Association between the dietary inflammatory index and all-cause mortality in osteoarthritis

BACKGROUND

To investigate the association between the Dietary Inflammatory Index (DII) and all-cause mortality in patients with osteoarthritis (OA).

METHODS

In this retrospective cohort study, data on OA patients were obtained from the National Health and Nutrition Examination Survey (NHANES) 2003-2018. OA diagnosis was self-reported. The study population was divided into low and high DII groups based on the DII's median. All-cause mortality was the outcome, which was determined via linkage to the National Death Index (NDI) until 31 December 2019. Multivariable Cox regression analyses were employed to investigate the association between the DII and all-cause mortality. The survival of the low and high DII groups was exhibited by Kaplan-Meier curves. Furthermore, subgroup analyses were carried out in terms of age and comorbidity.

RESULTS

A total of 3804 patients with OA were included, with 1902 (50%) in the low DII group and 1902 (50%) in the high DII group. Patients with a high DII had a significantly greater risk of all-cause mortality than those with a low DII (HR = 1.21, 95%CI: 1.02-1.44, P = 0.025). A high DII was associated with a significantly increased risk of all-cause mortality compared with a low DII in patients aged ≥ 65 years [hazard ratio (HR) = 1.28, 95% confidence level (CI): 1.07-1.53, P = 0.006). Hypertensive patients with a high DII had a significantly greater risk of all-cause mortality than those with a low DII (HR = 1.25, 95%CI: 1.03-1.52, P = 0.025). For patients with cardiovascular disease (CVD), a high DII was associated with a significantly higher risk of all-cause mortality than a low DII (HR = 1.43, 95%CI: 1.17-1.75, P < 0.001). A high DII was associated with a significantly greater risk of all-cause mortality, as compared with a low DII in patients with chronic kidney disease (CKD) (HR = 1.22, 95%CI: 1.02-1.45, P = 0.026).

CONCLUSION

The DII was positively associated with the risk of all-cause mortality in patients with OA. This association differed by age, hypertension, CVD, and CKD. Adherence to diet with a low DII may be beneficial in prognosis improvement.

Association between hyperuricemia and the risk of mortality in patients with osteoarthritis: A study based on the National Health and Nutrition Examination Survey database

BACKGROUND

The purpose of this study was to evaluate the relationship between hyperuricemia and the risks of all-cause mortality and cardiovascular disease (CVD) mortality in patients with osteoarthritis (OA).

METHODS

A retrospective cohort study was performed on 3,971 patients using data from the National Health and Nutrition Examination Survey database between 1999 and 2018. OA was diagnosed through specific questions and responses. The weighted COX regression models were used to explore the factors associated with all-cause mortality/CVD mortality in OA patients. Subgroup analyses were conducted based on age, gender, hypertension, dyslipidemia, CVD, and chronic kidney disease (CKD). Hazard ratio (HR) and 95% confidence interval (95% CI) were measured as the evaluation indexes.

RESULTS

During the duration of follow-up time (116.38 ± 2.19 months), 33.69% (1,338 patients) experienced all-cause mortality, and 11.36% (451 patients) died from CVD. Hyperuricemia was associated with higher risks of all-cause mortality (HR: 1.22, 95% CI: 1.06-1.41, P = 0.008) and CVD mortality (HR: 1.32, 95% CI: 1.02-1.72, P = 0.036) in OA patients. Subgroup analyses showed that hyperuricemia was related to the risk of all-cause mortality in OA patients aged >65 years (HR: 1.17, 95% CI: 1.01-1.36, P = 0.042), in all male patients (HR: 1.41, 95% CI: 1.10-1.80, P = 0.006), those diagnosed with hypertension (HR: 1.17, 95% CI: 1.01-1.37, P = 0.049), dyslipidemia (HR: 1.18, 95% CI: 1.01-1.39, P = 0.041), CVD (HR: 1.30, 95% CI: 1.09-1.55, P = 0.004), and CKD (HR: 1.31, 95% CI: 1.01-1.70, P = 0.046). The association between hyperuricemia and a higher risk of CVD mortality was found in OA patients aged ≤ 65 years (HR: 1.90, 95% CI: 1.06-3.41, P = 0.032), who did not suffer from diabetes (HR: 1.36, 95% CI: 1.01-1.86, P = 0.048), who did not suffer from hypertension (HR: 2.56, 95% CI: 1.12-5.86, P = 0.026), and who did not suffer from dyslipidemia (HR: 2.39, 95% CI: 1.15-4.97, P = 0.020).

CONCLUSION

These findings emphasize the importance of monitoring serum uric acid levels in OA patients for potentially reducing mortality associated with the disease.

J-shaped association of serum uric acid concentrations with all-cause mortality in individuals with osteoarthritis: A prospective cohort study

OBJECTIVE

The purpose of this study was to explore the relationship between serum uric acid (SUA) concentrations and all-cause mortality in individuals with osteoarthritis (OA).

METHODS

All participant data were retrieved from the National Health and Nutrition Examination Survey database. A total of 4671 participants (age range: 20 to 85 years old), including 2988 females and 1683 males, were included in this study. The determination of death outcome was based on the National Death Index (up to December 31, 2019). We explored the nonlinear relationship between SUA concentrations and all-cause mortality in OA patients by establishing a Cox proportional risk model and a two-segment Cox proportional risk model and ran an interaction test to identify the high-risk population for all-cause mortality.

RESULTS

During 30,645 person-years of follow-up, the number of all-cause deaths for females and males was 736 and 516, respectively. After multivariate adjustment, we found a nonlinear relationship between SUA concentrations and all-cause mortality in both females and males with OA. In addition, we found a J-shaped relationship between SUA concentrations and all-cause mortality. The SUA concentration thresholds for all-cause mortality of females and males were stable at 5.6mg/dl and 6.2mg/dl, respectively. Compared with SUA concentrations below the inflection point, the all-cause mortality risk at higher SUA concentrations in females and males with OA increased by 20% (hazard ratio [HR]: 1.2, 95% confidence interval [CI]: 1.1 to 1.2) and 25% (HR: 1.2, 95% CI: 1.12 to 1.39), respectively.

CONCLUSIONS

There is a nonlinear relationship between SUA concentrations and all-cause mortality in the American OA population (J-shaped association). The all-cause mortality thresholds for SUA concentrations in females and males are 5.6mg/dl and 6.2mg/dl, respectively.

Intraarticular triamcinolone hexacetonide, stanozolol, Hylan G-F 20 and platelet concentrate in a naturally occurring canine osteoarthritis model

Osteoarthritis (OA) is a disease transversal to all mammals, a source of chronic pain and disability, a huge burden to societies, with a significant toll in healthcare cost, while reducing productivity and quality of life. The dog is considered a useful model for the translational study of the disease, closely matching human OA, with the advantage of a faster disease progression while maintaining the same life stages. In a prospective, longitudinal, double-blinded, negative controlled study, one hundred (N = 100) hip joints were selected and randomly assigned to five groups: control group (CG, n = 20, receiving a saline injection), triamcinolone hexacetonide group (THG, n = 20), platelet concentrate group (PCG, n = 20), stanozolol group (SG, n = 20) and hylan G-F 20 group (HG). Evaluations were conducted on days 0 (T0, treatment day), 8, 15, 30, 60, 90, 120, 150 and 180 days post-treatment, consisting of weight distribution analysis and data from four Clinical Metrology Instruments (CMI). Kaplan-Meier estimators were generated and compared with the Breslow test. Cox proportional hazard regression analysis was used to investigate the influence of variables of interest on treatment survival. All results were analyzed with IBM SPSS Statistics version 20 and a significance level of p < 0.05 was set. Sample included joints of 100 pelvic limbs (of patients with a mean age of 6.5 ± 2.4 years and body weight of 26.7 ± 5.2 kg. Joints were graded as mild (n = 70), moderate (n = 20) and severe (n = 10) OA. No differences were found between groups at T0. Kaplan-Meier analysis showed that all treatments produced longer periods with better results in the various evaluations compared to CG. Patients in HG and PCG took longer to return to baseline values and scores. A higher impact on pain interference was observed in THG, with a 95% improvement over CG. PCG and HG experienced 57-81% improvements in functional evaluation and impairments due to OA, and may be a better options for these cases. This study documented the efficacy of several approaches to relieve OA clinical signs. These approaches varied in intensity and duration. HG and PCG where the groups were more significant improvements were observed throughout the follow-up periods, with lower variation in results.

Relationship between cardiac biomarker concentrations and long-term mortality in subjects with osteoarthritis

Osteoarthritis (OA) is associated with adverse cardio-metabolic features. N-terminal pro-B-type natriuretic peptide (NT-proBNP) and high-sensitivity troponins T and I (hs-cTnT and hs-cTnI) are well-characterized cardiac markers and provide prognostic information. The objective was to assess the association of cardiac biomarker concentrations with long-term mortality in subjects with OA. In a cohort of 679 OA subjects, undergoing hip or knee replacement during 1995/1996, cardiac biomarkers were measured and subjects were followed over 20 years. During a median follow-up of 18.4 years, 332 (48.9%) subjects died. Median of hs-cTnT, hs-cTnI, and NT-proBNP at baseline was 3.2 ng/L, 3.9 ng/L, and 96.8 ng/L. The top quartile of NT-proBNP was associated with increased risk of mortality (Hazard Ratio (HR) 1.79, 95% confidence interval (CI) 1.17–2.73) after adjustment for covariates including troponins (hs-cTnT HR 1.30 (95% CI 0.90–1.89), hs-cTnI HR 1.32 (95% CI 0.87–2.00) for top category). When biomarker associations were evaluated as continuous variables, only NT-proBNP (HR per log-unit increment 1.34, 95% CI 1.16–1.54) and hs-cTnI (HR 1.38, 95% CI 1.11–1.72) showed robust results. Elevated cardiac biomarker concentrations predicted an increased risk of long-term mortality and strongest for NT-proBNP and hs-cTnI. These results might help to identify subjects at risk and target preventive efforts early.

Surgical Management of Glenohumeral Osteoarthritis With Glenoid Erosion and Static Posterior Subluxation (Walch B2): Techniques, Outcomes, and Survivorship Rates

The purpose of this study was to systematically assess the surgical techniques and outcomes related to the management of Walch B2 glenoids. PubMed, Medline, and Embase were searched from inception to July 2018. Overall, 24 studies (787 B2 glenoids) were identified. Revision-free survivorship was highest for reverse total shoulder arthroplasty (98.6%) and anatomic total shoulder arthroplasty with asymmetric reaming and a non-augmented glenoid implant (95.6%). Walch B2 glenoids are most commonly managed by asymmetric reaming in the context of anatomic total shoulder arthroplasty, and by the ream-and-run technique in hemiarthroplasty. The optimal treatment strategy remains elusive due to a lack of high-quality, comparative studies with long-term surveillance. [Orthopedics. 2020;43(4):e191-e201.].

Association of Tramadol With All-Cause Mortality Among Patients With Osteoarthritis

IMPORTANCE

An American Academy of Orthopaedic Surgeons guideline recommends tramadol for patients with knee osteoarthritis, and an American College of Rheumatology guideline conditionally recommends tramadol as first-line therapy for patients with knee osteoarthritis, along with nonsteroidal anti-inflammatory drugs.

OBJECTIVE

To examine the association of tramadol prescription with all-cause mortality among patients with osteoarthritis.

DESIGN, SETTING, AND PARTICIPANTS

Sequential, propensity score-matched cohort study at a general practice in the United Kingdom. Individuals aged at least 50 years with a diagnosis of osteoarthritis in the Health Improvement Network database from January 2000 to December 2015, with follow-up to December 2016.

EXPOSURES

Initial prescription of tramadol (n = 44 451), naproxen (n = 12 397), diclofenac (n = 6512), celecoxib (n = 5674), etoricoxib (n = 2946), or codeine (n = 16 922).

MAIN OUTCOMES AND MEASURES

All-cause mortality within 1 year after initial tramadol prescription, compared with 5 other pain relief medications.

RESULTS

After propensity score matching, 88 902 patients were included (mean [SD] age, 70.1 [9.5] years; 61.2% were women). During the 1-year follow-up, 278 deaths (23.5/1000 person-years) occurred in the tramadol cohort and 164 (13.8/1000 person-years) occurred in the naproxen cohort (rate difference, 9.7 deaths/1000 person-years [95% CI, 6.3-13.2]; hazard ratio [HR], 1.71 [95% CI, 1.41-2.07]), and mortality was higher for tramadol compared with diclofenac (36.2/1000 vs 19.2/1000 person-years; HR, 1.88 [95% CI, 1.51-2.35]). Tramadol was also associated with a higher all-cause mortality rate compared with celecoxib (31.2/1000 vs 18.4/1000 person-years; HR, 1.70 [95% CI, 1.33-2.17]) and etoricoxib (25.7/1000 vs 12.8/1000 person-years; HR, 2.04 [95% CI, 1.37-3.03]). No statistically significant difference in all-cause mortality was observed between tramadol and codeine (32.2/1000 vs 34.6/1000 person-years; HR, 0.94 [95% CI, 0.83-1.05]).

CONCLUSIONS AND RELEVANCE

Among patients aged 50 years and older with osteoarthritis, initial prescription of tramadol was associated with a significantly higher rate of mortality over 1 year of follow-up compared with commonly prescribed nonsteroidal anti-inflammatory drugs, but not compared with codeine. However, these findings may be susceptible to confounding by indication, and further research is needed to determine if this association is causal.

Can Osteoarthritis Predict Mortality?

Osteoarthritis is the most common musculoskeletal condition. Due to the aging population and rising obesity worldwide, the projected increase in osteoarthritis is expected to be substantial. Since osteoarthritis has been associated with disability and many chronic conditions such as obesity, diabetes, and cardiovascular disease, it is important to consider its impact on mortality.

Clinico-pathogenic aspects of osteodeficiency in osteoarthritis in combination with chronic pancreatitis

OBJECTIVE

Introduction: Pathology of the musculoskeletal system creates a number of important and complex medical problems affecting the economic situation of society, health and quality of life of individuals and their families. One of these problems and the most common disease of the joints which is diagnosed in 20% of the population of the planet is osteoarthritis (OA). The aim: The article deals with modern views on the problem of comorbidity of osteoarthritis, chronic pancreatitis and osteodefiсiency. Dual energy X-ray densitometry data were analyzed, as well as indicators of activation of lipid peroxidation (malonic aldehyde), antioxidant protection system (superoxide dismutase and SH-group, ceruloplasmin, сatalase) and tissue destruction (oxyproline).

PATIENTS AND METHODS

Materials and Methods:The complex examination of 72 patients was made. Patients were divided into two groups: 30 patients with OA and 42 - with OA in combination with CP. The control group included 20 apparently healthy individuals. Evaluation of CT scan was performed using Dual Energy X-Ray Absorptiometry - DXA by Lunar corp. (Madison, WI) - Lunar DPX-A No. 2589 in the lumbar region of the vertebral column. The evaluation of the indicators was carried out in accordance with WHO recommendations (WHO, Geneva, 1994) [1]. The study of LPO was carried out on the level of malonic aldehyde (MA). To assess AOP, we determined SOD, ceruloplasmin (CPN); SH-groups; catalase. The endogenous intoxication and the level of degradation of the connective tissue in the body was estimated by levels of free oxyproline. The influence of CP on the state of LPO-AOP was established by the following clinical characteristics of CP: age of the patients, structural condition of the pancreas with the help of the method of ultrasound, expressed in points. Excretory function of the pancreas was investigated on the level of fecal α-elastase ( by ELISA test using the kits BIOSERV ELASTASE 1-ELISA).

RESULTS

Results: During the examination of the mineral bone density by the dual energy X-ray densitometry it was discovered that the presence of CP in patients with OA led to a significant reduction of BMD and deterioration of the bone tissue (BT): the proportion of patients with normal bone decreased from 67% to 16%, the number of patients with osteopenia increased from 10% to 67%; patients with OP appeared - 17%.Besides, the increased degradation of bone tissue in OA with CP was accompanied by strengthening of oxidative changes (by MA-level), weakening of the antioxidant defense (SOD and SH-groups), the increase in the severity of inflammation and endotoxemia (levels of catalase and ceruloplasmin), as well as increased degradation of connective and bone tissue in the joints and progression of fibrosis in tissue (the level of oxyproline).

CONCLUSION

Conclusions: It was found out that the presence of CP in patients with OA led to a significant reduction of BMD and the deterioration of the bone tissue. It was discovered that during the combined course of OA and CP with osteopenia there occurs the weakening of the AOP (by SOD and SH-groups) and a relatively high level of LPO activation (by MAlevel) as well as the increased deterioration in connective and bone tissue and aggravation of osteopenia which is indicated by the increased levels of oxyproline.

Cardiovascular Disease Prevalence in Patients with Osteoarthritis, Gout, or Both

OBJECTIVE

Osteoarthritis (OA) and gout have each been associated with increased cardiovascular disease (CVD), but their relative impact is unknown. We compared CVD rates among patients with gout versus patients with OA and no gout (OA-only).

METHODS

We identified male patients at the VA New York Harbor Healthcare System with gout (with or without concur - rent OA) and with OA-only between August 2007 and August 2008. For each group, we collected baseline demographic data and CVD risk factors. The primary outcome was a composite index (CV4) of any diagnosis of coronary artery disease (CAD), angina, myocardial infarction (MI), or coro- nary bypass surgery (CABG). Secondary outcomes included individual diagnoses within the CV4, CHF, and death. We subsequently divided the gout patients into those who did versus did not have concurrent diagnoses of OA (gout-only; gout+OA). Logistic regression was used to compare the associations of OA-only, gout-only, and gout+OA with CV outcomes.

RESULTS

1,280 gout subjects met inclusion criteria (983 gout- only and 297 gout+OA), along with 1,231 OA-only subjects. Gout subjects overall had more CVD risk factors at baseline, including hypertension, hyperlipidemia, and chronic kidney disease, versus OA-only. Compared with OA-only, gout subjects overall had increased rates of all outcomes except MI. Both the gout-only and gout+OA subgroups also had increased risk for all outcomes except MI, and CABG in the case of gout+OA subjects. After adjusting for traditional CVD risk factors, both gout-only and gout+OA subjects continued to have increased risk for multiple CVD outcomes. Gout+OA did not impart ad- ditional risk over gout-only for any outcome studied.

CONCLUSION

Our data suggest that gout is associated with higher risk of CVD compared with OA, and that OA does not impart any additive CVD risk to patients who also have gout. Significance and Innovations: • In our dataset, gout subjects both with and without con- comitant OA had more cardiovascular disease (CVD) risk factors at baseline, and higher prevalence of CVD outcomes, than patients with OA only. • After adjusting for traditional CVD risk factors, gout-only and gout+OA subjects continued to have increased rates of multiple CVD outcomes, suggesting an intrinsic CVD risk to the diagnosis of gout, compared with OA. • These observations underline that gout patients represent a group at increased CVD risk, for whom both rheumatic disease management and CVD prevention need to be addressed.

Osteoarthritis and all-cause mortality in worldwide populations: grading the evidence from a meta-analysis

The objective of this study is to investigate the association between osteoarthritis (OA) and all-cause mortality in worldwide populations and to develop recommendations according to GRADE evidence levels. Literature search through Nov 2015 was performed using the electronic databases (including MEDLINE, EMBASE, EBSCO and Cochrane library). The prospective cohort trials that investigated the association between the symptomatic OA (SxOA) or radiological OA (ROA) and all-cause mortality were identified. Hazard ratios (HR) of all-cause mortality in patients with RxOA or ROA were pooled respectively. The evidence quality was evaluated using the GRADE system, while the recommendations were taken according to the quality. Nine of the published literature met the eligible criteria. Meta-analysis revealed that there was no significant difference in the association between SxOA and all-cause mortality (HR = 0.91, 95% CI: 0.68-1.23) and between ROA and all-cause mortality (HR = 1.13, 95% CI: 0.95-1.35). The overall GARDE evidence quality was very low, which will lower our confidence in taking recommendations. To summarize, there was no reliable and confident evidence existed currently in respect of the association between OA and all-cause mortality. Due to the very low level of evidence quality currently, high-quality studies are still required.

Mortality after shoulder arthroplasty

One year post-operative mortality among patients with primary elective total shoulder arthroplasty (ETSA) and traumatic shoulder arthroplasty (TSA) were compared to the general population of a large healthcare system. Standardized mortality ratios (SMRs) and 95% confidence intervals (CIs) were calculated. 614 ETSA patients, 1.0% one year mortality, and 168 TSA patients, 5.4% mortality rate, were evaluated. Patients with ETSA (SMR = 0.4, 95% CI 0.1-0.7) had lower odds of mortality than expected, while patients with TSA (SMR = 1.8, 95% CI 0.6-3.0) did not have higher than expected odds of mortality compared to the reference population. Understanding excess mortality following shoulder arthroplasty surgery allows providers to evaluate current practices and identify ways to optimize patients prior to surgery.

Do musculoskeletal degenerative diseases affect mortality and cause of death after 10 years in Japan?

There are several reports from Europe and the United States on mortality from musculoskeletal degenerative diseases; however, no reports have been published from Japan. This study is the first that has examined whether musculoskeletal degenerative diseases affect life prognosis in Japan. As many as 944 persons who were 60 years of age and older and who underwent one or more musculoskeletal checkups (knee, lower back, and bone mineral density examination) were enrolled. Survival and death after 10 years were examined. For each knee, lower back, and bone mineral density examination, subjects were divided into normal and abnormal groups. For each of the examinations (knee, lower back, or bone mineral density), 10-year mortality was compared between the two groups. Also, causes of death were examined after 10 years. As many as 805 subjects survived and 125 died. For those with and without osteoarthritis of the knee, mortality after 10 years was 17 and 10%, respectively. For those with and without lower back abnormalities, mortality after 10 years was 12 and 14%, respectively. For those with or without low bone mineral density, mortality after 10 years was 17 and 10%, respectively. Multivariate analysis adjusted for age, gender, body mass index, and lifestyle revealed that odds ratio of death after 10 years was 2.32 and 2.33 in the presence of osteoarthritis of the knee and a low bone mineral density, respectively, and thus the risk of death after 10 years was significantly high. With regard to the cause of death, cerebrovascular and cardiovascular diseases were most frequently evident in patients with osteoarthritis of the knee. Musculoskeletal degenerative diseases influence mortality after 10 years.

Joint arthroplasty within 10 years after primary charnley total hip arthroplasty

To evaluate the need for joint arthroplasty within 10 years after index primary Charnley total hip arthroplasty (THA) performed for osteoarthritis, we retrospectively reviewed the cases of 2,547 patients, 50 to 75 years old, from 1969 to 1984, with a minimum potential 20-year follow-up. In this article, we report the age, sex, and time data from this study. For the entire patient population, the 10-year rate of undergoing contralateral THA was 35.0%; ipsilateral hip revision, 6.2%; ipsilateral total knee arthroplasty (TKA), 0.6%; contralateral TKA, 1.9%; and bilateral TKA, 0.2%. The 10-year death rate was 21.8%. With more than 200,000 THAs being performed in the United States each year, these numbers can guide orthopedic surgeons in their discussions about subsequent arthroplasty procedures on other joints.

Mortality in osteoarthritis

Mortality has not been a major area of investigation in osteoarthritis. The author conducted a systematic review and identified seven studies that provided data on either mortality or survival in persons with osteoarthritis; an additional two articles with relevant data were identified through review of reference lists. Studies included persons with radiographic evidence of osteoarthritis as well as clinical samples of patients with osteoarthritis. Results were pooled using the method of best evidence synthesis. Overall, there was moderate evidence of increased mortality among persons with osteoarthritis compared with the general population. Increased cause-specific mortality was observed in some studies from cardiovascular and gastrointestinal disorders. Risk factors for mortality in persons with osteoarthritis included an increased burden of osteoarthritis, advanced age, and presence of comorbid conditions. Possible explanations for the excess mortality include reduced levels of physical activity among persons with osteoarthritis due to involvement of lower limb joints and presence of comorbid conditions, as well as adverse effects of medications used to treat symptomatic osteoarthritis, particularly non-steroidal anti-inflammatory drugs.

Osteoarthritis: a comorbid marker for longer life?

PURPOSE

Diseases are often described and studied in isolation, yet there is increasing recognition of the complex interrelatedness of diseases and treatments in patients with multiple chronic diseases. Our objective was to describe the impact of selected diseases involving chronic inflammation (chronic obstructive pulmonary disease [COPD], osteoarthritis, and rheumatoid arthritis) on mortality.

METHODS

We identified a cohort aged 55 to 64 years with one or more chronic conditions. Clusters of mutually exclusive disease combinations were created. Five-year all-cause mortality was determined and the relative risk (RR) of mortality was estimated when COPD, osteoarthritis, and rheumatoid arthritis were added to clusters.

RESULTS

In 741,847 persons the 5-year mortality rates were lowest among persons with one condition and increased with more chronic conditions. The presence of osteoarthritis in a cluster was an exception where the risk was lower compared with that cluster without osteoarthritis: COPD (RR = 0.73 [95% confidence interval (CI), 0.65, 0.81]); ischemic heart disease (0.63 [0.52, 0.76]); hypertension (0.77 [0.71, 0.83]); dementia (0.63 [0.42, 0.93]); depression (0.65 [0.50, 0.84]); hypertension plus diabetes (0.85 [0.77, 0.93]); and ischemic heart disease plus hypertension (0.83 [0.73, 0.94]).

CONCLUSIONS

The association between osteoarthritis and lower rates of mortality is notable and replicating these findings to explore causal relationships is important.

Increased risk of treatment with antidepressants in stroke compared with other chronic illness

The prevalence of depression and anxiety is higher in patients with stroke than in the general population but it is unclear whether patients with stroke are at an increased risk of being treated for depression and anxiety compared with patients with other chronic illness. The objective of the present study was to investigate whether the rate of treatment with antidepressants is increased in patients with stroke compared with patients with other chronic illness and compared with the general population. By linkage of nationwide case registers, all patients who received a main diagnosis of stroke or osteoarthritis at their first ever admission or first outpatient contact during the period from 1995 to 2001 in Denmark were identified, and the rates of subsequent purchase of antidepressants were calculated. In total, 9,999 patients with a main first diagnosis of stroke and 12,127 patients with a main first diagnosis of osteoarthritis were included. In all, 23.6% of patients with stroke and 9.1% of patients with osteoarthritis purchased antidepressants during follow-up. Patients who received a first diagnosis of stroke had a 3.44 (95% confidence interval: 3.19-3.70) times increased rate of subsequently purchasing antidepressants compared with patients with a first diagnosis of osteoarthritis. The rate was increased in all subgroups of patients regardless of sex, age, socioeconomic group and time since diagnosis. Furthermore, the rate of treatment was greater than the rate among a sex, age and calendar-matched sample of the general population. It is concluded that stroke is associated with an increased rate of antidepressant treatment in clinical practice regardless of sex, age, socioeconomic group and time since diagnosis.

[The causes of death of patients with rheumatic diseases in Moscow]

The study was held in order to analyze the main causes of death in cases of rheumatic diseases (RD) in Moscow. The authors studied the pathology records of autopsies performed in 1999-2002 in two pathology departments of Moscow clinics. Cases with RD were selected. The study found 165 cases of RD, which constituted 2% of all autopsies performed in these departments. There were 99 cases (60%) of rheumatic heart disease (RHD), 4 cases (2.4%) of rheumatic fever (RF) relapse, 28 cases (17%) of rheumatoid arthritis (RA), 8 cases (4.8%) of systemic lupus erythematosus (SLE), 3 cases (1.8%) of scleroderma systematica (SS), 2 cases (1.2%) of ankylosing spondylitis (AS), 2 cases (1.2%) of systemic vasculitis (SPV), 11 cases (7.3%) of osteoarthrosis, 3 cases (1.8%) of gout, 1 case (0.6%) of polymyositis. The death of patients with RHD had been caused by hemodynamic decompensation (HD) in 54% of the cases, acute cardiovascular collapse (ACC) in 14% of the cases, 6% of the patients had died from thromboembolism (TE) and 26%--from other conditions (intoxication, uremia, brain and lung edema etc). The death of patients with RF was caused by TE in 2 cases, by HD in 1 case and by ACC in 1 case. Secondary amyloidosis resulting in chronic renal failure and uremia occurred in 5 out of 28 cases of RA, HD--in 3, ACC--in 7, TE--in 1, infectious complications--in 5, other complications--in 7 cases. Patients with SLE died from various conditions: uremia in 2 cases, acute adrenal failure in 1 case, infectious complications in 2, ACC--in 2, brain edema--in 1 case. The complications of SS were uremia and intoxication. ACC was the cause of death in cases of gout and SS. The majority of RD cases were patients with RHD. The main cause of death in RD was cardiovascular disorders.

Rationale for testing the cardiovascular risk for patients with COX-2 inhibitors on the basis of biomarker NT-proBNP

Owing to the selective inhibition of PGI2 synthesis, treatment with COX-2 inhibitors constitutes a potential risk for the increased occurrence of thrombotic cardiovascular incidents and of the first-time occurrence or a deterioration in pre-existing heart failure. Elderly patients, particularly those with a history of ischemic heart disease, hypertension or heart failure, are at risk. One key indication for selective COX-2 inhibitors is the chronic treatment of patients suffering from rheumatoid arthritis or osteoarthritis. However, these patients have an excess cardiovascular mortality, which relates particularly to cardiovascular incidents or heart failure. The use of nonselective antiphlogistic drugs and COX-2 inhibitors is associated with a higher potential risk in these patient groups. In essence, more than 80 million patients worldwide were treated with rofecoxib up to its voluntary withdrawal. The high number of patients who are still being treated with COX-2 inhibitors or for whom the use of COX-2 inhibitors is planned justifies the use of a biochemical marker which, as a screening instrument, is initially designed to recognize the patients who are "ill" despite the lack of symptoms. In asymptomatic patients with NT-proBNP levels below the cut-off, high-risk patients require further work-up. Recognition of these risk factors is easily accomplished considering the case history and the results of an established cardiovascular risk score (e.g. PROCAM score). These risk patients should then also be referred for intensive diagnostic work-up. On the other hand, symptomatic patients or those with high NT-proBNP levels should primarily be referred for more extensive cardiovascular diagnosis before a decision is taken concerning the use of COX-2 inhibitors. As an integral part of this extensive work-up the determination of NT-proBNP can help to improve the accuracy of diagnosis and prognostic assessment. With the exception of patients showing symptoms of an unstable coronary heart disease, imminent cerebral ischemia, uncontrolled arterial hypertension or decompensated heart failure, the use of a COX-2 inhibitor is possible provided special caution is exercised. Termination of treatment is advisable if there is a clinical deterioration of specific symptoms or signs in those patients (product information). Follow-up with NT-proBNP (monitoring) can be helpful in detecting imminent cardiac decompensation at an earlier stage in order to take suitable countermeasures.

[Causes of death in patients with rheumatic diseases in Moscow]

AIM

To study causes of death of rheumatic patients in Moscow.

MATERIAL AND METHODS

Autopsy protocols for 1999-2002 were analysed for two pathoanatomic departments of Moscow.

RESULTS

Rheumatic diseases were detected in 165 cases (2.0% of overall number of autopsies in these departments). Rheumatic heart disease (RHD) was stated in 99 (60.0%) cases, rheumatic fever relapse (RFR) in 4 (2.4%), rheumatoid arthritis (RA) in 28 (17.0%), systemic lupus erythematosus (SLE) in 8 (4.8%), systemic sclerosis (SS) in 3 (1.8%), ankylosing spondilarthritis (AS) in 2 (1.2%), systemic vasculitis (SV) in 2 (1.2%), osteoarthrosis in 11 (7.3%), gout in 3 (1.8%), polymyositis in 1 (0.6%). RHD patients died of decompensated circulation (DC) (54%), acute heart failure (AHF) (14%), thromboembolism (TE) (6%), other causes (26%). RF patients died of TE (n = 2), DC (n = 1), AHF (n = 1). Out of 28 RA patients, 5 patients died of secondary amyloidosis, 3 of DC, 7 of AHF, 1 of TE, 5 of infectious complications, 7 of other causes. SLE patients died of uremia (n = 2), acute adrenal failure (n = 1), infectious complications (n = 2), AHF (n = 2), brain edema (n = 1).

CONCLUSION

Among rheumatic diseases, rheumatic heart valve disease was most severe as it caused the highest mortality. Cardiovascular pathology caused death in most of the rheumatic patients.

Osteoarthritis in the carpometacarpal joint of the thumb. Prevalence and associations with disability and mortality

BACKGROUND

This study was designed to investigate the prevalence of osteoarthritis in the carpometacarpal joint of the thumb in adults thirty years of age or older in Finland.

METHODS

Between 1978 and 1980, a representative population sample of 8000 Finns thirty years of age or older were invited to have a comprehensive health examination; 90% accepted. Hand radiographs were made of 3595 subjects. Since the examination, the subjects have been followed systematically to assess work disability and mortality by reviewing registers covering the whole population.

RESULTS

The age-adjusted prevalence of thumb carpometacarpal osteoarthritis of Kellgren grade 2, 3, or 4 was 7% for men and 15% for women. After adjustment for age, sex, and other alleged risk factors, body mass index was found to be directly proportional to the prevalence of thumb carpometacarpal osteoarthritis in both sexes. The adjusted odds ratio was 1.29 (95% confidence interval, 1.15 to 1.43) per 5-kg/m(2) increment in body mass index. No significant association was found between the physical workload history and thumb carpometacarpal osteoarthritis. Restricted mobility of the thumb and local tenderness and swelling were frequently found in conjunction with radiographic evidence of thumb carpometacarpal osteoarthritis. Advanced (grade-3 or 4) thumb carpometacarpal osteoarthritis predicted the total mortality rate in men (adjusted relative risk, 1.32; 95% confidence interval, 1.03 to 1.69). Radiographic signs of thumb carpometacarpal osteoarthritis did not predict work disability.

CONCLUSIONS

and

CLINICAL RELEVANCE

Obesity is a strong determinant of thumb carpometacarpal osteoarthritis in both sexes. The effect of thumb carpometacarpal osteoarthritis on disability and mortality in the general population is modest. Because of the rarity of ensuing disability, carpometacarpal osteoarthritis of the thumb is likely to be underdiagnosed in clinical practice.

All-cause mortality and vascular events among patients with rheumatoid arthritis, osteoarthritis, or no arthritis in the UK General Practice Research Database

OBJECTIVE

To compare all-cause mortality rates and the incidence of major vascular events among patients with rheumatoid arthritis (RA), osteoarthritis (OA) without RA, or no arthritis using the UK General Practice Research Database (GPRD) while adjusting for age and sex. Clinic-based studies have found that patients with RA have higher all-cause and cardiovascular (CV) mortality than those without RA, after adjusting for age and sex. Much smaller elevations in risk have been found in the few community-based studies that have addressed this question.

METHODS

After excluding patients with a history of myocardial infarction or cerebrovascular events, we followed a retrospective cohort of patients 40 years and older from GPRD practices until the earliest of death, disenrollment, or the occurrence of an incident vascular event. Using Poisson regression we compared age and gender adjusted incidence rates for RA, OA, or no arthritis.

RESULTS

Five hundred and ninety-four practices contributed 2.37 million patients (1.11 million men and 1.26 million women) to the analysis. Over a mean duration of followup of almost 5 years, age and gender adjusted all-cause mortality rates were 60 to 70% higher in patients with RA compared to patients with OA and those with no arthritis. For the various vascular endpoints, the age and gender adjusted incidence rates were 30 to 60% higher in patients with RA compared to both patients with OA and those with no arthritis during the study period. The rates in patients with OA and those with no arthritis were essentially the same.

CONCLUSION

Compared to patients with OA and those with no arthritis, patients with RA had a higher age and gender adjusted incidence of all-cause mortality and of major vascular events during almost 5 years of followup.

Patient survival after total knee arthroplasty

The authors analyzed the 5-year and 9-year survival in 134 of 165 patients who underwent total knee arthroplasties from 1989 to 1996 in our department. Patients were followed until December 31, 1998, or until the time of death. Diagnoses were rheumatoid arthritis in 81 patients (132 knees) and osteoarthritis in 53 patients (79 knees). The survival of the patients was compared to that of the age- and sex-adjusted general population. Kaplan-Meier survival curves were constructed. Twenty-two patients in the study died before the end of the follow-up. The cumulative 5-year patient survival was 88.7%, and 9-year patient survival was 64.4% for total knee arthroplasty patients. The standardized mortality ratio was 0.11 (95% confidence interval: 0.02-0.40) for the patients with osteoarthritis, and 0.81 (95% confidence interval: 0.52-1.25) for the patients with rheumatoid arthritis. The Cox proportional hazards model showed that the factors of male sex and rheumatoid arthritis were related to a higher mortality rate in the total knee arthroplasty group.

Decreased survival with increasing prevalence of full-body, radiographically defined osteoarthritis in women

The relation between full-body, radiographically defined osteoarthritis and survival was examined in a cohort of 296 women aged 42-76 years (mean age, 57.1 years). These women were a random sample of women with very low body burdens of radium who were part of a larger cohort of women first employed in the US radium dial-painting industry between 1915 and 1945. At entry into the study between 1957 and 1982, these women had a clinical examination, and full-body radiographs were taken. Fifty-five joints (18 joint groups) of the hands, feet, cervical spine, lumbar spine, pelvis, and knees in each woman were graded for osteoarthritis by the method of J. H. Kellgren and J. S. Lawrence (Ann Rheum Dis 1957; 16:494-502). Through 1985, 18.6% (n = 55) of the women died. Cox regression showed a decreased survival for women with an increasing number of joint groups affected with osteoarthritis after adjusting for age at examination (hazard ratio = 1.45 for each increase in 3.1 joint groups (1 standard deviation) affected with osteoarthritis, 95% confidence interval 1.12-1.87). Further adjustment for a history of diabetes, smoking, alcohol use, and body mass index only slightly altered the risk. Similar results were obtained for the number of joints with osteoarthritis and the number of structures (e.g., left hand and right hand) with osteoarthritis. These results suggest that an increasing prevalence of full-body radiographic osteoarthritis is associated with decreased survival independent of age and several comorbid conditions related to osteoarthritis.

Establishing inter-hospital comparisons of outcomes

This paper describes the ongoing development of a region-wide system for monitoring the short-term outcomes of total knee replacement surgery. The system aims to collect data from a dozen hospitals, and relies on a close collaboration with locally based surgeons and medical audit staff. The intention is to provide routine comparative information based on a broad conception of outcome, that includes both clinical/technical measures and patient-derived assessments of general health status. These data may be reported in the context of relatively detailed case mix information. To date, both data capture and clinical support for the project have been good. Example reports are presented together with a discussion of current limitations and possible future developments.

Arthritis and mortality in the epidemiological follow-up to the National Health and Nutrition Examination Survey I

Subsets were analyzed of respondents from the Epidemiological Follow-up to the National Health and Nutrition Examination Survey I (NHANES I) who (1) answered a general arthritis question reflecting whether a doctor told the respondent that she or he had arthritis, (2) answered seven pain, swelling, and stiffness questions, and (3) had radiographs of knees and hips assessed for osteoarthritis at the time of the initial survey during the early 1970s. Data for the follow-up were collected between 1982 and 1984 and included 1,491 fatalities in the largest subsample analyzed here. The dependent variable was months of survival after the initial interview. No distinction was drawn between rheumatoid arthritis versus osteoarthritis. The NHANES I contained only limited information on rheumatoid arthritis versus osteoarthritis. Additional covariates included age, age squared, education, race, marital status, diastolic blood pressure, and body mass. After adjusting for age, no statistically significant associations emerged between answers to the general arthritis questions or any of the seven pain questions on the one hand, and mortality on the other. Similar statistically insignificant results were found when the association between radiographic diagnoses of osteoarthritis in the hips and months of survival was considered after adjusting for age. These statistically insignificant results persisted in repeated testing, which alternately included and excluded a number of covariates, and in separate subsamples of women, men, and persons older and younger than age 50. Some evidence was found, however, for a negative, statistically significant association between radiographic knee diagnoses of osteoarthritis and survival, especially among women, even after adjusting for covariates. These mixed results (1) do not discredit findings elsewhere suggesting that rheumatoid arthritis is associated with early death, since it is likely that the great majority of respondents answering in the affirmative to the general arthritis or seven pain questions in the NHANES I had osteoarthritis, and (2) suggest that future surveys should make greater attempts to distinguish between rheumatoid arthritis and osteoarthritis.

Post-operative electrolyte imbalance: its incidence and prognostic implications for elderly orthopaedic patients

In order to assess incidence and prognostic implications of post-operative electrolyte disorders for elderly patients, 180 patients aged 79.5 +/- 6.8 years, range 70-96 years, admitted to a geriatric-orthopaedic liaison service were prospectively followed from admission to discharge or death. The association of age, basic medical conditions, type of anaesthesia and perioperative complications with post-operative sodium/potassium imbalance and fatality was assessed by logistic regression analysis. The incidence of post-operative electrolyte imbalance and fatality was 15% and 8.8%, respectively. Electrolyte imbalance was independently predicted by spinal anaesthesia [odds ratio (OR) = 2, confidence limits (CL) = 1.24-3.19], multiple pathology (OR = 2, CL = 1.1-3.58), use of cathartics (OR = 1.76, CL = 1.05-2.91) and intra-operative complications (OR = 1.7, CL = 1.03-2.88). Death was predicted by electrolyte imbalance (OR = 2.32, CL = 1.21-4.43), post-operative noninfective complications (OR = 2.3, CL = 1.09-4.84) and age greater than 79 years (OR = 1.17, CL = 1.06-1.3). Post-operative electrolyte imbalance is a marker of very frail medical status and a risk factor for death among elderly orthopaedic patients.

Life expectancy after total hip arthroplasty

The 6-year survival rate was investigated in 646 patients undergoing total hip arthroplasty for osteoarthritis, rheumatoid arthritis, or complications following femoral neck fracture between 1978 and 1982. A comparison of mortality was done between patients treated by osteosynthesis for fresh femoral neck fracture and a matched general population. The mortality was lower than that of the matched general population after total hip arthroplasty and even lower for patients treated for fresh femoral neck fracture. Patients undergoing total hip arthroplasty for osteoarthritis had the highest survival rate, followed by patients with rheumatoid arthritis and complications after femoral neck fractures.

Survivorship of cemented knee replacements

The survivorship method of analysis has been used to compare the failure rate and overall success of 1,430 cemented primary total knee arthroplasties performed at The Hospital for Special Surgery over a 15-year period. There were 224 total condylar prostheses with a polyethylene tibia, 289 of the posterior stabilised type with an all polyethylene tibia, and 917 posterior stabilised with a metal-backed tibial component. There were 12 failures in the total condylar series, giving an average annual failure rate of 0.65% and a 15-year success rate of 90.56%. The posterior stabilised prosthesis with a polyethylene tibia showed an average annual failure rate of 0.27% and a 10-year success rate of 97.34%, and this prosthesis with a metal-backed tibial component gave an annual failure rate of 0.19% and a seven-year success rate of 98.75%. The overall survival rate was not influenced by sex or age, diagnosis or the percentage of ideal body weight. No metal-backed tibial components have yet needed revision for loosening. It seems that infection will be the major cause of failure.

Age of death of parents of patients with rheumatoid arthritis: data from a middle class sample

To test the observation that was made in a largely nonwhite, lower socioeconomic class clinic sample that parents of patients with rheumatoid arthritis (RA) had an earlier age of death than control parents, we determined parental age of death in 499 patients with RA and 491 controls (381 with osteoarthritis and 110 with fibromyalgia). Patients and controls were largely white (greater than 94%) and had a mean education level greater than 12 years. Parents did not differ in survival time or age of death at the 0.05 level, but parents in our series lived 6 years longer than those studied in the lower socioeconomic community.

The overall mortality rate in patients with total hip arthroplasty, with special reference to coxarthrosis

The mortality rate was calculated in 1385 patients with total hip arthroplasties compared with the population at risk in the period from 1968 to 1981. In elderly women with coxarthrosis, after the age of 70, the mortality rate decreased after the first postoperative year. There was no such effect in men. In women, there were no changes in mortality rate in those who had had revision operations, whereas in men operated on for coxarthrosis who were over the age of 70, there was an increased mortality rate after the first postoperative year following revision. Patients operated on for complications after hip fracture and/or rheumatoid arthritis had an increased mortality rate after the first postoperative year, including both women and men below age 70.