Sex differences in pain scores and localization in inflammatory arthritis: a systematic review and metaanalysis

Neuropathic pain, mood, and stress-related disorders: A literature review of comorbidity and co-pathogenesis

Neuropathic pain can be caused by multiple factors, and its prevalence can reach 10% of the global population. It is becoming increasingly evident that limited or short-lasting response to treatments for neuropathic pain is associated with psychological factors, which include psychiatric comorbidities known to affect quality of life. It is estimated that 60% of patients with neuropathic pain also experience depression, anxiety, and stress symptoms. Altered mood, including stress, can be a consequence of several painful conditions but can also favor pain chronicization when preexisting. Despite the apparent tight connection between clinical pain and mood/stress disorders, the exact physiological mechanisms remain unclear. This review aims to provide an overview of state-of-the-art research on the mechanisms of pain related to the pathophysiology of depression, anxiety, and stress disorders.

Older Age, Male Sex, and Early Start Time Lengthen the Recovery Room Stay Following Total Joint Arthroplasty in an Ambulatory Surgical Center

Background

Total joint arthroplasty (TJA) performed in the ambulatory surgical center (ASC) has been shown to be safe and cost-effective for an expanding cohort of patients. As criteria for TJA in the ASC become less restrictive, data guiding the efficient use of ASC resources are crucial.

Purpose

We sought to identify factors associated with length of stay in the recovery room after primary total hip arthroplasty (THA) and total knee arthroplasty (TKA) performed in the ASC.

Methods

We conducted a retrospective review of 411 patients who underwent primary THA or TKA at our institution's ASC between November 2020 and March 2022. We collected patient demographics, perioperative factors, success of same-day discharge (SDD), and length of time in the recovery room.

Results

Of 411 patients, 100% had successful SDD. The average length of time spent in recovery was 207 minutes (SD: 73.9 minutes). Predictors of longer time in recovery were increased age, male sex, and operative start time before 9:59 am. Body mass index, preoperative opioid use, Charlson Comorbidity Index, type of surgery (THA vs TKA), urinary retention risk, and type of anesthesia (spinal vs general) were not significant predictors of length of time in the recovery room.

Conclusion

In this retrospective study, factors associated with increased length of time in the recovery room included older age, male sex, and operative start time before 9:59 am. Such factors may guide surgeons in determining the optimal order of cases for each day at the ASC, but further prospective studies should seek to confirm these observations.

The Effect of Preoperative Exposure to Benzodiazepines on Opioid Consumption After One and Two-level Anterior Cervical Discectomy and Fusion

STUDY DESIGN

Retrospective cohort.

OBJECTIVE

Investigate the relationship between preoperative benzodiazepine exposure and postoperative opioid use in patients undergoing primary 1 or 2-level anterior cervical discectomy and fusion (ACDF).

BACKGROUND

Little is known about the effect of preoperative benzodiazepine exposure on postoperative opioid use in spine surgery.

PATIENTS AND METHODS

Patients undergoing primary 1 or 2-level ACDF at a single institution from February 2020 to November 2021 were identified through electronic medical records. The prescription drug monitoring program was utilized to record the name, dosage, and quantity of preoperative benzodiazepines/opioids filled within 60 days before surgery and postoperative opioids 6 months after surgery. Patients were classified as benzodiazepine naïve or exposed according to preoperative usage, and postoperative opioid dose and duration were compared between groups. Regression analysis was performed for outcomes that demonstrated statistical significance, adjusting for preoperative opioid use, age, sex, and body mass index.

RESULTS

Sixty-seven patients comprised the benzodiazepine-exposed group whereas 90 comprised the benzodiazepine-naïve group. There was no significant difference in average daily morphine milligram equivalents between groups (median: 96.0 vs 65.0, P = 0.11). The benzodiazepine-exposed group received postoperative opioids for a longer duration (median: 32.0 d vs 12.0 d, P = 0.004) with more prescriptions (median: 2.0 vs 1.0, P = 0.004) and a greater number of pills (median: 110.0 vs 59.0, P = 0.007). On regression analysis, preoperative benzodiazepine use was not significantly associated with postoperative opioid duration [incidence rate ratio (IRR): 0.93, P = 0.74], number of prescriptions (IRR: 1.21, P = 0.16), or number of pills (IRR: 0.89, P = 0.58).

CONCLUSIONS

While preoperative benzodiazepine users undergoing primary 1 or 2-level ACDF received postoperative opioids for a longer duration compared with a benzodiazepine naïve cohort, preoperative benzodiazepine use did not independently contribute to this observation. These findings provide insight into the relationship between preoperative benzodiazepine use and postoperative opioid consumption.

LEVEL OF EVIDENCE

Level III.

Sex Differences in Pain and Quantitative Sensory Testing in Patients With Rheumatoid Arthritis

OBJECTIVE

Women with rheumatoid arthritis (RA) have higher pain and worse functional outcomes compared to men, even when treated with similar medications. The objective of this study was to identify sex differences in pain intensity, pain interference, and quantitative sensory tests (QST), which are independent of inflammation, in patients with RA.

METHODS

This study is a post hoc analysis of participants in the Central Pain in Rheumatoid Arthritis cohort. Pain intensity was assessed using a 0-10 numeric rating scale. Pain interference was measured using a Patient-Reported Outcomes Measurement Information System computerized adaptive test. QST included pressure pain detection thresholds, temporal summation, and conditioned pain modulation. Women and men were compared using multiple linear regression, adjusted for age, education, race, research site, depression, obesity, RA disease duration, swollen joint count, and C-reactive protein.

RESULTS

Mean ± SD pain intensity was 5.32 ± 2.29 among women with RA, compared to 4.60 ± 2.23 among men with RA (adjusted difference 0.83 [95% confidence interval (95% CI) 0.14, 1.53]). Women with RA had lower pressure pain detection thresholds at the trapezius (adjusted difference -1.22 [95% CI -1.73, -0.72]), wrist (adjusted difference -0.57 [95% CI -1.07, -0.06]), and knee (adjusted difference -1.10 [95% CI -2.00, -0.21]). No statistically significant differences in pain interference, temporal summation, and conditioned pain modulation were observed.

CONCLUSION

Women reported higher pain intensity and lower pressure pain detection thresholds (higher pain sensitivity) than men. However, pain interference, temporal summation, and conditioned pain modulation did not differ between men and women.

Innate Immunity and Sex: Distinct Inflammatory Profiles Associated with Murine Pain in Acute Synovitis

Joint pain severity in arthritic diseases differs between sexes and is often more pronounced in women. This disparity is thought to stem from biological mechanisms, particularly innate immunity, yet the understanding of sex-specific differences in arthritic pain remains incomplete. This study aims to investigate these disparities using an innate immunity-driven inflammation model induced by intra-articular injections of Streptococcus Cell Wall fragments to mimic both acute and pre-sensitized joint conditions. Nociceptive behavior was evaluated via gait analysis and static weight-bearing, and inflammation was evaluated via joint histology and the synovial gene expression involved in immune response. Although acute inflammation and pain severity were comparable between sexes, distinct associations between synovial inflammatory gene expression and static nociceptive behavior emerged. These associations delineated sex-specific relationships with pain, highlighting differential gene interactions (Il6 versus Cybb on day 1 and Cyba/Gas6 versus Nos2 on day 8) between sexes. In conclusion, our study found that, despite similar pain severity between sexes, the association of inflammatory synovial genes revealed sex-specific differences in the molecular inflammatory mechanisms underlying pain. These findings suggest a path towards more personalized treatment strategies for pain management in arthritis and other inflammatory joint diseases.

Pain in autoimmune inflammatory myopathies: a scoping review

BACKGROUND

Pain is considered a priority for research by adult patients with autoimmune inflammatory myopathy (AIM) and their families. Our aim was to review the literature for studies reporting on pain in adult AIM and to summarise their findings.

METHODS

A scoping review was conducted searching for studies in PubMed and MEDLINE including more than five adult patients with AIM and assessing pain using a patient-reported outcome measure. Study population characteristics, pain measurement and clinical correlates of pain were extracted using a standardised protocol.

RESULTS

The search strategy identified 2831 studies with 33 meeting inclusion criteria. Most studies used visual analogue scales (n=14) and/or the Medical Outcomes Study 36-Item Short Form Bodily Pain Scale (n=17). Frequency of pain and/or myalgias ranged from 64% to 100%. Subjects with AIM had significantly more pain than the general population and comparable pain to other chronic rheumatic diseases. Insufficient results were available to identify significant clinical correlates of pain in AIM.

CONCLUSION

This review suggests that the burden of pain in AIM is considerable. Still, due to the heterogeneity and low quality of the evidence, significant knowledge gaps persist. Studies are needed to characterise pain trajectories of patients with AIM.

Sex differences among users of NSAIDs and opioids during COVID-19 Pandemic

BACKGROUND

Sex-based inequalities in healthcare have been exposed and amplified during the COVID-19 pandemic. However, few studies have reported sex differences in medication utilization and no studies have examined sex differences in prescribed non-steroidal anti-inflammatory drugs (NSAIDs) and opioids utilization.

AIM

To compare the utilization patterns of prescribed NSAIDs and opioids between males and females in Manitoba, Canada during the COVID-19 pandemic.

METHOD

A cohort of incident and prevalent users of prescribed NSAIDs and opioids was created. Interrupted times series analysis using autoregressive models were used to evaluate the quarterly change in the prevalent and incident users before and after COVID-19 restrictions were applied (first quarter of 2020).

RESULTS

COVID-19 restrictions were associated with a significant decrease in the utilization of prescribed NSAIDs and opioids in all users, followed by a revert to the pre-pandemic trends. Among female prevalent and incident NSAIDs users, there was a significant change in trend after COVID-19 restrictions were introduced (β₃ = 0.087 and 0.078, P = 0.023 and 0.028, respectively). However, there was non-significant change in trend among male prevalent and incident NSAIDs and opioids users during the pandemic.

CONCLUSION

In this study, a significant sharp decline in the use of prescribed NSAIDs and opioids was shown in both sexes at the onset of the pandemic. However, a significant upward trend is observed in female NSAIDs users as restrictions began to be lifted.

Positive Association between Peri-Surgical Opioid Exposure and Post-Discharge Opioid-Related Outcomes

Background: Multiple studies have investigated the epidemic of persistent opioid use as a common postsurgical complication. However, there exists a knowledge gap in the association between the level of opioid exposure in the peri-surgical setting and post-discharge adverse outcomes to patients and healthcare settings. We analyzed the association between peri-surgical opioid exposure use and post-discharge outcomes, including persistent postsurgical opioid prescription, opioid-related symptoms (ORS), and healthcare resource utilization (HCRU). Methods: A retrospective cohort study included patients undergoing cesarean delivery, hysterectomy, spine surgery, total hip arthroplasty, or total knee arthroplasty in an academic healthcare system between January 2015 and June 2018. Peri-surgical opioid exposure was converted into morphine milligram equivalents (MME), then grouped into two categories: high (>median MME of each surgery cohort) or low (≤median MME of each surgery cohort) MME groups. The rates of persistent opioid use 30 and 90 days after discharge were compared using logistic regression. Secondary outcomes, including ORS and HCRU during the 180-day follow-up, were descriptively compared between the high and low MME groups. Results: The odds ratios (95% CI) of high vs. low MME for persistent opioid use after 30 and 90 days of discharge were 1.38 (1.24−1.54) and 1.41 (1.24−1.61), respectively. The proportion of patients with one or more ORS diagnoses was greater among the high-MME group than the low-MME group (27.2% vs. 21.2%, p < 0.01). High vs. low MME was positively associated with the rate of inpatient admission, emergency department admissions, and outpatient visits. Conclusions: Greater peri-surgical opioid exposure correlates with a statistically and clinically significant increase in post-discharge adverse opioid-related outcomes. The study findings warrant intensive monitoring for patients receiving greater peri-surgical opioid exposure.

Lower odds of remission among women with rheumatoid arthritis: A cohort study in the Swiss Clinical Quality Management cohort

OBJECTIVE

To compare the likelihood of achieving remission between men and women with rheumatoid arthritis (RA) after starting their first biologic or targeted synthetic disease-modifying anti-rheumatic drug (b/tsDMARD).

METHODS

This cohort study in the Swiss Clinical Quality Management in Rheumatic Diseases (SCQM) registry included RA patients starting their first b/tsDMARD (1997-31/04/2018). The odds of achieving remission at ≤12-months, defined by disease activity score 28-joints (DAS28) <2.6, were compared between men and women. Secondary analyses were adjusted for age and seropositivity, and we investigated potential mediators or factors that could explain the main findings.

RESULTS

The study included 2839 (76.3%) women and 883 (23.7%) men with RA. Compared to women, men were older at diagnosis and b/tsDMARD start, but had shorter time from diagnosis to b/tsDMARD (3.4 versus 5.0 years, p<0.001), and they had lower DAS28 at b/tsDMARD start. Compared to women, men had 21% increased odds of achieving DAS28-remission, with odds ratio (OR) 1.21, 95% confidence interval (CI) 1.02-1.42. Adjusting for age and seropositivity yielded similar findings (adjusted OR 1.24, 95%CI 1.05-1.46). Analyses of potential mediators suggested that the observed effect may be explained by the shorter disease duration and lower DAS28 at treatment initiation in men versus women.

CONCLUSION

Men started b/tsDMARD earlier than women, particularly regarding disease duration and disease activity (DAS28), and had higher odds of reaching remission. This highlights the importance of early initiation of second line treatments, and suggests to target an earlier stage of disease in women to match the benefits observed in men.

Sex and gender differences in pain

Chronic pain affects 20% of adults and is one of the leading causes of disability worldwide. Women and girls are disproportionally affected by chronic pain. About half of chronic pain conditions are more common in women, with only 20% having a higher prevalence in men. There are also sex and gender differences in acute pain sensitivity. Pain is a subjective experience made up of sensory, cognitive, and emotional components. Consequently, there are multiple dimensions through which sex and gender can influence the pain experience. Historically, most preclinical pain research was conducted exclusively in male animals. However, recent studies that included females have revealed significant sex differences in the physiological mechanisms underlying pain, including sex specific involvement of different genes and proteins as well as distinct interactions between hormones and the immune system that influence the transmission of pain signals. Human neuroimaging has revealed sex and gender differences in the neural circuitry associated with pain, including sex specific brain alterations in chronic pain conditions. Clinical pain research suggests that gender can affect how an individual contextualizes and copes with pain. Gender may also influence the susceptibility to develop chronic pain. Sex and gender biases can impact how pain is perceived and treated clinically. Furthermore, the efficacy and side effects associated with different pain treatments can vary according to sex and gender. Therefore, preclinical and clinical research must include sex and gender analyses to understand basic mechanisms of pain and its relief, and to develop personalized pain treatment.

Baseline Characteristics and Treatment Response to Ixekizumab Categorised by Sex in Radiographic and Non-radiographic Axial Spondylarthritis Through 52 Weeks: Data from Three Phase III Randomised Controlled Trials

Objectives

Assess baseline characteristics and treatment response to ixekizumab (IXE) categorised by sex in patients with radiographic axial spondyloarthritis (r-axSpA) and non-radiographic axSpA (nr-axSpA) up to 52 weeks.

Methods

Data were analysed from three randomised controlled trials of IXE through 52 weeks. Patients fulfilled ASAS classification criteria for r-axSpA or nr-axSpA and were randomised to receive 80 mg subcutaneous administration of IXE every 2 weeks (Q2W) or 4 weeks (Q4W), or placebo (16 weeks COAST-V/W; 52 weeks COAST-X). Baseline characteristics and treatment outcomes were assessed. Patients were categorised by sex; methods included non-responder imputation for categorical variables, and modified baseline observation carried forward for continuous efficacy variables.

Results

At presentation, female patients had higher disease burden as reflected by significantly higher spinal pain at night, fatigue scores and pain/swelling in joints other than the neck, back or hip. ASAS40 response rate with the approved label dose, IXEQ4W, was achieved in 39% of male patients with r-axSpA by week 16, and 44% by week 52. For female patients, 16.7% and 33.3% achieved ASAS40 at week 16 and 52, respectively. In nr-axSpA, 46% of male patients achieved ASAS40 at week 16 and 30% at week 52. In total, 23.9% of female patients achieved ASAS40 at week 16, and 30.4% at week 52.

Conclusions

This analysis demonstrates that for the axSpA disease spectrum, female patients present with higher disease burden. Following treatment with IXE, there is a higher proportion of male responders up to 16 weeks, while female patients show less robust responses for the first 16 weeks but larger responses from weeks 16 through 52.

Trial Registration Numbers

NCT02696785, NCT02696798 and NCT02757352.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12325-022-02132-2.

Sex difference in disease burden of inflammatory arthritis patients treated with tumor necrosis factor inhibitors as part of standard care

Objective

Knowledge is needed on the total disease burden across the sexes in inflammatory arthritis (IA). We aimed to compare disease burden, including a broad range of health aspects, across men and women with IA treated with tumor necrosis factor inhibitors (TNFi).

Methods

Adult outpatients with IA (rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis) were included as part of standard care. Patient-reported outcomes, disease activity, TNFi trough levels, calprotectin, Work Productivity and Activity Impairment, comorbidities and cardiovascular risk profile were assessed. Unadjusted comparisons across sexes were done with independent t-test, Mann-Whitney U-test and X²-test and adjusted analyses with General Linear Models and logistic/ordinal logistic regression.

Results

A total of 305 IA patients were included (167 men, 138 women). A significantly lower proportion of women (45%) than men (59%) were in remission according to disease-specific composite scores (p = 0.02). Women had significantly worse scores on pain, joint pain, fatigue, enthesitis, Health Assessment Questionnaire and Short Form (SF)-36 vitality and social functioning (all p≤0.04). Both sexes had worse SF-36 scale scores than the general population. Women reported more absenteeism (work time missed) and activity impairment. TNFi trough levels, neutralizing antibodies and calprotectin were similar across sexes. A similar total number of comorbidities was seen. Self-reported hypothyroidism was more frequent in women. Men had higher 10-year calculated risk of fatal cardiovascular events.

Conclusion

Important differences in disease burden between men and women were seen. More attention to sex differences in the follow-up of IA patients is warranted.

Estrogen metabolites increase nociceptor hyperactivity in a mouse model of uterine pain

Pain emanating from the female reproductive tract is notoriously difficult to be treated and the prevalence of transient pelvic pain has been placed as high as 70-80% in women surveyed. Although sex hormones, especially estrogen, are thought to underlie enhanced pain perception in females, the underlying molecular and cellular mechanisms are not completely understood. Here we show that the pain-initiating TRPA1 channel is required for pain-related behaviors in a mouse model of estrogen-induced uterine pain in ovariectomized female mice. Surprisingly, 2- and 4-hydroxylated estrogen metabolites (HEMs) in the estrogen hydroxylation pathway, but not estrone, estradiol and 16-HEMs, directly increase nociceptor hyperactivity through TRPA1 and TRPV1 channels, and picomolar concentrations of 2- and 4-hydroxylation estrone (OHE1) can sensitize TRPA1 channel function. Moreover, both TRPA1 and TRPV1 are expressed in uterine-innervating primary nociceptors and their expressions are increased in the estrogen-induced uterine pain model. Importantly, pretreatment of 2- or 4-OHE1 recapitulates estrogen-induced uterine pain-like behaviors and intraplantar injections of 2- and 4-OHE1 directly produce a TRPA1-dependent mechanical hypersensitivity. Our findings demonstrate that TRPA1 is critically involved in estrogen-induced uterine pain-like behaviors, which may provide a potential drug target for treating female reproductive tract pain.

GPR171 Agonist Reduces Chronic Neuropathic and Inflammatory Pain in Male, But Not Female Mice

Chronic pain is a growing public health crisis that requires exigent and efficacious therapeutics. GPR171 is a promising therapeutic target that is widely expressed through the brain, including within the descending pain modulatory regions. Here, we explore the therapeutic potential of the GPR171 agonist, MS15203, in its ability to alleviate chronic pain in male and female mice using a once-daily systemic dose (10 mg/kg, i.p.) of MS15203 over the course of 5 days. We found that in our models of Complete Freund's Adjuvant (CFA)-induced inflammatory pain and chemotherapy-induced peripheral neuropathy (CIPN), MS15203 did not alleviate thermal hypersensitivity and allodynia, respectively, in female mice. On the other hand, MS15203 treatment decreased the duration of thermal hypersensitivity in CFA-treated male mice following 3 days of once-daily administration. MS15203 treatment also produced an improvement in allodynia in male mice, but not female mice, in neuropathic pain after 5 days of treatment. Gene expression of GPR171 and that of its endogenous ligand BigLEN, encoded by the gene PCSK1N, were unaltered within the periaqueductal gray (PAG) in both male and female mice following inflammatory and neuropathic pain. However, following neuropathic pain in male mice, the protein levels of GPR171 were decreased in the PAG. Treatment with MS15203 then rescued the protein levels of GPR171 in the PAG of these mice. Taken together, our results identify GPR171 as a GPCR that displays sexual dimorphism in alleviation of chronic pain. Further, our results suggest that GPR171 and MS15203 have demonstrable therapeutic potential in the treatment of chronic pain.

Understanding sex differences in zebrafish pain- and fear-related behaviors

Sex is an important variable in translational biomedical research. While overt sex differences have been reported for pain and fear-like behaviors in humans and rodents, these differences in other popular model organisms, such as zebrafish, remain poorly understood. Here, we evaluate potential sex differences in zebrafish behavioral responses to pain (intraperitoneal administration of 5% acetic acid) and fear stimuli (exposure to alarm substance). Overall, both male and female zebrafish exposed to pain (intraperitoneal 5% acetic acid injection) show lesser distance traveled, fewer top entries and more writhing-like pain-related behavior vs. controls. However, female fish more robustly (than males) altered some other pain-like behaviors (e.g., increasing freezing episodes and time in top) in this model. In contrast, zebrafish of both sexes responded equally strongly to fear evoked by alarm substance exposure. Collectively, these findings emphasize the growing importance of studying sex differences in zebrafish, including pain models.

Pain levels and associated factors in the Scleroderma Patient-centered Intervention Network (SPIN) cohort: a multicentre cross-sectional study

BACKGROUND

Pain is an important and detrimental feature of systemic sclerosis but is often overlooked or deprioritised in research and clinical care. Raynaud's phenomenon, arthritis, and cutaneous ulcers are among the commonly reported disease manifestations of systemic sclerosis that could be associated with pain. We aimed to assess levels of pain intensity and interference and to evaluate disease factors associated with pain intensity and interference.

METHODS

In this multicentre cross-sectional study, participants from the Scleroderma Patient-centered Intervention Network cohort who completed pain intensity and interference measures (Patient Reported Outcomes Information System-29 profile, version 2·0) as part of baseline assessments were included. Patients were recruited from 46 centres in Australia, Canada, France, Mexico, Spain, the UK, and the USA between April 15, 2014, and Jan 7, 2020. Eligible patients included those aged 18 years or older who met the criteria for systemic sclerosis devised by the American College of Rheumatology and the European League Against Rheumatism. Associations of pain intensity and pain interference with systemic sclerosis-related variables and overlap syndromes, controlling for sociodemographic variables, were assessed with multiple linear regression. Continuous independent variables were standardised.

FINDINGS

Among 2157 participants with systemic sclerosis (268 [12%] males and 1889 [88%] females), 1870 (87%) reported mild, moderate, or severe pain (defined as ≥1 on a 0 to 10 scale), and 815 (38%) reported moderate or severe pain (defined as ≥5). Moreover, 757 (35%) participants reported moderate or severe pain interference. Greater pain intensity was independently associated with female sex (0·58 points [95% CI 0·26-0·90]), non-White race or ethnicity (0·50 points [0·21-0·79]), fewer years in formal education (0·30 points per SD [0·19-0·41]), country (reference: USA; Canada: 0·29 points [0·01-0·57] and UK: 0·58 points [0·21-0·95]), greater body-mass index (0·35 points per SD [0·24-0·45]); joint contractures (0·67 points [0·39-0·94]), digital ulcers (0·33 points [0·10-0·55]), gastrointestinal involvement (0·66 points [0·33-0·98]), skin involvement (measured using modified Rodnan skin score; 0·22 points per SD [0·10-0·35]), rheumatoid arthritis (0·96 points [0·50-1·43]), and Sjögren's syndrome (0·42 points [0·01-0·83]). Pain interference results were similar.

INTERPRETATION

Pain is common among people with systemic sclerosis. Controlling for sociodemographic variables, greater pain was associated with multiple systemic sclerosis-related manifestations, including joint contractures, digital ulcers, gastrointestinal involvement, skin involvement, and the presence of overlap syndromes. Health-care providers should work with patients to address pain, including identifying and addressing systemic sclerosis manifestations associated with their pain, and supporting behavioural approaches to minimise impact on function and quality of life.

FUNDING

Canadian Institutes of Health Research, Arthritis Society, The Lady Davis Institute for Medical Research of the Jewish General Hospital, Jewish General Hospital Foundation, McGill University, Scleroderma Society of Ontario, Scleroderma Canada, Sclérodermie Québec, Scleroderma Manitoba, Scleroderma Atlantic, Scleroderma Association of BC, Scleroderma SASK, Scleroderma Australia, Scleroderma New South Wales, Scleroderma Victoria, and Scleroderma Queensland.

Gender Difference in Pain Management Among Adult Cancer Patients in Saudi Arabia: A Cross-Sectional Assessment

Objective

To compare gender differences in pain management among adult cancer patients in Saudi Arabia and to explore the predictors associated with attitudinal barriers of cancer patients to pain management.

Methods

A descriptive cross-sectional study was conducted among 325 cancer patients from tertiary hospitals in Saudi Arabia.

Result

Of the total participants, 67.4% were women (N = 219) and 32.6% were men (N = 106). The overall mean scores of the attitudinal barriers questionnaire were 49.51 ± 13.73 in men and 54.80 ± 22.53 in women. The analysis shows significant differences in scores in subscales of tolerance (men = 7.48 ± 2.37), (women = 8.41 ± 3.01) (p = 0.003) and fear of distraction in the course of treatment (men = 6.55 ± 1.34), and (women = 7.15 ± 2.63) (p = 0.008). Female patients reported a more moderate to severe level of pain than men (worst pain in last week of 7.07 ± 1.50, worst pain in last week of 5.84 ± 2.65, respectively). Splitting by gender, the significant predictor for physiology effect domains in male cancer patients includes age, marital status, employment status, monthly income, cancer type, and presence of comorbid disease (p < 0.050). Age was a significant predictor of the domains of fatalism, communication, and harmful effects (p < 0.050) among female cancer patients.

Conclusion

The present study revealed significant differences between men and women with attitudinal barriers to cancer pain management. Managing pain requires the involvement of all methods in a comprehensive manner, thus unalleviated pain influences the patient's psychological or cognitive aspect.

Sociodemographic determinants in the evolution of pain in inflammatory rheumatic diseases: results from ESPOIR and DESIR cohorts

Objective

To determine whether socio-demographic factors are associated with heterogeneity in pain evolution in inflammatory rheumatic diseases (IRDs) after accounting for disease-specific characteristics in a system with universal health care.

Methods

This analysis included the data from two prospective observational cohorts of early IRDs (ESPOIR for early RA and DESIR for early SpA). Data on pain was measured, respectively, on 13 and 9 occasions spanning 10 and 6 years of follow-up using the Short-Form 36 bodily pain score for 810 participants of ESPOIR, and 679 participants of DESIR. Linear mixed models were used to characterize differences in pain evolution as a function of age (tertiles), sex, ethnicity, education, marital, and professional status, after accounting for disease-related, treatment, lifestyle, and health factors.

Results

While transitioning from early (disease duration ≤6 months for RA and ≤3 years for SpA) to long-standing disease, differences in pain evolution emerged as a function of age (P < 0.001), sex (P = 0.050), and ethnicity (P = 0.001) in RA, and as a function of age (P = 0.048) in SpA; younger age, males, and Caucasians exhibited lower pain in the latter phases of both diseases. Highly educated participants (RA, β = −3.8, P = 0.007; SpA, β = −6.0, P < 0.001) for both diseases, and Caucasians (β = −5.6, P = 0.021) for SpA presented with low pain early in the disease, with no changes throughout disease course.

Conclusion

Being older, female, non-Caucasian and having lower education was found to be associated with worse pain in early and/or long-standing IRDs, despite universally accessible health-care. Early identification of at-risk populations and implementation of multidisciplinary strategies may reduce patient-reported health outcome disparities.

Trial registration registrations

ESPOIR: ClinicalTrials.gov, www.clinicaltrials.gov, NCT03666091. DESIR: ClinicalTrials.gov, www.clinicaltrials.gov, NCT01648907.

Men and Women Respond Equally Well to Spinal Cord and Dorsal Root Ganglion Stimulation

OBJECTIVES

The influence of gender on outcomes in individuals undergoing treatment for chronic pain is unclear. This retrospective, single-site study explored the impact of gender on pain, quality of life (QoL), revisions, and explants in patients with failed back surgery syndrome or visceral pain, who received a fully implanted 10 kHz spinal cord stimulation (SCS), burst SCS, or dorsal root ganglion (DRG) stimulation system.

MATERIALS AND METHODS

The following data were collected from paper and electronic records: gender, age, chronic pain diagnosis, system, baseline and follow-up scores (average pain [visual analog scale, VAS], worst pain [VAS], QoL [EQ-5D-3L]), revisions, and explants. Data were statistically analyzed by one-way ANCOVAs controlling for age, chi-square tests of independence and logistic regression.

RESULTS

The final sample comprised 387 patients (176 males and 211 females). Males were significantly older compared to females (mean difference: 2.33 years, p = 0.044). Controlling for age, baseline average pain was significantly lower in males than females (mean difference: -0.32, p = 0.049). Males and females responded equally well to 10 kHz SCS and burst SCS as well as DRG stimulation. A greater percentage of males (5%) than females (1%) had revisions due to lead fractures. Additionally, more females (13%) than males (6%) had an explant due to insufficient pain relief. Female gender and older age were associated with greater likelihood of having an explant compared to male gender and younger age.

CONCLUSION

Gender may play an influential role in pain severity at baseline but have little effect at follow-up. To help identify which patients may undergo a revision or explant, gender and age could be important factors and should be further scrutinized. Even though men and women responded equally well to SCS and DRG stimulation, more men had a revision due to lead fractures, and more women were explanted due to insufficient pain relief.

Gender-related differences in disease activity and clinical features in patients with peripheral psoriatic arthritis: A multi-center study

OBJECTIVE

This study sought to compare disease activity, clinical features, and patient-reported outcomes concerning anxiety, depression, fatigue, function, quality of life, and fibromyalgia between female and male patients with peripheral PsA in a Turkish population.

METHODS

This multi-center Turkish League Against Rheumatism (TLAR) Network study included 1038 patients (678 females, 360 males) diagnosed with peripheral PsA according to the CASPAR criteria. The demographic and clinic parameters of the patients were recorded. Disease activity was evaluated using the scores of DAS28 and cDAPSA. Remission, minimal disease activity (MDA), and very low disease activity (VLDA) were determined. Health Assessment Questionnaire (HAQ), Short-Form-36 (SF-36), Hospital Anxiety and Depression Scale (HAD), fatigue VAS (0-10), and Fibromyalgia Rapid ScreeningTool (FiRST) were used. Disease activity and patient-reported outcomes were compared in male and female patients, and the predictors of MDA for both genders were analyzed.

RESULTS

The patients' mean age was 47.6years (SD: 12) for females and 46.3years (SD: 12.3) for males. In terms of DAS28 and cDAPSA, female patients had significantly higher disease activity scores, while male patients had significantly higher remission rates (P<0.05). There was a significant difference in the rate of MDA in favor of males (P<0.05), but not in VLDA. The incidences of dactylitis, enthesitis, tenosynovitis, and inflammatory bowel disease were similar in male and female patients, except for spondylitis, which was higher in males (P<0.05). Overall, although there was no significant between-group difference in age and disease duration, female patients had significantly higher BMI and late-onset disease (P<0.05). Female patients had higher HAD, HAQ, and FiRST and lower SF-36 scores than males (P<0.05). In both male and female patients, the disease activity score of cDAPSA was significantly correlated with the scores of FiRST, HAD, VAS-F, and HAQ (P<0.05). In regression analysis, tender joint count, swollen joint count, PASI, pain VAS, and enthesitis were the MDA predictors in both genders.

CONCLUSION

In patients with peripheral PsA, males are more likely to develop spondylitis while other extraarticular manifestations are similar. Female patients appear to have lower rates of remission and MDA and higher levels of disease activity. Female patients experience a more severe course of PsA, with higher levels of pain and fatigue, lower quality of life, and increased functional limitations. The predictors of MDA, i.e., tender joint count, swollen joint count, PASI, pain VAS, and enthesitis are similar between the two genders.

Gender Differences in Preoperative Opioid Use in Spine Surgery Patients: A Systematic Review and Meta-analysis

OBJECTIVE

Opioids are frequently used in spine surgeries despite their adverse effects, including physical dependence and addiction. Gender difference is an important consideration for personalized treatment. There is no review assessing the prevalence of opioid use between men and women before spine surgeries.

DESIGN

We compared the prevalence of preoperative opioid use between men and women.

SETTING

Spine surgery.

SUBJECTS

Comparison between men and women.

METHODS

PubMed, Embase, and Cochrane were searched from inception to November 9, 2018. Clinical characteristics and prevalence of preoperative opioid use were collected. Where feasible, data were pooled from nonoverlapping studies using random-effects models.

RESULTS

Four studies with nonoverlapping populations were included in the meta-analysis (one prospective, three retrospective cohorts). The prevalence of preoperative opioid use was 0.64 (95% CI = 0.40-0.83). Comparing men with women, no statistically significant difference in preoperative opioid use was detected (relative risk [RR] = 0.99, 95% CI = 0.96-1.02). Surgery location (cervical, lumbar) and study duration (more than five years or five years or less) did not modify this association. All involved open spine surgery. Only one secondary analysis provided data on both pre- and postoperative opioid use stratified by gender, which showed a borderline significantly higher prevalence of postoperative use in women than men.

CONCLUSIONS

The prevalence of opioid use before spine surgery was similar between men and women, irrespective of surgery location or study duration. More studies characterizing the pattern of opioid use between genders are still needed.

Relationship Between Depression and Disease Activity in United States Veterans With Early Rheumatoid Arthritis Receiving Methotrexate

OBJECTIVE

Depression is common in patients with rheumatoid arthritis (RA), exacerbates disease activity, and may decrease response to first-line disease-modifying antirheumatic drugs. This study aimed to determine if depression affects disease activity among veterans with early RA prescribed methotrexate (MTX).

METHODS

Participants included veterans enrolled in the Veterans Affairs Rheumatoid Arthritis (VARA) registry with early RA (onset < 2 yrs) prescribed MTX. Depression was assessed at enrollment using the International Classification of Diseases, 9th revision codes (296.2-296.39, 300.4, 311). Disease activity was measured using the Disease Activity Score in 28 joints (DAS28) and other core measures of RA disease activity. Propensity score weights were used to adjust depressed (n = 48) and nondepressed (n = 220) patients on baseline confounders within imputed datasets. Weighted estimating equations were used to assess standardized mean differences in disease activity between depressed and nondepressed patients at 6-month, 1-year, and 2-year follow-ups.

RESULTS

The analytic sample was composed of 268 veterans with early RA prescribed MTX who were predominantly male (n = 239, 89.2%) and older (62.7 yrs, SD 10.6) than patients with RA in the general population. Adjusted estimates indicated that depression was associated with significantly higher DAS28 at 6 months (β 0.35, 95% CI 0.01-0.68) but not at the 1- or 2-year follow-up. Also, depression was associated with significantly worse pain at 6 months (β 0.39, 95% CI 0.04-0.73) and 1 year (β 0.40, 95% CI 0.04-0.75).

CONCLUSION

In early RA, depression is associated with greater short-term disease activity during MTX treatment, as well as more persistent and severe pain.

Molecular Mechanisms of Sex-Related Differences in Arthritis and Associated Pain

Clinical conditions leading to chronic pain show important sex-related differences in the prevalence, severity, and degree of functional disability. Decades of epidemiological and clinical studies have demonstrated that women are more sensitive to pain than men. Arthritis, including rheumatoid arthritis (RA) and osteoarthritis (OA), is much more prevalent in females and accounts for the majority of pain arising from musculoskeletal conditions. It is therefore important to understand the mechanisms governing sex-dependent differences in chronic pain, including arthritis pain. However, research into the mechanisms underlying the sex-related differences in arthritis-induced pain is still in its infancy due to the bias in biomedical research performed largely in male subjects and animals. In this review, we discuss current advances in both clinical and preclinical research regarding sex-related differences in the development or severity of arthritis and associated pain. In addition, sex-related differences in biological and molecular mechanisms underlying the pathogenesis of arthritis pain, elucidated based on clinical and preclinical findings, are reviewed.

Use of clodronate for painful knee prosthesis in osteoarthritis patients: a 6-month pilot study

BACKGROUND

Knee replacement surgery is one of the most common surgical procedures performed worldwide. Unfortunately, knee prostheses can become painful over time, necessitating appropriate analgesic treatment. Bisphosphonates such as clodronate (CLO) may play an important role in the treatment of painful knee prostheses by virtue of its analgesic and anti-inflammatory properties.

METHODS

In this prospective open label pilot study, eighteen consecutive patients aged 73.2±8.9 years affected by knee painful prosthesis and osteoarthritis were treated with a rehabilitation cycle in addition to i.v. or i.m. CLO. Induction dose was 2.0-2.1g, followed by a weekly dose of 200 mg (i.m.) for 6 months. Visual analogue scale (VAS) pain score and Tegner Lysholm Score (TLS) were used to assess improvement following CLO treatment.

RESULTS

Thirteen out of 18 patients completed the 6-month follow-up. VAS pain score decreased from 8.1±1.8 at baseline to 5.6±2.6 (P<0.05) and TLS increased from 40.4±20.3 at baseline to 62.7±24.1 at 6 months (P<0.05). Univariate regression revealed that among a range of variables, BMI was positively correlated with VAS (r=0.73, P=0.004) and lower TLS after 1 month (r= -0.62, P=0.006).

CONCLUSIONS

CLO in association with rehabilitation exercises can reduce pain and ameliorate the functionality of painful knee prostheses. Administration of a high dose (induction dose) of CLO every 3 months appears to be the most effective regimen compared to a weekly maintenance dose.

Comparative Disease Burden in Patients with Rheumatoid Arthritis, Psoriatic Arthritis, or Axial Spondyloarthritis: Data from Two Corrona Registries

INTRODUCTION

Rheumatoid arthritis (RA), psoriatic arthritis (PsA), and axial spondyloarthritis (axSpA) are three common inflammatory rheumatic diseases that can lead to deformities and joint destruction. Few studies have compared disease burden across patients with these diseases. The objective of this study was to compare disease burden in patients with RA, PsA, or axSpA in routine US clinical practice.

METHODS

This study included adults with RA, PsA, or axSpA enrolled in the Corrona RA and PsA/SpA registries between March 2013 and March 2018. Patient and clinical characteristics at enrollment were compared between patients with RA vs. PsA and RA vs. axSpA using t tests or Wilcoxon rank-sum tests for continuous variables and χ2 or Fisher's exact tests for categorical variables.

RESULTS

A total of 11,350 patients with RA, 2003 with PsA, and 495 with axSpA were included. Patients with RA had shorter mean symptom and disease duration (9.4 and 7.6 years, respectively) than those with PsA (11.2 and 8.4 years) or axSpA (16.7 and 9.8 years). Patients with PsA had lower mean physician global assessment (18.6 vs. 27.3), higher patient global assessment (43.2 vs. 36.9), comparable pain (38.9 vs. 39.5), and lower fatigue (41.1 vs. 43.4) scores than those with RA. Patients with axSpA had comparable mean physician global assessment (25.5 vs. 27.3) and higher patient global assessment (50.2 vs. 36.9), pain (46.1 vs. 39.5), and fatigue (48.3 vs. 43.4) scores than those with RA.

CONCLUSIONS

Disease burden in patients with PsA or axSpA was comparable to or greater than that in patients with RA on the basis of common patient-reported outcome measures but appeared lower when assessed using RA disease activity measures, suggesting that disease-specific approaches to care are needed to optimize disease management.

FUNDING

This study was sponsored by Corrona, LLC, and financial support was provided by Novartis. The Rapid Service Fee was funded by Novartis. Plain language summary available for this article.

Is There Gender Discrimination in Acute Renal Colic Pain Management? A Retrospective Analysis in an Emergency Department Setting

BACKGROUND

Pain is a widespread problem, affecting both men and women; studies have found that women in the emergency department receive analgesic medication and opioids less often compared with men.

AIMS

The aim of this study was to examine the administration and management of analgesics by the medical/paramedical staff in relation to the patients' gender, and thereby to examine the extent of gender discrimination in treating pain.

DESIGN

This is a single-center retrospective cohort study that included 824 patients.

SETTINGS

Emergency department of tertiary hospital in Israel.

PARTICIPANTS/SUBJECTS

The patients stratified by gender to compare pain treatments and waiting times between men and women in renal colic complaint.

METHODS

As an acute pain model, we used renal colic with a nephrolithiasis diagnosis confirmed by imaging. We recorded pain level by Visual Analog Scale (VAS) scores and number of VAS examinations. Time intervals were calculated between admissions to different stations in the emergency department. We recorded the number of analgesic drugs administered, type of drugs prescribed, and drug class (opioids or others).

RESULTS

A total of 824 patients (414 women and 410 men) participated. There were no significant differences in age, ethnicity, and laboratory findings. VAS assessments were higher in men than in women (6.43 versus 5.90, p = .001, respectively). More men than women received analgesics (68.8% versus 62.1%, p = .04, respectively) and opioids were prescribed more often for men than for women (48.3 versus 35.7%, p = .001). The number of drugs prescribed per patient was also higher in men compared with women (1.06 versus 0.93, p = .03). A significant difference was found in waiting time length from admission to medical examination between non-Jewish women and Jewish women.

CONCLUSIONS

We found differences in pain management between genders, which could be interpreted as gender discrimination. Yet these differences could also be attributed to other factors not based on gender discrimination but rather on gender differences.

Gender aspects of the pain syndrome

In recent years, the subject of sex differences in the pain experience attracts a growing interest. The epidemiological and clinical data indicate that women have increased risk of chronic pain, and according to some sources, even experience more intense pain. The hypothetical biological mechanisms underlying sex differences in pain perception consist in the modulating effects produced by sex hormones in relation to the neural substrate. This is confirmed by data on the distribution of gonadal hormones and their receptors in the areas of the peripheral and central nervous system that provide nociceptive transmission. The complexity of the estradiol and progesterone effects on pain sensitivity lies in the fact that, according to various data, both have pre-nociceptive and antinociceptive effects, and testosterone appears to be more characterized by antinociceptive properties. The lion’s share of researches demonstrates the effect of a clinical pain exacerbation during the menstrual cycle. There is irrefutable information about gender differences in responses to drug and non-drug pain treatment, although the results vary depending on a specific therapy and may depend on pain characteristics. Since the recommended dosage of a medication is often based on an “average” male weigh 70 kg, female patients may be facing the risk of increased therapeutic or adverse effects of a drug. The cause is in a higher average percentage of body fat, a lower mean body weight, which contributes to higher median drug concentrations compared with male patients. At present, the available evidence does not allow adapting the methods of pain syndrome treatment to a gender. However, such innovations are quite possible and desirable in the foreseeable future. Additional studies will be required to clarify the mechanisms that determine sex differences in pain responses in order to provide adequate pain relief, according to the patient’s needs.

Sex differences in high opioid dose escalation among Malaysian patients with long term opioid therapy

Purpose: This study evaluated the risk of opioid dose escalation as it relates to sex differences among patients receiving opioids for long-term therapy.

Patients and methods: This retrospective cohort study was conducted in tertiary hospital settings in Malaysia using electronic prescription records. Opioid naïve patients, aged ≥18 years, who were undergoing long-term opioid therapy of ≥90 days, with at least one opioid prescription (buprenorphine, morphine, oxycodone, fentanyl, dihydrocodeine or tramadol) between 1st January 2011 and 31st December 2016, were included in the study. They were followed until (i) the end of the study period, (ii) death from any cause or (iii) discontinuation of therapy from their first opioid prescription without any intervals of ≥120 days between successive prescriptions. The risk of high opioid dose escalation to ≥100 mg/day and ≥200 mg/day relative to men and women was measured.

Results: A total of 4688 patients (58.8% women, 41.3% men) on long-term opioid therapy were identified. Among these patients, 248 (5.29%) were escalated to high opioid doses of ≥100 mg/day and 69 (1.47%) were escalated to ≥200 mg/day. The escalation to high-dose opioid therapy was more likely to occur in men than in women, even after adjustment for age (dose ≥100 mg/day [adjusted hazard ratio 2.32; 95% confidence interval (CI), 1.79 to 3.00; p<0.0001] and ≥200 mg/day [adjusted hazard ratio 6.10; 95% CI, 3.39 to 10.98; p<0.0001]).

Conclusion: The risk of opioid dose escalation differed between men and women, as men were at higher risk than women for high opioid dose escalation.

The comparative responsiveness of Hospital Universitario Princesa Index and other composite indices for assessing rheumatoid arthritis activity

Objective

To evaluate the responsiveness in terms of correlation of the Hospital Universitario La Princesa Index (HUPI) comparatively to the traditional composite indices used to assess disease activity in rheumatoid arthritis (RA), and to compare the performance of HUPI-based response criteria with that of the EULAR response criteria.

Methods

Secondary data analysis from the following studies: ACT-RAY (clinical trial), PROAR (early RA cohort) and EMECAR (pre-biologic era long term RA cohort). Responsiveness was evaluated by: 1) comparing change from baseline (Δ) of HUPI with Δ in other scores by calculating correlation coefficients; 2) calculating standardised effect sizes. The accuracy of response by HUPI and by EULAR criteria was analyzed using linear regressions in which the dependent variable was change in global assessment by physician (ΔGDA-Phy).

Results

ΔHUPI correlation with change in all other indices ranged from 0.387 to 0.791); HUPI’s standardized effect size was larger than those from the other indices in each database used. In ACT-RAY, depending on visit, between 65 and 80% of patients were equally classified by HUPI and EULAR response criteria. However, HUPI criteria were slightly more stringent, with higher percentage of patients classified as non-responder, especially at early visits. HUPI response criteria showed a slightly higher accuracy than EULAR response criteria when using ΔGDA-Phy as gold standard.

Conclusion

HUPI shows good responsiveness in terms of correlation in each studied scenario (clinical trial, early RA cohort, and established RA cohort). Response criteria by HUPI seem more stringent than EULAR’s.

Is a Fundamental Change in the Interpretation of Rheumatoid Arthritis Disease Activity Necessary?

Disease Activity Score (DAS) composite models are moderately precise and robust measures of disease severity when they are used in rheumatoid arthritis (RA) cohorts. They are less so when used for individual patients. This is because subjective components, patient global assessment of well-being and tender joint count, modified by factors other than RA biological disease activity, often obfuscate interpretation of disease activity. Comorbidities, especially distress, can disproportionately inflate these components. Fibromyalgia, essentially synonymous with distress, pain augmentation, and depression, is a common comorbidity. Its presence and severity can be determined by the Polysymptomatic Distress Scale (PSD). The differential effects of distress and fibromyalgia syndrome on the DAS can be demonstrated by manipulating information already there: the arithmetic differences or ratios of the tender joint count and swollen joint count and comparison of the modified disease activity score with 28 joints to the disease activity score with 28 joints-patient (DAS28-derived indices that measure the contribution of the relatively objective or relatively subjective components, respectively). The potentially more objective multibiomarker disease activity might also be used to test the severity of biological RA disease activity. These tools may be used to elucidate disproportionate values for subjective DAS model components, which then should facilitate identification of the underlying process factors, including depression, for potential treatment.

Impact of gender on the response and tolerance to abatacept in patients with rheumatoid arthritis: results from the 'ORA' registry

Objective

The impact of gender on the response and tolerance to abatacept was assessed in a large prospective cohort during 2 years of follow-up.

Methods

From the 1017 patients included in the Orencia and Rheumatoid Arthritis registry, disease activity was assessed at baseline, 6, 12 and 24 months. The relationship between the European League Against Rheumatism (EULAR) response, Disease Activity Score 28 (DAS28) remission, rate of adverse events and gender was explored in multivariate analysis.

Results

990 patients, 79.3%female, with at least one follow-up visit were analysed. At baseline, women had longer disease duration, higher disease activity and more often received antitumour necrosis factor (TNF) drugs. The remission was not different between men and women during the follow-up after adjustment on age, disease duration and activity, rheumatoid factor and anti-cyclic citrullinated pyeptide (CCP) positivity, and current disease-modifying antirheumatic drugs (DMARDs), previous TNF blockers and corticosteroids use. The proportion of men and women achieving EULAR good-or-moderate response at any endpoints was similar (52.4% vs 55.5%), as well as time to achieving EULAR response (5.4±4.9 vs 5.6±5.2 months). Moderate EULAR response was more frequent in women at 6 months (OR=1.80, p=0.02) but was no longer significant at 12 or 24 months. During the follow-up, the DAS28, the tender joint count score and the patient global assessment remained higher in women (p=0.001, 0.04 and 0.06, respectively). Drug retention and safety were comparable.

Conclusion

In this large daily practice cohort of established rheumatoid arthritis treated with abatacept, women achieved similar remission and EULAR response than men despite higher disease activity and tender joint count during the treatment course.

Prevalence of pain medication prescriptions in France, Germany, and the UK - a cross-sectional study including 4,270,142 patients

OBJECTIVES

The goal of the present study was to analyze the prevalence of pain medication prescriptions in general practices in France, Germany, and the UK.

METHODS

This study included all patients aged ≥18 years followed in 2016 in general practitioner practices in France, Germany and the UK. The primary outcome was the prevalence of patients receiving prescriptions for pain medications in France, Germany, and the UK in 2016. The following drugs were included in the analysis: anti-inflammatory and antirheumatic products, non-steroids and analgesics including opioids, antimigraine preparations, and other analgesics and antipyretics. Demographic variables included age and gender.

RESULTS

This study included 4,270,142 patients. The prevalences of pain medication prescriptions were 57.3% in France, 29.6% in Germany, and 21.7% in the UK. Although this prevalence generally remained consistent between age groups in France (54.3%-60.3%), it increased with age in Germany (18-30 years: 23.8%; >70 years: 35.8%) and in the UK (18-30 years: 9.3%; >70 years: 43.8%). Finally, the prevalence of pain medication prescriptions was higher in women than in men in all three countries. Paracetamol was prescribed to 82.3% and 60.1% of patients receiving pain medication in France and the UK, respectively, whereas ibuprofen was prescribed to 46.5% of individuals in Germany.

CONCLUSIONS

The prevalence of pain medication prescriptions was higher in France than in Germany and the UK. Further research is needed to gain a better understanding of the differences in the prescription patterns between these three European countries.

Healthy lifestyle behavior and risk of long duration troublesome neck pain or low back pain among men and women: results from the Stockholm Public Health Cohort

Background

The role of healthy lifestyle behavior (HLB) in terms of physical activity, alcohol intake, smoking, and diet put together has not yet been explored for the risk of low back pain (LBP) and neck pain (NP). Our aim was to study if an HLB is protective against the onset of long duration troublesome LBP and NP in men and women.

Methods

Two cohorts from the Stockholm Public Health Cohort, free from LBP (n=12,483) and NP (n=10,539), respectively, in 2006, were surveyed with questionnaires. Baseline information about physical activity, alcohol intake, diet, and smoking were dichotomized into being healthy/not healthy and combined in a categorical variable according to the number of healthy behaviors present. Binomial regression analyses were used to evaluate the role of HLB for the outcomes 4 years later.

Results

When men with three or four healthy lifestyles were compared to men with none or one, the risk ratio (RR) of LBP was 0.63 (95% confidence interval [CI]: 0.39–1.02). The corresponding RR for LBP in women was 0.86 (95% CI: 0.56–1.32). When men with three or four healthy lifestyles were compared to men with none or one, the RR for NP was 1.13 (95% CI: 0.74–1.71). The corresponding RR for NP in women was 0.52 (95% CI: 0.35–0.77).

Conclusion

An HLB seems to be protective for long duration troublesome LBP in men, and for long duration troublesome NP in women.

Mortality causes and outcomes in Indigenous populations of Canada, the United States, and Australia with rheumatic disease: A systematic review

BACKGROUND

Indigenous populations of Canada, America, Australia, and New Zealand have increased rates and severity of rheumatic disease. Our objective was to summarize mortality outcomes and explore disease and social factors related to mortality.

METHODS

A systematic search was performed in medical (Medline, EMBASE, and CINAHL), Indigenous and conference abstract databases (to June 2015) combining search terms for Indigenous populations and rheumatic diseases. Studies were included if they reported measures of mortality (crude frequency, mortality rate, survival, and potential years of life lost (PYLL)) in Indigenous populations from the four countries.

RESULTS

Of 5269 titles and abstracts identified, 504 underwent full-text review and 12 were included. No studies from New Zealand were found. In five Canadian studies of systemic lupus erythematosus (SLE) patients, First Nations ethnicity was associated with lower survival after adjusting for disease and social factors, and an increased frequency of death from lupus and its complications compared to Caucasians was found. All-cause mortality was higher in Native Americans (n = 2 studies) relative to Whites with SLE after adjusting for disease and social factors, but not in those with lupus nephritis alone. Australian Aborigines with SLE frequently developed infection and lupus complications leading to death (n = 3 studies). Mortality rates were increased in Pima Indians in the United States with rheumatoid arthritis (RA) compared to those without RA. One study in Native Americans with scleroderma found nearly all deaths were related to progressive disease.

CONCLUSIONS

Canadian and American Indigenous populations with SLE have increased mortality rates compared to Caucasian populations. Mortality in Canadian and Australian Indigenous populations with SLE, and in Native American populations with RA and scleroderma, is frequently attributed to disease progression or complications. The proportional attribution of rheumatic disease severity and social factors to mortality and complications leading to death between Indigenous and non-Indigenous populations has not been fully evaluated.

TFOS DEWS II Sex, Gender, and Hormones Report

One of the most compelling features of dry eye disease (DED) is that it occurs more frequently in women than men. In fact, the female sex is a significant risk factor for the development of DED. This sex-related difference in DED prevalence is attributed in large part to the effects of sex steroids (e.g. androgens, estrogens), hypothalamic-pituitary hormones, glucocorticoids, insulin, insulin-like growth factor 1 and thyroid hormones, as well as to the sex chromosome complement, sex-specific autosomal factors and epigenetics (e.g. microRNAs). In addition to sex, gender also appears to be a risk factor for DED. "Gender" and "sex" are words that are often used interchangeably, but they have distinct meanings. "Gender" refers to a person's self-representation as a man or woman, whereas "sex" distinguishes males and females based on their biological characteristics. Both gender and sex affect DED risk, presentation of the disease, immune responses, pain, care-seeking behaviors, service utilization, and myriad other facets of eye health. Overall, sex, gender and hormones play a major role in the regulation of ocular surface and adnexal tissues, and in the difference in DED prevalence between women and men. The purpose of this Subcommittee report is to review and critique the nature of this role, as well as to recommend areas for future research to advance our understanding of the interrelationships between sex, gender, hormones and DED.

Remaining Pain in Early Rheumatoid Arthritis Patients Treated With Methotrexate

Objective

To investigate the frequency of remaining pain in early rheumatoid arthritis (RA) after 3 months of treatment with methotrexate as the only disease modifying antirheumatic drug, with a special focus on patients with a good clinical response.

Methods

The study base was cases reported to a population‐based early RA cohort who had followup data from the Swedish Rheumatology Quality Register (n = 1,241). The Disease Activity Score in 28 joints European League Against Rheumatism (EULAR) response criteria were used to evaluate clinical response to treatment as good, moderate, and no response. The primary end point was remaining pain at the 3‐months followup visit, defined as pain >20 mm on a 100‐mm visual analog scale (VAS).

Results

Remaining pain in spite of a EULAR good response at followup was associated with higher baseline disability, using the Health Assessment Questionnaire (adjusted odds ratio [OR] 2.2 [95% confidence interval (95% CI) 1.4–3.4] per unit increase), and less baseline inflammation, using the erythrocyte sedimentation rate (adjusted OR 0.81 [95% CI 0.70–0.93] per 10‐mm increase). Similar associations were detected for remaining pain at followup in spite of low inflammatory activity, defined as a C‐reactive protein level <10. Increase in VAS pain during the treatment period was observed in 19% of the whole cohort, with frequencies in the EULAR response groups of 9% (good response), 15% (moderate response), and 45% (no response).

Conclusion

These results are in line with the hypothesis that a subgroup of early RA patients exhibits pain that is not inflammatory mediated, where alternative treatment strategies to traditional antiinflammatory medications need to be considered.

Sex differences in prescription opioid use

PURPOSE OF REVIEW

Recent literature focused on prescription opioids has neglected sex differences in use. Here, we evaluated the recent literature (since 2015) examining sex differences in prescription opioid use.

RECENT FINDINGS

Between 2015 and 2016, our review found only eight articles addressing sex differences in prescription opioid use mostly opioid misuse in North America among individuals with chronic pain. Risk factors included depression, pain, and polydrug use. In addition to that review, we had the opportunity to further address sex differences in, and risk factors for, prescription opioid use through a community engagement program, HealthStreet. Among the sample (n = 8525, Mage = 43.7 years, 58.6% women), approximately half reported use of prescription opioids. Women were significantly more likely to report lifetime use (54.9 vs. 42.2%; P < 0.0001) and report cancer compared with men, yet, women with cancer had a significantly reduced risk of using opioids compared with men with cancer (odds ratio: 0.46; 95% confidence interval, 0.36-0.59).

SUMMARY

Only a few recently published studies analyzed sex differences related to prescription opioid use. Findings from the literature and our data suggest women are more likely to use prescription opioids compared with men. There is limited information on sex differences in opioid use risk factors and outcomes and more research in this area is warranted.

Rheumatoid Arthritis: Are psychological factors effective in disease flare?

OBJECTIVE

Rheumatoid arthritis (RA) is clinically an undulant disease, and reasons for flare or remission vary. We aimed to identify factors potentially associated with disease flare and remission.

MATERIAL AND METHODS

Two hundred and seventy-four patients with RA who were admitted to our center between January 2010 and January 2016 were included. Disease activity was evaluated using disease activity score 28 (DAS 28); functional status was evaluated using the modified Health Assessment Questionnaire (m-HAQ), a questionnaire that comprises flare or remission domains such as psychological stress and mood status, physical trauma, nutrition regimen, infection, antibiotic use, and seasonal weather changes. Beck Depression Inventory (BDI) and Beck Anxiety Inventory (BAI) were used to identify if patients had a mood disorder. Four subscales of Arthritis Impact Measurement Scale-2 (AIMS-2) (level of tension, mood, general perception of health, and satisfaction with health) were used to determine patient quality of life.

RESULTS

Of the 274 patients, 261 were female (95.3%) and 13 were male (4.7%); the mean age was 52.10±9.41 years. According to patients' perception, the most frequent reasons for joint symptoms were psychological stress/mood disorder (86.1%), followed by infection (49.6%) and trauma (46.4%). The most frequent factors for remission of symptoms were antibiotic use (42.7%), cold weather (34.3%), and hot weather (19%).

CONCLUSION

Psychological stress and mood status are independent factors for relapse periods in patients with RA. These should be considered particularly in patients who are resistant to different treatment regimens and in whom any other reason for disease flare is not obvious.

Systematic review of rheumatic disease phenotypes and outcomes in the Indigenous populations of Canada, the USA, Australia and New Zealand

We performed a systematic review designed to characterize clinical phenotypes and outcomes in Indigenous populations with rheumatic disease to enhance the understanding of how rheumatic disease presents in Indigenous populations and allow for better projection of the healthcare needs of the communities affected. A systematic search was performed in medical (Medline, EMBASE, CINAHL), Indigenous and conference abstract databases (to June 2015). Search terms for Indigenous populations were combined with terms for inflammatory arthritis conditions, connective tissue disorders, crystal arthritis and osteoarthritis. Studies were included if they reported on disease features, disease activity measures, or patient-reported outcomes in Canadian, American, Australian or New Zealand Indigenous populations. Data were extracted in duplicate, and a narrative summary was prepared. A total of 5269 titles and abstracts were reviewed, of which 504 underwent full-text review and 85 met inclusion criteria. Nearly all the studies described outcomes in the North American populations (n = 77), with only four studies from Australia and four studies from New Zealand. The majority of studies were in rheumatoid arthritis (n = 31) and systemic lupus erythematosus (n = 19). Indigenous patients with rheumatoid arthritis had higher disease activity and reported more significant impact on patient-reported outcomes and quality of life than non-Indigenous patients. Spondyloarthropathy features were described in North American populations, with most patients having advanced manifestations. In systemic lupus erythematosus, nephritis was more frequent in Indigenous populations. Gout and osteoarthritis were more severe in New Zealand Maori populations. The existing literature supports differences in disease phenotype and severity in Indigenous populations of Canada, America, Australia and New Zealand. We encourage investigators in this area of research to undertake contemporary studies that disentangle differences between phenotype and severity that are biologic in etiology or merely reflecting differences in access to care and that provide a longitudinal assessment of outcomes in more diverse populations.

Gender differences among patients with primary ankylosing spondylitis and spondylitis associated with psoriasis and inflammatory bowel disease in an iberoamerican spondyloarthritis cohort

The aim of the study was to compare clinical manifestations, disease activity, functional capacity, spinal mobility, and radiological findings between men and women from a multicenter, multiethnic Ibero-American cohort of patients with Spondyloarthritis (SpA).This observational cross-section study included 1264 consecutive SpA patients who fulfilled the modified New York criteria for ankylosing spondylitis (AS). Demographic, clinical, and radiologic data were evaluated. Categorical data were compared by X or Fisher's exact tests and continuous variables by ANOVA with post-hoc tests.Primary AS was diagnosed in 1072 patients, psoriatic spondylitis in 147, and spondylitis associated to inflammatory bowel disease (IBD) in 45 patients. Overall, male patients were significantly younger, had longer diagnostic delay, lower disease activity, worse spinal mobility, better quality of life, and more severe radiologic damage. Dactylitis and enthesitis, as well as swollen joint count, were significantly more common among women. In primary AS, there was a marked male predominance (76.2%). Among patients with psoriatic spondylitis, male predominance was lower (57.8%), but was also associated with worse spinal mobility and more severe radiologic damage. In the total population, male patients with primary AS referred higher permanent work disability (13.2% vs 6.9%; P < 0.05), although no difference was observed in psoriatic or IBD spondylitis according to the gender.Among Ibero-American SpA patients, there are some differences in clinical and radiological manifestations, men showing more structural damage, whereas women more active disease. These data suggest that the phenotype of SpA differs between genders. This can influence the subsequent diagnostic approach and therapeutic decisions.

Healthcare utilization for arthritis by indigenous populations of Australia, Canada, New Zealand, and the United States: A systematic review☆

PURPOSE

Indigenous populations of Australia, Canada, New Zealand, and the United States of America (USA) experience a higher prevalence of arthritis conditions. Differences in clinical outcomes and mortality may reflect healthcare service use inequities. The objective of this study was to summarize healthcare service use patterns described in the existing literature in order to identify gaps and inform strategies to limit the pronounced negative impact of arthritis on Indigenous populations.

METHODS

Medline, EMBASE, CINAHL, and Indigenous-specific electronic databases (to June 2015) were used to identify cohort, case-control and cross-sectional studies describing healthcare service use by Indigenous populations with specified inflammatory arthritis, osteoarthritis, or rheumatic disease conditions. We extracted information on the study setting and methodology, primary outcome and assessed study quality, and risk of bias.

RESULTS

In total, 19 studies were identified describing three types of healthcare service use: physician visits, hospitalizations, and surgeries. In Canada and New Zealand, Indigenous populations had 36-51% fewer visits to specialists than the non-Indigenous population. Indigenous populations in Canada, New Zealand, and the USA had 37-300% more hospitalizations due to arthritis complications than the non-Indigenous population. Indigenous populations in Australia, Canada, and New Zealand had 27-85% fewer arthroplasties for osteoarthritis than the non-Indigenous population.

CONCLUSIONS

Indigenous populations had higher hospitalization rates but lower use of specialized services for arthritis conditions. Strategies to improve access to specialized arthritis services might reduce health outcome inequities.

Effect of ethnicity on disease activity and physical function in psoriatic arthritis in a multiethnic Asian population

Geographic differences in manifestation of psoriatic arthritis (PsA) could be related to differences in genetic or environmental factors. We aimed to compare the disease activity and functional status using validated outcome measures among patients with PsA of different ethnicities living in the same environment. We performed a cross-sectional study on consecutive patients with PsA classified by the Classification Criteria for Psoriatic Arthritis (CASPAR) criteria from a single center. Sociodemographic data, clinical variables, and patient-reported outcomes were collected using a standardized protocol. Disease activities were assessed by validated composite scores: clinical Disease Activity Index for Psoriatic Arthritis (cDAPSA), Composite Psoriatic Disease Activity Index (CPDAI), and minimal disease activity (MDA). Physical function was assessed with Health Assessment Questionnaire (HAQ) and the Medical Outcome Study Short-Form 36 (SF36) physical function subscales. Linear regression analyses were performed to identify variables associated with disease activities and physical function. Ninety-eight patients (51.5%, men) with mean (±SD) age and duration of PsA of 51.5 ± 13.8 and 5.5 ± 8.4 years were recruited. Indian was overrepresented compared with the national distribution of ethnicities. Compared to Chinese, Indian patients were more likely to be using biological therapies, have higher tender joint count, and worse enthesitis. Higher proportion of Indians had higher disease activity categories measured by cDAPSA, CPDAI, and MDA and had poorer physical function. In the multivariable analysis, ethnicity was significantly associated with HAQ and SF36-PF. Compared to Chinese, Indians with PsA living in the same environment had worse disease activity and physical function measured by validated outcomes.

Is there any gender-specific difference in the cut-off values of ankylosing spondylitis disease activity score in patients with axial spondyloarthritis?

AIM

To assess the validity of Assessment in Spondyloarthritis International Society (ASAS) endorsed Ankylosing Spondylitis Disease Activity Score (ASDAS) C-reactive protein (-CRP) and ASDAS erythrocyte sedimentation rate (-ESR) in axial spondyloarthritis (axSpA) and to estimate the cut-off values for male and female patients with axSpA.

METHODS

Patients with axSpA were assessed for disease activity, functions, mobility and AS Quality of Life (ASQoL) and pain. The discriminant ability of ASDAS versions was assessed using standardized mean differences. Optimal cut-off values of ASDAS versions were calculated.

RESULTS

Patients with axSpA were included (196 AS, 164 non-radiographic axSpA). ASDAS versions and Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) had good correlations with patient's global (PtG) and physician's global (PhG) assessment in both groups; however, men had relatively higher coefficients. Women had significantly higher pain, ASQoL, ASDAS-ESR, BASDAI item scores, PtG, PhG and ESR. Discriminant abilities of ASDAS-CRP, ASDAS-ESR and BASDAI were similar in men and women regarding low and high disease activity. ASDAS cut-offs are quite similar in both genders and in accordance with predefined values. The cut-offs for ASDAS-ESR were relatively lower than ASDAS-CRP and women tend to have higher cut-offs than men.

CONCLUSION

The construct validity of ASDAS-CRP to discriminate low and high disease activity and cut-off values are similar in male and female patients with axSpA; however, cut-offs for ASDAS-ESR need to be defined.

Sex and Gender Differences in Central Nervous System-Related Disorders

There are important sex differences in the brain that seem to arise from biology as well as psychosocial influences. Sex differences in several aspects of human behavior and cognition have been reported. Gonadal sex steroids or genes found on sex chromosomes influence sex differences in neuroanatomy, neurochemistry and neuronal structure, and connectivity. There has been some resistance to accept that sex differences in the human brain exist and have biological relevance; however, a few years ago, it has been recommended by the USA National Institute of Mental Health to incorporate sex as a variable in experimental and clinical neurological and psychiatric studies. We here review the clinical literature on sex differences in pain and neurological and psychiatric diseases, with the aim to further stimulate interest in sexual dimorphisms in the brain and brain diseases, possibly encouraging more research in the field of the implications of sex differences for treating these conditions.

The relationship of bone-tumor-induced spinal cord astrocyte activation and aromatase expression to mechanical hyperalgesia and cold hypersensitivity in intact female and ovariectomized mice

Recently, our group established a relationship between tumor-induced spinal cord astrocyte activation and aromatase expression and the development of bone tumor nociception in male mice. As an extension of this work, we now report on the association of tumor-induced mechanical hyperalgesia and cold hypersensitivity to changes in spinal cord dorsal horn GFAP and aromatase expression in intact (INT) female mice and the effect of ovariectomy on these parameters. Implantation of fibrosarcoma cells produced robust mechanical hyperalgesia in INT animals, while ovariectomized (OVX) females had significantly less mechanical hyperalgesia. Cold hypersensitivity was apparent by post-implantation day 7 in INT and OVX females compared to their saline-injected controls and increased throughout the experiment. The decrease in mechanical hyperalgesia in OVX females was mirrored by significant decreases in spinal astrocyte activity in laminae I-II, III-IV, V-VI and X and aromatase expression in laminae V-VI and X in the dorsal horn of tumor-bearing animals. Administration of the aromatase inhibitor letrozole reduced tumor-induced hyperalgesia in INT females only suggesting that the tumor-induced increase in aromatase expression and its associated increase in spinal estrogen play a role in the development of bone tumor-induced hyperalgesia. Finally, intrathecal (i.t.) administration of 17β-estradiol caused a significant increase in tumor-induced hyperalgesia in INT tumor-bearing females. Since i.t. 17β-estradiol increases tumor pain and ovariectomy significantly decreases tumor pain, as well as spinal aromatase, estrogen may play a critical role in the spinal cord response to the changing tumor environment and the development of tumor-induced nociception.

Hand pains in women and men in early rheumatoid arthritis, a one year follow-up after diagnosis. The Swedish TIRA project

Purpose This research analysed general pain intensity, hand pain at rest and hand pain during activity in women and men in early rheumatoid arhtritis (RA). Method Out of the 454 patients that were recruited into the Swedish early RA project "TIRA" the 373 patients (67% women) that remained at 12 months follow-up are reported here. Disease activity 28 joint score (DAS-28), disability (Health Assessment Questionnaire = HAQ) and pain (VAS) were recorded at inclusion and after 3 (M3), 6 (M6) and 12 (M12) months. General pain, hand pain during rest, hand pain during test of grip force as assessed by Grippit™, prescribed disease-modifying anti-inflammatory drugs (DMARDs) and hand dominance were recorded. Results DAS-28 and HAQ scores were high at inclusion and improved thereafter in both women and men. There were no significant differences between sexes at inclusion but women had higher DAS-28 and HAQ at all follow-ups. Women were more often prescribed DMARDs than were men. In both women and men all pain types were significantly lower at follow-up compared to at inclusion and women reported higher pain than men at follow-ups. The pain types differed significantly from each other at inclusion into TIRA, general pain was highest and hand pain during rest was lowest. There were no significant differences in hand pain related to hand dominance or between right and left hands. Conclusions Disease activity, disability and pain were high at inclusion and reduced over the first year. Despite more DMARDs prescribed in women than in men, women were more affected than were men. General pain was highest and not surprisingly hand pain during active grip testing was higher than hand pain during rest that was lowest in both sexes. Although our cohort was well controlled, it was evident that hand pain remains a problem. This has implications for rehabilitation and suggests potential ongoing activity limitations that should continue to receive attention from a multi-professional team. Implications for Rehabilitation General pain and hand pain remain a problem in RA despite today's early intervention and effective disease control with new era biologics. The extent of hand pain evidenced in our work gives a more detailed and comprehensive account of pain status. Higher hand pain during active grip testing than that during rest indicates a potential relationship to ongoing activity limitation. Hand pain assessment can help guiding multi-professional interventions directed to reduce hand pain and thereby probably reduce activity limitations.

Fat Mass Is Associated with Foot Pain in Men: The Geelong Osteoporosis Study

OBJECTIVE

Foot pain is a common complaint in adults. Evidence suggests that body composition is involved in the development of foot pain. However, whether this is the case in men remains unclear because previous studies mainly examined women. The aim of this cross-sectional study was to determine the relationship between body composition and foot pain in men while accounting for important risk factors.

METHODS

Among 978 men (median age 60 yrs, range 24-98) from the Geelong Osteoporosis Study who participated in a followup study in 2006 to 2011, 796 provided responses to questions on health status and foot pain. Foot pain was determined using the Manchester Foot Pain and Disability Index, and body composition was measured using dual-energy x-ray absorptiometry.

RESULTS

Of the 796 respondents, 177 (22%) had foot pain. Risk factors for foot pain were age (OR 1.03, 95% CI 1.02-1.04), self-reported depression (OR 2.05, 95% CI 1.30-3.20), decreased mobility (OR 1.54, 95% CI 1.05-2.24), and lower education (OR 1.47, 95% CI 1.03-2.09). Foot pain was associated with body mass index (OR 1.05, 95% CI 1.00-1.10), fat mass (OR 1.02, 95% CI 1.03-1.05), and fat mass index (OR 1.08, 95% CI 1.01-1.15), but not fat-free mass (OR 1.01, 95% CI 0.98-1.04) or fat-free mass index (OR 1.05, 95% CI 0.95-1.15) after appropriate adjustments were made.

CONCLUSION

Fat mass is associated with foot pain in men. These findings complement those in studies that have mainly examined women, and provide further evidence for the relationship between obesity and foot pain.