Determining minimally important changes in generic and disease-specific health-related quality of life questionnaires in clinical trials of rheumatoid arthritis

Effects of smoking on clinical treatment outcomes amongst patients with chronic inflammatory diseases initiating biologics: secondary analyses of the prospective BELIEVE cohort study

The prevalence and disease burden of chronic inflammatory diseases (CIDs) are predicted to rise. Patients are commonly treated with biological agents, but the individual treatment responses vary, warranting further research into optimizing treatment strategies. This study aimed to compare the clinical treatment responses in patients with CIDs initiating biologic therapy based on smoking status, a notorious risk factor in CIDs. In this multicentre cohort study including 233 patients with a diagnosis of Crohn's disease, ulcerative colitis, rheumatoid arthritis, axial spondyloarthritis, psoriatic arthritis or psoriasis initiating biologic therapy, we compared treatment response rates after 14 to 16 weeks and secondary outcomes between smokers and non-smokers. We evaluated the contrast between groups using logistic regression models: (i) a "crude" model, only adjusted for the CID type, and (ii) an adjusted model (including sex and age). Among the 205 patients eligible for this study, 53 (26%) were smokers. The treatment response rate among smokers (n = 23 [43%]) was lower compared to the non-smoking CID population (n = 92 [61%]), corresponding to a "crude" OR of 0.51 (95% CI: [0.26;1.01]) while adjusting for sex and age resulted in consistent findings: 0.51 [0.26;1.02]. The contrast was apparently most prominent among the 38 RA patients, with significantly lower treatment response rates for smokers in both the "crude" and adjusted models (adjusted OR 0.13, [0.02;0.81]). Despite a significant risk of residual confounding, patients with CIDs (rheumatoid arthritis in particular) should be informed that smoking probably lowers the odds of responding sufficiently to biological therapy. Registration: Clinical.Trials.gov NCT03173144.

PERI-operative biologic DMARD management: Stoppage or COntinuation during orthoPaEdic operations (the PERISCOPE trial) - a study protocol for a pragmatic, UK multicentre, superiority randomised controlled trial with an internal pilot, economic evaluation and nested qualitative study

INTRODUCTION

Biological disease-modifying antirheumatic drugs (bDMARDs) have revolutionised the treatment of inflammatory arthritis (IA). However, many people with IA still require planned orthopaedic surgery to reduce pain and improve function. Currently, bDMARDs are withheld during the perioperative period due to potential infection risk. However, this predisposes patients to IA flares and loss of disease control. The question of whether to stop or continue bDMARDs in the perioperative period has not been adequately addressed in a randomised controlled trial (RCT).

METHODS AND ANALYSIS

PERISCOPE is a multicentre, superiority, pragmatic RCT investigating the stoppage or continuation of bDMARDs. Participants will be assigned 1:1 to either stop or continue their bDMARDs during the perioperative period. We aim to recruit 394 adult participants with IA. Potential participants will be identified in secondary care hospitals in the UK, screened by a delegated clinician. If eligible and consenting, baseline data will be collected and randomisation completed. The primary outcome will be the self-reported PROMIS-29 (Patient Reported Outcome Measurement Information System) over the first 12 weeks postsurgery. Secondary outcome measures are as follows: PROMIS - Health Assessment Questionnaire (PROMIS-HAQ), EQ-5D-5L, Disease activity: generic global Numeric Rating Scale (patient and clinician), Self-Administered Patient Satisfaction scale, Health care resource use and costs, Medication use, Surgical site infection, delayed wound healing, Adverse events (including systemic infections) and disease-specific outcomes (according to IA diagnosis). The costs associated with stopping and continuing bDMARDs will be assessed. A qualitative study will explore the patients' and clinicians' acceptability and experience of continuation/stoppage of bDMARDs in the perioperative period and the impact postoperatively.

ETHICS AND DISSEMINATION

Ethical approval for this study was received from the West of Scotland Research Ethics Committee on 25 April 2023 (REC Ref: 23/WS/0049). The findings from PERISCOPE will be submitted to peer-reviewed journals and feed directly into practice guidelines for the use of bDMARDs in the perioperative period.

TRIAL REGISTRATION NUMBER

ISRCTN17691638.

Patient-reported outcomes and radiographic progression in patients with rheumatoid arthritis in sustained remission versus low disease activity

OBJECTIVE

To compare clinical and patient-reported outcomes (PROs) over 5 years between patients with rheumatoid arthritis (RA) in sustained remission (sREM), sustained low disease activity (sLDA) or active disease (AD) in the first year after diagnosis.

METHODS

All patients with RA from the treatment in the Rotterdam Early Arthritis CoHort trial, a multicentre, stratified, single-blinded trial with a treat-to-target approach, aiming for LDA (Disease Activity Score (DAS) ≤2.4), were studied. Patients were categorised into: (1) sREM (mean DAS from 6 to 12 months <1.6) (n=173); (2) sLDA (mean DAS from 6 to 12 months 1.6-2.4) (n=142); and (3) AD (mean DAS from 6 to 12 months >2.4) (n=59). Pain, fatigue, functional impairment, health-related quality of life (HRQoL), health status and productivity loss during 5 years were compared between groups. Radiographic progression (modified Total Sharp Score (mTSS)) was compared over 2 years.

RESULTS

Patients in sLDA in the first year had worse PROs during follow-up, compared with patients in sREM: pain (0-10 Likert) was 0.90 units higher (95% CI 0.52 to 1.27), fatigue (Visual Analogue Scale) was 12.10 units higher (95% CI 7.27 to 16.92), functional impairment (Health Assessment Questionnaire-Disability Index) was 0.28 units higher (95% CI 0.17 to 0.39), physical HRQoL (36-item Short Form Health Survey (SF-36) Physical Component Summary score) was 4.42 units lower (95% CI -6.39 to -2.45), mental HRQoL (SF-36 Mental Component Summary score (MCS)) was 2.95 units lower (95% CI -4.83 to -1.07), health status (European Quality of life 5-Dimensions 3-Levels (EQ-5D-3L)) was 0.06 units lower (95% CI -0.09 to -0.03) and productivity loss (0%-100%) was 7.76% higher (95% CI 2.76 to 12.75). Differences between the AD and sREM group were even larger, except for the SF-36 MCS and EQ-5D-3L. No differences in mTSS were found between groups.

CONCLUSION

Patients with RA who reach sREM in the first year have better HRQoL and function, and less pain, fatigue and productivity loss in the years thereafter, compared with patients with RA who are in sLDA or AD in the first year.

Minimal clinically important difference of the functional independence measure in older adults with hip fracture

PURPOSE

To investigate the responsiveness and minimal clinically important difference (MCID) of the Functional Independence Measure (FIM) from a clinician's perspective in hip-fractured elderly undergoing inpatient rehabilitation.

MATERIALS AND METHODS

Data of 701 hip-fractured elderly admitted to our rehabilitation institute were retrospectively collected. Ten a priori hypotheses were formulated.

RESULTS

The effect size of the FIM scores after treatment were large (total = 1.38, motor = 1.78). Moderate correlations were found between the change total score of FIM and Barthel Index (BI, rs = 0.51), Functional Ambulation Categories (FAC, rs = 0.52) and a checklist regarding participants' independence in transfers (rs = 0.59). The area under the receiving operating characteristics were 0.82, 0.81, and 0.85 when BI, FAC and checklist were used as anchors, respectively. Based on these findings, the FIM showed high responsiveness (9/10 hypotheses met). Triangulation of findings showed that MCIDs of 22 and 21 points were the most appropriate for the FIM total and motor score, respectively.

CONCLUSIONS

The FIM scale is appropriate for assessing independence and functional recovery in hip-fractured elderly. Improvements of 22 and 21 points at the total and motor FIM were identified as indicators of minimal clinical change in those admitted to a rehabilitation facility with an FIM total score between 40 and 80.

Enthesitis in patients with psoriatic arthritis treated with secukinumab or adalimumab: a post hoc analysis of the EXCEED study

OBJECTIVES

To evaluate enthesitis treatment response, including time to resolution and data from multiple enthesitis instruments, in patients with PsA treated with secukinumab or adalimumab for 52 weeks.

METHODS

In this post hoc analysis of the EXCEED study, patients receiving secukinumab 300 mg or adalimumab 40 mg per the label were grouped by presence or absence of baseline enthesitis based on the Leeds Enthesitis Index (LEI) and the Spondyloarthritis Research Consortium of Canada Enthesitis Index (SPARCC). Efficacy was assessed according to several enthesitis-related instruments using non-responder imputation for the achievement of enthesitis resolution (LEI/SPARCC = 0), Kaplan-Meier analysis for time to resolution, and as-observed data for other outcomes.

RESULTS

Enthesitis was present at baseline in 498 of 851 patients (58.5%) as assessed by LEI and in 632 of 853 patients (74.1%) as assessed by SPARCC. Patients with baseline enthesitis generally presented with greater disease activity. Similar proportions of patients receiving secukinumab or adalimumab achieved resolution of LEI and SPARCC at weeks 24 (secukinumab: LEI/SPARCC, 49.6%/45.8%; adalimumab: LEI/SPARCC, 43.6%/43.5%) and 52 (secukinumab: LEI/SPARCC, 60.7%/53.2%; adalimumab: LEI/SPARCC, 55.3%/51.4%), with comparable mean time to enthesitis resolution. Improvements were similar for both drugs at individual enthesitis sites. Resolution of enthesitis with secukinumab or adalimumab was associated with improvements in quality of life at week 52.

CONCLUSION

Secukinumab and adalimumab showed similar efficacy, including time to resolution, with respect to resolution of enthesitis. Inhibition of IL-17 with secukinumab reduced clinical enthesitis similarly to TNF-α inhibition.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02745080.

Systematic Literature Review of Real-World Evidence on Baricitinib for the Treatment of Rheumatoid Arthritis

INTRODUCTION

Baricitinib, an orally available small-molecule inhibitor of Janus kinase (JAK)1 and JAK2, is indicated to treat active moderate-to-severe rheumatoid arthritis (RA).

OBJECTIVE

This systematic review described the real-world clinical characteristics of baricitinib-treated patients with RA, prescription patterns, effectiveness, drug persistence, patient-reported outcomes (PROs; physical function, pain, health-related quality of life [HRQoL]), patient global assessment (PGA), and safety of baricitinib.

METHODS

A PRISMA systematic review of real-world studies was conducted to identify relevant literature published between January 2016 and September 2022 using MEDLINE®, EMBASE®, and evidence-based medicine review databases. Websites or online repositories of the American College of Rheumatology and the European Alliance of Associations for Rheumatology were searched manually to include relevant abstracts from conferences held between January 2016 and November 2022.

RESULTS

A total of 11,472 records were identified by searching online databases. Seventy studies were included in the study, of which 40 were abstracts. Most patients were older (51-71 years), female, and with mean RA duration of 4-19 years. Baricitinib was mostly used after the failure of one or more bDMARDs, and 4 mg dosing was prevalent in patients with RA (range 22-100%). Clinical effectiveness of baricitinib was reported in real-world settings regardless of prior biologic/targeted synthetic disease-modifying antirheumatic drug (DMARD) use and concomitant conventional synthetic DMARD use. Achievement of Clinical Disease Activity Index (CDAI) remission was reported in 8.7-60% of patients at week 12 and CDAI low disease activity (LDA) in 20.2-81.6% at week 24. The proportion of patients attaining Simple Disease Activity Index (SDAI) remission was reported in 12% at week 4 to 45.4% at 24 weeks. Drug persistence was high, similar, or equal to anti-tumor necrosis factor drugs. No new safety signals were identified.

CONCLUSION

Baricitinib demonstrated effectiveness in the real-world setting with a consistent safety profile observed in clinical studies. Better persistence rates for baricitinib compared to bDMARDs with improvement in PROs were reported, although baricitinib-treated patients had RA with poor prognostic characteristics.

Effect of research participation versus usual clinical care in patients with rheumatic and musculoskeletal disorders: a prospective cohort study

OBJECTIVE

To compare illness perception (IP), pain, functional level and health-related quality of life (HR-QoL) between patients with musculoskeletal pain who participate versus those who do not participate in clinical research projects.

METHODS

Data were collected between 1 January 2019 and 31 December 2021 in patients visiting the Outpatient Osteoarthritis Clinic at Frederiksberg Hospital, Copenhagen, as part of either clinical research or regular treatment. Questionnaires were collected at baseline and after 10-18 months. Major outcome measure was the change from baseline to follow-up in the Brief Pain Inventory - Short Form (BPI-SF) item 'Average pain'. Secondary outcome measures included The Brief Illness Perception Questionnaire (B-IPQ), measured only at baseline, the EuroQol (EQ-5D-3L), the Health Assessment Questionnaire Disability Index and PainDETECT.

RESULTS

1495 patients were included with 358 (24%) categorised as research participants (exposed) and 1137 (76%) being non-participants (unexposed). The baseline B-IPQ item scores were generally more favourable in the exposed group with statistically significant standardised differences (SD) of 0.2-0.3. Similarly, an SD of 0.3 on the EQ-5D-3L score indicated a better HR-QoL in the exposed group. At follow-up, 24% in the exposed group and 27% in the unexposed group, completed the questionnaires. The mean BPI-sf Average pain between-group difference was: -0.01 points (95% CI: -0.6 to 0.6). Similar clinically irrelevant differences were seen in the other outcomes.

CONCLUSIONS

Among musculoskeletal pain patients, research participants report more positive IP and better HR-QoL than non-participants. No additional effect of research participation was found in any outcome over time.

TRIAL REGISTRATION NUMBER

NCT03785561.

Assessment of short- and long-term functionality and quality of life in patients with post-acute COVID-19 syndrome

BACKGROUND

Although the number of new cases of coronavirus 2019 (COVID-19) has been drastically reduced worldwide, patients who demonstrate long-term symptoms need more attention from health systems, as these symptoms can negatively affect functionality and quality of life.

OBJECTIVE

To evaluate muscle function and quality of life at 3, 6, 9 and 12 months in patients with post-acute COVID-19 syndrome and to assess their associations with general fatigue and lung function.

METHODS

This observational and longitudinal study evaluated patients with post-acute COVID-19 syndrome. Participants were subjected to the following evaluations: Short Form-36; handgrip strength; Functional Assessment of Chronic Illness Therapy-Fatigue scale; and spirometry.

RESULTS

Among the 350 participants who were evaluated in the third month, 74.6%, 61.4% and 45.4% reported general fatigue, dyspnoea and cough, respectively. In the comparisons between the third month and the sixth month, there were significant increases in Functional Assessment of Chronic Illness Therapy-Fatigue scale, pulmonary function and several Short Form-36 domains. In the comparisons between the sixth month and the ninth month, there was a significant increase only in the social functioning domain of the Short Form-36. In the comparisons between the ninth month and the twelfth month, there was an increase only in some Short Form-36 domains. Significant correlations were observed between the Short Form-36 domains with Functional Assessment of Chronic Illness Therapy-Fatigue scale, handgrip strength and pulmonary function.

CONCLUSION

In patients with post-acute COVID-19 syndrome, there was a progressive improvement in quality of life, general fatigue and pulmonary function during the 12 months of follow-up, with this improvement being more pronounced in the first 6 months. There was a relationship between functionality and quality of life in these patients.

Effects of Disease-Worsening Following Withdrawal of Etanercept or Methotrexate on Patient-Reported Outcomes in Patients With Rheumatoid Arthritis: Results From the SEAM-RA Trial

BACKGROUND/OBJECTIVE

The effect of treatment withdrawal on patient-reported outcomes (PROs) in patients with rheumatoid arthritis (RA) whose disease is in sustained remission has not been well described. This analysis aimed to compare PRO changes in patients with RA following medication withdrawal and disease worsening.

METHODS

SEAM-RA (Study of Etanercept and Methotrexate in Combination or as Monotherapy in Subjects With Rheumatoid Arthritis) was a phase 3, multicenter, randomized withdrawal, double-blind controlled study in patients with RA taking methotrexate plus etanercept and in remission (Simple Disease Activity Index ≤3.3). Patient's Global Assessment of Disease Activity, Patient's Assessment of Joint Pain, Health Assessment Questionnaire-Disability Index, and 36-Item Short-Form Health Survey were evaluated for 48 weeks following methotrexate or etanercept withdrawal. Treatment differences for patients with versus without disease worsening were evaluated using a 2-sample t test for continuous end points and log-rank test for time-to-event end points.

RESULTS

Of 253 patients, 121 experienced disease worsening and 132 did not. All PRO scores were similar to those of a general population at baseline and deteriorated over time across the study population. The PtGA and Patient's Assessment of Joint Pain values deteriorated less in those on etanercept monotherapy compared with methotrexate monotherapy. More patients with versus without disease worsening experienced deterioration that was greater than the minimal clinically important difference (MCID) for all PROs tested. In patients with disease worsening, PtGA deterioration more than the MCID preceded Simple Disease Activity Index disease worsening.

CONCLUSIONS

Etanercept monotherapy showed benefit over methotrexate in maintaining PRO scores. Patients with disease worsening experienced a more rapid worsening of PtGA beyond the MCID versus patients without disease worsening.Categories: autoinflammatory disease, biological therapy, DMARDs, rheumatoid arthritis.

Associations between biomarkers of matrix metabolism and inflammation with pain and fatigue in participants suspected of early hip and or knee osteoarthritis: data from the CHECK study

OBJECTIVES

To assess the associations of biomarkers in serum [highsensitivity C-reactive protein (hs-CRP), serum cartilage oligomeric protein (sCOMP), serum propeptide of type I procollagen (sPINP) and serum osteocalcin (sOC)] and urine [urinary type II collagen telopeptide (uCTX-2)] with the extent and progression of nocturnal pain, pain while walking, and fatigue in participants with hip and/or knee pain suspected to be early stage osteoarthritis (OA).

METHODS

hs-CRP, uCTX-2, sCOMP, sPINP and sOC were measured at baseline in 1,002 participants of the Cohort Hip and Cohort Knee (CHECK). Nocturnal pain, pain while walking and fatigue were assessed by self-reported questionnaires at baseline and 2-year follow-up. Associations between these biomarkers and symptoms were examined using logistic and linear regression analyses.

RESULTS

hs-CRP was significantly associated with mild nocturnal pain (OR 1.18 95% CI 1.01-1.37), with mild and moderate pain while walking (OR 1.17 95% CI 1.01-1.35 and OR 1.56 95% CI 1.29-1.90, respectively) and with progression of nocturnal pain (OR 1.25 95% CI 1.07-1.46). uCTX-2 was associated with mild nocturnal pain (OR 1.40 95% CI 1.05-1.85) and with mild and severe-extreme pain while walking (OR 1.35 95% CI 1.04-1.75 and OR 2.55 95% CI 1.03-6.34, respectively). sPINP was associated with severe-extreme nocturnal pain (OR 0.45 95% CI 0.25-0.82). No significant associations were found for sCOMP and sOC, nor for any of the biomarkers and fatigue.

CONCLUSION

This study of biomarkers in a large cohort of participants with hip and/or knee pain suspected to reflect early stage hip and/or knee OA suggests that inflammation and cartilage matrix degeneration play a role in pain, but not in fatigue.

Efficacy and Safety of JAK Inhibitors for Rheumatoid Arthritis: A Meta-Analysis

Background: More and more trials have been conducted. We aimed to assess the efficacy and safety of different JAKinibs in RA. Methods: A systematic search of randomized controlled trials (RCTs) with JAKinib treatment in RA published in the Medline, Embase, and Cochrane databases up to May 2021 was performed. Results: 37 trials involving 15,174 patients were identified. Pooled analysis revealed that JAKinibs were associated with significant therapeutic improvement in RA patients as determined by ACR20 (RR = 2.03, 95% CI: 1.85 to 2.28) and HAQ-DI (MD = −0.31, 95% CI: −0.33 to −0.28) over placebo. Compared to placebo, JAKinib treatment was also associated with more adverse events (RR = 1.10, p < 0.001; RR = 1.29, p < 0.001; RR = 1.59, p = 0.02). Baricitinib and upadacitinib were related to more frequent adverse events (RR = 1.10; 95% CI: 1.01, 1.21; RR = 1.19; 95% CI: 1.11, 1.28) and infection (RR = 1.22; 95% CI: 1.09, 1.37; RR = 1.38; 95% CI: 1.22, 1.56), whereas only baricitinib was associated with more herpes zoster (RR = 3.15; 95% CI: 1.19, 8.33). Conclusions: JAKinibs were superior to placebo for improving signs, symptoms, and health-related quality of life in RA patients at short term, whereas the overall risk of adverse events and infections were greater with baricitinib and upadacitinib, and a higher risk of herpes zoster was only associated with baricitinib. More trials are needed to investigate the long-term safety.

Change in serum urate level with urate-lowering therapy initiation associates in the immediate term with patient-reported outcomes in people with gout

OBJECTIVE

To examine the associations of changes in serum urate (SU) with health-related quality of life (HRQOL) in gout.

METHODS

We used the first 6-months of data from four interventional trials and one observational, open-label study of urate-lowering therapy (ULT) use. HRQOL were assessed at baseline and every 3-months, and SU was measured monthly. Primary outcome measures were Short-form 36 physical and mental component summary scores, Health Assessment Questionnaire Disability Index (HAQ-DI), Sheehan Disability Scale (SDS), Patient Global Assessment, and pain scores in the last week. Linear mixed models for each outcome were adjusted as appropriate for current SU, change in urate in the last month, number of flare-affected days in the last month, baseline BMI, age, comorbidities, sex, ethnicity, trial/study and treatment combination, and tophi status (fixed effects); subject, and the trial/study month were random effects.

RESULTS

Higher current SU correlated with reduced physical and mental HRQOL, and increased SDS and pain but not with HAQ-DI score. In the first 6-months of new/escalating ULT use, absolute change in SU levels associated with poorer outcomes on the HAQ-DI scale (β (95% CI) = 0.013 (0.007-0.019)) and poorer outcomes on SDS, SF-36 MCS, patient global and pain scales. Reduction of SU associated with poorer outcomes in all six measures.

CONCLUSION

High SU levels were associated with poorer HRQOL, pain and Sheehan disability score. Recent SU level fluctuations are associated with poorer outcomes, primarily driven by a reduction in SU. Clinical emphasis on slow rather than fast SU reduction and the routine use of effective, anti-inflammatory medications at ULT initiation/escalation may avoid short-term poor outcomes.

Stability of SF-36 profiles between 2007 and 2016: A study of 27,302 patients surgically treated for lumbar spine diseases

Background

Previous studies have shown that patients with different lumbar spine diseases report different SF-36 profiles, but data on the stability of the SF-36 profiles are limited. The primary aim of the current study was to evaluate the stability of the SF-36 profile for lumbar spine diseases.

Methods

Patients, surgically treated between 2007 and 2016 for three lumbar spine diseases, lumbar spinal stenosis (LSS) with degenerative spondylolisthesis (DS), LSS without DS, and lumbar disk herniations (LDH), were identified in the Swedish spine register. Preoperative and 1 year postoperative SF-36 data for a total of 27,302 procedures were available for analysis. The stability of the SF-36 profiles over the 10-year period was evaluated using graphical exploration, linear regression, difference in means, and 95% confidence intervals. The responsiveness of the SF-36 domains to surgical treatment was evaluated using the standardized response mean (SRM).

Results

LSS and LDH have different SF-36 profiles. LSS with DS and LSS without DS have similar SF-36 profiles. The preoperative and the 1 year postoperative SF-36 profiles were stable from 2007 to 2016 for all three diagnoses. There were no major changes in the effect size of change (SRM) during the study period for all three diagnoses. For LSS with DS, the number of fusions peaked in 2010 and then decreased. The postoperative SF-36 profiles for LSS with DS were unaffected by changes in surgical treatment trends.

Conclusions

Patients with lumbar spinal stenosis and lumbar disk herniations have different SF-36 profiles. Concomitant degenerative spondylolisthesis had no impact on the SF-36 profile of lumbar spinal stenosis. Adding fusion to the decompression did not alter the postoperative SF-36 profile of lumbar spinal stenosis. The SF-36 health profiles are stable from a 10 years perspective.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12955-022-01999-7.

Maximal strength training in patients with inflammatory rheumatic disease: implications for physical function and quality of life

PURPOSE

Patients with inflammatory rheumatic disease (IRD) have attenuated muscle strength in the lower extremities, resulting in impaired physical function and quality of life. Although maximal strength training (MST), applying heavy resistance, is documented to be a potent countermeasure for such attenuation, it is uncertain if it is feasible in IRD given the pain, stiffness, and joint swelling that characterize the population.

METHODS

23 patients with IRD (49 ± 13 years; 20 females/3 males), diagnosed with spondyloarthritis, rheumatoid arthritis, or systemic lupus erythematosus, were randomized to MST or a control group (CG). The MST group performed four × four repetitions dynamic leg press two times per week for 10 weeks at ~ 90% of one repetition maximum (1RM). Before and after training 1RM, rate of force development (RFD), and health-related quality of life (HRQoL) were measured.

RESULTS

Session attendance in the MST group was 95%, of which 95% conducted according to MST protocol. Furthermore, MST increased 1RM (29 ± 12%, p = 0.001) and early and late phase RFD (33-76%, p < 0.05). All improvements were different from the CG (p < 0.05). MST also resulted in HRQoL improvements in the dimensions; physical functioning, general health, and vitality (p < 0.05). Physical functioning was associated with 1RM (rho = 0.55, p < 0.01) and early phase RFD (rho = 0.53-0.71, p < 0.01; different from CG p < 0.05).

CONCLUSIONS

Despite being characterized by pain, stiffness, and joint swelling, patients with IRD appear to tolerate MST well. Given the improvements in 1RM, RFD, and HRQoL MST should be considered as a treatment strategy to counteract attenuated muscle strength, physical function, and HRQoL.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT04998955, retrospectively registered.

Maintenance of Patient-Reported Outcomes in Baricitinib-Treated Patients with Moderate-to-Severe Active Rheumatoid Arthritis: Post Hoc Analyses from Two Phase 3 Trials

INTRODUCTION

Baricitinib has been shown to improve patient-reported outcomes (PROs) in patients with rheumatoid arthritis (RA) who are inadequate responders (IR) to conventional synthetic and biologic disease-modifying antirheumatic drugs (csDMARDs and bDMARDs, respectively). We assessed the ability of baricitinib 2-mg to maintain minimal clinically important differences (MCIDs) in PROs until week 24 among week 4 and 12 responders.

METHODS

Data were from two phase 3 trials, RA-BUILD (NCT01721057; csDMARD-IR patients) and RA-BEACON (NCT01721044; bDMARD-IR patients). PROs included Pain Visual Analogue Scale, Health Assessment Questionnaire-Disability Index, Functional Assessment of Chronic Illness Therapy-Fatigue, Short-Form 36 Physical Component Score, and Patient's Global Assessment of Disease Activity. Outcomes were evaluated by proportions of patients achieving MCID improvements, number needed to treat (NNT) at weeks 4, 12, and 24, proportions of patients maintaining MCID responses at week 24 among week 4 or 12 responders, and median time to achieve substantial response with baricitinib 2-mg versus placebo.

RESULTS

A higher proportion of baricitinib-treated patients achieved MCID improvements, with NNTs ranging from 5 to 8 for baricitinib 2-mg versus placebo at week 24. Generally, early MCID responses in PROs at weeks 4 or 12 were better maintained through week 24 in RA patients treated with baricitinib 2-mg versus placebo. Patients treated with baricitinib 2-mg also achieved substantial PRO responses or normative values more quickly than placebo.

CONCLUSIONS

These results suggest baricitinib-treated patients with RA achieving MCID improvement in PROs at weeks 4 and 12 maintained those improvements over time and that substantial PRO responses were achieved quickly.

Impact of a Mobile Telerehabilitation Solution on Metabolic Health Outcomes and Rehabilitation Adherence in Patients With Obesity: Randomized Controlled Trial

Background

Obesity is a major public health issue. Combining exercise training, nutrition, and therapeutic education in metabolic rehabilitation (MR) is recommended for obesity management. However, evidence from randomized controlled studies is lacking. In addition, MR is associated with poor patient adherence. Mobile health devices improve access to MR components.

Objective

The aim of this study is to compare the changes in body composition, anthropometric parameters, exercise capacity, and quality of life (QOL) within 12 weeks of patients in the telerehabilitation (TR) program to those of usual care patients with obesity.

Methods

This was a parallel-design randomized controlled study. In total, 50 patients with obesity (BMI>30 kg/m²) were included in a TR group (TRG) or a usual care group (UCG) for 12 weeks. Patients underwent biometric impedance analyses, metabolic exercise tests, actimetry, and QOL and satisfaction questionnaires. The primary outcome was the change in fat mass at 12 weeks from baseline. Secondary outcomes were changes in body weight, metabolic parameters, exercise capacity, QOL, patients’ adhesion, and satisfaction.

Results

A total of 49 patients completed the study. No significant group × time interaction was found for fat mass (TRG: mean 1.7 kg, SD 2.6 kg; UCG: mean 1.2 kg, SD 2.4 kg; P=.48). Compared with the UCG, TRG patients tended to significantly improve their waist to hip ratios (TRG: −0.01 kg, SD 0.04; UCG: +0.01 kg, SD 0.06; P=.07) and improved QOL physical impact (TRG: +21.8, SD 43.6; UCG: −1.2, SD 15.4; P=.005). Significant time effects were observed for body composition, 6-minute walk test distance, exercise metabolism, sedentary time, and QOL. Adherence (95%) and satisfaction in the TRG were good.

Conclusions

In adults with obesity, the TR program was not superior to usual care for improving body composition. However, TR was able to deliver full multidisciplinary rehabilitation to patients with obesity and improve some health outcomes. Given the patients’ adherence and satisfaction, pragmatic programs should consider mobile health devices to improve access to MR. Further studies are warranted to further establish the benefits that TR has over usual care.

Trial Registration

ClinicalTrials.gov NCT03396666; http://clinicaltrials.gov/ct2/show/NCT03396666

Single item self-rated general health: SF-36 based observations from 16,910 spine surgery procedures

PURPOSE

In spine surgery single item patient-reported outcome assessment has been used for many years. Items 1 and 2 of SF-36 are used for assessment of general health. We used these items to explore single item, self-rated, general health assessment after spine surgery.

METHODS

Patients operated for lumbar disc herniation or lumbar spinal stenosis between 2007 and 2017, were recruited from the national Swedish spine register. A total of 16,910 procedures were eligible for analysis. The responsiveness of the SF-36 general health assessment items to surgical treatment was evaluated with the standardized response mean (SRM). Improvement in self-rated general health was used to dichotomize SF-36 profiles and EQ VAS distributions.

RESULTS

For disc herniation, 5852 (83%) patients reported improvement in general health 1 year after surgery. For spinal stenosis, the corresponding numbers were 6,482 (66%). The additional improvement after year 1 was small. The responsiveness of the SF-36 item 2 (the health transition item) to surgical treatment of disc herniation or spinal stenosis was substantial. There was a clear association between improvement in SF-36 item 2 and improvements in all domains of SF-36.

CONCLUSIONS

Surgery for disc herniation or spinal stenosis improve patients' perception of general health 1 year after surgery. The improvement in general health after year 1 is limited. The SF-36 item 2 is a responsive measure of self-rated general health that may be used for dichotomization of SF-36 and EQ VAS data when evaluating surgical outcome in spine surgery.

Smartphone-Assisted High-Intensity Interval Training in Inflammatory Rheumatic Disease Patients: Randomized Controlled Trial

BACKGROUND

Patients with inflammatory rheumatic diseases (IRDs) experience disease-related barriers to physical training. Compared with the general population, IRD patients are reported to have reduced maximal oxygen uptake (VO2max) and physical activity levels. Supervised high-intensity interval training (HIIT) is documented to counteract the reduced VO2max and poor cardiovascular health associated with IRDs. However, supervised HIIT is resource demanding.

OBJECTIVE

This study sought to investigate if self-administered 4×4-min HIIT guided by a smartphone app (Myworkout GO) could yield similar HIIT-induced effects as standard 4×4-min HIIT performed under the guidance and supervision of health care professionals. The effects studied were on VO2max and health-related quality of life (HRQoL).

METHODS

Forty patients (33 female patients, mean age 48 years, SD 12 years; 7 male patients, mean age 52 years, SD 11 years) diagnosed with rheumatoid arthritis, spondyloarthritis, or systemic lupus erythematosus were randomized to a supervised group (SG) or an app group (AG). Both groups were instructed to perform 4×4-min intervals with a rate of perceived exertion of 16 to 17, corresponding to 85% to 95% of the maximal heart rate, twice a week for 10 weeks. Treadmill VO2max and HRQoL measured using RAND-36 were assessed before and after the exercise period.

RESULTS

VO2max increased (P<.001) in both groups after 10 weeks of HIIT, with improvements of 3.6 (SD 1.3) mL/kg/min in the SG and 3.7 (SD 1.5) mL/kg/min in the AG. This was accompanied by increases in oxygen pulse in both groups (P<.001), with no between-group differences apparent for either measure. Improvements in the HRQoL dimensions of bodily pain, vitality, and social functioning were observed for both groups (P<.001 to P=.04). Again, no between-group differences were detected.

CONCLUSIONS

High-intensity 4×4-min interval training increased VO2max and HRQoL, contributing to patients' reduced cardiovascular disease risk, improved health and performance, and enhanced quality of life. Similar improvements were observed following HIIT when IRD patients were guided using perceived exertion by health care professionals or the training was self-administered and guided by the app Myworkout GO. Utilization of the app may help reduce the cost of HIIT as a treatment strategy in this patient population.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04649528; https://clinicaltrials.gov/ct2/show/NCT04649528.

Responsiveness of the Brazilian IdFAI questionnaire in patients with chronic ankle instability

PURPOSE

This study aimed to determine the responsiveness of the Brazilian version of the Identification of Functional Ankle Instability (IdFAI) questionnaire in students who received an eight-week treatment for chronic ankle instability (CAI).

METHODS

Twenty-five college students (aged 23.12 ± 2.80 years) with CAI, as identified by the IdFAI questionnaire, were recruited. We used distribution and anchor-based methods to assess the responsiveness of the questionnaire, and its ability to determine clinical changes in participants. Eleven anchors were used: Visual Analog Scale for instability (VAS-i); Cumberland Ankle Instability Tool (CAIT); Isometric dorsiflexion, plantar flexion, inversion, and eversion muscle strength measured using a manual dynamometer; Dynamic balance as assessed through the Star Excursion Balance Test (SEBT-Y); Active ankle dorsiflexion range of motion as measured using the weight-bearing lunge test; and Functional performance assessment using three hop tests: single hop, triple crossover hop, and side hop. The distribution-based method used effect size (ES) and standardized response mean (SRM), whereas the anchor-based method used paired t-tests. Both methods allowed the calculation of the minimal important difference (MID).

RESULTS

The Brazilian IdFAI showed high responsiveness, with a large magnitude of change (ES = 1.34) and a high responsiveness index (SRM = 1.28) when assessed after a treatment for CAI. The IdFAI total score (p < .001) and all the 11 anchors [VAS-i (p < .001); CAIT (p < .001); Isometric dorsiflexion (p < .001), plantar flexion (p < .001), inversion (p < .001), and eversion (p < .001) muscle strength; SEBT-Y (p < .001); Lunge test (p = .002); Single hop (p < .001); triple crossover hop (p < .001); and side hop tests (p < .001)] showed significant differences. The anchor and distribution-based methods demonstrated MID values of 3.72 and 1.49-2.27, respectively.

CONCLUSION

The Brazilian IdFAI questionnaire is a patient-reported outcome measure sensitive to clinical changes in individuals with CAI. It can be used as an identification of patients with CAI, and as a parameter to verify clinical changes of clinical trials or therapeutic interventions in the population with CAI.

The Comprehensive Aachen Knee Score: Development and validation of a new patient-reported outcome measure for patellofemoral pathologies

BACKGROUND

Existing patient-reported outcome measures (PROMs) that assess knee pain and symptoms show insufficient quality regarding their psychometric properties. We developed and validated a new PROM assessing knee pain and especially patellofemoral pathologies, the COMPrehensive AaChen Knee Score (COMPACK).

METHODS

We followed a three-phase process of development and validation. (1) Scale development: we conducted a systematic literature research to collect and analyse the most commonly used PROMs for knee and patellofemoral pathologies to identify appropriate items. (2) Pilot testing: we assessed the content validity of the COMPACK based on interviews with patients and health experts regarding relevance, comprehensibility and comprehensiveness of the used items. (3) Field testing: we used the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) guidelines to evaluate the structural validity, internal consistency and test-retest reliability of the COMPACK.

RESULTS

The COMPACK scale showed good structural validity, with two subscales measuring pain intensity and frequency. Further, scores of the COMPACK correlated positively with those obtained from the International Knee Documentation Committee Subjective Knee Form (IKDC) (r = 0.64) and the 12-item Short Form Health Survey subscale of physical function: (r = 0.43). Both the total scale and the two subscales showed good internal consistency (Cronbach's α > 0.82) and good to excellent test-retest reliability (Cronbach's α > 0.82).

CONCLUSIONS

The final COMPACK score was shown to be a valid and reliable instrument and thus meets the most important psychometric quality criteria. In its development, we specifically focused on its content validity, structural validity and applicability.

Minimal clinically important differences in SF-36 global score: Current value in orthopedic oncology

The SF-36 is widely used to evaluate the health-related quality of life (HRQoL) of patients with musculoskeletal tumors. Instead of typical methods, calculating the SF-36 Global Score has recently become an increasingly common reporting approach. However, numerical changes lack clear clinical relevance. The minimal clinically important difference (MCID) is useful for interpreting changes in functional scores by defining the smallest change patients may perceive as clinically meaningful. The aim of this study is to determine the MCID of the SF-36 Global Score in orthopedic oncology patients, which has not been reported to date. Three-hundred ten patients who underwent surgery and completed two surveys during postoperative follow-up were reviewed. The two most common methods for calculating the SF-36 Global Score were used: (1) anchor-based methods and receiver operating characteristic analysis based on one-half of the SD of change score and standard error of measurement at baseline and; (2) distribution-based methods. Using anchor-based methods, the MCIDs of SF-36 Global Scores #1 and #2 were 2.7 (area under the curve [AUC] = 0.85) and 2.5 (AUC = 0.79) for improvement, and -1.5 (AUC = 0.81) and -0.6 (AUC = 0.83) for deterioration, respectively. Using distribution-based methods, the MCIDs of SF-36 Global Scores #1 and #2 were 4.1 and 4.4 by half SD, and 4.1 and 4.5 by standard error of measurement, respectively. Our findings provide benchmark values, which can serve as a reference for future studies in musculoskeletal tumor patients using the SF-36 Global Score as a single measure for HRQoL.

Editor's Choice - Cost Effectiveness of Primary Stenting in the Superficial Femoral Artery for Intermittent Claudication: Two Year Results of a Randomised Multicentre Trial

OBJECTIVE

Invasive treatment of intermittent claudication (IC) is commonly performed, despite limited evidence of its cost effectiveness. IC symptoms are mainly caused by atherosclerotic lesions in the superficial femoral artery (SFA), and endovascular treatment is performed frequently. The aim of this study was to investigate its cost effectiveness vs. non-invasive treatment.

METHODS

One hundred patients with IC due to lesions in the SFA were randomised to treatment with primary stenting, best medical treatment (BMT) and exercise advice (stent group), or to BMT and exercise advice alone (control group). Patients were recruited at seven hospitals in Sweden. For this analysis of cost effectiveness after 24 months, 84 patients with data on quality adjusted life years (QALY; based on the EuroQol Five Dimensions EQ-5D 3L™ questionnaire) were analysed. Patient registry and imputed cost data were used for accumulated costs regarding hospitalisation and outpatient visits.

RESULTS

The mean cost per patient was €11 060 in the stent group and €4 787 in the control group, resulting in a difference of €6 273 per patient between the groups. The difference in mean QALYs between the groups was 0.26, in favour of the stent group, which resulted in an incremental cost effectiveness ratio (ICER) of € 23 785 per QALY.

CONCLUSION

The costs associated with primary stenting in the SFA for the treatment of IC were higher than for exercise advice and BMT alone. With concurrent improvement in health related quality of life, primary stenting was a cost effective treatment option according to the Swedish national guidelines (ICER < €50 000 - €70 000) and approaching the UK's National Institute for Health and Care Excellence threshold for willingness to pay (ICER < £20 000 - £30 000). From a cost effectiveness standpoint, primary stenting of the SFA can, in many countries, be used as an adjunct to exercise training advice, but it must be considered that successful implementation of structured exercise programmes and longer follow up may alter these findings.

Comparative effectiveness of exercise programs for psychological well-being in knee osteoarthritis: A systematic review and network meta-analysis

OBJECTIVES

The benefits of exercise are well established for psychological well-being, but it is unknown whether one type of exercise can be recommended over another for psychological well-being in knee osteoarthritis (OA). This study aimed to compare the effectiveness of different types of exercise on psychological well-being in people with knee OA.

METHODS

Five databases including MEDLINE, EMBASE, Cochrane Register of Controlled Trials, CINAHL and PEDro) were searched from inception until April 2021. Randomised controlled trials comparing the effect of exercise with a non-exercise control or another type of exercise on overall mental health, depressive symptoms or anxiety in people with knee OA. Trial data were extracted independently by two researchers. Network meta-analyses using random-effect models were conducted. The Grading of Recommendations, Assessment, Development and Evaluation framework was used to appraise evidence certainty.

RESULTS

Strengthening exercise was more beneficial for overall mental health on the Short Form survey compared to aerobic (mean difference 15.88, 95%CI [6.77, 24.99]), mixed (12.77, 95%CI [5.12, 20.42]) and mind-body (12.51, [4.25, 20.77]) exercise based on 13 trials (n = 796). Strengthening exercise (standardised mean difference 6.81, [5.03, 8.58]), and mixed exercise (6.64, [4.88, 8.40]),) were more beneficial for depressive symptoms than stretching exercise based on 6 trials (n = 627). No differences were observed for anxiety based on 4 trials (n = 557). Certainty of the evidence ranged from very low to low.

CONCLUSION

The available evidence supports the recommendation of strengthening exercise as the most beneficial for overall mental health, and strengthening exercise or mixed exercise over stretching exercise for depressive symptoms. No exercise recommendations can be made for anxiety.

Secukinumab Efficacy on Psoriatic Arthritis GRAPPA-OMERACT Core Domains in Patients with or Without Prior Tumor Necrosis Factor Inhibitor Use: Pooled Analysis of Four Phase 3 Studies

Background

Psoriatic arthritis (PsA) is a chronic, heterogeneous, immune-mediated disease manifesting as a spectrum of possible inflammatory signs and symptoms. Clinicians need therapeutic choices that work across all active PsA disease domains, as well as practical information about efficacy of available treatments for individual domains in specific groups of patients. The objective of this study was to evaluate the effect of prior tumor necrosis factor inhibitor (TNFi) exposure on the efficacy of secukinumab across PsA core domains.

Methods

Data were pooled from 2049 participants with PsA in four phase 3 studies (FUTURE 2–5). Efficacy at week 16 was evaluated for each GRAPPA-OMERACT PsA core domain using nonresponder imputation for musculoskeletal disease activity and Psoriasis Area and Severity Index scores or as-observed data for other outcomes. For each measure, comparisons with placebo were made separately in the TNFi-naive and TNFi-inadequate responder/intolerant (TNF-IR) cohorts.

Results

Treatment with secukinumab improved PsA disease activity across all disease domains regardless of previous TNFi use, although TNFi-naive patients experienced numerically greater benefits in most outcomes. Among patients treated with secukinumab 300 mg, 41.5% and 24.4% of TNFi-naive patients (P < 0.05 vs placebo) and 18.6% and 9.0% of TNF-IR patients (nonsignificant vs placebo) experienced resolution in 66 swollen and 68 tender joint counts, respectively; additionally, 37.2% of TNFi-naive patients and 24.2% of TNF-IR patients achieved complete resolution of psoriasis at week 16 (all P < 0.05 vs placebo). Secukinumab effect sizes were generally larger in TNFi-naive vs TNF-IR patients for musculoskeletal and patient-reported domains.

Conclusions

Secukinumab demonstrated efficacy vs placebo across GRAPPA-OMERACT PsA core domains. Higher responses among TNFi-naive vs TNF-IR patients suggest that secukinumab should be considered for first-line use in PsA.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40744-021-00337-5.

Psoriatic arthritis (PsA) is a long-term disease that can affect a patient’s joints, skin, lower back, physical function, mental health, productivity, and other areas. Drugs called tumor necrosis factor inhibitors (TNFis) can be used to treat PsA, although not all patients benefit from TNFis and many seek other treatment options. These patients, known as TNFi-inadequate responders (TNF-IR), have PsA that is difficult to treat. Another treatment option is secukinumab, a drug that blocks a molecule called interleukin-17 that is involved in PsA. Doctors need to know how different drugs work for treating PsA signs and symptoms in different groups of patients, including TNF-IR patients and those who have never received TNFis (TNFi-naive patients). This study used data from 2049 patients in four different PsA clinical trials (FUTURE 2–5) to see how well secukinumab worked at treating different signs and symptoms of PsA in TNFi-naive and TNF-IR patients. After 16 weeks of treatment, patients who took secukinumab saw greater improvements across all measured PsA signs and symptoms than those who took placebo. This was true for both TNFi-naive and TNF-IR patients. TNFi-naive patients seemed to benefit slightly more than TNF-IR patients—especially in their joint symptoms—although this study was not designed to judge the significance of these differences. These results suggest that secukinumab would be an effective first treatment option for patients with PsA. Since secukinumab improves the skin, joints, and other affected areas, it can be useful in treating the whole patient who has psoriatic disease.

Complete Capsular Closure Provides Higher Rates of Clinically Significant Outcome Improvement and Higher Survivorship Versus Partial Closure After Hip Arthroscopy at Minimum 5-Year Follow-Up

PURPOSE

To (1) compare the rates of reaching threshold hip-specific outcome scores for achieving the minimal clinically important difference (MCID) and patient acceptable symptomatic state (PASS) in patients who underwent partial versus complete T-capsulotomy repair and (2) identify the failure rates in each group 5 years after undergoing hip arthroscopy for femoroacetabular impingement syndrome (FAIS).

METHODS

Data from consecutive patients who underwent hip arthroscopy for FAIS performed by a single fellowship-trained surgeon from January 2011 to March 2013 were collected and analyzed. Baseline data, hip-specific outcomes, and clinical failure rates were recorded at a minimum of 5 years postoperatively. Patients with partial T-capsulotomy repair were matched 1:3 by age, body mass index, and sex to patients with complete T-capsulotomy repair. Threshold scores for achieving the MCID and PASS were calculated and compared between the 2 groups. Additionally, rates of revision and conversion to total hip arthroplasty (THA) were compared between the groups.

RESULTS

A total of 379 patients were available for analysis (39 partial and 340 complete repairs), with 100 patients included in the matching process (25 in the partial-repair group and 75 in the complete-repair group). Comparison of radiographic parameters, including the Tönnis grade, alpha angle, and lateral center-edge angle, between the 2 groups showed no statistically significant difference (P > .05 for all). Comparison of postoperative score averages between the partial- and complete-closure groups showed a significant difference in the Hip Outcome Score-Activities of Daily Living Subscale (85.4 ± 17.7 vs 94.6 ± 7.8, P < .001), Hip Outcome Score-Sports Subscale (76.6 ± 26.2 vs 89.3 ± 16.8, P = .034), modified Harris Hip Score (83.2 ± 19.7 vs 90.5 ± 11.2, P = .035), and visual analog scale pain score (24.5 ± 30.8 vs 13.4 ± 15.8, P = .035). A total of 65 complete-repair patients (95.6%) achieved the MCID for at least 1 outcome measure versus 18 patients with partial repair (78.3%) (P = .04). A total of 69 complete-repair patients (92%) achieved the PASS for at least 1 outcome measure versus 18 partial-repair patients (72%) (P = .017). Of the 39 partial-repair patients, 35.9% (n = 14) underwent revision or conversion to THA, as compared with 2.9% (n = 10) in the overall cohort.

CONCLUSIONS

At a minimum 5-year follow-up, patients with complete capsular closure after hip arthroscopy for FAIS show superior long-term outcomes and achieve higher rates of meaningful clinical success when compared with patients with partial capsular closure. Furthermore, patients with partial capsular repair undergo revision or conversion to THA at high rates.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Hip Arthroscopy for Femoroacetabular Impingement Syndrome in Adolescents Provides Clinically Significant Outcome Benefit at Minimum 5-Year Follow-Up

PURPOSE

To report the rates of achieving clinically significant outcomes as defined by the minimal clinically important difference (MCID), patient acceptable symptomatic state (PASS), or substantial clinical benefit (SCB) in adolescent patients and the rates of clinical failure 5 years after undergoing hip arthroscopy for femoroacetabular impingement syndrome (FAIS).

METHODS

Data from consecutive adolescent patients (defined by the American Academy of Pediatrics as age 11 to 21 years) who underwent primary hip arthroscopy with routine capsular closure for the treatment of FAIS between January 2012 and January 2015 by a single, fellowship-trained surgeon was collected. Baseline data, clinical outcomes including Hip Outcome Score (HOS)-Activities of Daily Living, HOS-Sports Subscale, modified Harris hip score, international Hip Outcome Tool, and clinical failure rates were recorded at 5 years after operative. Clinical failure was defined by revision hip arthroscopy or conversion to total hip arthroplasty. Clinically significant outcomes was defined as achieving MCID, PASS, or SCB on at least 1 hip-specific outcome measure.

RESULTS

Of the 139 eligible patients, a total of 85 (60.4%) patients (85 hips) were included in the final analysis, with an age and body mass index average of 17.6 ± 2.5 years (range 13-21) and 22.3 ± 3.1 kg/m², respectively. The majority of the patients were female (80.6%) and participated in sports (76.2%). There was statistically significant difference between preoperative and postoperative score averages across every reported outcome (P < .001). At 5 years, 88.4%, 67.6%, and 64.9% reached at least 1 threshold for achieving MCID, PASS, and SCB, respectively, whereas 89.2% achieved at least one of the meaningful outcome thresholds. Last, 2 patients (2.4%) failed clinically, with both undergoing revision (2.4%) because of continued pain. There were no conversions to total hip arthroplasty.

CONCLUSION

This study demonstrated that a large majority (89.2%) of adolescent patients undergoing primary arthroscopic treatment for symptomatic FAIS achieved meaningful clinically significant outcomes. Furthermore, only 2.4% of patients failed clinically, requiring revision hip arthroscopy because of continued pain.

LEVEL OF EVIDENCE

IV, Retrospective Case Series.

Comparative efficacy of subcutaneous (CT-P13) and intravenous infliximab in adult patients with rheumatoid arthritis: a network meta-regression of individual patient data from two randomised trials

BACKGROUND

A subcutaneous (SC) formulation of infliximab biosimilar CT-P13 is approved in Europe for the treatment of adult patients with rheumatoid arthritis (RA). It may offer improved efficacy versus intravenous (IV) infliximab formulations.

METHODS

A network meta-regression was conducted using individual patient data from two randomised trials in patients with RA, which compared CT-P13 SC with CT-P13 IV, and CT-P13 IV with reference infliximab IV. In this analysis, CT-P13 SC was compared with CT-P13 IV, reference infliximab IV and pooled data for both reference infliximab IV and CT-P13 IV. Outcomes included changes from baseline in 28-joint Disease Activity Score based on C-reactive protein (DAS28-CRP), Simplified Disease Activity Index (SDAI) and Clinical Disease Activity Index (CDAI), and rates of remission, low disease activity or clinically meaningful improvement in functional disability per Health Assessment Questionnaire-Disability Index (HAQ-DI).

RESULTS

The two studies enrolled 949 patients with RA; pooled data for 840 and 751 patients were evaluable at weeks 30 and 54, respectively. For the CT-P13 SC versus pooled IV treatment arm comparison, differences in changes from baseline in DAS28-CRP (- 0.578; 95% confidence interval [CI] - 0.831, - 0.325; p < 0.0001), CDAI (- 3.502; 95% CI - 5.715, - 1.289; p = 0.002) and SDAI (- 4.031; 95% CI - 6.385, - 1.677; p = 0.0008) scores at 30 weeks were statistically significant in favour of CT-P13 SC. From weeks 30 to 54, the magnitude of the differences increased and remained statistically significant in favour of CT-P13 SC. Similar results were observed for the comparison of CT-P13 SC with CT-P13 IV and with reference infliximab IV. Statistically significant differences at week 30 favoured CT-P13 SC over the pooled IV treatment arms for the proportions of patients achieving EULAR-CRP good response, American College of Rheumatology (ACR) 50 and ACR70 responses, DAS28-CRP-defined remission, low disease activity (DAS28-CRP, CDAI and SDAI criteria) and clinically meaningful HAQ-DI improvement.

CONCLUSIONS

CT-P13 SC was associated with greater improvements in DAS28-CRP, CDAI and SDAI scores and higher rates of clinical response, low disease activity and clinically meaningful improvement in functional disability, compared with CT-P13 IV and reference infliximab IV.

TRIAL REGISTRATION

EudraCT, 2016-002125-11 , registered 1 July 2016; EudraCT 2010-018646-31 , registered 23 June 2010.

Health- and Vision-Related Quality of Life in a Randomized Controlled Trial Comparing Methotrexate and Mycophenolate Mofetil for Uveitis

PURPOSE

To evaluate changes in health-related and vision-related quality of life (VRQoL) among patients with noninfectious uveitis who were treated with antimetabolites.

DESIGN

Secondary analysis of a randomized controlled trial.

PARTICIPANTS

Patients with noninfectious uveitis from India, the United States, Australia, Saudi Arabia, and Mexico.

METHODS

From 2013 through 2017, 216 participants were randomized to receive 25 mg weekly oral methotrexate or 1.5 g twice daily oral mycophenolate mofetil. Median changes in quality of life (QoL) were measured using Wilcoxon signed-rank tests, and differences between treatment groups were measured using linear mixed models, adjusting for baseline QoL score, age, gender, and site. Among Indian patients, VRQoL scores from a general scale (the National Eye Institute Visual Function Questionnaire [NEI-VFQ]) and a culturally specific scale (the Indian Visual Function Questionnaire [IND-VFQ]) were compared using Pearson correlation tests.

MAIN OUTCOME MEASURES

Vision-related QoL (NEI-VFQ and IND-VFQ) and health-related QoL (HRQoL; physical component score [PCS] and mental component score [MCS] of the Medical Outcomes Study 36-Item Short Form Survey [SF-36v2]) were measured at baseline, the primary end point (6 months or treatment failure before 6 months), and the secondary end point (12 months or treatment failure between 6 and 12 months).

RESULTS

Among 193 participants who reached the primary end point, VRQoL increased from baseline by a median of 12.0 points (interquartile range [IQR], 1.0-26.1, NEI-VFQ scale), physical HRQoL increased by a median of 3.6 points (IQR, -1.4 to 14.9, PCS SF-36v2), and mental HRQoL increased by a median of 3.0 points (IQR, -3.7 to 11.9, MCS SF-36v2). These improvements in NEI-VFQ, SF-36v2 PCS, and SF-36v2 MCS scores all were significant (P < 0.01). The linear mixed models showed that QoL did not differ between treatment groups for each QoL assessment (NEI-VFQ, IND-VFQ, PCS SF-36v2, and MCS SF-36v2; P > 0.05 for all). The NEI-VFQ and IND-VFQ scores for Indian participants were correlated highly at baseline and the primary and secondary end points (correlation coefficients, 0.87, 0.80, and 0.90, respectively).

CONCLUSIONS

Among patients treated with methotrexate or mycophenolate mofetil for uveitis, VRQoL and HRQoL improved significantly over the course of 1 year and did not differ by treatment allocation. These findings suggest that antimetabolites could improve overall patient well-being and daily functioning.

Widespread non-joint pain in early rheumatoid arthritis

Objective: The aim of the study was to assess the development of widespread non-joint pain (WNP) in a cohort of patients with early rheumatoid arthritis (RA), the associated health-related quality of life (HRQoL), and clinical and demographic risk factors for WNP.Method: Incident cases with RA, from the Swedish population-based study Epidemiological Investigation of Rheumatoid Arthritis (EIRA), with a follow-up of at least 3 years, constituted the study population. WNP was defined as pain outside the joints in all four body quadrants and was assessed at the 3 year follow-up. Patients who reported WNP were compared to patients without WNP regarding HRQoL, measured by the Short Form-36, at 3 years, and clinical and demographic characteristics at the time of RA diagnosis.Results: A total of 749 patients constituted the study sample, of whom 25 were excluded after reporting already having severe pain before RA diagnosis. At the 3 year follow-up, 8% of the patients reported having WNP as well as statistically significant worse HRQoL. At the time of RA diagnosis, the patients with WNP had worse pain and pain-related features, while no difference was seen in the inflammatory parameters.Conclusion: WNP occurs in a substantial subset of patients with RA, also early in the course of the disease, and the HRQoL for these patients is significantly reduced. Patients who develop WNP at 3 years are already distinguishable at the time of diagnosis by displaying more pronounced pain ratings together with an average level of inflammatory disease activity.

Predictive value of anti-CarP and anti-PAD3 antibodies alone or in combination with RF and ACPA for the severity of rheumatoid arthritis

OBJECTIVES

The objective of this study was to analyse the predictive value of anti-carbamylated protein (anti-CarP) and anti-peptidyl-arginine deiminase type-3 (anti-PAD3) antibodies, alone or in combination with RF and ACPA, to identify patients at high risk of developing severe RA outcomes.

METHODS

Patients within the Swiss Clinical Quality Management registry with a biobank sample were tested for RF, ACPA, anti-CarP, and anti-PAD3 antibodies. We examined the association of each autoantibody with DAS28, HAQ and radiographic damage (Ratingen) at baseline and longitudinally.

RESULTS

Analyses included 851 established RA patients and 516 disease controls [axial spondyloarthritis (axSpA = 320) and PsA (196)]. Anti-CarP and anti-PAD3 antibodies were, respectively, present in 22.4% and 10.7% of the whole RA population, and in 13.2% and 3.8% of the RF and ACPA double seronegative patients. At baseline, RA patients with anti-PAD3 had higher DAS28 (4.2 vs 3.7; P= 0.005) and significantly more radiographic damage (14.9 vs 8.8; P= 0.02) than anti-PAD3-negative patients. In the ACPA-negative subgroup, baseline Ratingen scores were significantly higher in anti-PAD3-positive patients (P= 0.01). The combination of anti-PAD3, RF IgM, and ACPA was associated with significantly higher baseline radiographic scores than the double seropositive group (P= 0.04). The presence of any two of the previous autoantibodies was associated with significantly greater radiographic progression over 10 years than if all were absent (P= 0.02). There were no differences in RA outcome measures with regards to anti-CarP.

CONCLUSIONS

Anti-PAD3 antibodies are associated with higher disease activity and joint damage scores in RA patients.

Long-term noninvasive ventilation in COPD: current evidence and future directions

Introduction: Long-term noninvasive ventilation (NIV) is an established treatment for end-stage COPD patients suffering from chronic hypercapnic respiratory failure. This is reflected by its prominent position in national and international medical guidelines. Areas covered: In recent years, novel developments in technology such as auto-titrating machines and hybrid modes have emerged, and when combined with advances in information and communication technologies, these developments have served to improve the level of NIV-based care. Such progress has largely been instigated by the fact that healthcare systems are now confronted with an increase in the number of patients, which has led to the need for a change in current infrastructures. This article discusses the current practices and recent trends, and offers a glimpse into the future possibilities and requirements associated with this form of ventilation therapy. Expert opinion: Noninvasive ventilation is an established and increasingly used treatment option for patients with chronic hypercapnic COPD and those with persistent hypercapnia following acute hypercapnic lung failure. The main target is to augment alveolar hypoventilation by reducing P_aCO₂ to relieve symptoms. Nevertheless, when dealing with severely impaired patients, it appears necessary to switch the focus to patient-related outcomes such as health-related quality of life.

Determination of thresholds for minimally important difference and clinically important response on the functional outcomes of sleep questionnaire short version in adults with narcolepsy or obstructive sleep apnea

PURPOSE

This study estimated thresholds for clinically important responses and minimally important differences for two indicators of improvement for the 10-item version of the functional outcomes of sleep questionnaire (FOSQ-10).

METHODS

Participants with excessive daytime sleepiness with narcolepsy or obstructive sleep apnea received 12 weeks of solriamfetol treatment. Participants completed the FOSQ-10 and other patient-reported outcome measures, including the single-item patient global impression of change (PGI-C) assessment. Clinicians completed the single-item clinician global impression of change (CGI-C) for each participant. Data from the two studies were analyzed separately, both without regard to treatment assignment. In total, 690 participants (47% female, mean age 48 years, 77% Caucasian, 91% from North America) were enrolled. Two clinically important changes, defined as a minimally important difference and a clinically important response, were determined using distribution and anchor-based analyses. A receiver operating characteristic analysis was used to determine the optimal FOSQ-10 change threshold.

RESULTS

Spearman correlations between change in FOSQ-10 scores and PGI-C and CGI-C were - 0.57 and - 0.49 for participants with narcolepsy and - 0.42 and - 0.37 for participants with obstructive sleep apnea. Receiver operating characteristic analysis suggested minimally important difference and clinically important response estimates of 1.7 and 2.5 and 1.8 and 2.2 points in narcolepsy and obstructive sleep apnea, respectively.

CONCLUSIONS

Minimally important difference and clinically important response estimates for the FOSQ-10 for adults with excessive daytime sleepiness in narcolepsy or obstructive sleep apnea will be helpful for interpreting changes over time and defining a clinical responder. CLINICALTRIALS.

GOV IDENTIFIERS

NCT02348593 (first submitted January 15, 2015) and NCT02348606 (first submitted January 15, 2015).

Taylor Spatial Frame or Reamed Intramedullary Nailing for Closed Fractures of the Tibial Shaft: A Randomized Controlled Trial

OBJECTIVES

To compare a modern ring fixator [Taylor Spatial Frame (TSF)] and reamed intramedullary nailing (IMN) for the treatment of closed tibial shaft fractures.

DESIGN

Randomized controlled trial.

SETTING

Two university hospitals.

PATIENTS

Patients between 18 and 70 years of age surgically treated for an acute tibial shaft fracture.

INTERVENTION

TSF (n = 31) versus a reamed intramedullary nail (n = 32). The patients were followed up for 2 years.

MAIN OUTCOME MEASUREMENTS

The physical component summary of Short Form 36 (SF-36) at 2 years was the primary outcome measure. Secondary outcomes included the other components of the SF-36, pain assessed by a visual analogue scale (VAS), complications, and resource consumption.

RESULTS

The mean age was 43 years (SD 14.0), and 42 (67%) were men. The physical component summary at 2 years was 52.4 (SD 6.3) in the TSF group and 53.3 (SD 8.0) in the IMN group (P = 0.35). There were modest differences in the other SF-36 scores during the follow-up period. Up to and including 12 months, the TSF group had less knee pain [at 12 months: VAS 0.5 (SD 1.2) vs. VAS 2.4 (SD 2.2; P < 0.001)], but this was not statistically significant at 24 months [VAS 0.7 (SD 1.4) vs. VAS 1.5 (SD 2.0; P = 0.11)]. Superficial skin infections were more frequent in the TSF group [22 (71%) vs. 4 (13%); P < 0.001]. The number of other complications was similar between the groups.

CONCLUSIONS

Both TSF and IMN provided good clinical results. TSF had more pin-track infections but less knee pain the first year.

LEVEL OF EVIDENCE

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Association of Autologous Hematopoietic Stem Cell Transplantation in Systemic Sclerosis With Marked Improvement in Health-Related Quality of Life

OBJECTIVE

To quantify the magnitude, domains, and duration of change in health-related quality of life (HRQoL) in patients with systemic sclerosis (SSc) who underwent autologous hematopoietic stem cell transplantation (HSCT) as compared to SSc patients with similar characteristics who did not undergo autologous HSCT.

METHODS

The study was designed as a retrospective study comparing SSc patients who underwent autologous HSCT and SSc patients who met the criteria for transplantation but were treated with conventional care. Outcomes included scores on the 36-item Short Form (SF-36) health survey and the Health Assessment Questionnaire (HAQ) and its disease-specific symptom scales. Differences in scores between the groups were compared using linear models, adjusting for baseline scores and inverse probability of treatment and censoring weights.

RESULTS

In total, 41 SSc patients who underwent autologous HSCT and 65 SSc patients treated with conventional care were compared. In marginal linear weighted models, the SF-36 physical component summary score was a mean ± SEM 7.02 ± 1.94 points higher at the first annual visit (P = 0.001) and 14.40 ± 6.16 points higher at the seventh annual visit (P = 0.03) in patients treated with autologous HSCT compared to the conventional care group. HAQ scores were significantly better in the autologous HSCT group compared to the conventional care group during follow-up (mean ± SEM difference from baseline -0.57 ± 0.13 [P < 0.001] at the first annual visit and -0.94 ± 0.49 [P = 0.07] at the seventh annual visit). There were no differences in the SF-36 mental component summary scores between the 2 groups either at baseline or during follow-up.

CONCLUSION

This study provides robust complementary HRQoL data, including overall and event-free survival data, to expand on the standard repertoire of biomedical variables, thus potentially supporting the physical benefits of autologous HSCT in patients with SSc.

What Are the Minimum Clinically Important Differences in SF-36 Scores in Patients with Orthopaedic Oncologic Conditions?

BACKGROUND

The SF-36 is widely used to evaluate the health-related quality of life of patients with musculoskeletal tumors. The minimum clinically important difference (MCID) is useful for interpreting changes in functional scores because it defines the smallest change each patient may perceive. Since the MCID is influenced by the population characteristics, MCIDs of the SF-36 should be defined to reflect the specific conditions of orthopaedic oncology patients.

QUESTIONS/PURPOSES

(1) What is the MCID of SF-36 physical component summary (PCS) and mental component summary (MCS) scores in patients with orthopaedic oncologic conditions when calculated with distribution-based methods? (2) What is the MCID of SF-36 PCS and MCS scores in patients with orthopaedic oncologic conditions when calculated by anchor-based methods?

METHODS

Of all 960 patients who underwent surgery from 1999 to 2005, 32% (310) of patients who underwent musculoskeletal oncologic surgery and completed two surveys during postoperative follow-up were reviewed. We evaluated a dataset that ended in 2005, completing follow-up of data accrued as part of the cooperative effort between the American Academy of Orthopaedic Surgeons and the Council of Musculoskeletal Specialty Societies to create patient reported quality of life instruments for lower extremity conditions. This effort, started in 1994 was validated and widely accepted by its publication in 2004. We believe the findings from this period are still relevant today because (1) this critical information has never been available for clinicians and researchers to distinguish real differences in outcome among orthopaedic oncology patients, (2) the SF-36 continues to be the best validated and widely used instrument to assess health-related quality of life, and unfortunately (3) there has been no significant change in outcome for oncology patients over the intervening years. SF-36 PCS and MCS are aggregates of the eight scale scores specific to physical and mental dimension (scores range from 0 to 100, with higher scores representing better health). Their responsiveness has been shown postoperatively for several surgical procedures (such as, colorectal surgery). Two different methods were used to calculate the MCID: the distribution-based method, which was based on half the SD of the change in score and standard error of the measurement at baseline, and anchor-based, in which a receiver operating characteristic (ROC) curve analysis was performed. The anchor-based method uses a plain-language question to ask patients how their individual conditions changed when compared with the previous survey. Answer choices were "much better," "somewhat better," "about the same," "somewhat worse," or "much worse." The ROC curve-derived MCIDs were defined as the change in scores from baseline, with sensitivity and specificity to detect differences in patients who stated their outcome was, about the same and those who stated their status was somewhat better or somewhat worse. This approach is based on each patient's perception. It considers that the definition of MCID is the minimal difference each patient can perceive as meaningful.

RESULTS

Using the distribution-based method, we found that the MCIDs of the PCS and MCS were 5 and 5 by half the SD, and 6 and 5 by standard error of the measurement. In the anchor-based method, the MCIDs of the PCS and MCS for improvement/deterioration were 4 (area under the curve, 0.82)/-2 (area under the curve, 0.79) and 4 (area under the curve, 0.72)/ (area under the curve, 0.68), respectively.

CONCLUSIONS

Since both anchor-based and distribution-based MCID estimates of the SF-36 in patients with musculoskeletal tumors were so similar, we have confidence in the estimates we made, which were about 5 points for both the PCS and the MCS subscales of the SF-36. This suggests that interventions improving SF-36 by less than that amount are unlikely to be perceived by patients as clinically important. Therefore, those interventions may not justify exposing patients to risk, cost, or inconvenience. When applying new interventions to orthopaedic oncology patients going forward, it will be important to consider these MCIDs for evaluation purposes.

LEVEL OF EVIDENCE

Level III, diagnostic study.

Enhanced treatment strategies and distinct disease outcomes among autoantibody-positive and -negative rheumatoid arthritis patients over 25 years: A longitudinal cohort study in the Netherlands

BACKGROUND

Based on different genetic and environmental risk factors and histology, it has been proposed that rheumatoid arthritis (RA) consists of 2 types: autoantibody-positive and autoantibody-negative RA. However, until now, this remained hypothetical. To assess this hypothesis, we studied whether the long-term outcomes differed for these 2 groups of RA patients.

METHODS AND FINDINGS

In the Leiden Early Arthritis Clinic cohort, 1,285 consecutive RA patients were included between 1993 and 2016 and followed yearly. Treatment protocols in routine care improved over time, irrespective of autoantibody status, and 5 inclusion periods were used as instrumental variables: 1993-1996, delayed mild disease-modifying antirheumatic drug (DMARD) initiation (reference period); 1997-2000, early mild DMARDs; 2001-2005, early methotrexate; 2006-2010, early methotrexate followed by treat-to-target adjustments; 2011-2016, similar to 2006-2010 plus additional efforts for very early referral. Three long-term outcomes were studied: sustained DMARD-free remission (SDFR) (persistent absence of clinical synovitis after DMARD cessation), mortality, and functional disability measured by yearly Health Assessment Questionnaire (HAQ). Treatment response in the short term (disease activity) was measured by Disease Activity Score-28 with erythrocyte sedimentation rate (DAS28-ESR). Linear mixed models and Cox regression were used, stratified for autoantibody positivity, defined as IgG anti-CCP2 and/or IgM rheumatoid factor positivity. In total, 823 patients had autoantibody-positive RA (mean age 55 years, 67% female); 462 patients had autoantibody-negative RA (age 60 years, 64% female). Age, gender, and percentage of autoantibody-positive patients were stable throughout the inclusion periods. Disease activity significantly decreased over time within both groups. SDFR rates increased after introduction of treat-to-target (hazard ratio [HR] 2006-2010 relative to 1993-1996: 3.35 [95% CI 1.46 to 7.72; p = 0.004]; HR 2011-2016: 4.57 [95% CI 1.80 to 11.6; p = 0.001]) in autoantibody-positive RA, but not in autoantibody-negative RA. In autoantibody-positive RA, mortality decreased significantly after the introduction of treat-to-target treatment adjustments (HR 2006-2010: 0.56 [95% CI 0.34 to 0.92; p = 0.023]; HR 2011-2016: 0.33 [95% CI 0.14 to 0.77; p = 0.010]), but not in autoantibody-negative RA (HR 2006-2010: 0.79 [95% CI 0.40 to 1.56; p = 0.50]; HR 2011-2016: 0.36 [95% CI 0.10 to 1.34; p = 0.13]). Similarly, functional disability improved in autoantibody-positive RA for the periods after 2000 relative to 1993-1996 (range -0.16 [95% CI -0.29 to -0.03; p = 0.043] to -0.32 [95% CI -0.44 to -0.20; p < 0.001] units of improvement), but not in autoantibody-negative RA (range 0.10 [95% CI -0.12 to 0.31; p = 0.38] to -0.13 [95% CI -0.34 to 0.07; p = 0.20] units of improvement). Limitations to note were that treatment was not randomized-but it was protocolized and instrumental variable analysis was used to obtain comparable groups-and that a limited spread of ethnicities was included.

CONCLUSIONS

Although disease activity has improved in both autoantibody-positive and autoantibody-negative RA in recent decades, the response in long-term outcomes differed. We propose that it is time to subdivide RA into autoantibody-positive RA (type 1) and autoantibody-negative RA (type 2), in the hope that this leads to stratified treatment in RA.

Responsiveness of the Persian health assessment questionnaire measures in differentiating among disease activity levels in rheumatoid arthritis patients

OBJECTIVES

Evidence suggests that inflammation has a harmful effect on muscle strength as well as on functional disability. The purpose of the present study was to examine the association of objectively measured disease activity levels and functional disability among Iranian patients with Rheumatoid Arthritis (RA), and to analyse whether a Persian version of the health assessment questionnaire-disability index (PHAQ-DI) can distinguish between RA patients at different stages of the disease progression.

MATERIALS & METHODS

198 RA patients were requested to complete the PHAQ-DI. The disease activity score for each patient was evaluated using the disease activity score (DAS-28). The association analysis between the PHAQ-DI scores and the four levels of disease activity was measured using a Spearman correlation coefficient. A Kruskal-Wallis analysis was utilized to determine differences in PHAQ-DI scores among the levels of disease activity. The Receiver operating characteristic (ROC) curve was also utilized to determine the PHAQ-DI total score cut-off for predicting the level of disease activity.

RESULTS

Spearman's correlation coefficients between the PHAQ-DI and the disease activity level ranged between 0.59 and 0.75. There were significant differences in the PHAQ-DI total score among known groups with various disease activity levels (P = 0.001); However, HAQ-DI total score could not differentiate the remission phase from low disease activity levels in patients with RA (p = 0.37). The PHAQ-DI total score cut-off for distinguishing remission-low disease activity from moderate-high disease activity was 1.19, with a specificity of 0.91 and a sensitivity of 0.615.

CONCLUSION

The present findings provide evidence for the degree to which the PHAQ-DI measures identify and distinguish disease activity levels in patients with rheumatoid arthritis. The PHAQ-DI questionnaire, as a patient-administered, non-invasive, fast, inexpensive and available tool, can be used in the rheumatologist's office as a substitute for determining disease activity in patients with active RA.

Efficacy and Safety of Tofacitinib, Baricitinib, and Upadacitinib for Rheumatoid Arthritis: A Systematic Review and Meta-Analysis

OBJECTIVE

To assess the efficacy and safety profiles of different dosing regimens of tofacitinib, baricitinib, and upadacitinib, novel selective oral Janus activated kinase inhibitors, in rheumatoid arthritis (RA).

METHODS

Randomized controlled trials of tofacitinib (5 and 10 mg twice daily) baricitinib (2 and 4 mg daily), and upadacitinib (15 and 30 mg daily) in RA were identified from MEDLINE, EMBASE, and Cochrane databases through December 11, 2019. Random-effects models were used to estimate pooled mean differences and relative risks (RRs). American College of Rheumatology 20%, Health Assessment Questionnaire-Disability Index, adverse events, risk for infection, venous thromboembolic events, and malignancy were calculated.

RESULTS

Twenty trials with an overall low risk of bias involving 8982 patients were identified. Tofacitinib, baricitinib, and upadacitinib improved RA control as determined by American College of Rheumatology 20% (RR, 2.03; 95% CI, 1.87 to 2.20) and Health Assessment Questionnaire-Disability Index scores (mean differences, -0.31; 95% CI, -0.34 to -0.28) compared with placebo. Adverse events were more frequent with upadacitinib, 30 mg, daily (RR, 1.15; 95% CI, 1.02 to 1.30); upadacitinib, 15 mg, daily (RR, 1.14; 95% CI, 1.02 to 1.27); and baricitinib, 4 mg, daily (RR, 1.13; 95% CI, 1.02 to 1.24). The risk for infection was highest with tofacitinib, 10 mg, twice daily (RR, 2.75; 95% CI, 1.72 to 4.41), followed by upadacitinib, 15 mg, daily (RR, 1.35; 95% CI, 1.14 to 1.60) and baricitinib, 4 mg, daily (RR, 1.28; 95% CI, 1.12 to 1.45). Data for venous thromboembolic events were not available for tofacitinib or baricitinib, but there was no increase in risk with upadacitinib (15 mg daily: RR, 2.34; 95% CI, 0.34 to 15.92).

CONCLUSION

Tofacitinib, baricitinib, and upadacitinib significantly improve RA control. Head-to-head Janus activated kinase inhibitor clinical trials are needed to further inform decision making.

Health-Related Quality of Life in Sarcoidosis

Health-related quality of life (HRQoL) describes an individual's perception of the impact of health, disease, and treatment on their quality of life (QoL). It is a reflection of how the manifestation of an illness and its treatment is personally experienced. Assessing HRQoL is particularly important in sarcoidosis because the attributable disease mortality is relatively low, and one of the major reasons for initiating treatment is to improve quality of life. HRQoL has been assessed in sarcoidosis using various generic and sarcoid-specific patient-reported outcome measures (PROMs). It is important that both the direct and indirect effects of the disease, as well as potential toxicities of therapy, are captured in the various PROMs used to assess HRQoL in sarcoidosis. This article provides a general overview of HRQoL in patients with sarcoidosis. It describes the various PROMs used to assess HRQoL in sarcoidosis and addresses the various factors that influence HRQoL in sarcoidosis. Specific attention is paid to fatigue, small fiber neuropathy, corticosteroid therapy, and other disease-specific factors that affect HRQoL in sarcoidosis. It also provides an insight into interventions that have been associated with improved HRQoL in sarcoidosis and offers suggestions for future research in this important area.

Patients With Borderline Hip Dysplasia Achieve Clinically Significant Improvement After Arthroscopic Femoroacetabular Impingement Surgery: A Case-Control Study With a Minimum 5-Year Follow-up

BACKGROUND

Hip arthroscopy for the treatment of femoroacetabular impingement syndrome (FAIS) in patients with borderline hip dysplasia (BHD) is becoming a more common practice. However, the literature on achieving meaningful outcomes at midterm follow-up, as well as predictors of these outcomes, is limited.

PURPOSE

To (1) compare the rates of achieving meaningful clinical outcomes between patients with and without BHD and (2) identify the predictors for achieving clinical success among patients with BHD 5 years after undergoing hip arthroscopic surgery for FAIS.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Data from consecutive patients who underwent primary hip arthroscopic surgery with routine capsular closure for the treatment of FAIS between January 2012 and August 2014 were collected and retrospectively analyzed. Patients with BHD (lateral center-edge angle [LCEA] 20°-25°) were matched 1:2 by age (±1 year) and body mass index (BMI; ±5 kg/m²) to control patients with normal acetabular coverage (LCEA 25°-40°). Data collected included baseline and 5-year postoperative patient-reported outcomes. The minimal clinically important difference (MCID) and patient acceptable symptom state (PASS) were calculated for each patient-reported outcome measure and compared between the 2 groups. A binary logistic regression analysis was used to identify significant predictors of achieving the MCID and PASS in the BHD group.

RESULTS

The MCID in the BHD group was defined as 9.6, 14.1, and 9.5 for the Hip Outcome Score-Activities of Daily Living, Hip Outcome Score-Sports Subscale, and modified Harris Hip Score, respectively. Threshold scores for achieving the PASS in both groups were 90.9, 76.6, and 81.9, respectively. A total of 88 patients were identified with having BHD and were matched to 176 controls. No statistical differences were identified for age, BMI, or sex. Both the BHD and the non-BHD groups had statistically significant increases in patient-reported outcome scores over the 5-year period, but the difference in both groups was not statistically significant (P > .05 for all). There was no statistical difference in the frequency of patients in the BHD and non-BHD groups achieving the MCID (86.6% vs 85.2%, respectively; P = .804) or PASS (76.0% vs 73.7%, respectively; P = .675) on at least 1 outcome measure. The logistic regression model demonstrated that being physically active (odds ratio [OR], 27.59; P = .005) and being female (OR, 14.64; P = .025) were independent predictors of achieving the MCID, while running (OR, 11.1; P = .002), being female (OR, 7.6; P = .011), and a larger preoperative LCEA (OR, 2.3; P = .001) were independent preoperative predictors of achieving the PASS.

CONCLUSION

The rates of achieving clinical success 5 years after undergoing arthroscopic treatment with capsular closure for FAIS were not significantly different between patients with BHD and those with normal acetabular coverage. Being physically active, running for exercise, female sex, and a larger LCEA were preoperative predictors of achieving clinical success at 5 years in patients with BHD.

Nutritional Determinants of Quality of Life in a Mediterranean Cohort: The SUN Study

Health related quality of life (HRQoL) is a subjective appreciation of how personal characteristics and health influence well-being. This cross-sectional analysis aimed to quantitatively measure the influence of dietary, lifestyle, and demographic factors on HRQoL. A sub-sample of the Seguimiento Universidad de Navarra (SUN) Project, a Mediterranean cohort, was analyzed (n = 15,674). Through self-administered questionnaires the relationship between HRQoL and dietary patterns (Mediterranean-diet (MedDiet) and provegetarian food pattern (FP) assessment), lifestyles (sleeping hours, physical activity) and demographic characteristics were measured. Multivariate linear regression and flexible regression models were used to estimate the pondered effect of personal factors on Short Form-36 (SF-36) scores. Coefficients for MedDiet and provegetarian scores (β-coefficient for global SF-36 score: 0.32 (0.22, 0.42); 0.09 (0.06, 0.12) respectively for every unit increase), physical activity (β: 0.03 (0.02, 0.03) for every metabolic equivalent of task indexes (MET)-h/week) had a positive association to HRQoL. The female sex (β: −3.28 (−3.68, −2.89)), and pre-existing diseases (diabetes, β: −2.27 (−3.48, −1.06), hypertension β: −1.79 (−2.36, −1.22), hypercholesterolemia β: −1.04 (−1.48, −0.59)) account for lower SF-36 scores. Adherence to MedDiet or provegetarian FP, physical activity and sleep are associated with higher HRQoL, whereas the female sex, “other” (versus married status) and the presence of chronic diseases were associated with lower SF-36 scores in this sample.

Minimum clinically important difference of major patient-reported outcome measures in patients undergoing decompression surgery for lumbar spinal stenosis

OBJECTIVE

A minimum clinically important difference (MCID) has been increasingly well known in the current era of patient-centered care because it reflects a smallest change that is meaningful for patients following a clinical intervention. Previous studies suggested MCID values are disease and/or procedure dependent. No MCID values have been reported on the lumbar spinal stenosis (LSS) following decompression surgery despite LSS is the most common spinal disease and the main treatment is decompression surgery. Therefore, this study aimed to determine the MCID values as major outcome measures including the Numeric Rating Scale (NRS) of back pain, leg pain and numbness, Roland-Morris Disability Questionnaire (RMDQ), and Physical Component Summary (PCS) and Mental Component Summary (MCS) of Short Form 8 (SF-8) for patients with LSS undergoing decompression surgery.

PATIENTS AND METHODS

This is a retrospective cohort study using prospectively collected data from consecutive patients who underwent lumbar decompression without fusion for LSS at a single institution between May 2014 and March 2016. Inclusion criteria were 1) minimum 1-year follow-up 2) a complete set of preoperative and final follow-up questionnaires available, including the NRS, RMDQ, and SF-8. Revision surgery or non-degenerative etiology such as infection or tumor was excluded. MCIDs of each outcome measure were determined using two major approaches, distribution- and anchor-based methods. The distribution-based method uses the distributional characteristics of the sample. This method expresses the observed degree of variation to obtain a standardized metric such as the standard deviation or standard error of measurement. The anchor-based method uses an external criterion known as anchor to determine the factors that should be considered by patients for an important improvement. Anchor-based methods assess how much changes in the measurement instrument correspond with a minimal important change defined on the anchor. We used symptom severity, physical function, and satisfaction scores from Zurich Claudication Questionnaire as anchors for NRS and RMDQ, PCS, and MCS, respectively.

RESULTS

A total of 126 patients were included. From the anchor-based method, MCIDs were determined to be 2 points for back pain, 4 points for leg pain and numbness, 5 points for RMDQ, 5 points for PCS, and 2 points for MCS. From the distribution-based method, MCIDs were determined to be 2 points for back pain, leg pain and numbness, 3-4 points for RMDQ, 6 points for PCS, and 5 points for MCS.

CONCLUSION

We first identified the MCIDs of the NRS, RMDQ, and SF-8 specific to patients undergoing decompression surgery for LSS.

Minimal clinically important differences and substantial clinical benefits for Knee Society Scores

PURPOSE

There is a paucity of literature defining the minimal clinically important difference (MCID) for the Knee Society Scores (KSS) after total knee arthroplasty (TKA), and no data on the substantial clinical benefit (SCB) for KSS have been reported. The purpose of this study was to determine MCID and SCB for the KSS in patients with primary TKA.

METHODS

The median age of patients was 71.6 (range 50-88) years, and 60.3% were females 507 patients with TKA were prospectively enrolled. Patients completed the KSS before surgery and at second postoperative year. The MCID values of the KSS were estimated using anchor-based method, distribution-based method and receiver operating characteristic (ROC) curve analysis with calculation of the area under curve (AUC). SCB was estimated using ROC.

RESULTS

The MCID for KSS-knee score was 7.2 points by the anchor-based method, 7.2 by the distribution-based method, and using a ROC analysis the cutoff point was 8.9 points with an AUC of 0.75. For KSS-function score, the MCID values were 9.7, 6.3, and 10.3 (AUC 0.71), respectively. SCB values were 39.7 points (AUC 0.74) for the KSS-knee score, and 38.6 (AUC 0.76) for the KSS-function score. Logistic regression showed age and Charlson index to negatively affect the changes in KSS.

CONCLUSION

Different methods for MCID calculation lead to different results. With the use of ROC curve analysis, patients with an improvement of at least 9 points for KSS-knee and 10 points for KSS-function scores experience a clinically important change, whereas those who have at least an improvement of 40 points for KSS-knee and 39 points for KSS-function scores experience a substantial clinical benefit. These findings can ensure clinical improvement from the patient's perspective and also aid in interpreting results from clinical studies.

LEVEL OF EVIDENCE

III.

Defining the Clinically Meaningful Outcomes for Arthroscopic Treatment of Femoroacetabular Impingement Syndrome at Minimum 5-Year Follow-up

BACKGROUND

Minimal clinically important difference (MCID), substantial clinical benefit (SCB), and patient acceptable symptomatic state (PASS) have gained prominence as important variables in the orthopaedic outcomes literature. In hip preservation surgery, much attention has been given to defining early clinically meaningful outcome; however, it is unknown what represents meaningful patient-reported outcome improvement in the medium to long term.

PURPOSE

(1) To define MCID, PASS, and SCB at a minimum 5 years after hip arthroscopy for femoroacetabular impingement syndrome (FAIS) and (2) to evaluate the time-dependent nature of MCID, PASS, and SCB.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Patients undergoing primary hip arthroscopy for FAIS between January 2012 and March 2014 were included. Clinical and demographic data were collected in an institutional hip preservation registry. MCID, PASS, and SCB were calculated for each outcome score including the Hip Outcome Score-Activities of Daily Living subscale (HOS-ADL), Hip Outcome Score-Sport-Specific subscale (HOS-SS), modified Harris Hip Score (mHHS), and International Hip Outcome Tool (iHOT-12) at 1, 2, and 5 years. MCID was calculated by use of a distribution-based method, whereas PASS and SCB were calculated by use of an anchor method.

RESULTS

The study included 283 patients with a mean ± SD age of 34.2 ± 11.9 years. The mean changes in 1-year, 2-year, and 5-year scores, respectively, required to achieve MCID were as follows: HOS-ADL (8.8, 9.7, 10.2); HOS-SS (13.9, 14.3, 15.2); mHHS (6.9, 9.2, 11.4); and iHOT-12 (15.1, 13.9, 15.1). The threshold scores for achieving PASS were as follows: HOS-ADL (89.7, 88.2, 99.2); HOS-SS (72.2, 76.4, 80.9); mHHS (84.8, 83.3, 83.6); and iHOT-12 (69.1, 72.2, 74.3). Last, the threshold scores for achieving SCB scores were as follows: HOS-ADL (89.7, 91.9, 94.6); HOS-SS (78.1, 77.9, 85.8); mHHS (86.9, 85.8, 94.4); and iHOT-12 (72.6, 76.8, 87.5). More patients achieved MCID, SCB, and PASS at 2-year compared with 1-year follow-up; however, by 5 years, fewer patients had achieved clinically meaningful outcome (minimum 1-, 2-, and 5-year follow-up, respectively: MCID, 82.6%, 87.3%, 79.3%; PASS, 67.6%, 74.9%, 67.5%; SCB, 62.3%, 67.2%, 56.6%).

CONCLUSION

The greatest proportion of patients achieved MCID, PASS, and SCB at 2-year follow-up after arthroscopic treatment of FAIS compared with 1- and 5-year time points. Improvements were maintained out to 5-year follow-up, although the proportion of patients achieving clinical significance was slightly decreased.

Association of handgrip strength with patient-reported outcome measures after total hip and knee arthroplasty

About 33% patients with osteoarthritis undergoing total hip/knee arthroplasty are not satisfied with the outcome, warranting the need to improve patient selection. Handgrip strength (HGS) has been suggested as a proxy for overall muscle strength and may be associated with post-arthroplasty function. This study aims to assess the association of pre-operative HGS with change in hip/knee function and quality of life in patients with arthroplasty. 226 hip (THA) and 246 knee (TKA) arthroplasty patients were included in this prospective cohort study. Pre-operative HGS was assessed by means of a dynamometer and the HOOS/KOOS and SF-36 questionnaires were collected before arthroplasty and 1 year thereafter. The association of HGS with score change on each sub-domain of the included questionnaires was assessed by linear regression models, adjusting for sex, body mass index and baseline score. Mean pre-operative HGS was 26 kg for patients undergoing THA and 24 kg for those undergoing TKA. HGS was positively associated with an increased improvement score on “function in sport and recreation”-domain in hip (β = 0.68, P = 0.005) and knee (β = 0.52, P = 0.049) and “symptoms”-domain in hip (β = 0.56, P = 0.001). For patients with THA, HGS was associated with the “quality of life” domain (β = 0.33, P = 0.033). In patients with TKA, HGS was associated with the physical component score (β = 0.31, P = 0.001). All statistically significant effects were positive, indicating that with greater pre-operative HGS, an increased gain in 1-year post-surgery score was observed. HGS can be used as a tool to inform patients with OA who are future candidates for a prosthesis about the possible improvements of certain aspects of life after arthroplasty.

Abatacept in rheumatoid arthritis: survival on drug, clinical outcomes, and their predictors-data from a large national quality register

BACKGROUND

There are limited data regarding efficacy of abatacept treatment for rheumatoid arthritis (RA) outside clinical trials. Quality registers have been useful for observational studies on tumor necrosis factor inhibition in clinical practice. The aim of this study was to investigate clinical efficacy and tolerability of abatacept in RA, using a national register.

METHODS

RA patients that started abatacept between 2006 and 2017 and were included in the Swedish Rheumatology Quality register (N = 2716) were investigated. Survival on drug was estimated using Kaplan-Meier analysis. The European League Against Rheumatism (EULAR) good response and Health Assessment Questionnaire (HAQ) response (improvement of ≥ 0.3) rates (LUNDEX corrected for drug survival) at 6 and at 12 months were assessed. Predictors of discontinuation were investigated by Cox regression analyses, and predictors of clinical response by logistic regression. Significance-based backward stepwise selection of variables was used for the final multivariate models.

RESULTS

There was a significant difference in drug survival by previous biologic disease-modifying antirheumatic drug (bDMARD) exposure (p < 0.001), with longer survival in bionaïve patients. Men (hazard ratio (HR) 0.86, 95% confidence interval (CI) 0.74-0.98) and methotrexate users (HR 0.85, 95% CI 0.76-0.95) were less likely to discontinue abatacept, whereas a high pain score predicted discontinuation (HR 1.14 per standard deviation, 95% CI 1.07-1.20). The absence of previous bDMARD exposure, male sex, and a low HAQ score were independently associated with LUNDEX-corrected EULAR good response. The absence of previous bDMARD exposure also predicted LUNDEX-corrected HAQ response.

CONCLUSIONS

In this population-based study of RA, bDMARD naïve patients and male patients were more likely to remain on abatacept with a major clinical response.

Two-Year Patient-Reported Outcomes for Patients Undergoing Revision Hip Arthroscopy with Capsular Incompetency

PURPOSE

To determine clinical outcomes of patients undergoing revision hip arthroscopy for failure to improve with magnetic resonance imaging (MRI) and intraoperative evidence of a capsular incompetency as compared with (1) patients undergoing revision hip arthroscopy without evidence of a capsular incompetency and (2) patients undergoing primary surgery for femoroacetabular impingement syndrome (FAIS) at a minimum follow up of 2 years.

METHODS

Data from consecutive patients undergoing revision hip arthroscopy with MRI/arthrogram-confirmed capsular incompetency between January 2012 and June 2016 were analyzed. All revision patients with capsular incompetency was matched 1:1 by age and body mass index to FAIS revision patients without capsular incompetency and primary FAIS patients. Outcomes included the Hip Outcome Score (HOS)-Activities of Daily Living (ADL), HOS-Sports Subscale (SS), Modified Harris Hip Score (mHHS), pain, and satisfaction. The minimal clinically important difference was calculated for HOS-ADL, HOS-SS, and mHHS.

RESULTS

In total, 49 patients (54.4%) of 90 undergoing revision hip arthroscopy had MRI evidence of a capsular incompetency. Most patients were female (79.6%), with a mean age of 30 ± 10.5 years and body mass index of 25.7 ± 5.5. The difference among pre- and postoperative HOS-ADL, HOS-SS, mHHS, and visual analog scale score for pain were all statistically significant (P < .05). Analysis of reported outcomes among matched groups demonstrated statistically significant differences, with the group undergoing primary surgery having the greatest 2-year outcomes. Only 66.7% of patients undergoing revision surgery with capsular incompetency achieved a minimal clinically important difference; however, there was no significant difference when compared with revision patients without capsular incompetency. When compared with patients undergoing primary surgery, the difference in frequency was statistically significant (66.7% vs 91.3%; P < .001).

CONCLUSIONS

More than one half of patients undergoing revision hip arthroscopy had MRI and intraoperative evidence of capsular incompetency. Revision arthroscopy for capsular incompetency results in significantly improved 2-year outcomes. However, patients undergoing revision for capsular incompetency and intact capsule revision patients reported significantly lower outcomes compared with primary patients.

LEVEL OF EVIDENCE

Level III, Retrospective Comparative Study.

Racial/Ethnic Differences in Dialysis Discontinuation and Survival after Hospitalization for Serious Conditions among Patients on Maintenance Dialysis

BACKGROUND

Racial and ethnic minorities on dialysis survive longer than whites, and are less likely to discontinue dialysis. Both differences have been attributed by some clinicians to better health among minorities on dialysis.

METHODS

To test if racial and ethnic differences in dialysis discontinuation reflected better health, we conducted a retrospective cohort study of survival and dialysis discontinuation among patients on maintenance dialysis in the US Renal Data System after hospitalization for either stroke (n=60,734), lung cancer (n=4100), dementia (n=40,084), or failure to thrive (n=42,950) between 2003 and 2014. We examined the frequency of discontinuation of dialysis and used simulations to estimate survival in minorities relative to whites if minorities had the same pattern of dialysis discontinuation as whites.

RESULTS

Blacks, Hispanics, and Asians had substantially lower frequencies of dialysis discontinuation than whites in each hospitalization cohort. Observed risks of mortality were also lower for blacks, Hispanics, and Asians. In simulations that assigned discontinuation patterns similar to those found among whites across racial and ethnic groups, differences in survival were markedly attenuated and hazard ratios approached 1.0. Survival and dialysis discontinuation frequencies among American Indians and Alaska Natives were close to those of whites.

CONCLUSIONS

Racial and ethnic differences in dialysis discontinuation were present among patients hospitalized with similar health events. Among these patients, survival differences between racial and ethnic minorities and whites were largely attributable to differences in the frequency of discontinuation of dialysis.