Incidence and Mortality of Osteoporotic Fracture in Rheumatoid Arthritis in South Korea Using Nationwide Claims Data

Incidence of and Risk of Mortality After Hip Fractures in Rheumatoid Arthritis Relative to the General Population

OBJECTIVE

Osteoporosis, a known complication of rheumatoid arthritis (RA), increases the risk of hip fracture, which is associated with high morbidity and mortality. Fracture risk estimates in patients with RA treated with contemporary treatment strategies are lacking. The objectives were (1) estimate age-specific and sex-specific incidence rates and compare the risk of hip fractures in RA relative to age-matched and sex-matched general population controls, and (2) compare the risk of all-cause mortality in RA and general population controls after hip fracture.

METHODS

A longitudinal study of a population-based incident cohort of patients with RA diagnosed between 1997 and 2009, followed until 2014, with age-matched and sex-matched controls from the general population of British Columbia, using administrative health data. Hip fracture outcomes (International Classification of Diseases, Ninth Edition, Clinical Modification [ICD-9-CM] codes 820.0 or 820.2; ICD-10-Canada code S72.0 to S72.2) and mortality at predefined intervals after fracture (in hospital, 90 days, 1-year, 5-year) were identified. Hip fracture incidence rates for RA and controls, and incidence rate ratios (IRRs), were calculated. Cox proportional hazards models compared hip fracture and mortality risk in RA versus controls; logistic regression compared in-hospital mortality risk.

RESULTS

Overall, 1,314 hip fractures over 360,521 person-years were identified in 37,616 individuals with RA and 2,083 over 732,249 person-years in 75,213 controls, yielding a 28% greater fracture risk in RA (IRR 1.28 [95% confidence interval 1.20-1.37]). Mean age at time of fracture was slightly younger for RA than controls (79.6 ± 10.8 vs 81.6 ± 9.3 years). Postfracture mortality risk at one-year and five-years did not differ between RA and general population controls. Results were similar in a sensitivity analysis including only individuals with RA who received disease-modifying antirheumatic drugs.

CONCLUSION

People with RA had a greater risk of hip fractures, but no greater risk of mortality post fracture, than the general population. The relative risk of hip fractures observed was not as high as previously reported, likely reflecting better treatment of inflammation and management of osteoporosis and its risk factors.

Prediction of osteoporosis in patients with rheumatoid arthritis using machine learning

Osteoporosis is a serious health concern in patients with rheumatoid arthritis (RA). Machine learning (ML) models have been increasingly incorporated into various clinical practices, including disease classification, risk prediction, and treatment response. However, only a few studies have focused on predicting osteoporosis using ML in patients with RA. We aimed to develop an ML model to predict osteoporosis using a representative Korean RA cohort database. The KORean Observational study Network for Arthritis (KORONA) database, established by the Clinical Research Center for RA in Korea, was used in this study. Among the 5077 patients registered in KORONA, 2374 patients were included in this study. Four representative ML algorithms were used for the prediction: logistic regression (LR), random forest, XGBoost (XGB), and LightGBM. The accuracy, F1 score, and area under the curve (AUC) of each model were measured. The LR model achieved the highest AUC value at 0.750, while the XGB model achieved the highest accuracy at 0.682. Body mass index, age, menopause, waist and hip circumferences, RA surgery, and monthly income were risk factors of osteoporosis. In conclusion, ML algorithms are a useful option for screening for osteoporosis in patients with RA.

L-shaped association between serum 25-hydroxyvitamin D and all-cause mortality of individuals with rheumatoid arthritis

OBJECTIVE

We aimed to examine the relationship between serum 25-hydroxyvitamin D and all-cause, cause-specific mortality of patients with RA.

METHODS

This cohort study included 1466 patients with RA from The National Health and Nutrition Examination Survey (NHANES) 2001-14. Mortality status was obtained according to death certificate records from the National Death Index. Cox proportional risk models were used to estimate hazard ratios (HR) and 95% CI for mortality. A generalized additive model, smooth curve fitting and 2-piecewise Cox proportional hazards models were established to address the nonlinearity between serum 25-hydroxyvitamin D and mortality.

RESULTS

A total of 1466 patients [mean (s.d.) 59.89 (14.14) years old; 58.94% female] were enrolled. The weighted mean level of 25-hydroxyvitamin D was 59.26 (24.99) nmol/l and 38.95% were found with deficient (or severe deficient) vitamin D (<50.00 nmol/l). During 10453 person-years of follow-up, 268 patients were documented for all-cause death, including 52 cardiovascular disease （CVD）deaths and 48 cancer deaths. Compared with patients with serum 25-hydroxyvitamin D <25.00 nmol/l, patients with higher serum 25-hydroxyvitamin D were more likely to have lower rate of all-cause mortality. Nonlinear and L-shaped association between serum 25-hydroxyvitamin D and all-cause mortality was found, and decreased serum 25-hydroxyvitamin D was significantly associated with increased risk of all-cause mortality in patients with serum 25-hydroxyvitamin D <37.30 nmol/l [HR 0.95 (0.92, 0.98); P < 0.01].

CONCLUSION

An L-shaped association between serum 25-hydroxyvitamin D and all-cause mortality was found among patients with RA, indicating that serum 25-hydroxyvitamin D should be improved to a certain level for the prevention of premature death.

Effect of chrono-moxibustion and its influence on circadian rhythm for rheumatoid arthritis: A study protocol for a randomized controlled trial

BACKGROUND

Rheumatoid arthritis (RA) is a chronic disease which is characterized by a circadian variation of key clinical symptoms and findings, with prominent joint swelling, stiffness and pain occurring in the early morning and light clinical symptoms during the day. Chrono-moxibustion is carried out at different time, which could result in dissimilar therapeutic effects. However, its efficacy has seldom been systematically demonstrated and few studies have reported that Chrono-moxibustion may regulate the circadian rhythm of RA. We therefore designed a randomized trial to explore the effective difference of Chrono-moxibustion in RA treatment, as well as to study its influence on circadian rhythm of RA patients.

METHODS

This study is a randomized controlled trial involving 120 participants, and a total of 90 eligible RA patients will be randomly allocated to three groups in a 1:1:1 ratio as moxibustion at 7 to 9 am, moxibustion at 5 to 7 pm, and waiting list group, meanwhile, 30 healthy people will be divided into the control group. Patients in moxibustion groups will be treated for 30 minutes per session, 3 times a week, lasting 6 weeks. All of RA patients will be evaluated with questionnaires and laboratory tests before treatment, as well as 3 weeks, 6 weeks, and 3 months after treatment. One way analysis of variance (ANOVA) with multiple comparisons will be applied to identify differences more than two groups. Halberg cosiner software will be used to analysis the circadian rhythm.

RESULTS

The results of this study will be published in a peer-reviewed journal.

CONCLUSION

This study will provide evidence-based evidence for the effective difference of Chrono-moxibustion in RA treatment and its influence on circadian rhythm of RA patients.

Incidence and predictors of fragility fracture in postmenopausal rheumatoid arthritis patients receiving oral bisphosphonates: a longitudinal observational study

Background

Although many studies have reported the predictors of fractures in patients with rheumatoid arthritis (RA) who are not receiving anti-osteoporotic treatments or who are receiving unspecified treatments, studies focusing on the predictors of fracture in patients with RA who are currently being treated with oral bisphosphonates (BP) are quite scarce. This study aims to investigate the incidence and predictors of fragility fracture in postmenopausal patients with RA receiving oral BP.

Methods

This retrospective longitudinal observational study comprised 98 postmenopausal RA patients receiving oral BP for a minimum of 6 months between April 2015 and December 2020. The cumulative incidence of fragility fractures including vertebral and nonvertebral fractures was investigated using the Kaplan–Meier method. Cox proportional hazards analysis was used to analyze baseline predictors of future fragility fractures. To determine a cutoff value of continuous predictors, the receiver-operating characteristic curve was applied.

Results

Twenty patients developed fractures during the study period, with a cumulative incidence of 6.1% at 12 months, 10.5% at a median follow-up of 28 months, and 14.4% at 36 months. Multivariable Cox hazards analysis showed a history of prior vertebral fracture (hazard ratio [HR] 6.26, 95% confidence interval [CI] 1.99‒19.68, P = 0.001) and dose of methotrexate (HR 0.87, 95% CI 0.76‒0.99, P = 0.041) to be independent predictors. The cutoff value for methotrexate dose was 4 mg/week.

Conclusions

We found a cumulative incidence of any fractures of 10.5% at 28 months in patients with RA currently being treated with oral BP. A history of prior vertebral fractures and methotrexate dose were positive and negative predictors for fractures, respectively. Practitioners should consider selecting another anti-osteoporotic drug in patients with RA who remain at risk despite receiving oral BP.

A Comparison of the Risk of Fracture in Rheumatoid Arthritis Patients with and without Receiving Chinese Herbal Medicine

Objective

Patients with rheumatoid arthritis (RA) often suffer from bone complications due to persistent joint inflammation, especially incident fracture. Nowadays, Chinese herbal medicines (CHMs) have provided safe and effective therapy for treating skeletal conditions, but it is unclear whether CHMs can prevent fracture onset among RA individuals. This study aimed to determine the association between the use of CHMs and the risk of fracture among them.

Methods

This retrospective, population-based study retrieved administrative health data from the Taiwan National Health Insurance (NHI) database to identify patients with newly diagnosed RA between 2000 and 2009. Of the 6178 incident RA patients, 2495 matched pairs of CHMs users and non-CHMs users were identified by propensity score matching. Enrollees with hip fractures prior to RA onset were excluded. Included subjects were followed until the end of 2013. Incidence and adjusted hazard ratios (HR) of new-onset bone fracture in the multivariable Cox proportional hazard model were measured with 95% confidence interval (CI).

Results

Fracture incidence was lower in CHMs users than in the comparison cohort (26.91 vs 32.94 per 1000 person-years, respectively), with an adjusted HR of 0.82 (95% CI: 0.73-0.92). Subjects receiving CHMs for more than 2 years had a much lower risk of fracture onset by more than 50%. Some CHMs prescriptions (Yan Hu Suo, Bei Mu, Da Huang, Dang Shen, Fu-Zi, Shu-Jing-Huo-Xue-Tang, Dang-Gui-Nian-Tong-Tang, Jia-Wei-Xiao-Yao-San, Gan-Lu-Yin, and Gui-Zhi-Shao-Yao-Zhi-Mu-Tang) were associated with reduced fracture risk.

Conclusion

Adding CHMs to routine treatment was found to be related to lower fracture risk in RA patients.

A Randomized Trial Assessing the Muscle Strength and Range of Motion in Elderly Patients following Distal Radius Fractures Treated with 4- and 6-Week Cast Immobilization

BACKGROUND

There is no consensus among orthopedic surgeons as to the required period of cast immobilization in distal radius fractures in elderly patients. The purpose of this study was to assess muscle strength and range of motion symmetry in elderly patients after distal radius fractures with different periods of cast immobilization.

METHODS

This study evaluated 50 patients (33 women and 17 men), aged over 65 years, after cast immobilization treatment for distal radius fracture. The mean age at the beginning of treatment was 71 years. The mean duration of follow-up was 1 year and 3 months. The first subgroup (n = 24) comprised the patients whose fractures had been immobilized in a cast for 6 weeks, another subgroup (n = 26) comprised the patients with 4-week cast immobilization. We assessed: (1) muscle strength, (2) range of motion.

RESULTS

The mean grip strength in the treated limb was 71% and 81% of that in the healthy limb in the groups with 4-week and 6-week cast immobilization, respectively (p = 0.0432). The study groups showed no differences in the mean grip strength in the treated limbs or the mean grip strength in the healthy limbs. The mean treated limb flexion was 62° and 75° in the 4-week and 6-week immobilization groups, respectively (p = 0.025). The evaluated groups showed no differences in terms of any other range of motion parameters. The grip strength and range of motion values were significantly lower in the treated limb than in the healthy limb in both evaluated groups. Only the values of wrist radial deviation in the 6-week cast immobilization group showed no differences between the treated and healthy limbs.

CONCLUSION

Higher values of injured limb muscle strength and greater mean range of wrist flexion were achieved in the 6-week subgroup. Neither of the evaluated groups achieved a symmetry of muscle strength or range of motion after treatment. Full limb function did not return in any of the elderly distal radius fracture patients irrespective of cast immobilization duration.

Body composition and bone mineral density in postmenopausal women with rheumatoid arthritis

Aim – to study the relationship between body composition and bone mineral density (BMD) in postmenopausal women with rheumatoid arthritis (RA).

Material and methods. 68 postmenopausal women, median age 59 [54; 63] years, with RA were included in the study. Bone mineral density (BMD) and body composition were assessed with dual energy X-ray absorptiometry.

Results. 33 (48.5%) women had osteopenia, and 17 (25.0%) – osteoporosis (OP). Low lean muscle mass was found in 10 (14.7%) patients. There were positive correlations between different areal BMD and body weight, trunk fat, trunk lean muscle mass and total lean muscle mass. In the multivariate linear regression analysis total lean muscle mass was associated with BMD of lumbar spine (β=0.638; p=0.001) and total hip (β=0.473; p=0.008), and appendicular lean muscle mass, estimated using the appendicular muscle index, with femoral neck BMD (β=0.360; p=0.014).

Conclusion. 73.5% of patients with RA had a reduced BMD, and 14.7% women – low muscle mass. The revealed significant association between the lean muscle mass and BMD of lumbar spine and proximal femur indicates the importance of detecting and correcting low lean muscle mass, as well as preventing its decline in order to prevent loss of BMD and osteoporotic fractures.

Epidemiology of distal radius fractures in children and adults during the COVID-19 pandemic - a two-center study

Background

Distal radius fractures (DRFs) constitute 15–21% of all fractures. There are no detailed data on the possible changes in the epidemiology and treatment of DRFs in children and adults during the Covid pandemic. The purpose of our study was a comprehensive assessment of the impact of the COVID-19 pandemic on distal radius fractures (DRF) epidemiology, including both children and adults and various fracture fixation methods in two large trauma centers in Poland.

Methods

This study compared the medical data on the treatment of distal radius fractures in Poland in two periods: the period of the COVID-19 pandemic (from March 15 to October 15, 2020) and the corresponding period prior to the pandemic (from March 15 to October 15, 2019). We assessed detailed data from two trauma centers for pediatric and adult patients. Outpatients seeking medical attention at emergency departments and inpatients undergoing surgery at trauma-orthopedic wards were evaluated. We compared epidemiological data, demographic data, treatment type, and hospital stay duration.

Results

The total number of patients hospitalized due to DRF during the pandemic was 180, it was 15.1% lower than that from the pre-COVID-19 pandemic period (212). In the case of adult patients, the total number of those hospitalized during the pandemic decreased significantly (by 22%) from 132 to 103 patients. Analysis of the individual treatment methods revealed that the number of adults who underwent conservative treatment was considerably (by 30.3%) significantly lower in the period of the COVID-19 pandemic, from 119 to 83 patients. Compared to 13 patients from the pre-pandemic period, the number of surgically treated adults statistically increased to 20 patients (by 53.8%). Our analyses showed hospitalizations of surgically treated adults to be shorter by 12.7% during the pandemic, with the corresponding hospitalizations of surgically treated pediatric patients to be shorter by11.5%.

Conclusions

Our study showed a significant impact of the COVID-19 pandemic on the epidemiology and treatment of DRFs in children and adults. We found decreased numbers of pediatric and adult patients with DRFs during the COVID-19 pandemic. The pandemic caused an increase in the number of children and significantly increase adults undergoing surgical treatment for DRFs, a decrease in mean patient age, shorter significantly length of hospital stay, and an increased number of men with DRFs.