hip fracture admission. CONCLUSIONS: The use of osteoporosis medication for secondary prevention after admission for hip fracture in Hawaii from 2011 to 2019 was low. However, there was a small increase in treatment rates from 2011 to 2019. Disparities in treatment of osteoporosis after hip fracture were noted in men. Significant work is needed to increase treatment rates further, and to address the disparity in osteoporosis treatment between men and women.

Osteoporotic hip fracture mortality and associated factors in Hawai'i.

The 30-day mortality of osteoporotic hip fracture patients ≥ 50 years at Hawai'i Pacific Health (2015-2016) was 4.2%. Mortality increased to 17.1% (1 year), 24.5% (2 years), and 30.1% (3 years). Increased age, male sex, higher CCI score, primary insurance status-Medicare/Medicaid, and lower BMI were associated with increased mortality. PURPOSE: The objective of this study was to evaluate mortality and factors associated with mortality of osteoporotic hip fracture patients at community hospitals within a large healthcare system in Hawai'i. METHODS: A retrospective chart review was conducted of 428 patients, ≥ 50 years, and hospitalized for a osteoporotic hip fracture from January 2015 to May 2016 within a large healthcare system in Hawai'i. Patient demographics, comorbidities, and treatment were collected from retrospective chart review. We determined the date of death by review of medical records and online public obituary records. We calculated 30-day, 90-day, 1-year, 2-year, and 3-year mortality after discharge for hip fracture admission. Multivariable logistic regression and proportional hazards regression were used to evaluate associations between variables and the mortality of the patients. RESULTS: The 30-day and 90-day mortality after admission for hip fracture were 4.2% and 8.6%. One-year mortality, 2-year mortality, and 3-year mortality were 17.1%, 24.5%, and 30.1%, respectively. Through proportional hazards regression, older age (hazard ratio (HR) = 1.06, p < 0.001), high comorbidity load (HR = 1.30, p < 0.001), and primary insurance status-Medicare/Medicaid (HR = 3.78, p = 0.021) were associated with increased mortality, while female sex (HR = 0.54, p < 0.001) and higher BMI (HR = 0.94, p = 0.002) were associated with lower mortality. CONCLUSION: After admission for osteoporotic hip fracture, the 30-day mortality was 4.2%. At 1 year, 2 years, and 3 years, mortality increased to 17.1%, 24.5%, and 30.1%, respectively. Increased age, male sex, higher Charlson comorbidity index score, primary insurance status-Medicare/Medicaid, and lower body mass index were associated with increased mortality.

Challenges in Optimizing Medical Education for Rheumatologists.

The field of rheumatology has expanded rapidly in recent years, and innovations in immunology, epigenetics, and bone metabolism continue at an astonishing pace. In this fast changing field, optimizing medical education for rheumatologists is vital for maintaining a competent workforce to meet the needs of patients with rheumatic diseases. Several key challenges lie ahead and efforts to optimize medical education for rheumatologists are discussed in this article.