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issn:2151-464
1.  Measures of Knee Function 
Arthritis care & research  2011;63(0 11):S208-S228.
doi:10.1002/acr.20632
PMCID: PMC4336550  PMID: 22588746
3.  [No title available] 
PMCID: PMC3946810  PMID: 24022862
4.  [No title available] 
PMCID: PMC4072663  PMID: 23926094
5.  Meeting Physical Activity Guidelines and the Risk of Incident Knee Osteoarthritis: The Johnston County Osteoarthritis Project 
Arthritis care & research  2014;66(1):139-146.
Objective
Knee osteoarthritis (OA) remains a leading cause of disability and joint pain. Though other risk factors of knee OA have been identified, how physical activity affects incident knee OA remains unclear.
Methods
Using data from the Johnston County Osteoarthritis Project study’s first (1999–2004) and second follow-up (2005–2010), we tested the association between meeting physical activity guidelines and incident knee outcomes among 1522 adults aged ≥ 45 years. The median (range) follow-up time was 6.5 (4.0–10.2) years. Physical activity at baseline (moderate-equivalent min/week) was calculated using the Minnesota Leisure Time Physical Activity questionnaire. Incident knee radiographic OA (ROA) was defined as the development of a Kellgren-Lawrence grade of ≥ 2 in a knee at follow-up. Incident knee symptomatic ROA (sROA) was defined as the development of ROA and symptoms in at least one knee at follow-up. Weibull regression modeling was used to estimate hazard ratios (HR) and 95% confidence intervals (CI) for interval censored data.
Results
In multivariable models, meeting the 2008 HHS physical activity guidelines (≥150 min/week) was not significantly associated with ROA (HR: 1.20; 95% CI=0.94, 1.56) or sROA (HR: 1.24; 95% CI=0.87, 1.76). Adults in the highest (≥300 min/week) level of physical activity had a higher risk of knee ROA and sROA compared with inactive (0-<10 min/week) participants; however these associations were not statistically significant (HR: 1.62; 95% CI=0.97, 2.68 and HR: 1.42; 95% CI=0.76, 2.65, respectively).
Conclusion
Meeting HHS physical activity guidelines was not associated with incident knee ROA or sROA in a cohort of middle-aged and older adults.
doi:10.1002/acr.22120
PMCID: PMC4309362  PMID: 23983187
physical activity; radiographic and symptomatic knee osteoarthritis; incidence; Weibull regression modeling; interval censoring
6.  Incident symptomatic hip osteoarthritis is associated with differences in hip shape by active shape modeling 
Arthritis care & research  2014;66(1):74-81.
Objective
To investigate hip shape by active shape modeling (ASM) as a potential predictor of incident radiographic and symptomatic hip OA (rHOA and srHOA).
Methods
All hips developing rHOA from baseline (Kellgren-Lawrence [KL] grade 0/1) to mean 6 year follow up (KL ≥2, 190 hips), and 1:1 control hips (KLG 0/1 at both times, 192 hips) were included. Proximal femur shape was defined on baseline AP pelvis radiographs and submitted to ASM, producing a mean shape and continuous variables representing independent modes of shape variation. Mode scores (n=14, explaining 95% of shape variance) were simultaneously included in logistic regression models, with incident rHOA and srHOA as dependent variables, adjusted for intra-person correlations, sex, race, body mass index (BMI), baseline KL and/or symptoms.
Results
We evaluated 382 hips from 342 individuals: 61% women, 83% white, with mean age 62 years and BMI 29 kg/m2. Several modes differed by sex and race, but no modes were associated with incident rHOA overall. Among men only, modes 1 and 2 were significantly associated (for a 1-SD decrease in mode 1 score, OR 1.7 [95% CI 1.1, 2.5], and for a 1-SD increase in mode 2 score, OR 1.5 [95% CI 1.0, 2.2]) with incident rHOA. A 1-SD decrease in mode 2 or 3 score increased the odds of srHOA by 50%.
Conclusion
This study confirms other reports that variations in proximal femur shape have a modest association with incident hip OA. The observation of proximal femur shape associations with hip symptoms requires further investigation.
doi:10.1002/acr.22094
PMCID: PMC3959908  PMID: 23926053
7.  Variations among Primary Care Physicians in Exercise Advice, Imaging, and Analgesics for Musculoskeletal Pain: Results from a Factorial Experiment 
Arthritis care & research  2014;66(1):147-156.
Objective
To examine whether medical decisions regarding evaluation and management of musculoskeletal pain conditions varied systematically by characteristics of the patient or provider.
Methods
We conducted a balanced factorial experiment among primary care physicians in the U.S. Physicians (N=192) viewed two videos of different patients (actors) presenting with pain: (1) undiagnosed sciatica symptoms or (2) diagnosed knee osteoarthritis. Systematic variations in patient gender, socioeconomic status (SES), race, physician gender and experience (<20 vs. ≥20 years in practice) permitted estimation of unconfounded effects. Analysis of variance was used to evaluate associations between patient or provider attributes and clinical decisions. Quality of decisions was defined based on the current recommendations of the ACR, American Pain Society, and clinical expert consensus.
Results
Despite current recommendations, under one-third of physicians would provide exercise advice (30.2% for osteoarthritis, 32.8% for sciatica). Physicians with fewer years in practice were more likely to provide advice on lifestyle changes, particularly exercise (P<0.01), and to prescribe NSAIDs for pain relief, both of which were appropriate and consistent with current recommendations for care. Newer physicians ordered fewer tests, particularly basic laboratory investigations or urinalysis. Test ordering decreased as organizational emphasis on business or profits increased. Patient factors and physician gender had no consistent effects on pain evaluation or treatment.
Conclusion
Physician education on disease management recommendations regarding exercise and analgesics, and implementation of quality measures may be useful, particularly for physicians with more years in practice.
doi:10.1002/acr.22143
PMCID: PMC4067704  PMID: 24376249
8.  Risk Factors for Early Revision after Total Hip Arthroplasty 
Arthritis care & research  2014;66(6):907-915.
Objective
Revision total hip arthroplasty (THA) is associated with increased cost, morbidity, and technical challenge compared to primary THA. A better understanding of the risk factors for early revision is needed to inform strategies to optimize patient outcomes.
Methods
207,256 patients who underwent primary THA between 1997–2005 in California and New York were identified from statewide databases. Unique patient identifiers were used to identify early revision THA (<10 years from index procedure). Patient characteristics (demographics, comorbidities, insurance type, preoperative diagnosis), community characteristics (education level, poverty, population density), and hospital characteristics (annual THA volume, bed size, teaching status) were evaluated using multivariable regression to determine risk factors for early revision.
Results
The probabilities of undergoing early aseptic revision and early septic revision were 4% and less than 1% at 5 years, respectively. Women were 29% less likely than men to undergo early septic revision (p<0.001). Patients with Medicaid and Medicare were 91% and 24%, respectively, more likely to undergo early septic revision than privately-insured patients (p=0.01; p<0.001). Hospitals performing <200 THA annually had a 34% increased risk of early aseptic revision compared to hospitals performing >400 THA annually (p<0.001).
Conclusion
A number of identifiable factors, including younger age, Medicaid, and low hospital volume increase the risk of undergoing early revision THA. Patient-level characteristics distinctly affect the risk of revision within 10 years, particularly if due to infection. Our findings reinforce the need for continued investigation of the predictors of early failure following THA.
doi:10.1002/acr.22240
PMCID: PMC4269321  PMID: 24285406
9.  Lipid and lipoprotein levels and trends in rheumatoid arthritis compared to the general population 
Arthritis care & research  2013;65(12):2046-2050.
Objectives
Differences in lipid levels associated with cardiovascular (CV) risk between rheumatoid arthritis (RA) and the general population remain unclear. Determining these differences is important in understanding the role of lipids in CV risk in RA.
Methods
We studied 2,005 RA subjects from two large academic medical centers. We extracted electronic medical record (EMR) data on the first low density lipoprotein (LDL), total cholesterol (TChol) and high density lipoprotein (HDL) within 1 year of the LDL. Subjects with an electronic statin prescription prior to the first LDL were excluded.
We compared lipid levels in RA to levels from the general United States population (Carroll, et al., JAMA 2012), using the t-test and stratifying by published parameters, i.e. 2007–2010, women. We determined lipid trends using separate linear regression models for TChol, LDL and HDL, testing the association between year of measurement (1989–2010) and lipid level, adjusted by age and gender. Lipid trends were qualitatively compared to those reported in Carroll, et al.
Results
Women with RA had a significantly lower Tchol (186 vs 200mg/dL, p=0.002) and LDL (105 vs 118mg/dL, p=0.001) compared to the general population (2007–2010). HDL was not significantly different in the two groups. In the RA cohort, Tchol and LDL significantly decreased each year, while HDL increased (all with p<0.0001), consistent with overall trends observed in Carroll, et al.
Conclusion
RA patients appear to have an overall lower Tchol and LDL than the general population, despite the general overall risk of CVD in RA from observational studies.
doi:10.1002/acr.22091
PMCID: PMC4060244  PMID: 23925980
10.  Planus Foot Posture and Pronated Foot Function are Associated with Foot Pain: The Framingham Foot Study 
Arthritis care & research  2013;65(12):1991-1999.
Objective
To examine the associations of foot posture and foot function to foot pain.
Methods
Data were collected on 3,378 members of the Framingham Study who completed foot examinations in 2002–2008. Foot pain (generalized and at six locations) was based on the response to the question “On most days, do you have pain, aching or stiffness in either foot?” Foot posture was categorized as normal, planus or cavus using static pressure measurements of the arch index. Foot function was categorized as normal, pronated or supinated using the center of pressure excursion index from dynamic pressure measurements. Sex-specific multivariate logistic regression models were used to examine the effect of foot posture and function on generalized and location-specific foot pain, adjusting for age and weight.
Results
Planus foot posture was significantly associated with an increased likelihood of arch pain in men (odds ratio [OR] 1.38, 95% confidence interval [CI] 1.01 – 1.90), while cavus foot posture was protective against ball of foot pain (OR 0.74, 95% CI 0.55 – 1.00) and arch pain (OR 0.64, 95% CI 0.48 – 0.85) in women. Pronated foot function was significantly associated with an increased likelihood of generalized foot pain (OR 1.28, 95% CI 1.04 – 1.56) and heel pain (OR 1.54, 95% CI 1.04 – 2.27) in men, while supinated foot function was protective against hindfoot pain in women (OR 0.74, 95% CI 0.55 – 1.00).
Conclusion
Planus foot posture and pronated foot function are associated with foot symptoms. Interventions that modify abnormal foot posture and function may therefore have a role in the prevention and treatment of foot pain.
doi:10.1002/acr.22079
PMCID: PMC4089968  PMID: 23861176
11.  Clinical and health care use characteristics of patients newly prescribed allopurinol, febuxostat and colchicine for gout 
Arthritis care & research  2013;65(12):2008-2014.
Background
Gout is a common inflammatory arthritis with the increasing prevalence in the developed countries. It is well-known that many patients with gout have significant comorbidities and high health care utilization.
Methods
Using US insurance claims data (2009–2011), a population-based cohort study was conducted to describe clinical characteristics and health care utilization patterns in patients with gout newly prescribed allopurinol, febuxostat or colchicine.
Results
There were 25,051 allopurinol, 4,288 febuxostat and 6,238 colchicine initiators. Mean age was 53 years and 83%–87% were male. More than half of patients had hypertension and hyperlipidemia, 20% had diabetes and 10% cardiovascular disease. The mean uric acid level (mg/dl) was similar at baseline ranging from 8.1 to 8.5 across the groups. Compared to allopurinol or colchicine initiators, febuxostat initiators had more comorbidities and greater health care uses including outpatient, inpatient or emergency room visits, both at baseline and during the follow-up. Use of gout related drugs, such as opioids, steroids and non-steroidal anti-inflammatory drugs, was most common in febuxostat and least common in colchicine initiators. The median daily dose at both start and end of treatment was 300mg for allopurinol, 40mg for febuxostat, and 1.2mg for colchicine. The dosage of allopurinol and febuxostat was rarely increased during the follow-up.
Conclusion
Patients who started allopurinol, febuxostat or colchicine for gout generally had hyperuricemia and multiple comorbidities. Febuxostat initiators had more comorbidities and greater use of health care resources and gout-related drugs than other groups. Overall, the dosages of allopurinol or febuxostat remained unchanged over time.
doi:10.1002/acr.22067
PMCID: PMC4096791  PMID: 23861232
gout; allopurinol; febuxostat; colchicine
12.  Who Makes It to the Base? Selection Procedure for a Physical Activity Trial Targeting People With Rheumatoid Arthritis 
Arthritis Care & Research  2014;66(5):662-670.
Objective
To compare those who were finally included in a large well-defined sample of individuals with rheumatoid arthritis (RA) at target for a physical activity (PA) trial with those who were not.
Methods
In total, 3,152 individuals answered questionnaires on sociodemographic, disease-related, and psychosocial factors and PA levels. The differences between individuals making it to the baseline assessments and those who did not were analyzed in 3 steps.
Results
In a first step, 1,932 individuals were eligible for the trial if they were interested in participating, not physically active enough, and fluent in Swedish and if they were not participating in any other study. The participants were mainly younger women, had higher education and income, were more likely to live with children, and had better support for exercise and had higher outcome expectations of PA than the 1,208 ineligible individuals. In a second step, the 286 individuals accepting participation had higher income and education, more support for exercise, less fear-avoidance beliefs, and higher outcome expectations of PA than the 1,646 individuals declining participation. In a third step, the 244 individuals assessed at baseline reported less fatigue than the 42 withdrawing before assessment.
Conclusion
To our knowledge, this is the first study describing the entire selection procedure, from a target sample for a PA trial to the sample assessed at baseline, in individuals with RA. Factors other than those related to the disease seemed to mainly determine participation and largely resembled determinants in the general population. Sociodemographic and psychosocial factors should be recognized as important for PA in people with RA.
doi:10.1002/acr.22189
PMCID: PMC4227591  PMID: 24124063
13.  “Somebody to Say ‘Come On We Can Sort This’”: A Qualitative Study of Primary Care Consultation Among Older Adults With Symptomatic Foot Osteoarthritis 
Arthritis Care & Research  2013;65(12):2051-2055.
Objective
To examine the experiences of primary care consultation among older adults with symptomatic foot osteoarthritis (OA).
Methods
Eleven participants (6 women and 5 men) ages 56–80 years who had radiographically confirmed symptomatic foot OA and consulted a general practitioner in the last 12 months for foot pain were purposively sampled. Semistructured interviews explored the nature of the foot problem, help-seeking behaviors, and consultation experiences. Verbatim transcripts were analyzed using interpretative phenomenological analysis.
Results
The decision to consult a physician was often the outcome of a complex process influenced by quantitative and qualitative changes in symptoms, difficulty maintaining day-to-day roles and responsibilities and the effect this had on family and work colleagues, and a reluctance to present a fragile or aging self to the outside world. Self-management was commonly negotiated alongside multimorbidities. Upon seeking help, participants often believed they received limited information, they were given a brief or even cursory assessment, and that treatment was focused on the prescription of analgesic drugs.
Conclusion
This is the first qualitative study of primary care experiences among patients with symptomatic foot OA. The experience of primary care seldom appeared to move beyond a label of arthritis and an unwelcome emphasis on pharmacologic treatment.
doi:10.1002/acr.22073
PMCID: PMC4225467  PMID: 23861315
14.  Phase III Study of the Efficacy and Safety of Subcutaneous Versus Intravenous Tocilizumab Monotherapy in Patients With Rheumatoid Arthritis 
Arthritis Care & Research  2014;66(3):344-354.
Objective
To evaluate the efficacious noninferiority of subcutaneous tocilizumab injection (TCZ-SC) monotherapy to intravenous TCZ infusion (TCZ-IV) monotherapy in Japanese patients with rheumatoid arthritis (RA) with an inadequate response to synthetic and/or biologic disease-modifying antirheumatic drugs (DMARDs).
Methods
This study had a double-blind, parallel-group, double-dummy, comparative phase III design. Patients were randomized to receive TCZ-SC 162 mg every 2 weeks or TCZ-IV 8 mg/kg every 4 weeks; no DMARDs were allowed during the study. The primary end point was to evaluate the noninferiority of TCZ-SC to TCZ-IV regarding the American College of Rheumatology criteria for 20% improvement in disease activity (ACR20) response rates at week 24 using an 18% noninferiority margin. Additional efficacy, safety, pharmacokinetic, and immunogenicity parameters were assessed.
Results
At week 24, ACR20 response was achieved in 79.2% (95% confidence interval [95% CI] 72.9, 85.5) of the TCZ-SC group and in 88.5% (95% CI 83.4, 93.5) of the TCZ-IV group; the weighted difference was −9.4% (95% CI −17.6, −1.2), confirming the noninferiority of TCZ-SC to TCZ-IV. Remission rates of the Disease Activity Score in 28 joints using the erythrocyte sedimentation rate and the Clinical Disease Activity Index at week 24 were 49.7% and 16.4% in the TCZ-SC group and 62.2% and 23.1% in the TCZ-IV group, respectively. Serum trough TCZ concentrations were similar between the groups over time. Incidences of all adverse events and serious adverse events were 89.0% and 7.5% in the TCZ-SC group and 90.8% and 5.8% in the TCZ-IV group, respectively. Anti-TCZ antibodies were detected in 3.5% of the TCZ-SC group; no serious hypersensitivity was reported in these patients.
Conclusion
TCZ-SC monotherapy demonstrated comparable efficacy and safety to TCZ-IV monotherapy. TCZ-SC could provide additional treatment options for patients with RA.
doi:10.1002/acr.22110
PMCID: PMC4225471  PMID: 23983039
15.  Mortality Trends in Patients With Early Rheumatoid Arthritis Over 20 Years: Results From the Norfolk Arthritis Register 
Arthritis Care & Research  2014;66(9):1296-1301.
Objective
To examine mortality rates in UK patients with early rheumatoid arthritis (RA) from 1990–2011 and compare with population trends.
Methods
The Norfolk Arthritis Register (NOAR) recruited adults with ≥2 swollen joints for ≥4 weeks: cohort 1 (1990–1994), cohort 2 (1995–1999), and cohort 3 (2000–2004). At baseline, serum rheumatoid factor and anti–citrullinated protein antibody were measured and the 2010 American College of Rheumatology/European League Against Rheumatism RA classification criteria were applied. Patients were followed for 7 years, until emigration or death. The UK Office for National Statistics notified the NOAR of the date and cause of deaths, and provided mortality rates for the Norfolk population. All-cause and cardiovascular-specific standardized mortality ratios (SMRs) were calculated. Poisson regression was used to compare mortality rate ratios (MRRs) between cohorts and then, with cubic splines, to model rates by calendar year. Analyses were performed in patients 1) with early inflammatory arthritis, 2) classified as having RA, and 3) autoantibody positive.
Results
A total of 2,517 patients were included, with 1,639 women (65%) and median age 55 years, and 1,419 (56%) fulfilled the 2010 RA criteria. All-cause and cardiovascular-specific SMRs were significantly elevated in the antibody-positive groups. There was no change in mortality rates over time after accounting for changes in the population rates. In RA patients, all-cause MRRs, compared to cohort 1, were 1.13 (95% confidence interval [95% CI] 0.84–1.52) and 1.00 (95% CI 0.70–1.43) in cohorts 2 and 3, respectively.
Conclusion
Mortality rates were increased in patients with RA and SMRs were particularly elevated in those who were autoantibody positive. Compared to the general population, mortality rates have not improved over the past 20 years.
doi:10.1002/acr.22296
PMCID: PMC4226330  PMID: 24497371
16.  The utility of the PedsQL™ Rheumatology Module as an outcome measure in juvenile fibromyalgia 
Arthritis care & research  2013;65(11):1820-1827.
Objective
The PedsQL™ Rheumatology Module is currently the only available measure of disease-specific Quality of Life (QOL) for children and adolescents with juvenile fibromyalgia (JFM) but limited information has been published about the psychometric properties of the instrument specifically in JFM. The objective of this study was to assess the reliability, validity and sensitivity to change of the 5 scales (pain and hurt, daily activities, treatment, worry and communication) of the patient and parent-proxy versions of the PedsQL™ Rheumatology Module in the context of a randomized clinical trial in JFM.
Methods
The entire PedsQL™ Rheumatology Module was administered as a supplementary outcome measure at pre-treatment, post-treatment and 6-month follow-up assessments of 114 children and adolescents with JFM enrolled in a trial testing the efficacy of cognitive-behavioral therapy (CBT).
Results
Results indicated that internal consistency reliabilities for the scales were adequate to strong (Cronbach αs 0.68 - 0.86). Parent-proxy and child reports on most scales (except for daily activities and communication) showed moderate correlations (Spearman rs 0.33-0.45). Support for construct validity was found based on comparing child and parent reports with other related measures of pain and functioning (Visual Analog Scale pain ratings and the Functional Disability Inventory). Finally, sensitivity to change was demonstrated by significant changes in 4/5 of the scales (excluding the daily activities scale) after treatment.
Conclusion
The PedsQL™ Rheumatology Module generally appears to have good utility for use in JFM patients but some caveats to interpretation of the specific scales in this population are discussed. Key words: PedsQL™ Rheumatology Module, quality of life, juvenile fibromyalgia, outcome measurement
doi:10.1002/acr.22045
PMCID: PMC3783625  PMID: 23686969
17.  Psychological Profiles and Pain Characteristics of Older Adults With Knee Osteoarthritis 
Arthritis care & research  2013;65(11):1786-1794.
Objective
To identify psychological profiles in persons with knee osteoarthritis (OA) and to determine the relationship between these profiles and specific pain and sensory characteristics, including temporal summation and conditioned pain modulation.
Methods
Individuals with knee OA (n = 194) completed psychological, health, and sensory assessments. Hierarchical cluster analysis was used to derive psychological profiles that were compared across several clinical pain/disability and experimental pain responses.
Results
Cluster 1 had high optimism with low negative affect, pain vigilance, anger, and depression, along with the lowest self-reported pain/disability and the lowest sensitivity to mechanical, pressure, and thermal pain (P < 0.01 for all). Cluster 2 had low positive affect with high somatic reactivity, while cluster 3 showed high pain vigilance with low optimism. Clusters 2 and 3 had intermediate levels of self-reported pain/disability and cluster 3 experienced central sensitization to mechanical stimuli. Participants in cluster 3 also displayed significant pain facilitation (P < 0.05). Cluster 4 exhibited the highest pain vigilance, reactivity, negative affect, anger, and depression. These individuals experienced the highest self-reported pain/disability, including widespread pain (P < 0.001 for all). Cluster 4 was most sensitive to mechanical, pressure, and thermal stimuli, and showed significant central sensitization to mechanical and thermal stimuli (P < 0.001 for all).
Conclusion
Our findings demonstrate the existence of homogeneous psychological profiles displaying unique sets of clinical and somatosensory characteristics. Multidisciplinary treatment approaches consistent with the biopsychosocial model of pain should provide significant advantages if targeted to profiles such as those in our OA sample.
doi:10.1002/acr.22070
PMCID: PMC3922880  PMID: 23861288
18.  Illness Perceptions and Fatigue in Systemic Vasculitis 
Arthritis care & research  2013;65(11):1835-1843.
Objective
To compare illness perceptions among patients with different forms of vasculitis, identify risk factors for negative illness perceptions, and determine the association between illness perceptions and fatigue.
Methods
Participants were recruited from an online registry in vasculitis to complete the revised Illness Perception Questionnaire (IPQ-R). Mean scores on each IPQ-R dimension were compared across types of vasculitis. Cluster analysis and stepwise regression identified predictors of negative illness perception. Fatigue was measured using the general subscale of the Multidimensional Fatigue Inventory (MFI). Patient-reported measures of disease activity and IPQ-R dimensions were assessed in relation to MFI scores using linear regression in sequential, additive models with model-fit comparisons.
Results
692 participants with 9 forms of vasculitis completed the IPQ-R. For 6 out of 8 IPQ-R dimensions, there were no significant differences in mean scores between the different vasculitides. Scores in identity and cyclical dimensions were significantly higher in Behçet’s disease compared to other types of vasculitis (13.5 vs 10.7; 4.0 vs 3.2, p<0.05). Younger age (OR=1.04; 95%CI 1.02–1.06), depression (OR=4.94; 95%CI 2.90–8.41), active disease status (OR=2.05; 95%CI 1.27–3.29), and poor overall health (OR=3.92; 95%CI 0.88–17.56) were associated with negative illness perceptions. Sequential models demonstrated that IPQ-R dimensions explained an equivalent proportion of variability in fatigue scores compared to measures of disease activity.
Conclusion
Illness perceptions are similar across different types of vasculitis, and younger age is a risk factor for negative illness perceptions. Illness perceptions explain differences in fatigue scores beyond what can be explained by measures of disease activity.
doi:10.1002/acr.22069
PMCID: PMC3962511  PMID: 23861259
vasculitis; illness perceptions; fatigue
19.  Associations of Foot Posture and Function to Lower Extremity Pain: The Framingham Foot Study 
Arthritis care & research  2013;65(11):1804-1812.
Objective
Studies have implicated foot posture and foot function as risk factors for lower extremity pain. Empirical population-based evidence for this assertion is lacking; therefore, the purpose of this study was to evaluate cross-sectional associations of foot posture and foot function to lower extremity joint pain in a population-based study of adults.
Methods
Participants were members of the Framingham Foot Study. lower extremity joint pain was determined by the response to the NHANES-type question, “On most days do you have pain, aching or stiffness in your [hips, knees, ankles, or feet]?” Modified Arch Index (MAI) classified participants as having planus, rectus (referent) or cavus foot posture. Center of Pressure Excursion Index (CPEI) classified participants as having over-pronated, normal (referent) or over-supinated foot function. Crude and adjusted (age, gender, BMI) logistic regression determined associations of foot posture and function to lower extremity pain.
Results
Participants with planus structure had higher odds of knee (1.57, 95% CI: 1.24– 1.99) or ankle (1.47, 95% CI: 1.05–2.06) pain, whereas those with a cavus foot structure had increased odds of ankle pain only (7.56, 95% CI: 1.99–28.8) and pain at one lower extremity site (1.37, 95% CI: 1.04–1.80). Associations between foot function and lower extremity joint pain were not statistically significant, except for a reduced risk of hip pain in those with an over-supinated foot function (0.69, 95% CI: 0.51–0.93).
Conclusions
These findings offer a link between foot posture and lower extremity pain, highlighting the need for longitudinal or intervention studies.
doi:10.1002/acr.22049
PMCID: PMC4039193  PMID: 24591410
high-arched feet; flat feet; low-arched feet; lower extremity pain
20.  Clinical characteristics and medication uses among fibromyalgia patients newly prescribed amitriptyline, duloxetine, gabapentin or pregabalin 
Arthritis care & research  2013;65(11):1813-1819.
Background
Fibromyalgia is a common chronic pain disorder with unclear etiology. No definitive treatment is available for fibromyalgia and treatment with antidepressants or antiepileptics is often used for symptom management.
Methods
Using US health care utilization data, a large population-based cohort study was conducted to describe clinical characteristics and medication use patterns in patients diagnosed with fibromyalgia who newly started amitriptyline, duloxetine, gabapentin or pregabalin.
Results
There were 13,404 amitriptyline, 18,420 duloxetine, 23,268 gabapentin, and 19,286 pregabalin starters. The mean age ranged from 48 to 51 years and 72% to 84% were women in each group. Back pain was the most frequent comorbidity in all four groups (48%-64%) and hypertension, headache, depression, and sleep disorder were also common. Median daily dose at the start of follow-up was 25mg for amitriptyline, 60mg for duloxetine, 300mg for gabapentin, and 75mg for pregabalin and more than 60% of patients remained on the same dose throughout the follow-up period. Only one fifth of patients continued the treatment started for at least one year. The mean number of different prescription drugs at baseline ranged from 8 to 10 across the groups. More than a half of patients used opioids and a third used benzodiazepines, sleep disorder drugs and muscle relaxants.
Conclusion
Patients who started one of the four common drugs for fibromyalgia similarly had multiple comorbidities and other fibromyalgia-related drug use, but continued the treatment only for a short time. The dose of the four drugs was not increased in most patients during the follow-up.
doi:10.1002/acr.22071
PMCID: PMC4059353  PMID: 23861291
fibromyalgia; cohort study; amitriptyline; duloxetine; gabapentin; pregabalin
22.  Occurrence of Radiographic Osteoarthritis of the Knee and Hip Among African Americans and Whites: A Population-Based Prospective Cohort Study 
Arthritis care & research  2013;65(6):928-935.
Objective
To compare the incidence and progression of radiographic osteoarthritis (OA) in the knee and hip among African Americans and whites.
Methods
Using the joint as the unit of analysis, we analyzed data from the Johnston County Osteoarthritis Project, a population-based prospective cohort study in rural North Carolina. Baseline and followup assessments were 3–13 years apart. Assessments included standard knee and hip radiographs read for Kellgren/Lawrence (K/L) radiographic grade. Weighted analyses controlled for age, sex, body mass index, level of education, and baseline K/L grade; bootstrap methods adjusted for lack of independence between left and right joints. Time-to-event analysis was used to analyze the data.
Results
For radiographic knee OA, being African American had no association with incidence (adjusted hazard ratio [HRadj] 0.80, 95% confidence interval [95% CI] 0.53–1.22), but had a positive association with progression (HRadj 1.67, 95% CI 1.05–2.67). For radiographic hip OA, African Americans had a significantly lower incidence (HRadj 0.44, 95% CI 0.27–0.71), whereas the association with progression was positive but nonsignificant (HRadj 1.46, 95% CI 0.53–4.01). In sensitivity analyses, the association with hip OA incidence was robust to a wide range of assumptions.
Conclusion
African Americans are protected against incident hip OA, but may be more susceptible to progressive knee OA.
doi:10.1002/acr.21924
PMCID: PMC4206562  PMID: 23281251
23.  Patterns of disease-modifying anti-rheumatic drug use in rheumatoid arthritis patients after 2002: a systematic review 
Arthritis care & research  2013;65(12):1927-1935.
Objectives
To report and synthesize patterns of disease modifying agent (DMARD) use reported in observational studies of patients with established and early RA after the publication of ACR guidelines promoting universal DMARD use.
Methods
We searched PubMed for English-language full-length articles published between January 1, 2002, and October 1, 2012 that examined DMARD use. Data abstracted from articles included patient characteristics, country of study, time period studied, patient source, and treating physician type. Study quality was assessed using a modified Newcastle Ottawa Quality Assessment Scale.
Results
We reviewed 1287 abstracts; 98 full-length articles were selected for additional review, and 27 studies describing 28 cohorts of patients were included. Twelve studies described data from cohorts of patients with established RA, and DMARD use in this group of studies ranged from 73-100%. Five studies described data from patients sourced through administrative data demonstrated consistently lower DMARD use, ranging from 30-63%. Three studies conducted population-based surveys to define cases of RA where DMARD use ranged from 47-73%. Eight studies investigated patients with early RA. DMARD use among patients followed by rheumatologists ranged from 77-98% whereas DMARD use reported for patients seen by a mix of physicians was significantly lower (39-63%).
Conclusion
DMARD use in studies from RA cohorts or registries (in which patients were followed by rheumatologists) ranged from 73-100%, compared with 30-73% in studies from administrative data or population-based surveys (in which patients were not necessarily getting rheumatology subspecialty care).
doi:10.1002/acr.22084
PMCID: PMC4204800  PMID: 23926092
24.  Validity and reliability of Patient-Reported Outcomes Measurement Information System (PROMIS) Instruments in Osteoarthritis 
Arthritis care & research  2013;65(10):1625-1633.
Objective
Evaluation of known group validity, ecological validity, and test-retest reliability of four domain instruments from the Patient Reported Outcomes Measurement System (PROMIS) in osteoarthritis (OA) patients.
Methods
Recruitment of an osteoarthritis sample and a comparison general population (GP) through an Internet survey panel. Pain intensity, pain interference, physical functioning, and fatigue were assessed for 4 consecutive weeks with PROMIS short forms on a daily basis and compared with same-domain Computer Adaptive Test (CAT) instruments that use a 7-day recall. Known group validity (comparison of OA and GP), ecological validity (comparison of aggregated daily measures with CATs), and test-retest reliability were evaluated.
Results
The recruited samples matched (age, sex, race, ethnicity) the demographic characteristics of the U.S. sample for arthritis and the 2009 Census for the GP. Compliance with repeated measurements was excellent: > 95%. Known group validity for CATs was demonstrated with large effect sizes (pain intensity: 1.42, pain interference: 1.25, and fatigue: .85). Ecological validity was also established through high correlations between aggregated daily measures and weekly CATs (≥ .86). Test-retest validity (7-day) was very good (≥ .80).
Conclusion
PROMIS CAT instruments demonstrated known group and ecological validity in a comparison of osteoarthritis patients with a general population sample. Adequate test-retest reliability was also observed. These data provide encouraging initial data on the utility of these PROMIS instruments for clinical and research outcomes in osteoarthritis patients.
doi:10.1002/acr.22025
PMCID: PMC3779528  PMID: 23592494
pain; fatigue; physical functioning; patient outcomes assessment; reliability and validity; osteoarthritis
25.  The Submaximal Heart and Pulmonary Evaluation: A Novel Noninvasive Test to Identify Pulmonary Hypertension in Patients with Systemic Sclerosis 
Arthritis care & research  2013;65(10):1713-1718.
Objective
Pulmonary hypertension (PH) is a leading cause of death in patients with systemic sclerosis (SSc). Although right heart catheterization is the gold standard for diagnosing PH, it is an invasive test with associated risks. The submaximal heart and pulmonary evaluation (step test) is a noninvasive, submaximal stress test that could be used to identify patients with PH. The purpose of this study is to assess the correlation between change in end tidal carbon dioxide (ΔPETCO2) from rest to end-exercise on the step test and mean pulmonary artery pressure (mPAP) on RHC in SSc patients.
Methods
This is a retrospective cohort study of patients with limited or diffuse cutaneous SSc who were evaluated in an academic cardiology practice between November 2007 and November 2011 and underwent a step test and RHC. Statistical analysis was performed using Spearman’s correlation and multivariable linear regression.
Results
679 charts were reviewed. Nineteen SSc patients who underwent a step test and RHC were included. ΔPETCO2 was negatively correlated with mPAP (r = −0.82, p-value < 0.0001). In a multivariable linear regression model evaluating the relationship between ΔPETCO2 and mPAP, controlling for age, sex, time between and order of step test and RHC, ΔPETCO2 remained the only variable statistically significantly associated with mPAP (p-value < 0.001). The step test had a sensitivity of 100%, specificity of 75%, PPV of 93.8%, and NPV of 100% for the diagnosis of PH.
Conclusions
ΔPETCO2 on the step test has a strong, statistically significant negative correlation with mPAP on RHC.
doi:10.1002/acr.22051
PMCID: PMC4084928  PMID: 23740875

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