T1Gd is reduced in bone marrow lesions overlying cartilage in the hip.

OBJECTIVE: Bone Marrow Lesions (BMLs) are areas in bone with high fluid signal on MRI associated with painful and progressive OA. While cartilage near BMLs in the knee has been shown to be degenerated, this relationship has not been investigated in the hip. RESEARCH QUESTION: is T1Gd lower in areas of cartilage overlying BMLs in the hip? DESIGN: 128 participants were recruited from a population-based study of hip pain in 20-49-year-olds. Proton-density weighted fat-suppressed and delayed Gadolinium Enhanced MR Imaging of Cartilage (dGEMRIC) images were acquired to locate BMLs and quantify hip cartilage health. BML and cartilage images were registered and cartilage was separated into BML overlying and surrounding regions. Mean T1Gd was measured in 32 participants with BMLs in both cartilage regions and in matched regions in 32 age- and sex-matched controls. Mean T1Gd in the overlying cartilage was compared using linear mixed-effects models between BML and control groups for acetabular and femoral BMLs, and between cystic and non-cystic BML groups. RESULTS: Mean T1Gd of overlying cartilage was lower in the BML group compared to the control group (acetabular: -105 ms; 95% CI: -175, -35; femoral: -8 ms; 95% CI: -141, 124). Mean T1Gd in overlying cartilage was lower in cystic compared to non-cystic BML subjects, but the confidence interval is too large to provide certainty in this difference (-3 [95% CI: -126, 121]). CONCLUSIONS: T1Gd is reduced in overlying cartilage in hips from a population-based sample of adults aged 20-49, which suggests BMLs are associated with local cartilage degeneration in hips.

Risk of severe infections after the introduction of biologic DMARDs in people with newly diagnosed rheumatoid arthritis: a population-based interrupted time-series analysis.

OBJECTIVES: To determine the impact of the introduction of biologic DMARDs (bDMARDs) on severe infections among people newly diagnosed with RA compared with non-RA individuals. METHODS: In this population-based retrospective cohort study using administrative data (from 1990-2015) for British Columbia, Canada, all incident RA patients diagnosed between 1995 and 2007 were identified. General population controls with no inflammatory arthritis were matched to RA patients based on age and gender, and were assigned the diagnosis date (i.e. index date) of the RA patients they were matched with. RA/controls were then divided into quarterly cohorts according to their index dates. The outcome of interest was all severe infections necessitating hospitalization or occurring during hospitalization after the index date. We calculated 8-year severe infection rates for each cohort and conducted interrupted time-series analyses to compare severe infection trends in RA/controls with index date during pre-bDMARDs (1995-2001) and post-bDMARDs (2003-2007) periods. RESULTS: A total of 60 226 and 588 499 incident RA/controls were identified. We identified 14 245 severe infections in RA, and 79 819 severe infections in controls. The 8-year severe infection rates decreased among RA/controls with increasing calendar year of index date in the pre-bDMARDs period, but increased over time only among RA, not controls, with index date in the post-bDMARDs period. The adjusted difference between the pre- and post-bDMARDs secular trends in 8-year severe infection rates was 1.85 (P = 0.001) in RA and 0.12 (P = 0.29) in non-RA. CONCLUSION: RA onset after bDMARDs introduction was associated with an elevated severe infection risk in RA patients compared with matched non-RA individuals.

Effect of digital monitoring and counselling on self-management ability in patients with rheumatoid arthritis: a randomised controlled trial.

OBJECTIVES: To assess a remote physiotherapist (PT) counselling intervention using self-monitoring tools for improving self-management ability, physical activity participation, and health outcomes in people with rheumatoid arthritis (RA). METHODS: Eligible participants were randomly assigned to receive group education, a Fitbit®, a self-monitoring app, and PT counselling phone calls (Immediate Group). The Delayed Group received a monthly e-newsletter until week 26, and then the intervention. The primary outcome was Patient Activation Measure (PAM-13). Participants were assessed at baseline, 27 weeks (the primary end point) and 53 weeks. Secondary outcomes included disease activity, pain, fatigue, depression, sitting/walking habits, daily physical activity time, and daily awake sedentary time. Generalized Linear Mixed-effect Models (GLMMs) were used to assess the effect of the intervention on the change of each outcome measure from the initiation to 27 weeks after the intervention. RESULTS: Analysis included 131 participants (91.6% women; 80.2% completed during the COVID-19 pandemic). The mean change of PAM-13 at 27 weeks was 4.6 (SD = 14.7) in the Immediate Group vs -1.6 (SD = 12.5) in the Delayed Group. The mean change in Delayed Group at 53 weeks (after the 26-week intervention) was 3.6 (SD = 14.6). Overall, the intervention improved PAM-13 at 27 weeks post-intervention from the GLMM analysis (adjusted coefficient: 5.3; 95% CI: 2.0, 8.7; p = <0.001). Favourable intervention effects were also found in disease activity, fatigue, depression, and self-reported walking habit. CONCLUSION: Remote counselling paired with self-monitoring tools improved self-management ability in people with RA. Findings of secondary outcomes indicate that the intervention had a positive effect on symptom management.

Has the incidence of total joint arthroplasty in rheumatoid arthritis decreased in the era of biologics use? A population-based cohort study.

OBJECTIVES: To determine whether the introduction of biological DMARDs (bDMARDs) was associated with reduced incidences of total hip and knee arthroplasty (THA/TKA) among patients with RA compared with OA. METHODS: Using a population-based cohort in British Columbia, Canada, RA and OA patients diagnosed between 1995 and 2007 were divided into semi-annual cohorts according to diagnosis date. For each cohort, we calculated 8-year incidence rates of THA and TKA. We compared levels and trends of THA/TKA incidence in RA/OA patients diagnosed during pre-bDMARDs (1995-2001) and post-bDMARDs (2003-2007) periods using interrupted time-series analysis, adjusting for baseline characteristics. Adjusted 8-year total joint arthroplasty incidence estimated for RA/OA cohorts diagnosed five years after bDMARDs introduction were compared with expected rates assuming no bDMARDs introduction, based on extrapolation of pre-bDMARDs trends. RESULTS: We identified 60 227 RA and 288 260 OA incident cases. For cohorts diagnosed pre-bDMARDs, 8-year THA/TKA incidence rates increased over time in both RA and OA. For cohorts diagnosed post-bDMARDs, these rates decreased over time in RA but continued to increase for OA. For RA, differences between the post- and pre-bDMARDs secular trends in incidence rates were -0.49 (P = 0.002) for THA and -0.36 (P = 0.003) for TKA, compared with +0.40 (P = 0.006) and +0.54 (P < 0.001), respectively, for OA. For RA cohorts diagnosed five years after bDMARDs introduction, 8-year incidences were 26.9% and 12.6% lower for THA and TKA, respectively, than expected rates. In contrast, corresponding rates in OA were higher by 11.7% and 16.6%, respectively. CONCLUSION: Arthritis onset after bDMARDs introduction is associated with a significant reduction in THA/TKA incidence in RA, but not in OA. The reduction reflects a significant improvement in RA treatment during the biological era.

Prevalence of joint-specific osteoarthritis and joint pain in British Columbia, Canada.

The objective is to determine the prevalence of self-reported physician-diagnosed osteoarthritis (OA) and musculoskeletal symptoms (pain, stiffness or discomfort) in specific joints among adults in British Columbia (BC), Canada. We carried out a cross-sectional mixed-mode survey in a random population sample of persons 18 years of age and older. Estimates were weighted to reflect the age and sex distribution of the population of BC. We obtained responses from 2,233 individuals. Overall, 18.4% (95% CI 16.8-20.1) of the adult population reported OA. Of those, more than 40% had OA in multiple sites. Prevalence ranged from 8.8% (95% CI 7.6-10.1) in the knee to 2.7% (2.1-3.5) in the foot. One-year prevalence of symptoms ranged from 49.1% (47.0-51.2) in the lower back to 23.3% (21.5-25.1) in the hip. Females reported more symptoms and OA than males in all joints. The most common site of self-reported physician-diagnosed OA in BC is the knee, but OA in the hands, hips, and feet is also common. Having OA in one joint is a strong predictor of OA in other joints.

Magnetic resonance imaging predictors (cartilage, osteophytes and meniscus) of prevalent and 3-year incident medial and lateral tibiofemoral knee joint tenderness and patellofemoral grind.

OBJECTIVE: To identify magnetic resonance imaging (MRI) predictors (cartilage [C], osteophytes [O] and meniscus [M] scores) of prevalent and 3-year incident medial tibiofemoral (MTF) and lateral tibiofemoral (LTF) knee joint tenderness and patellofemoral (PF) grind.  METHODS: Population-based knee pain cohort aged 40-79 was assessed at baseline (N = 255), 3- and 7-year follow-up (N = 108 × 2 = 216). COM scores were measured at 6/8/6 subregions respectively. Age-sex-BMI adjusted logistic models predicted prevalence versus relevant COM predictors (medial, lateral or patellar / trochlear groove scores). Fully adjusted models also included all relevant COM predictors. Binary generalized estimating equations models predicting 3-year incidence were also adjusted for individual follow-up time between cycles. RESULTS: Significant predictors of prevalent MTF tenderness: medial femoral cartilage (fully adjusted odds ratio [aOR] 1.84; 95% confidence interval [CI] 1.11, 3.05), female (aOR = 3.05; 1.67, 5.58), BMI (aOR = 1.53 per 5 units BMI; 1.10, 2.11). Predictors of prevalent LTF tenderness: female (aOR = 2.18; 1.22, 3.90). There were no predictors of prevalent PF grind in the fully adjusted model. However, medial patellar osteophytes was predictive in the age-sex-BMI adjusted model. There were no predictors of 3-year incident MTF tenderness. Predictors of 3-year incident LTF tenderness: female (aOR = 3.83; 1.25, 11.77). Predictors of 3-year incident PF grind: lateral patellar osteophytes (aOR = 4.82; 1.69, 13.77). In the age-sex-BMI adjusted model, patellar cartilage was also a predictor. CONCLUSION: We explored potential MRI predictors of prevalent and 3-year incident MTF/LTF knee joint tenderness and PF grind. These findings could guide preemptive strategies aimed at reducing these symptoms in the present and future (3-year incidence).

Reducing the burden of low back pain: results from a new microsimulation model.

BACKGROUND: Low back pain (LBP) causes the highest morbidity burden globally. The purpose of the present study was to project and compare the impact of three strategies for reducing the population health burden of LBP: weight loss, ergonomic interventions, and an exercise program. METHODS: We have developed a microsimulation model of LBP in Canada using a new modeling platform called SimYouLate. The initial population was derived from Cycle 1 (2001) of the Canadian Community Health Survey (CCHS). We modeled an open population 20 years of age and older. Key variables included age, sex, education, body mass index (BMI), type of work, having back problems, pain level in persons with back problems, and exercise participation. The effects of interventions on the risk of LBP were obtained from the CCHS for the effect of BMI, the Global Burden of Disease Study for occupational risks, and a published meta-analysis for the effect of exercise. All interventions lasted from 2021 to 2040. The population health impact of the interventions was calculated as a difference in years lived with disability (YLDs) between the base-case scenario and each intervention scenario, and expressed as YLDs averted per intervention unit or a proportion (%) of total LBP-related YLDs. RESULTS: In the base-case scenario, LBP in 2020 was responsible for 424,900 YLDs in Canada and the amount increased to 460,312 YLDs in 2040. The effects of the interventions were as follows: 27,993 (95% CI 23,373, 32,614) YLDs averted over 20 years per 0.1 unit change in log-transformed BMI (9.5% change in BMI) among individuals who were overweight and those with obesity, 19,416 (16,275, 22,557) YLDs per 1% reduction in the proportion of workers exposed to occupational risks, and 26,058 (22,455, 29,661) YLDs averted per 1% increase in the proportion of eligible patients with back problems participating in an exercise program. CONCLUSIONS: The study provides new data on the relationship between three types of interventions and the resultant reductions in LBP burden in Canada. According to our model, each of the interventions studied could potentially result in a substantial reduction in LBP-related disability.

Increased risk of severe infections and mortality in patients with newly diagnosed systemic lupus erythematosus: a population-based study.

OBJECTIVE: To evaluate the risk of severe infection and infection-related mortality among patients with newly diagnosed SLE. METHODS: We conducted an age- and gender-matched cohort study of all patients with incident SLE between 1 January 1997 and 31 March 2015 using administrative health data from British Columbia, Canada. Primary outcome was the first severe infection after SLE onset necessitating hospitalization or occurring during hospitalization. Secondary outcomes were total number of severe infections and infection-related mortality. RESULTS: We identified 5169 SLE patients and matched them with 25 845 non-SLE individuals from the general population, yielding 955 and 1986 first severe infections during 48 367 and 260 712 person-years follow-up, respectively. The crude incidence rate ratios for first severe infection and infection-related mortality were 2.59 (95% CI: 2.39, 2.80) and 2.20 (95% CI: 1.76, 2.73), respectively. The corresponding adjusted hazard ratios were 1.82 (95% CI: 1.66, 1.99) and 1.61 (95% CI: 1.24, 2.08). SLE patients had an increased risk of a greater total number of severe infections with crude rate ratio of 3.24 (95% CI: 3.06, 3.43) and adjusted rate ratio of 2.07 (95% CI: 1.82, 2.36). CONCLUSION: SLE is associated with increased risks of first severe infection (1.8-fold), a greater total number of severe infections (2.1-fold) and infection-related mortality (1.6-fold).

The risk and trend of pulmonary embolism and deep vein thrombosis in rheumatoid arthritis: a general population-based study.

OBJECTIVES: To estimate the overall risk of venous thromboembolism (VTE), pulmonary embolism (PE) and deep vein thrombosis (DVT) among patients newly diagnosed with RA compared with the general population without RA; and to estimate the risk trends of VTE, PE and DVT after RA diagnosis up to 5 years compared with the general population. METHODS: Using previously validated RA case definition, we conducted a matched cohort study using the population-based administrative health database from the province of British Columbia, Canada. We calculated incidence rates (IRs) and fully adjusted hazard ratios (HRs) for the risk of VTE, DVT and PE after RA index date. RESULTS: Among 39 142 incident RA patients (66% female, mean age 60), 1432, 543 and 1068 developed VTE, PE and DVT, respectively. IRs for the RA cohort were 3.79, 1.43 and 2.82 per 1000 person-years vs 2.70, 1.03 and 1.94 per 1000 person-years for the non-RA cohort. After adjusting for VTE risk factors, the HRs (95% CI) were 1.28 (1.20, 1.36), 1.25 (1.13, 1.39) and 1.30 (1.21, 1.40) for VTE, PE and DVT, respectively. The fully adjusted HRs for VTE during the first five years after RA diagnosis were 1.60, 1.47, 1.40, 1.30 and 1.28, respectively. A similar trend was shown in PE. CONCLUSION: This population-based study demonstrates that RA patients have an increased risk of VTE, PE and DVT after diagnosis compared with the general population. This risk is independent of traditional VTE risk factors and is highest during the first year after RA diagnosis, then progressively declined.

Trends of venous thromboembolism risk before and after diagnosis of gout: a general population-based study.

OBJECTIVE: To estimate the overall risk and the temporal trend of venous thromboembolism (VTE), deep vein thrombosis (DVT), and pulmonary embolism (PE) before and after gout diagnosis in an incident gout cohort compared with the general population. METHODS: We conducted a matched cohort study using a province-wide population-based administrative health database in Canada. We calculated incidence rates (IRs) and multivariable adjusted hazard ratios (HRs) for the risk of VTE, DVT and PE before and after gout diagnosis. RESULTS: Among 130 708 incident individuals with gout (64% male, mean age 59 years), 2071 developed VTE, 1377 developed DVT and 1012 developed PE. IRs per 1000 person-years for gout were 2.63, 1.74 and 1.28 compared with 2.03, 1.28 and 1.06 for non-gout, respectively. The fully adjusted HRs (95% CI) for VTE, DVT and PE were 1.22 (1.13, 1.32), 1.28 (1.17, 1.41) and 1.16 (1.05, 1.29). For the pre-gout period, the fully adjusted HRs (95% CI) were 1.51 (1.38, 1.64), 1.55 (1.40, 1.72) and 1.47 (1.31, 1.66) for VTE, DVT and PE. During the third, second and first years preceding gout, the fully adjusted HRs for VTE were 1.44, 1.56 and 1.62. During the first, second, third, fourth and fifth years after gout, the fully adjusted HRs were 1.63, 1.29, 1.33, 1.28 and 1.22. Similar trends were also seen for DVT and PE. CONCLUSION: Increased risks of VTE, DVT and PE were found both before and after gout diagnosis. The risk increased gradually before gout, peaking in the year prior to diagnosis, and then progressively declined. Gout-associated inflammation may contribute to venous thrombosis risk.

Specific manifestations of knee osteoarthritis predict depression and anxiety years in the future: Vancouver Longitudinal Study of Early Knee Osteoarthritis.

BACKGROUND: To evaluate whether knee osteoarthritis (OA) manifestations predict depression and anxiety using cross-sectional and longitudinal prediction models. METHODS: A population-based cohort (n = 122) with knee pain, aged 40-79, was evaluated at baseline, 3 and 7 years. Baseline predictors were: age decade; sex; BMI ≥ 25; physical exam knee effusion; crepitus; malalignment; quadriceps atrophy; flexion; flexion contracture; Kellgren-Lawrence (KL) x-ray grade (0/1/2/3+); WOMAC pain ≥25; WOMAC stiffness ≥25; self-reported knee swelling; and knee OA diagnosis (no/probable/definite). Depression and anxiety, cutoffs 5+ and 7+ respectively, were measured via the Hospital Anxiety and Depression Scale. We fit logistic models at each cycle using multivariable models selected via lowest Akaike's information criterion. RESULTS: Baseline depression model: sex (female OR = 0.27; 0.10, 0.76) and KL grade (KL 1 OR = 4.21; 1.31, 13.48). Three-year depression model: KL grade (KL 1 OR = 18.92; 1.73, 206.25). Seven-year depression model: WOMAC stiffness ≥25 (OR = 3.49; 1.02, 11.94) and flexion contracture ≥1 degree (OR = 0.23; 0.07, 0.81). Baseline anxiety model: knee swelling (OR = 4.11; 1.51, 11.13) and age (50-59 vs. 40-49 OR = 0.31 [0.11, 0.85]; 60-69 OR = 0.07 [0.01, 0.42]). Three-year anxiety model: WOMAC stiffness ≥25 (OR = 5.80; 1.23, 27.29) and KL grade (KL 1 OR = 6.25; 1.04, 37.65). Seven-year anxiety model: sex (female OR = 2.71; 0.87, 8.46). CONCLUSION: Specific knee OA-related manifestations predict depression and anxiety cross-sectionally, 3 years in the future, and for depression, 7 years in the future. This information may prove useful to clinicians in helping to identify patients most at risk of present or future depression and anxiety, thus facilitating preemptive discussions that may help counter that risk.

Quality of care for cardiovascular disease prevention in rheumatoid arthritis: compliance with hyperlipidemia screening guidelines.

Objective: To evaluate compliance with hyperlipidaemia screening guidelines for cardiovascular disease prevention in RA compared with the general population. Methods: We conducted a longitudinal study of a population-based RA cohort including all prevalent cases in British Columbia between 1996 and 2006, followed up until 2010, with matched general population controls. Using administrative data, we measured compliance with general population guidelines (testing lipids every 5 years for women ⩾50 and men ⩾40), after excluding individuals with previous diabetes, coronary artery disease or hyperlipidaemia. Compliance was measured as the proportion of 5-year eligibility periods with one or more lipid test. Compliance rates in RA and controls were compared by Chi-square test. Odds ratio (95% CI) of compliance in RA (vs controls) was estimated using generalized estimating equation models, adjusting for age and sex. Mean compliance rate per patient was also calculated and compared using Mann-Whitney U test. Results: Analyses included 5587 RA individuals and 5613 controls, contributing 6993 and 7208 5-year eligibility periods, respectively. Lipids were measured in 56.6 and 59.5% of eligibility periods in RA and controls, respectively [adjusted odds ratio (95% CI): 0.97 (0.90, 1.06)]. Screening improved over time in RA relative to the general population, but remained suboptimal even after 2003, at 65.8%. Mean (s.d.) compliance rate per patient was 56.6 (47.2)% for RA and 59.5 (46.6)% for controls. Family physicians ordered almost all the lipid tests. Conclusion: Compliance with general population guidelines for hyperlipidaemia screening in RA was poor and did not differ from the general population, despite a higher risk of cardiovascular diseases.

Utility of Electronic Medical Records in Community Rheumatology Practice for Assessing Quality of Care Indicators for Gout: A Feasibility Study.

OBJECTIVES: With comprehensive capture of information on patient encounters, electronic medical records (EMRs) may have utility for assessing adherence to quality indicators (QIs) in gout. Our objectives were to translate 10 previously established gout QIs into relevant EMR data and evaluate and describe the feasibility of using EMRs to assess gout QIs. METHODS: Using EMRs from 3 community rheumatology practices in Vancouver, British Columbia, Canada, we identified gout patients seen between January 1, 2012, and December 31, 2013. We translated each gout QI into potential EMR variables that would allow identification of patients the QI pertains to and whether the QI could be assessed. We extracted deidentified EMR data on gout diagnosis, medications, laboratory tests, radiological tests, and clinical notes and calculated the percent availability of data for each QI. RESULTS: We included 125 patients with gout, with mean age of 64 ± 17 years and with males comprising 78%. Overall, there were sufficient EMR data to allow translation of 7 QIs and assessment of 6 QIs including therapy-related gout QIs (69%-83% data availability) and one counseling-related QI (8% data availability). The highest percent data availability was observed in the single QI translated into EMR data and assessed based on diagnostic codes and prescription medications and not laboratory tests. CONCLUSIONS: Electronic medical records are promising tools for assessing QIs for gout. It was feasible to translate seven gout QIs into relevant EMR variables and there was sufficient EMR data to feasibly assess six of these QIs -Our findings lend evidence to support the utility of EMRs for ut QI assessment, with implications for helping improve management of this disease.

Mortality in ANCA-associated vasculitis: ameta-analysis of observational studies.

OBJECTIVE: To determine the magnitude of all-cause mortality risk in patients with antineutrophil cytoplasmic antibodies-associated vasculitis (AAV) compared with the general population through a meta-analysis of observational studies. METHODS: We searched Medline and Embase databases from their inception to April 2015. Observational studies that met the following criteria were assessed by two researchers: (1) clearly defined AAV identified by either the American College of Rheumatology 1990 classification criteria or the 2012 Chapel Hill Consensus Conference disease definitions, and (2) reported standardised mortality ratios (SMR) and 95% CI. We calculated weighted-pooled summary estimates of SMRs (meta-SMRs) for all-cause mortality using random-effects model, tested for publication bias and heterogeneity. RESULTS: Ten studies met the inclusion criteria, comprising 3338 patients with AAV enrolled from 1966 to 2009, and a total of 1091 observed deaths. Overall, we found a 2.7-fold increased risk of death in patients with AAV when compared with the general population (meta-SMR: 2.71 (95% CI 2.26 to 3.24)). Analysis on studies that included only granulomatosis with polyangiitis cases also indicated a similar mortality risk (meta-SMR: 2.63 (95% CI 2.02 to 3.43)). There was no significant publication bias or small-study effect. Subgroup analyses showed that mortality risks were higher in older cohorts, with a trend towards improvement over time (ie, those with their midpoint of enrolment periods that were between 1980-1993 and 1994-1999, vs 2000-2005). CONCLUSION: Published data indicate there is a 2.7-fold increase in mortality among patients with AAV compared with the general population.

Association of body mass index with knee cartilage damage in an asymptomatic population-based study.

BACKGROUND: Cartilage changes are an important early finding of osteoarthritis (OA), which can exist even before symptoms. Our objective was to determine the prevalence of knee cartilage damage on magnetic resonance imaging (MRI) in an asymptomatic population-based cross-sectional study and to evaluate the association of body mass index (BMI) with cartilage damage. METHODS: Subjects, aged 40-79 years, without knee pain (n = 73) were recruited as a random population sample and assessed for BMI (kg/m2), including current BMI (measured), past BMI at age 25 (self-reported) and change in BMI. Knee cartilage was scored semi-quantitatively (grades 0-4) on MRI. In primary analysis, cartilage damage was defined as ≥2 (at least moderate) and in a secondary analysis as ≥3 (severe). We also conducted a sensitivity analysis by dichotomizing current BMI as <25 vs. ≥25. Logistic regression was used to evaluate the association of each BMI variable with prevalent MRI-detected cartilage damage, adjusted for age and sex. RESULTS: Of 73 subjects, knee cartilage damage ≥2 and ≥3 was present in 65.4% and 28.7%, respectively. The median current BMI was 26.1, median past BMI 21.6, and median change in BMI was a gain of 2.8. For cartilage damage ≥2, current BMI had a non-statistically significant OR of 1.65 per 5 units (95% CI 0.93-2.92). For cartilage damage ≥3, current BMI showed a trend towards statistical significance with an OR of 1.70 per 5 units (95% CI 0.99-2.92). Past BMI and change in BMI were not significantly associated with cartilage damage. Current BMI ≥ 25 was statistically significantly associated with cartilage damage ≥2 (OR 3.04 (95% CI 1.10-8.42)), but not for ≥3 (OR 2.63 (95% CI 0.86-8.03)). CONCLUSIONS: MRI-detected knee cartilage damage was highly prevalent in this asymptomatic population-based cohort. We report a trend towards significance of BMI with cartilage damage severity. Subjects with abnormal current BMI (≥25) had a 3-fold increased odds of cartilage damage ≥2, compared to those with normal BMI. This study lends support towards the role of obesity in the pathogenesis of knee cartilage damage at an asymptomatic stage of disease.

Femoroacetabular impingement and osteoarthritis of the hip.

OBJECTIVE: To outline the clinical presentation, physical examination findings, diagnostic criteria, and management options of femoroacetabular impingement (FAI). SOURCES OF INFORMATION: PubMed was searched for relevant articles regarding the pathogenesis, diagnosis, treatment, and prognosis of FAI. MAIN MESSAGE: In recent years, FAI has been increasingly recognized as a potential precursor and an important contributor to hip pain in the adult population and idiopathic hip osteoarthritis later in life. Femoroacetabular impingement is a collection of bony morphologic abnormalities of the hip joint that result in abnormal contact during motion. Cam-type FAI relates to a non-spherical osseous prominence of the proximal femoral neck or head-neck junction. Pincer-type FAI relates to excessive acetabular coverage over the femoral head, which can occur owing to several morphologic variants. Patients with FAI present with chronic, deep, or aching anterior groin pain most commonly in the sitting position, or during or after activity. Patients might also experience occasional sharp pains during activity. A thorough history should be taken that includes incidence of trauma and exercise frequency. A physical examination should be performed that includes a full hip, low back, and abdominal examination to assess for alternate causes of anterior groin pain. Diagnosis of FAI should be confirmed with radiography. Femoroacetabular impingement can be managed conservatively with rest, modification of activities, medications, and physiotherapy, or it can be treated surgically. CONCLUSION: Femoroacetabular impingement is an important cause of anterior groin pain. Early recognition and intervention by the primary care provider might be critical to alleviating morbidity and preventing FAI progression.

"Employment and arthritis: making it work" a randomized controlled trial evaluating an online program to help people with inflammatory arthritis maintain employment (study protocol).

BACKGROUND: Arthritis and musculoskeletal conditions are the leading cause of long-term work disability (WD), an outcome with a major impact on quality of life and a high cost to society. The importance of decreased at-work productivity has also recently been recognized. Despite the importance of these problems, few interventions have been developed to reduce the impact of arthritis on employment. We have developed a novel intervention called "Making It Work", a program to help people with inflammatory arthritis (IA) deal with employment issues, prevent WD and improve at-work productivity. After favorable results in a proof-of-concept study, we converted the program to a web-based format for broader dissemination and improved accessibility. The objectives of this study are: 1) to evaluate in a randomized controlled trial (RCT) the effectiveness of the program at preventing work cessation and improving at-work productivity; 2) to perform a cost-utility analysis of the intervention. METHODS/DESIGN: 526 participants with IA will be recruited from British Columbia, Alberta, and Ontario in Canada. The intervention consists of a) 5 online group sessions; b) 5 web-based e-learning modules; c) consultations with an occupational therapist for an ergonomic work assessment and a vocational rehabilitation counselor. Questionnaires will be administered online at baseline and every 6 months to collect information about demographics, disease measures, costs, work-related risk factors for WD, quality of life, and work outcomes. Primary outcomes include at-work productivity and time to work cessation of > 6 months for any reason. Secondary outcomes include temporary work cessation, number of days missed from work per year, reduction in hours worked per week, quality adjusted life year for the cost utility analysis, and changes from baseline in employment risk factors. Analysis of Variance will evaluate the intervention's effect on at-work productivity, and multivariable Cox regression models will estimate the risk of work cessation associated with the intervention after controlling for risk factors for WD and other important predictors imbalanced at baseline. DISCUSSION: This program fills an important gap in arthritis health services and addresses an important and costly problem. Knowledge gained from the RCT will be useful to health care professionals, policy planners and arthritis stakeholders. TRIAL REGISTRATION: ClinicalTrials.gov NCT01852851; registered April 13, 2012; first participant randomized on July 6, 2013.

Antimalarial Adherence and Risk of Cardiovascular Events in Patients With Rheumatoid Arthritis and Systemic Lupus Erythematosus: A Population-Based Study.

OBJECTIVE: We aimed to assess the association between antimalarial adherence and cardiovascular events between incident rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE) population-based cohorts. METHODS: All patients with incident RA/SLE and incident antimalarial use in British Columbia, Canada, between January 1997 and March 2015 were identified using provincial administrative databases. The outcomes were incident cardiovascular events, including myocardial infarction (MI), stroke, or venous thromboembolism (VTE). The exposure was antimalarial adherence with levels: discontinuation (proportion of days covered [PDC = 0]), nonadherence (0 < PDC < 0.90), and adherence (PDC ≥ 0.90). We used marginal structural models to estimate the effect of antimalarial adherence on the rate of cardiovascular events, accounting for potential confounders. RESULTS: We identified 16,538 individuals with incident RA/SLE and incident antimalarial use without any cardiovascular event before the index date. Over nine years mean follow-up, 2,174 incident cardiovascular events (13.2%) were observed. The adjusted hazard ratio (aHR) for incident cardiovascular events for antimalarial adherence relative to discontinuation was 0.72 (95% confidence interval [CI] 0.64-0.81) and 1.01 (95% CI 0.90-1.14) for nonadherence. Additionally, the aHRs for all cardiovascular events, MI, stroke, and VTE for adherence relative to nonadherence was 0.71 (95% CI 0.61-0.82), 0.62 (95% CI 0.51-0.75), 0.45 (95% CI 0.36-0.58), and 0.65 (95% CI 0.46-0.93), respectively. We found older age modified the association between antimalarial adherence and cardiovascular events (P = 0.02). CONCLUSION: When people newly diagnosed with RA or SLE take their antimalarial regularly as prescribed (PDC ≥ 0.90), they have a 29% lower risk of sustaining a cardiovascular event than patients with a lower degree of adherence (PDC < 0.90) and a 28% lower risk than if they discontinue antimalarials.

Immediate and past cumulative effects of oral glucocorticoids on the risk of acute myocardial infarction in rheumatoid arthritis: a population-based study.

OBJECTIVES: To determine the effect of glucocorticoids (GCs) on acute myocardial infarction (MI) risk in patients with RA. METHODS: Using administrative health data, we conducted a population-based cohort study of 8384 incident RA cases (1997-2006). Primary exposure was incident GC use. MI events were ascertained using hospitalization and vital statistics data. We used Cox proportional-hazards models and modelled GC use as four alternative time-dependent variables (current use, current dose, cumulative dose and cumulative duration), adjusting for demographics, comorbidities, cardiovascular drug use, propensity score and RA characteristics. Sensitivity analyses explored potential effects of unmeasured confounding. RESULTS: Within 50 238 person-years in 8384 RA cases, we identified 298 incident MI events. Multivariable models showed that current GC use was associated with 68% increased risk of MI [Hazard ratio (HR) = 1.68, 95% CI 1.14, 2.47]. Similarly, separate multivariable models showed that current daily dose (HR = 1.14, 95% CI 1.05, 1.24 per each 5 mg/day increase), cumulative duration of use (HR = 1.14, 95% CI 1.00, 1.29 per year of GC use) and total cumulative dose (HR = 1.06, 95% CI 1.02, 1.10 per gram accumulated in the past) were also associated with increased risk of MI. Furthermore, in the same multivariable model, current dose and cumulative use were independently associated with an increased risk of MI (10% per additional year on GCs and 13% per 5 mg/day increase). CONCLUSION: GCs are associated with an increased risk of MI in RA. Our results suggest a dual effect of GCs on MI risk, an immediate effect mediated through current dosage and a long-term effect of cumulative exposure.

Development of a paper-and-pencil semi-adaptive questionnaire for 5 domains of health-related quality of life (PAT-5D-QOL).

OBJECTIVES: To develop a paper-and-pencil semi-adaptive test for 5 domains of health-related quality of life (PAT-5D-QOL) based on item response theory (IRT). METHODS: The questionnaire uses items from previously developed item banks for 5 domains: (1) walking, (2) handling objects, (3) daily activities, (4) pain or discomfort, and (5) feelings. For each domain, respondents are initially classified into 4 functional levels. Depending on the level, they are instructed to respond to a different set of 5 additional questions. IRT scores for each domain and overall health utility scores are obtained using a simple spreadsheet. The questions were selected using psychometric and conceptual criteria. The format of the questionnaire was developed through focus groups and cognitive interviews. Feasibility was tested in two population surveys. A simulation study was conducted to compare PAT-5D-QOL with a computerized adaptive test (CAT-5D-QOL) and a fixed questionnaire, developed from the same item banks, in terms of accuracy, bias, precision, and ceiling and floor effects. RESULTS: Close to 90 % of the participants in feasibility studies followed the skip instructions properly. In a simulation study, scores on PAT-5D-QOL for all domains tended to be more accurate, more precise, less biased, and less affected by a ceiling effect than scores on a fixed IRT-based questionnaire of the same length. PAT-5D-QOL was slightly inferior to a fully adaptive instrument. CONCLUSIONS: PAT-5D-QOL is a novel, semi-adaptive, IRT-based measure of health-related quality of life with a broad range of potential applications.