Arthritis Care & Research最新文献

Objective: Many adolescent patients view their rheumatologist as their primary physician, and therefore it is important to screen youth for sexual activity and substance use as recommended by the American Academy of Pediatrics. We implemented an electronic social history questionnaire (SHQ) and alert system to identify at-risk behaviors in adolescents with rheumatic disease.

Methods: The SHQ was administered to adolescents 14 years and older with a goal to survey patients' sexual activity and alcohol, tobacco, and drug use. The SHQ was given via tablet at each rheumatology outpatient visit. A positive response triggered a best practice advisory (BPA) alert when the chart was opened to remind the clinician to discuss these results privately.

Results: A total of 877 unique patients were surveyed. Ninety patients (12%) reported being sexually active, and sexually active patients were significantly older than those who were not (17.2 vs 15 years; P < 0.001). Seventy-two percent of patients were female, and the mean age was 15.8 years. Sexually active patients were more likely to be smokers, to drink alcohol, and to use other drugs (P < 0.001). Strong associations were observed between alcohol use and male sex (P = 0.0227), White race (P = 0.0052), and public insurance (P = 0.0021).

Conclusion: Overall, 12% of patients reported being sexually active, underscoring the need to screen adolescents for sexual activity given many rheumatology patients take teratogenic medication. A smaller proportion used substances. Implementing an electronic medical record-based SHQ can help identify patients most at risk, and the BPA serves as a useful tool to remind clinicians to discuss the SHQ privately.

Objective: The study objective was to determine whether the clinical response of older adults with knee osteoarthritis and overweight or obesity to 18 months of diet and exercise (D + E) or attention control (C) interventions differed between participants from rural versus urban communities.

Methods: Participants were 823 older adults (mean age, 64.6 years; 77% women) with knee osteoarthritis and overweight or obesity who resided in rural (n = 410) and urban (n = 413) counties in North Carolina. All were enrolled in the Weight Loss and Exercise for Communities with Arthritis in North Carolina clinical trial that randomly assigned participants to either 18 months of D + E or C interventions. General linear models were used to examine differences in clinical outcomes between rural and urban groups after adjusting for covariates.

Results: The rural group had significant differences (P < 0.05) at baseline in clinical outcomes, education, comorbidities, medication use, and income compared with the urban dwellers. After adjusting for baseline differences, the group (rural or urban) by treatment (D + E or C) interactions for Western Ontario McMasters Universities Osteoarthritis Index (WOMAC) pain (rural: D + E - C = -0.63, 95% confidence interval [CI] -1.31 to 0.06; urban: D + E - C= -0.29, 95% CI -0.99 to 0.41; P = 0.50) and WOMAC function (rural: D + E - C = -4.60, 95% CI -6.89 to -2.31; urban: D + E - C = -1.38, 95% CI -3.73 to 0.94; P = 0.054) indicated that the groups responded similarly to the interventions.

Conclusion: Among participants with knee osteoarthritis and overweight or obesity, D + E compared to C led to similar pain outcomes in rural and urban dwellers that favored D + E. The possibility that there may be greater differential efficacy in functional outcomes among rural participants needs further study.

Objective: We wanted to determine if higher compliance with American College of Sports Medicine (ACSM) exercise prescription guidelines influences exercise outcomes in knee osteoarthritis (OA).

Methods: We conducted a systematic review. We searched the Cochrane Central Register of Controlled Trials, MEDLINE, and Embase up to January 4, 2024, for randomized controlled trials evaluating resistance and/or aerobic exercise for knee OA. Interventions were classified as higher compliance (meeting ≥60% of ACSM guideline recommendations for frequency, intensity, and duration) or lower compliance (meeting <60% of recommendations). Effects on pain and function were evaluated via meta-analysis, stratified by compliance.

Results: Twenty-five trials (3,290 participants) evaluated combined resistance and aerobic programs, with no differences in outcomes between those with higher and lower compliance (standardized mean difference [SMD] pain: -0.38 [95% confidence interval (CI) -0.59 to -0.17] vs -0.31 [95% CI -0.45 to -0.16], respectively; SMD function: -0.43 [95% CI -0.64 to -0.21] vs -0.36 [95% CI -0.58 to -0.14]). Sixty-six trials (5,231 participants) evaluated resistance exercise, with no differences between interventions with higher and lower compliance (SMD pain: -0.60 [95% CI -0.81 to -0.39] vs -0.93 [95% CI -1.27 to -0.59]; SMD function: -0.64 [95% CI -0.83 to -0.44] vs -0.85 [95% CI -1.20 to -0.49]). Twelve trials (958 participants) evaluated aerobic exercise, with no differences between interventions with higher and lower compliance (SMD pain: -0.79 [95% CI -1.20 to -0.38] vs -1.00 [95% CI -2.52 to 0.53]; SMD function: -0.83 [95% CI -1.27 to -0.38] vs -0.76 [95% CI -2.02 to 0.50]).

Conclusion: Higher or lower compliance with ACSM exercise prescription guidelines did not influence exercise outcomes. Given there was substantial heterogeneity and many publications were at risk of bias, our results should be interpreted with caution.

Objective: We aimed to characterize presentation and care pathways of patients with systemic lupus erythematosus (SLE), and delays in access to SLE-specialized care.

Methods: We included patients with incident SLE from the Lupus Midwest Network registry. Time from the first medical encounter for SLE clinical manifestation to access to SLE-specialized care, physician diagnosis, and treatment was estimated. Delays were defined as ≥6 months to access specialized care. We compared SLE manifestations, disease activity, and Systemic Lupus International Collaborating Clinics/American College of Rheumatology damage indexes (SDI) between patients with and without delays. Logistic regression models assessed associations with delays.

Results: The study included 373 patients with SLE. The median time to access SLE-specialized care was 1.1 (95% confidence interval [CI] 0.9-1.5) months, time to diagnosis was 30.6 (95% CI 18.9-48.1) months, and time to treatment initiation was 4.7 (95% CI 3.9-8.4) months. Approximately 25% of patients (93 out of 373) experienced delays accessing specialized care, which were associated with fewer SLE manifestations at first SLE-related encounter (fewer than two SLE domains; 92% vs 72%, P < 0.001). Patients with mucocutaneous or musculoskeletal manifestations were less likely to experience delays, whereas hematologic (odds ratio [OR] 1.71, 95% CI 1.03-2.84) or antiphospholipid antibodies domains (OR 6.05, 95% CI 2.46-14.88) were associated with delays. Delays were associated with damage at first access to SLE-specialized care (SDI ≥1; 30% vs 7%, P < 0.001).

Conclusion: Patients follow a heterogeneous pathway to receive care. One-fourth of patients experienced delays accessing SLE-specialized care, which was associated with disease-related damage. Fewer manifestations, hematologic manifestations, or antiphospholipid antibodies were associated with delays.

Objective: We aimed to estimate the burden and identify potential correlates of limitations in activities of daily living (ADLs) among persons with systemic lupus erythematosus (SLE).

Methods: Individuals with SLE were recruited from a population-based cohort (October 2019 to May 2022) and reported their ability to independently perform various instrumental ADLs (IADLs) and basic ADLs (BADLs) via survey. Limitations were defined as having at least some difficulty performing at least one of the IADLs or BADLs. Descriptive statistics were calculated, and associations (adjusted odds ratios [aORs]) of various participant characteristics with IADL and BADL limitations were assessed with logistic regression adjusting for age, sex, and race.

Results: The mean age of the 436 participants was 46.2 years; most were female (91.7%) and Black (82.8%). More than half (56.2%) reported limitations in IADLs, most commonly housekeeping (50.7%), laundry (37.2%), and shopping (33.0%); 43.8% reported limitations in independently performing BADLs, most commonly transferring (26.6%), bathing (25.3%), dressing (24.4%), and continence (22.0%). Higher disease activity (greater than or equal to vs less than the median) was strongly associated with IADLs (aOR 6.49, 95% confidence interval [CI] 4.15-10.2) and BADLs (aOR 7.35, 95% CI 4.70-11.5), along with higher depression and perceived stress scores, lower educational attainment and income, and older age.

Conclusion: IADL and BADL limitations may be common in individuals with SLE and more prevalent among those who report higher disease activity, depressive symptoms, and lower income and among those who are older. Research to support evidence-based strategies for improvement in quality of life and maintenance of independence in the older SLE population is warranted.

Objective: The physician global assessment of disease activity (PhGA) is a tool used nearly ubiquitously by pediatric rheumatologists for the assessment of patient disease activity status. However, this tool lacks standardization in its scoring. This survey aimed to identify score influencing factors, along with inclusion or exclusion of extra-articular manifestations and imaging, when scoring the PhGA in juvenile idiopathic arthritis (JIA).

Methods: Electronic surveys were sent to Paediatric Rheumatology International Trials Organisation and Pediatric Rheumatology Care and Outcomes Improvement Network members who completed a previous survey on scoring of the PhGA. Respondents were asked to rank their top seven factors for inclusion in the PhGA for nonsystemic JIA (nsJIA) and systemic JIA (sJIA), along with ranking extra-articular manifestations and imaging for inclusion. Frequency and percentage of rank and Likert responses were analyzed, and geographic regions as well as level of experience were compared using the chi-square test and Fisher's test.

Results: A total of 276 respondents from 54 countries and six continents participated. For nsJIA, factors selected by >50% included number of swollen joints, active uveitis, duration of morning stiffness, and number of tender joints. For sJIA, factors selected by >50% were presence and duration of fever, laboratory tests, number of swollen joints, serositis, rash, hepatomegaly, lung disease, and lymphadenopathy. Agreement on the inclusion of extra-articular factors, such as uveitis, macrophage activation syndrome, and sJIA-associated lung disease, had >70% moderate or strong agreement for inclusion, whereas psoriasis had only 50.5% agreement for inclusion and imaging had 64.7% agreement for inclusion. Variations in rank between different geographic regions or level of experience were minor.

Conclusion: This survey identifies factors that pediatric rheumatology providers find important for PhGA scoring of disease activity, documents varying agreement on inclusion of extra-articular manifestations of disease, and lays the framework for further consensus work.

Objective: Differential disease control may contribute to racial disparities in outcomes of childhood-onset systemic lupus erythematosus (cSLE). We evaluated associations of race and individual- or neighborhood-level social determinants of health (SDoH) with achievement of low lupus disease activity state (LLDAS), a clinically relevant treatment target.

Methods: In this cSLE cohort study using the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry, the primary exposure was self-reported race and ethnicity, and collected SDoH included insurance status and area deprivation index (ADI). Outcomes included LLDAS, disease activity, and time-averaged prednisone exposure. Associations among race and ethnicity, SDoH, and disease activity were estimated with multivariable regression models, adjusting for disease-related and demographic factors.

Results: Among 540 children with cSLE, 27% identified as Black, 25% identified as White, 23% identified as Latino/a, 11% identified as Asian, 9% identified as more than one race, and 5% identified as other. More Black children (41%) lived in neighborhoods of highest ADI compared to White children (16%). Black race was associated with lower LLDAS achievement (adjusted odds ratio 0.56, 95% confidence interval [CI] 0.38-0.82) and higher disease activity (adjusted β 0.94, 95% CI 0.11-1.78). The highest ADI was not associated with lower LLDAS achievement on adjustment for renal disease and insurance. However, renal disease was found to be a significant mediator (P = 0.04) of the association between ADI and prednisone exposure.

Conclusions: Children with cSLE who identified as Black are less likely to achieve LLDAS and have a higher disease activity. Living in areas of higher ADI may relate to renal disease and subsequent prednisone exposure. Strategies to address root causes will be important to design interventions mitigating cSLE racial disparities.

Objective: Radiographs are frequently obtained for patients with knee osteoarthritis (KOA), with magnetic resonance imaging (MRI) reserved for those with complex KOA. There are few data on how often subsequent MRI reveals clinically actionable but unanticipated findings. The purpose of this study is to estimate the prevalence of these findings on MRI for patients managed nonoperatively for suspected meniscal tears.

Methods: The Treatment of Meniscal Problems and Osteoarthritis (TeMPO) study enrolled patients aged 45 to 85 years with knee pain, osteoarthritis (Kellgren-Lawrence [KL] grades 0-3), and suspected meniscal tear. We reviewed baseline MRI and recorded notable findings, including subchondral insufficiency fractures of the knee (SIFKs), avascular necrosis (AVN), tumors, and nonsubchondral fractures. Other baseline data included demographic characteristics, Knee Injury and Osteoarthritis Outcome Score, duration of knee symptoms, and KL grade.

Results: Study-ordered MRI was performed on 760 patients, with 61 concerning findings identified (8.03%, 95% confidence interval 6.09%-9.96%). A total of 25 participants had SIFKs, 10 had nonsubchondral fractures, 4 had AVN, 8 had benign tumors, and 14 had other clinically relevant findings.

Conclusion: We estimated the prevalence of clinically relevant incidental findings on MRI to be 8.03% in middle-aged adults with mild to moderate KOA and suspected meniscal tear. These data may prompt clinicians to be more aware of the range of findings that can underlie knee symptoms, some of which could change management but may require different modalities of imaging to detect. Future research is needed to pinpoint factors associated with these concerning findings so that patients who are at risk can be identified and referred for advanced imaging.

Objective: We evaluated the association of 25-hydroxyvitamin D (25(OH)D) levels with adverse pregnancy outcomes in systemic lupus erythematosus (SLE).

Methods: The Hopkins Lupus Cohort includes visits of pregnant patients, including assessment of 25(OH)D levels at each visit. We examined the relationship between 25(OH)D levels and adverse pregnancy outcomes (miscarriage, preterm delivery, and small for gestational age). We also used a time-to-event analysis to assess whether time-varying of 25(OH)D levels were associated with time to miscarriage or preterm delivery.

Results: In subgroups of patients defined by the average of 25(OH)D levels, we observed significantly different risks of miscarriage (P = 0.0045), preterm delivery (P = 0.0007), and the composite measure of all three adverse pregnancy outcomes (P = 0.011). The highest risks were observed among those with the lowest or highest levels of vitamin D. Nine of 10 pregnant patients with low vitamin D levels during the second trimester resulted in having a premature delivery. The time-to-event model confirmed the same U-shaped association after adjustment for SLE disease activity; however, the increased risk among those with highest levels of vitamin D was not statistically significant. Body mass index did not appear to be a confounding factor.

Conclusion: Our study is not able to prove causation, but the results strongly suggest an association of 25(OH)D at both lower and higher levels with adverse pregnancy outcomes. We recommend the monitoring of maternal serum 25(OH)D levels during SLE pregnancies, aiming for the ideal range of 40 to 59 ng/mL.

Objective: We linked pharmacy dispensing data to clinical data in the electronic health record (EHR) to (1) identify characteristics associated with adherence to methotrexate (MTX) and (2) determine the association between adherence and disease activity in patients with juvenile idiopathic arthritis (JIA).

Methods: We conducted a single-center retrospective cohort study of incident MTX recipients with JIA treated between January 2016 and September 2023 for ≥12 months. Using pharmacy dispensing data, complemented by EHR data, we estimated adherence using medication possession ratios (MPRs) over the first 365 days of treatment. We used Fisher's exact and Wilcoxon rank-sum tests to compare patient characteristics between adherent (MPR ≥80%) and nonadherent (MPR <80%) groups and multivariable linear regression to investigate associations between MPR and active joint count.

Results: Among 224 patients, 81 (36.2%) were classified as nonadherent. In bivariate analysis, patients of younger age, of Black race, and from areas with lower child opportunity index were more likely to be classified as nonadherent. In multivariable analysis, active joint count changed from baseline to 12-month follow-up by -0.38 joints in the adherent compared to nonadherent group (95% confidence interval [CI] -0.74 to -0.01) and by -1.18 joints in patients with polyarticular course (95% CI -2.23 to -0.13).

Conclusion: Linking dispense data to clinical EHR data offers a novel, objective method for evaluating adherence to chronic medications. We identified demographic and area-level determinants of adherence, along with small but statistically significant differences in JIA disease activity measures by adherence status. Future work is needed to evaluate adherence as a potential mediator of known outcome disparities for socially disadvantaged populations.