Serum uric acid and risk of occupational disability: Findings from a cohort study of male construction workers in Germany

Objective

The role of serum uric acid (UA) as an independent risk factor for several health outcomes remains controversial. However, given the accumulating evidence that UA is related to predictors of occupational disability such as obesity, excessive alcohol consumption, hypertension, and diabetes mellitus, UA may represent a relevant risk indicator for occupational disability, which has emerged as an important public health problem.

Methods

The association between UA and occupational disability was examined in a cohort of 16,532 male construction workers in Germany who underwent occupational health examinations from 1986 to 1992 and were followed until 2005. Cox regression analysis was employed with adjustment for established risk factors.

Results

A total of 3,002 cases of disability pension occurred during the followup. Risk of all‐cause occupational disability was significantly increased for UA concentration in the top quartile (hazard ratio [HR] 1.25, 95% confidence interval [95% CI] 1.12–1.40) after adjustment for potential confounders when compared with UA levels in the lowest quartile (≤5.23 mg/dl). Cause‐specific analysis revealed a significant association between increased UA and occupational disability due to cardiovascular diseases (HR 1.62, 95% CI 1.20–2.17). In addition, positive but statistically nonsignificant associations were observed for occupational disabilities due to respiratory diseases (HR 1.78, 95% CI 0.99–3.23), musculoskeletal disorders (HR 1.16, 95% CI 0.98–1.37), diseases of the digestive system (HR 1.59, 95% CI 0.69–3.67), and mental disorders (HR 1.40, 95% CI 0.95–2.06).

Conclusion

Our study is the first to our knowledge to indicate that increased UA might also serve as a potential independent risk indicator for occupational disability, in particular due to cardiovascular diseases.

     

Prognostic factors in short‐term disability due to musculoskeletal disorders

Objective

To identify factors associated with poor outcome in temporary work disability (TWD) due to musculoskeletal disorders (MSDs).

Methods

We conducted a secondary data analysis of a 2‐year randomized controlled trial in which all patients with TWD due to MSDs in 3 health districts of Madrid (Spain) were included. Analyses refer to the patients in the intervention group. Primary outcome variables were duration of TWD and recurrence. Diagnoses, sociodemographic, work‐related administrative, and occupational factors were analyzed by Cox proportional hazards models.

Results

We studied 3,311 patients with 4,424 TWD episodes. The following were independently associated with slower return to work: age (hazard ratio [HR] 0.99, 95% confidence interval [95% CI] 0.98–0.99), female sex (HR 0.84, 95% CI 0.78–0.90), married (HR 0.90, 95% CI 0.83–0.97), peripheral osteoarthritis (HR 0.77, 95% CI 0.6–0.9), sciatica (HR 0.59, 95% CI 0.54–0.65), self‐employment (HR 0.56, 95% CI 0.48–0.65), unemployment (HR 0.41, 95% CI 0.28–0.58), manual worker (HR 0.86, 95% CI 0.79–0.94), and work position covered during sick leave (HR 0.84, 95% CI 0.77–0.92). The factors that better predicted recurrence were peripheral osteoarthritis (HR 1.75, 95% CI 1.14–2.6), inflammatory diseases (HR 1.66, 95% CI 1.009–2.72), sciatica (HR 1.30, 95% CI 1.08–1.56), indefinite work contract (HR 1.43, 95% CI 1.14–1.75), frequent kneeling (HR 1.39, 95% CI 1.15–1.69), manual worker (HR 1.19, 95% CI 1.003–1.42), and duration of previous episodes (HR 1.003, 95% CI 1.001–1.005).

Conclusion

Sociodemographic, work‐related administrative factors, diagnosis, and, to a lesser extent, occupational factors may explain the duration and recurrence of TWD related to MSD.     

Insecticide use and risk of rheumatoid arthritis and systemic lupus erythematosus in the Women's Health Initiative Observational Study

Objective

Farming and agricultural pesticide use has been associated with 2 autoimmune rheumatic diseases, rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE). However, risk associated with other residential or work place insecticide use is unknown.

Methods

We analyzed data from the Women's Health Initiative Observational Study (n = 76,861 postmenopausal women, ages 50–79 years). Incident cases (n = 213: 178 for RA, 27 for SLE, and 8 for both) were identified based on self‐report and use of disease‐modifying antirheumatic drugs at year 3 of followup. We examined self‐reported residential or work place insecticide use (personally mixing/applying by self and application by others) in relation to RA/SLE risk, overall and in relation to farm history. Hazard ratios (HRs) and 95% confidence intervals (95% CIs) were adjusted for age, race, region, education, occupation, smoking, reproductive factors, asthma, other autoimmune diseases, and comorbidities.

Results

Compared with never used, personal use of insecticides was associated with increased RA/SLE risk, with significant trends for greater frequency (HR 2.04, 95% CI 1.17–3.56 for ≥6 times/year) and duration (HR 1.97, 95% CI 1.20–3.23 for ≥20 years). Risk was also associated with long‐term insecticide application by others (HR 1.85, 95% CI 1.07–3.20 for ≥20 years) and frequent application by others among women with a farm history (HR 2.73, 95% CI 1.10–6.78 for ≥6 times/year).

Conclusion

These results suggest residential and work place insecticide exposure is associated with the risk of autoimmune rheumatic diseases in postmenopausal women. Although these findings require replication in other populations, they support a role for environmental pesticide exposure in the development of autoimmune rheumatic diseases.     

Effect of new disability subtype on 3-year mortality in Chinese older adults

OBJECTIVES: To examine a new method of classifying disability subtypes by combining self‐reported and performance‐based tools to predict mortality in older Chinese adults. DESIGN: Prospective cohort study. SETTING: Community‐dwelling older adults. PARTICIPANTS: Sixteen thousand twenty Chinese adults aged 65 and older from the Chinese Longitudinal Healthy Longevity Survey (CLHLS). MEASUREMENTS: Self‐reported activities of daily living (ADLs) and physical performance (PP) tests (chair standing, lifting a book from floor, turning 360°) cross‐classified to create mutually exclusive disability subtypes: subtype 0 (no limitations in PP or ADLs), subtype 1 (limitations in PP, no limitations in ADLs), subtype 2 (no limitations in PP, limitations in ADLs), and subtype 3 (limitations in PP and ADLs). Outcome was mortality over 3 years. RESULTS: Cox proportional hazard models, controlling for sociodemographic variables, living situation, healthcare access, social support, health status, and life‐style, showed that older adults without any limitations in ADLs or PP had significantly lower mortality risk than those with other disability subtypes and that there was a graded pattern of greater mortality according to subtype 1 (hazard ratio (HR)=1.31, 95% confidence interval (CI)=1.20–1.42), 2 (HR=1.39, 95% CI=1.23–1.59), and 3 (HR=1.88, 95% CI=1.72–2.05). When compared with the average survival curve in the cohort, subtypes of isolated performance deficits or self‐reported disability did not substantially discriminate risks of death over 3 years. CONCLUSION: Combined use of self‐reported and PP tools is necessary when screening for mutually exclusive disability subtypes that confer significantly higher or lower mortality risks on a population of older adults.     

Effectiveness of self‐management of low back pain: Systematic review with meta‐analysis

Objective

To determine the effectiveness of self‐management for nonspecific low back pain (LBP).

Methods

We performed a systematic review searching the Medline, Embase, CINAHL, PsycINFO, LILACS, PEDro, AMED, SPORTDiscus, and Cochrane databases from earliest record to April 2011. Randomized controlled trials evaluating self‐management for nonspecific LBP and assessing pain and disability were included. The PEDro scale was used to assess the methodologic quality of included trials. Data were pooled where studies were sufficiently homogenous. Analyses were conducted separately for short‐ (less than 6 months after randomization) and long‐term (at least 12 months after randomization) followup. Six criteria for self‐management were used to assess the content of the intervention.

Results

The search identified 2,325 titles, of which 13 original trials were included. Moderate‐quality evidence showed that self‐management is effective for improving pain and disability for people with LBP. The weighted mean difference at short‐term followup for pain was ?3.2 points on a 0–100 scale (95% confidence interval [95% CI] ?5.1, ?1.3) and for disability was ?2.3 points (95% CI ?3.7, ?1.0). The long‐term effects were ?4.8 (95% CI ?7.1, ?2.5) for pain and ?2.1 (95% CI ?3.6, ?0.6) for disability.

Conclusion

There is moderate‐quality evidence that self‐management has small effects on pain and disability in people with LBP. These results challenge the endorsement of self‐management in treatment guidelines.

     

Predicting depression in rheumatoid arthritis: The signal importance of pain extent and fatigue,and comorbidity

Objective

To determine the incidence of self‐reported depression (SRD) in rheumatoid arthritis and to identify and rank clinically useful predictors of depression.

Methods

We assessed 22,131 patients for SRD between 1999 and 2008. We collected demographic, clinical and treatment data, household income, employment and work disability status, comorbidity, scales for function, pain, global, and fatigue, the Regional Pain Scale (RPS), the Symptom Intensity (SI) scale (a linear combination of the RPS and the fatigue scales) and linear combinations of the Health Assessment Questionnaire, pain and global severity. We used logistic regression analyses with multivariable fractional polynomial predictors, and Random Forest analysis to determine the importance of the predictors.

Results

The cross‐sectional prevalence of self‐reported depression was 15.2% (95% confidence interval [95% CI] 14.7–15.7%) and the incidence rate was 5.5 (95% CI 5.3–5.7) per 100 patient years of observation. The cumulative risk of SRD after 9 years was 38.3% (95% CI 36.6–40.1%). Almost all variables were significant predictors in logistic models. In Random Forest analyses, the SI scale, followed by comorbidity, best predicted self‐reported depression, and no other variable or combination of variables improved prediction compared with the SI scale.

Conclusion

Pain extent and fatigue (SI scale) are the dominant predictors of SRD. These variables, also of central importance in the symptomatology of fibromyalgia, are powerful markers of distress. A strong case can be made for the inclusion of these assessments in routine rheumatology practice. In addition, actual knowledge of comorbidity provides important insights into the patient's global health and associated perceptions.     

Moderate Alcohol Intake and Risk of Functional Decline: The Health, Aging, and Body Composition Study

OBJECTIVES: To investigate the prospective relationship between alcohol consumption and incident mobility limitation. DESIGN: Cohort study. SETTING: The Health Aging and Body Composition study, conducted in Memphis, Tennessee, and Pittsburgh, Pennsylvania. PARTICIPANTS: Three thousand sixty‐one adults aged 70 to 79 without mobility disability at baseline. MEASUREMENTS: Incidence of mobility limitation, defined as self‐report at two consecutive semiannual interviews of any difficulty walking one‐quarter of a mile or climbing stairs, and incidence of mobility disability, defined as severe difficulty or inability to perform these tasks at two consecutive reports. Alcohol intake, lifestyle‐related variables, diseases, and health status indicators were assessed at baseline. RESULTS: During a follow‐up time of 6.5 years, participants consuming moderate levels of alcohol had the lowest incidence of mobility limitation (total: 6.4 per 100 person‐years (person‐years); men: 6.4 per 100 person‐years; women: 7.3 per 100 person‐years) and mobility disability (total: 2.7 per 100 person‐years; men: 2.5 per 100 person‐years; women: 2.9 per 100 person‐years). Adjusting for demographic characteristics, moderate alcohol intake was associated with lower risk of mobility limitation (hazard ratio (HR)=0.70, 95% confidence interval (CI)=0.55–0.89) and mobility disability (HR=0.66, 95% CI=0.45–0.95) than never or occasional consumption. Additional adjustment for lifestyle‐related variables substantially reduced the strength of the associations (HR=0.85, 95% CI=0.66–1.08 and HR=0.81, 95% CI=0.56–1.18, respectively). Adjustment for diseases and health status indicators did not affect the strength of the associations, suggesting that lifestyle is most important in confounding this relationship. CONCLUSION: Lifestyle‐related characteristics mainly accounted for the association between moderate alcohol intake and lower risk of functional decline over time. These findings do not support a direct causal effect of alcohol intake on physical function.     

Factors associated with restricted mobility outside the home in community‐dwelling adults ages fifty years and older with knee pain: An example of use of the International Classification of Functioning to investigate participation restriction

Objective

To investigate the links between knee pain characteristics and restricted mobility outside the home, and how these are influenced by mobility‐specific activity limitation, age, sex, socioeconomic status, environmental factors, and comorbidity.

Methods

We conducted a cross‐sectional survey of community‐dwelling adults age ≥50 years. A total of 2,252 responders reporting pain in and around the knee in the last year were eligible. The primary outcome was self‐reported restricted mobility outside the home in the previous 4 weeks (dichotomized as present or absent).

Results

Knee pain severity was strongly associated with restricted mobility outside the home, an association largely mediated by perceived limitation in walking. After adjusting for demographic and socioeconomic characteristics, individual contributions from selected comorbidities, knee pain severity, limitation in walking, and specific environmental factors remained. These environmental factors included perceived need of aids and assistance (adjusted odds ratio [OR] 3.1, 95% confidence interval [95% CI] 2.2–4.4), poor access to public transportation (adjusted OR 2.3, 95% CI 1.4–3.9), and having no access to a car (adjusted OR 1.6, 95% CI 1.1–2.4).

Conclusion

There are a range of potential health and social targets that, if addressed, might reduce restricted mobility outside the home in middle‐aged and older individuals with knee pain. Our results suggest that, in addition to treating the knee symptoms, such targets might include comorbidity, walking ability, and environmental barriers such as poor access to public transportation. Moreover, removing environmental barriers may reduce immobility outside the home even in the continued presence of osteoarthritis symptoms and specific activity limitations.     

Potentially inappropriate medication use is associated with increased risk of incident disability in healthy older adults

Background

Efforts to minimize medication risks among older adults include avoidance of potentially inappropriate medications (PIMs). However, most PIMs research has focused on older people in aged or inpatient care, creating an evidence gap for community-dwelling older adults. To address this gap, we investigated the impact of PIMs use in the ASPirin in Reducing Events in the Elderly (ASPREE) clinical trial cohort.

Methods

Analysis included 19,114 community-dwelling ASPREE participants aged 70+ years (65+ if US minorities) without major cardiovascular disease, cognitive impairment, or significant physical disability. PIMs were defined according to a modified 2019 AGS Beers Criteria. Cox proportional-hazards regression models were used to estimate the association between baseline PIMs exposure and disability-free survival, death, incident dementia, disability, and hospitalization, with adjustment for sex, age, country, years of education, frailty, average gait speed, and comorbidities.

Results

At baseline, 7396 (39% of the total) participants were prescribed at least one PIM. Compared with those unexposed, participants on a PIM at baseline were at an increased risk of persistent physical disability (adjusted hazard ratio [HR] 1.47, 95% confidence interval [CI] 1.21, 1.80) and hospitalization (adjusted HR 1.26, 95% CI 1.20, 1.32), but had similar rates of disability-free survival (adjusted HR 1.02; 95% CI 0.93, 1.13) and death (adjusted HR 0.92, 95% CI 0.81, 1.05). These effects did not vary by polypharmacy status in interaction analyses. PIMs exposure was associated with higher risk of disability followed by hospitalization (adjusted HR 1.92, 95% CI 1.25, 2.96) as well as vice versa (adjusted HR 1.54, 95% CI 1.15, 2.05). PPIs, anti-psychotics and benzodiazepines, were associated with increased risk of disability.

Conclusions

PIMs exposure is associated with subsequent increased risk of both incident disability and hospitalization. Increased risk of disability prior to hospitalization suggests that PIMs use may start the disability cascade in healthy older adults. Our findings emphasize the importance of caution when prescribing PIMs to older adults in otherwise good health.     

Correlates of Use and Perceived Effectiveness of Non-pharmacologic Strategies for Chronic Pain Among Patients Prescribed Long-term Opioid Therapy

Objective

Non-pharmacologic treatments (NPTs) are recommended for chronic pain. Information is limited on patient use or perceptions of NPTs. We examined the frequency and correlates of use and self-rated helpfulness of NPTs for chronic pain among patients who are prescribed long-term opioid therapy (LTOT).

Methods

Participants (n?=?517) with musculoskeletal pain who were prescribed LTOT were recruited from two integrated health systems. They rated the frequency and utility of six clinician-directed and five self-directed NPTs for chronic pain. We categorized NPT use at four levels based on number of interventions used and frequency of use (none, low, moderate, high). Analyses examined clinical and demographic factors that differed among groups for both clinician-directed and self-directed NPTs.

Results

Seventy-one percent of participants reported use of any NPT for pain within the prior 6 months. NPTs were rated as being helpful by more than 50% of users for all treatments assessed (range 51–79%). High users of clinician-directed NPTs were younger than non-users or low-frequency users and had the most depressive symptoms. In both clinician-directed and self-directed categories, high NPT users had significantly higher pain disability compared to non-NPT users. No significant group differences were detected on other demographic or clinical variables. In multivariable analyses, clinician-directed NPT use was modestly associated with younger age (OR?=?0.97, 95% CI?=?0.96–0.98) and higher pain disability (OR?=?1.01, 95% CI?=?1.00–1.02). Variables associated with greater self-directed NPT use were some college education (OR?=?1.80, 95% CI?=?1.13–2.84), college graduate or more (OR?=?2.02, 95% CI?=?1.20–3.40), and higher pain disability (OR?=?1.01, 95% CI?=?1.01–1.02).

Conclusions

NPT use was associated with higher pain disability and younger age for both clinician-directed and self-directed NPTs and higher education for self-directed NPTs. These strategies were rated as helpful by those that used them. These results can inform intervention implementation and be used to increase engagement in NPTs for chronic pain.

     

Benzodiazepine use and physical disability in community-dwelling older adults

OBJECTIVES: To determine whether benzodiazepine use is associated with incident disability in mobility and activities of daily living (ADLs) in older individuals. DESIGN: A prospective cohort study. SETTING: Four sites of the Established Populations for Epidemiologic Studies of the Elderly. PARTICIPANTS: This study included 9,093 subjects (aged > or =65) who were not disabled in mobility or ADLs at baseline. MEASUREMENTS: Mobility disability was defined as inability to walk half a mile or climb one flight of stairs. ADL disability was defined as inability to perform one or more basic ADLs (bathing, eating, dressing, transferring from a bed to a chair, using the toilet, or walking across a small room). Trained interviewers assessed outcomes annually. RESULTS: At baseline, 5.5% of subjects reported benzodiazepine use. In multivariable models, benzodiazepine users were 1.23 times as likely as nonusers (95% confidence interval (CI) = 1.09-1.39) to develop mobility disability and 1.28 times as likely (95% CI = 1.09-1.52) to develop ADL disability. Risk for incident mobility was increased with short- (hazard ratio (HR) = 1.27, 95% CI = 1.08-1.50) and long-acting benzodiazepines (HR = 1.20, 95% CI = 1.03-1.39) and no use. Risk for ADL disability was greater with short- (HR = 1.58, 95% CI = 1.25-2.01) but not long-acting (HR = 1.11, 95% CI = 0.89-1.39) agents than for no use. CONCLUSION: Older adults taking benzodiazepines have a greater risk for incident mobility and ADL disability. Use of short-acting agents does not appear to confer any safety benefits over long-acting agents.     

Smoking status on outcomes after percutaneous coronary intervention

Background:

The effect of smoking on prognosis among patients undergoing percutaneous coronary intervention (PCI) is controversial, and data on the importance of smoking cessation or reductions were lacking.

Hypothesis:

Smoking cessation or reductions could reduce the risk of adverse outcomes in patient after PCI.

Methods:

There were 19 506 consecutive patients who had undergone successful PCI between April 2004 and January 2010 followed. Extensive data, including self‐reported smoking habits, were obtained at baseline and during follow‐up.

Results:

Compared with post‐PCI quitters and persistent smokers, the nonsmokers and pre‐PCI quitters were older and had a higher prevalence of comorbid factors such as hypertension and impaired left ventricle function. The adjusted hazard ratios for mortality were 2.52 (95% confidence interval [CI]: 1.92–3.30) for nonsmokers, 0.52 (95% CI: 0.32–0.84) for pre‐PCI quitters, and 0.11 (95% CI: 0.06–0.22) for post‐PCI quitters, compared to persistent smokers. With respect to additional revascularizations, a higher risk was observed among the quitters (1.70 [95% CI: 1.40–2.08] for pre‐PCI quitters and 1.59 [95% CI: 1.36–1.85] for post‐PCI quitters) as well as the nonsmokers (1.40 [95% CI: 1.20–1.64]). Among persistent smokers, each reduction of 5 cigarettes/day was associated with a 72% decline in mortality risk (P < 0.001) but did not reach statistical significant for repeated revascularizations (0.80 [95% CI: 0.46–1.37], P = 0.4132).

Conclusions:

Despite a higher risk of revascularization, the cessation of smoking either before or after PCI is beneficial in all‐cause mortality. The apparent smoker's paradox may be explained by the differences in baseline risk or the reduced sensitivity to adverse outcomes as well as the reluctance to seek medical help among smokers. This study received an unrestricted grant from Pfizer Investment Co., China. The authors have no other funding, financial relationships, or conflicts of interest to disclose.     

Chronic upper extremity pain and co‐occurring symptoms in a general population

Objective

To estimate the prevalence of self reported chronic upper extremity pain associated with physical impairment in a general population, and its co‐occurrence with chronic upper extremity numbness or tingling and chronic pain at other locations.

Methods

A general health questionnaire was mailed to 3,000 persons (age 25–74 years) who were randomly selected from a general population register.

Results

The response rate was 83%. The prevalence of chronic upper extremity pain associated with physical impairment was 20.8% (95% confidence interval [95% CI] 19.2–22.5), and that of co‐occurring numbness or tingling was 6.7% (95% CI 5.7–7.7). Among the responders with chronic upper extremity pain associated with physical impairment, 84% reported more than 1 painful area.

Conclusion

Chronic upper extremity pain associated with physical impairment and co‐occurring chronic upper extremity numbness or tingling were common in the general population. The presence of more than 1 location for pain in the upper extremity as well as in other parts of the body was frequent.

     

Arthritis self‐management education programs: A meta‐analysis of the effect on pain and disability

Objective

Some reports suggest that education programs help arthritis patients better manage their symptoms and improve function. This review of the published literature was undertaken to assess the effect of such programs on pain and disability.

Methods

Medline and HealthSTAR were searched for the period 1964–1998. The references of each article were then hand‐searched for further publications. Studies were included in the meta‐analysis if the intervention contained a self‐management education component, a concurrent control group was included, and pain and/or disability were assessed as end points. Two authors reviewed each study. The methodologic attributes and efficacy of the interventions were assessed using a standardized abstraction tool, and the magnitude of the results was converted to a common measure, the effect size. Summary effect sizes were calculated separately for pain and disability.

Results

The search strategy yielded 35 studies, of which 17 met inclusion criteria. The mean age of study participants was 61 years, and 69% were female. On average, 19% of patients did not complete followup (range 0–53%). The summary effect size was 0.12 for pain (95% confidence interval [95% CI] 0.00, 0.24) and 0.07 for disability (95% CI 0.00, 0.15). Funnel plots indicated no significant evidence of bias toward the publication of studies with findings that showed reductions in pain or disability.

Conclusion

The summary effect sizes suggest that arthritis self‐management education programs result in small reductions in pain and disability.

     

Pain and Mortality in Older Adults: The Influence of Pain Phenotype

Objective

Moderate to severe chronic pain affects 1 in 5 adults. Pain may increase the risk of mortality, but the relationship is unclear. This study investigated whether mortality risk was influenced by pain phenotype, characterized by pain extent or pain impact on daily life.

Methods

The study population was drawn from 2 large population cohorts of adults ages ≥50 years, the English Longitudinal Study of Ageing (n = 6,324) and the North Staffordshire Osteoarthritis Project (n = 10,985). Survival analyses (Cox's proportional hazard models) estimated the risk of mortality in participants reporting any pain and then separately according to the extent of pain (total number of pain sites, widespread pain according to the American College of Rheumatology [ACR] criteria, and widespread pain according to Manchester criteria) and pain impact on daily life (pain interference and often troubled with pain). Models were cumulatively adjusted for age, sex, education, and wealth/adequacy of income.

Results

After adjustments, the report of any pain (mortality rate ratio [MRR] 1.06 [95% confidence interval (95% CI) 0.95–1.19]) or having widespread pain (ACR 1.07 [95% CI 0.92–1.23] or Manchester 1.16 [95% CI 0.99–1.36]) was not associated with an increased risk of mortality. Participants who were often troubled with pain (MRR 1.29 [95% CI 1.12–1.49]) and those who reported quite a bit of pain interference (MRR 1.38 [95% CI 1.20–1.59]) and extreme pain interference (MRR 1.88 [1.54–2.29]) had an increased risk of all‐cause mortality.

Conclusion

Pain that interferes with daily life, rather than pain per se, was associated with an increased risk of mortality. Future studies should investigate the mechanisms through which pain increases mortality risk.

     

Relationship between obesity and foot pain and its association with fat mass, fat distribution, and muscle mass

Objective

To examine the relationship between obesity, body composition, and foot pain as assessed by the Manchester Foot Pain and Disability Index (MFPDI).

Methods

Subjects 25–62 years of age (n = 136) were recruited as part of a study examining the relationship between obesity and musculoskeletal health. Foot pain was defined as current foot pain and pain in the last month, and an MFPDI score of ≥1. Body composition (tissue mass and fat distribution) was measured using dual x‐ray absorptiometry.

Results

The body mass index (BMI) in this population was normally distributed around a mean of 32.1 kg/m². The prevalence of foot pain was 55.1%. There was a positive association between BMI and foot pain (odds ratio [OR] 1.11, 95% confidence interval [95% CI] 1.06–1.17). Foot pain was also positively associated with fat mass (OR 1.05, 95% CI 1.02–1.09) and fat mass index (FMI; OR 1.16, 95% CI 1.06–1.28) when adjusted for age, sex, and skeletal muscle mass and age, sex, and fat‐free mass index (FFMI), respectively. When examining fat distribution, positive associations were observed for android/total body fat ratio (OR 1.42, 95% CI 1.11–1.83) and android/gynoid fat ratio (OR 35.15, 95% CI 2.60–475.47), although gynoid/total body fat ratio was inversely related to foot pain (OR 0.83, 95% CI 0.73–0.93). Skeletal muscle mass and FFMI were not associated with foot pain when adjusted for fat mass or FMI, respectively.

Conclusion

Increasing BMI, specifically android fat mass, is strongly associated with foot pain and disability. This may imply both biomechanical and metabolic mechanisms.     

Reduction of long-term disability in inflammatory polyarthritis by early and persistent suppression of joint inflammation: results from the Norfolk Arthritis Register

Objective

To test the predictive ability of remission in terms of long‐term disability in patients with recent‐onset inflammatory polyarthritis (IP).

Methods

Consecutive patients with early IP, recruited between 1990 and 1994 (first cohort) and 2000 and 2004 (second cohort), were included in this study. Remission was defined as the absence of clinically detectable joint inflammation on a 51–joint count. In additional analyses, less stringent definitions of remission were used based on the 40– and 28–joint counts. Remission was assessed at 1, 2, and 3 years after inclusion. A 5‐year Health Assessment Questionnaire score ≥1 (moderate disability) was chosen as the primary outcome measure.

Results

A total of 841 and 498 patients from the first and second cohorts, respectively, completed 5 years of followup. In the first cohort, patients with at least 1 episode of remission had lower odds of 5‐year disability (odds ratio [OR] 0.26, 95% confidence interval [95% CI] 0.17–0.41). The number of times in remission correlated with the odds of disability, with a mean decrease in the probability of disability of ～64% for each additional time point in remission (OR 0.38, 95% CI 0.28–0.52). The time until first remission was not associated with functional disability. Remission according to less stringent criteria showed a weaker protection against future disability. Similar results were found in the second cohort.

Conclusion

Patients with IP achieving a state of sustained remission early are less likely to show long‐term deterioration of function compared with patients who do not achieve remission. The most persistent remission under the most stringent definition of remission has the lowest probability of long‐term disability.     

Association of the Charlson comorbidity index with mortality in systemic lupus erythematosus

Objective

To investigate whether comorbidity as assessed by the Charlson Comorbidity Index (CCI) is associated with mortality in a long‐term followup of systemic lupus erythematosus (SLE) patients.

Methods

Data were collected from 499 SLE patients attending the Lupus Clinic at the McGill University Health Center, Montreal, Quebec, Canada, and 170 SLE patients from the Department of Rheumatology at Lund University Hospital, Lund, Sweden. This included data on comorbidity, demographics, disease activity, the Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index (SDI), and antiphospholipid antibody syndrome (APS). Variables were entered into a Cox proportional hazards survival model.

Results

Mortality risk in the Montreal cohort was associated with the CCI (hazard ratio [HR] 1.57 per unit increase in the CCI, 95% confidence interval [95% CI] 1.18–2.09) and age (HR 1.04 per year increase in age, 95% CI 1.00–1.09). The CCI and age at diagnosis were also associated with mortality in the Lund cohort (CCI: HR 1.35, 95% CI 1.13–1.60; age: HR 1.09, 95% CI 1.05–1.12). Furthermore, the SDI was associated with mortality in the Lund cohort (HR 1.40, 95% CI 1.19–1.64), while a wide CI for the estimate in the Montreal cohort prevented a definitive conclusion (HR 1.20, 95% CI 0.97–1.48). We did not find a strong association between mortality and sex, race/ethnicity, disease activity, or APS in either cohort.

Conclusion

In this study, comorbidity as measured by the CCI was associated with decreased survival independent of age, lupus disease activity, and damage. This suggests that the CCI may be useful in capturing comorbidity for clinical research in SLE.     

The importance of proteinuria and prior cardiovascular disease in all major clinical outcomes of atherosclerotic renovascular disease – a single-center observational study

Background

Identification of patients at risk of developing adverse events would enable aggressive medical therapy and possibly targeted revascularization. The aim of this study is to characterize the determinants of long-term outcomes in atherosclerotic renovascular disease (ARVD).

Methods

Patients with a radiological diagnosis of ARVD were recruited into this single-center prospective cohort study between 1986 and 2014. Data collected included baseline co-morbid conditions, annualized prescribed medications and laboratory data (serum creatinine [υmol/L], proteinuria [g/24 h]). Multivariable Cox regression analysis was used to explore association with these end-points: death, end-stage kidney disease (ESKD), cardiovascular event (CVE) and the first of any of these events.

Results

A total of 872 patients were recruited into this study. However, 42 patients were excluded due to missing baseline data and hence case records for 830 patients were reviewed. Over median follow-up of 57.1 months (interquartile range: 21.7–96.9), incidence per 100 patient years of death, ESKD, CVE and any event was 13.5, 4.2, 8.9 and 21.0 respectively. Macrovascular disease (MVD), congestive heart failure (CHF), flash pulmonary oedema (FPE) and greater proteinuria at baseline were individually associated with increased risk for all end-points in multivariable analysis (Death: MVD –HR 1.24 [95% CI 1.02–1.50]; CHF –HR 1.33 [95% CI 1.08–1.64]; FPE – HR 2.10 [95% CI 1.50–2.92]; proteinuria – HR 1.14 [95% CI 1.08–1.20]). Higher estimated glomerular filtration rate at time of diagnosis was significantly associated with reduced risk of all end-points (Death: HR 0.92 [95% CI 0.89–0.94])., Administration of statins and renin angiotensin blockade (RAB) at baseline were also associated with reduced adverse events, especially death (RAB: HR 0.83 [95% CI 0.70–0.98]; statins: HR 0.79 [95% CI 0.66–.94]) and ESKD (RAB: HR 0.84 [95% CI 0.71–1.00]; statins: HR 0.79 [95% CI 0.66–0.93]). Revascularization was associated with reduced risk of death (HR 0.65 [95% CI 0.51–0.83]) and ESKD (HR 0.59 [95% CI 0.46–0.76]).

Conclusion

All patients with ARVD require intensive vascular protection therapy to help mitigate systemic atherosclerosis, optimize cardiovascular risk and improve clinical outcomes. More effort is required to identify the minority of patients who may benefit from revascularization.

     

Association of a rheumatoid arthritis susceptibility variant at the CCL21 locus with premature mortality in inflammatory polyarthritis patients

Objective

To investigate whether recently identified rheumatoid arthritis (RA) susceptibility loci are also associated with disease severity, specifically all‐cause and cardiovascular disease (CVD) mortality, in patients with inflammatory polyarthritis (IP).

Methods

Subjects with recent‐onset IP were recruited from the Norfolk Arthritis Register. Seventeen RA susceptibility single‐nucleotide polymorphisms (SNPs) were tested using Sequenom MassArray iPLEX chemistry. Vital status was ascertained from central records. The association of SNP allele carriage with mortality risk was assessed using Cox proportional hazards models after adjusting by sex. The mortality risks of those SNP alleles found to be associated were then stratified by baseline anti–citrullinated peptide (anti‐CCP) antibody and shared epitope (SE) status.

Results

All SNPs were successfully genotyped in 2,324 IP subjects. The presence of 2 copies of the risk allele rs2812378 mapping to the CCL21 gene predicted all‐cause mortality (hazard ratio [HR] 1.40, 95% confidence interval [95% CI] 1.04–1.87), whereas risk allele carriage also predicted increased CVD mortality (HR 1.33, 95% CI 1.01–1.75). The highest mortality risks were seen in anti‐CCP antibody–positive subjects with 2 copies of the CCL21 risk alleles and 2 copies of the SE (all‐cause HR 3.20, 95% CI 1.52–6.72; CVD HR 3.73, 95% CI 1.30–10.72).

Conclusion

In this large study, we found that carriage of CCL21 risk alleles was associated with premature mortality in IP independently of anti‐CCP antibody and SE status. Interestingly, CCL21 expression has been reported in atherosclerotic plaques supporting the thesis that the increased CVD mortality in IP patients may be mediated by shared inflammatory mechanisms.