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1.  Complementary and Alternative Medicine Use in African Americans With Rheumatoid Arthritis 
Arthritis care & research  2014;66(2):180-189.
Racial/ethnic differences with regard to complementary and alternative medicine (CAM) use have been reported in the US. However, specific details of CAM use by African Americans with rheumatoid arthritis (RA) are lacking.
Data were collected from African Americans with RA enrolled in a multicenter registry regarding the use of CAM, including food supplements, topical applications, activities, and alternative care providers. Factors associated with CAM use by sex and disease duration were assessed using t-test, Wilcoxon’s rank sum test, chi-square test, and logistic regression analyses.
Of the 855 participants, 85% were women and mean age at enrollment was 54 years. Overall, ever using any of the CAM treatments, activities, and providers was 95%, 98%, and 51%, respectively (median of 3 for number of treatments, median of 5 for activities, and median of 1 for providers). Those with longer disease duration (>2 years) were significantly more likely (odds ratio >2.0, P < 0.05) to use raisins soaked in vodka/gin, to take fish oils, or to drink alcoholic beverages for RA treatment than those with early disease. As compared to men, women were significantly (P < 0.05) more likely to pray/attend church, write in a journal, and use biofeedback, but were less likely to smoke tobacco or topically apply household oils for treatment of RA.
CAM use was highly prevalent in this cohort, even in individuals with early disease. Health care providers need to be aware of CAM use as some treatments may potentially have interactions with conventional medicines. This could be important within this cohort of African Americans, where racial disparities are known to affect access to conventional care.
PMCID: PMC3977347  PMID: 23983105
2.  Severe Cutaneous Reactions requiring Hospitalization in Allopurinol Initiators: a Population-based Cohort Study 
Arthritis care & research  2013;65(4):578-584.
Rare but potentially life-threatening cutaneous adverse reactions have been associated with allopurinol, but population-based data on incidence and mortality of such reactions is scarce.
We conducted a propensity score-matched cohort study to evaluate incidence rate (IR) and in-hospital mortality of hospitalization for severe cutaneous adverse reactions (SCARs) in allopurinol initiators compared to non-allopurinol users, using data from five large Medicaid programs. The primary outcome was identified by the principal discharge diagnosis code 695.1. Cox proportional hazards model evaluated the relative risk of SCARs associated with use of allopurinol and determined the relative risk of SCARs associated with allopurinol dose.
During a follow-up period of 65,625 person-years for allopurinol initiators, 45 were hospitalized with SCARs. The crude IR was 0.69 (95% CI 0.50–0.92) per 1,000 person-years. All 45 cases occurred within 365 days and 41 (91.1%) within 180 days after initiating treatment with allopurinol. Twelve (26.7%) patients died during the hospitalization. The crude IR in non-allopurinol users was 0.04 (95% CI 0.02–0.08) per 1,000 person-years. The risk of SCARs was increased in allopurinol initiators vs. non-users (HR 9.67, 95% CI 4.55–20.57). Among allopurinol initiators, the HR for the high- (>300mg/day) vs. low-dose allopurinol was 1.30 (95% CI 0.31–5.36) after adjusting for age, comorbidities and recent diuretic use.
Among allopurinol initiators, SCARs were found to be rare but often fatal and occurred mostly in the first 180 days of treatment. The risk of SCARs was ten times as high in allopurinol initiators compared to allopurinol non-users.
PMCID: PMC3502684  PMID: 22899369
3.  Evaluation of test characteristics for outcome measures used in Raynaud's phenomenon clinical trials 
Arthritis care & research  2013;65(4):630-636.
Randomized controlled trials (RCTs) in Raynaud's phenomenon (RP) have shown conflicting efficacy data. Also, there is no consensus on the outcome measures that should be used. Our objectives were: 1) assess the reliability of individual core set measures used in 3 RCTs; 2) evaluate the placebo response for individual core set measures; and 3) determine if a composite of individual core set measures will decrease the placebo response which may improve our ability to see treatment effects in future trials.
Patients and Methods
We analyzed core set measures from 249 patients in the placebo-treated groups from 3 RCTs. Core set measures analyzed included Raynaud's condition score (RCS), patient and physician assessment of RP, pain, numbness, and tingling during an RP attack, average number of attacks/day, and duration of attacks. ICC correlation coefficients were calculated during the run-in period to the RCTs.
ICC coefficients of ≥0.70 were observed for RCS, attack symptoms, and average attacks/day. A high placebo response rate was observed for all individual core measures except the duration of attacks. For the RCS, the placebo response ranged from 56% with >10% improvement to 20% with ≥60% improvement. In contrast, placebo response rates of 10–20% were observed when several core set measures were combined to develop a composite score.
Outcome measures used in RP RCTs are associated with marked variability. Combination of outcome measures is associated with low placebo responses. Future studies are needed to assess if a composite score will be able to differentiate placebo from an effective agent.
PMCID: PMC3529989  PMID: 22972592
Raynaud 's phenomenon; Composite Response Index; systemic sclerosis; primary Raynaud's phenomenon; secondary Raynaud's phenomenon
4.  Severity of Coexisting Patellofemoral Disease is Associated with Increased Impairments and Functional Limitations in Patients with Knee Osteoarthritis 
Arthritis care & research  2013;65(4):544-551.
To evaluate the association between severity of coexisting patellofemoral (PF) disease with lower limb impairments and functional limitations in patients with tibiofemoral (TF) osteoarthritis (OA).
Radiographic views of the TF and PF compartments, knee extension strength and knee range of motion were obtained for 167 patients with knee OA. Additionally, knee-specific symptoms and functional limitations were assessed using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and Activities of Daily Living Scale (ADLS).
“Moderate/Severe PFOA” was associated with lower knee extension strength (1.4±0.5 Nm/BW) compared to “No PFOA” (1.8±0.5 Nm/BW). Additionally, total knee range of motion was significantly lower for patients with “Moderate/Severe PFOA” (120.8°±14.4°) compared to “No PFOA” (133.5°±10.7°) and “Mild PFOA” (125.8°±13.0°). “Moderate/Severe PFOA” and “Mild PFOA” were also associated with less pain while standing (OR= 0.2; 95% CI: 0.1,0.7 and OR= 0.2; 95% CI: 0.1,0.6, respectively) on the WOMAC and “Moderate/Severe PFOA” was associated with greater difficulty with going downstairs (OR=2.9; 95% CI: 1.0,8.1) on the ADLS.
It appears that knees with more severe coexisting PF disease demonstrate features distinct from those observed in TFOA in isolation or in combination with mild PF disease. Treatment strategies targeting the PF joint may be warranted to mitigate the specific lower limb impairments and functional problems present in this patient population.
PMCID: PMC3562754  PMID: 23045243
Arthritis care & research  2013;65(4):607-614.
Functional limitations in ankylosing spondylitis (AS) may be due to peripheral joint or axial involvement. To determine if the Bath AS Functional Index (BASFI), an axial-focused measure, can detect limitations related to peripheral joint involvement equally well as the Health Assessment Questionnaire modified for the Spondyloarthropathies (HAQ-S), a peripheral arthritis-focused measure, and vice versa, we compared associations of each questionnaire with spinal and hip range of motion, peripheral arthritis, and enthesitis in patients with AS.
We examined patients every 4 to 6 months in this prospective longitudinal study. We used mixed linear models to examine associations between ten physical examination measures and the BASFI and HAQ-S.
We studied 411 patients for a median of 1.5 years (3 visits). In multivariate analyses, cervical rotation, chest expansion, lateral thoracolumbar flexion, hip motion, tender joint count, and tender enthesis count were equally strongly associated with the BASFI and HAQ-S. Peripheral joint swelling was more strongly associated with the HAQ-S. Individual items of the BASFI were more likely than items of the HAQ-S to be associated with unrelated physical exam measures (e.g. association between difficulty rising from a chair and cervical rotation), which may have diminished the axial/peripheral distinction for the BASFI.
The BASFI and HAQ-S had similar associations with impairments in axial measures, while the HAQ-S had stronger associations with the number of swollen peripheral joints. The HAQ-S should be considered for use in studies focused on spondyloarthritis with peripheral joint involvement.
PMCID: PMC3567248  PMID: 23097327
Ankylosing spondylitis; functional limitations; metrology
6.  Measuring Illness Behavior in Patients with Systemic Sclerosis 
Arthritis care & research  2013;65(4):585-593.
Illness behaviors (cognitive, affective, and behavioral reactions) among individuals with systemic sclerosis (SSc) are of clinical concern due to relationships between these behaviors and physical and mental-health quality of life such as pain and symptoms of depression. Self-report measures with good psychometric properties can aid in the accurate assessment of illness behavior. The Illness Behavior Questionnaire (IBQ) was designed to measure abnormal illness behaviors; however, despite its long-standing use, there is disagreement regarding its subscales. The goal of the present study was to evaluate the validity of the IBQ in a cohort of patients with SSc.
Patients with SSc (N = 278) completed the IBQ at enrollment to the Genetics versus ENvironment In Scleroderma Outcome Study (GENISOS). Structural validity of previously derived factor solutions was investigated using confirmatory factor analysis. Exploratory factor analysis was utilized to derive SSc-specific subscales.
None of the previously derived structural models were supported for SSc patients. Exploratory factor analysis supported a SSc-specific factor structure with 5 subscales. Validity analyses suggested that the subscales were generally independent of disease severity, but were correlated with other health outcomes (i.e., fatigue, pain, disability, social support, mental health).
The proposed subscales are recommended for use in SSc, and can be utilized to capture illness behavior that may be of clinical concern.
PMCID: PMC3578093  PMID: 23097280
7.  The performance of matrix-based risk models for rapid radiographic progression in BRASS, a cohort of patients with established rheumatoid arthritis 
Arthritis care & research  2013;65(4):526-533.
Matrix-based risk models have been proposed as a tool to predict rapid radiographic progression (RRP) in rheumatoid arthritis (RA), but the experience with such models is limited. We tested the performance of three risk models for RRP in an observational cohort
Subjects from an observational RA cohort with hand radiographs and necessary predictor variables to be classified by the risk models were identified (n=478). RRP was defined as a yearly change in van der Heijde-Sharp score of ≥ 5 units. Patients were placed in the appropriate matrix categories, with a corresponding predicted risk of RRP. The mean predicted probability for cases and non-cases, integrated discrimination improvement, Hosmer-Lemeshow statistics and the c-statistics were calculated.
The median (IQR) age was 59 (50, 66) years, disease duration 12 (4, 23) years and swollen joint count 6 (2, 13), 84% were female and 86% had erosions at baseline. Twelve percent (32/271) of patients treated with synthetic DMARDs at baseline and 10% (21/207) of patients treated with biologic DMARDs experienced RRP. Most of the predictor variables had a skewed distribution in the population. All models had a suboptimal performance when applied to the BRASS cohort, with c-statistics of 0.59 (model A), 0.65 (model B) and 0.57 (model C) and Hosmer-Lemeshow chi-square p-values of 0.06 (model A), 0.005 (model B) and 0.05 (model C).
Matrix risk models developed in clinical trials of patients with early RA had limited ability to predict RRP in this observational cohort of RA patients.
PMCID: PMC3594116  PMID: 23044765
8.  Higher Rates and Clustering of Abnormal Lipids, Obesity, and Diabetes in Psoriatic Arthritis Compared with Rheumatoid Arthritis 
Arthritis care & research  2014;66(4):600-607.
We compared the prevalence and the clustering of the Metabolic Syndrome (MetS) components: obese body mass index (BMI ≥ 30 kg/m2), hypertriglyceridemia, low high-density lipids, hypertension and diabetes, in patients with psoriatic arthritis (PsA) and rheumatoid arthritis (RA) in the Consortium of Rheumatology Researchers of North America (CORRONA) registry.
We included CORRONA participants with the rheumatologist-confirmed clinical diagnoses of PsA and RA with complete data. We used a modified definition of MetS that did not include insulin resistance, waist circumference or blood pressure measurements. Logistic regression models were adjusted for age, sex and race.
In the overall CORRONA population, the rates of diabetes and obesity were significantly higher in PsA compared with RA. In 294 PsA and 1162 RA participants who had lipids measured, the overall prevalence of MetS in PsA vs. RA was 27% vs. 19%. The odds ratio (OR) of MetS in PsA vs. RA was 1.44 (95% confidence interval (CI) 1.05 to 1.96), p=0.02. The prevalence of hypertriglyceridemia was higher in PsA compared with RA, 38% vs. 28%, OR 1.51 (95% CI 1.15 to 1.98), p=0.003. The prevalence of type II diabetes was also higher in PsA compared with RA (15% vs. 11%), OR 1.56 (95% CI 1.07 to 2.28), p=0.02, in the adjusted model. Similarly, higher rates of hypertriglyceridemia and diabetes were observed in the subgroup of PsA and RA patients with obese BMI.
PsA is associated with the higher rates of obesity, diabetes, and hypertriglyceridemia, compared with RA.
PMCID: PMC3969762  PMID: 24115739
9.  Prevalent Vertebral Fractures among Children Initiating Glucocorticoid Therapy for the Treatment of Rheumatic Disorders 
Arthritis care & research  2010;62(4):516-526.
Vertebral fractures are an under-recognized problem in children with inflammatory disorders. We studied spine health among 134 children (87 girls) with rheumatic conditions (median age 10 years) within 30 days of initiating glucocorticoid (GC) therapy.
Children were categorized as follows: juvenile dermatomyositis (juvenile DM, N=30), juvenile idiopathic arthritis (JIA; N=28), systemic lupus erythematosus (SLE) and related conditions (N=26), systemic arthritis (N=22), systemic vasculitis (N=16), and other conditions (N=12). Thoracolumbar spine radiograph and dual energy x-ray absorptiometry for lumbar spine areal bone mineral density (LS BMD) were performed within 30 days of GC initiation. Genant semi-quantitative grading was used for vertebral morphometry. Second metacarpal morphometry was carried out on a hand radiograph. Clinical factors including disease and physical activity, calcium and vitamin D intake, cumulative GC dose, underlying diagnosis, LS BMD Z-score and back pain were analyzed for association with vertebral fracture.
Thirteen vertebral fractures were noted in 9 children (7%). Six patients had a single vertebral fracture and three patients had two to three fractures. Fractures were clustered in the mid-thoracic region (69%). Three vertebral fractures (23%) were moderate (Grade 2); the others were mild (Grade 1). For the entire cohort, mean (±SD) LS BMD Z-score was significantly different from zero (−0.55±1.2, p<0.001) despite a mean height Z-score that was similar to the healthy average (0.02±1.0, p=0.825). Back pain was highly associated with increased odds for fracture (OR 10.6, 95% CI 2.1 to 53.8, p=0.004).
In pediatric rheumatic conditions, vertebral fractures can be present prior to prolonged GC exposure.
PMCID: PMC3958950  PMID: 20391507 CAMSID: cams3808
Arthritis care & research  2013;65(3):372-381.
To evaluate the reproducibility and validity of the Pediatric Automated Neuropsychological Assessment Metrics (Ped-ANAM) when used in childhood-onset systemic lupus erythematosus (cSLE).
Forty children with cSLE and 40 matched controls were followed for up to 18 months. Formal neuropsychological testing at baseline was repeated after 18 months of follow-up; overall cognitive performance and domain-specific cognition (attention, working memory, processing speed and visuoconstructional ability) were measured and categorized as having normal cognition, mild/moderate or moderate/severe impairment. The 10 Ped-ANAM subtests were completed every 6 months and twice at baseline. Ped-ANAM performance was based on accuracy (AC), mean time to correct response (MNc), throughput, and coefficient of variation of the time required for a correct response (CVc) as a measure of response consistency.
Particularly MNc scores demonstrated moderate to substantial reproducibility (intraclass correlation coefficients: 0.47-0.80). Means of select Ped-ANAM scores (MNc, AC, CVc) differed significantly between children with different levels of cognitive performance and allowed for the detection of moderate or severe cognitive impairment with 100% sensitivity and 86% specificity. Six Ped-ANAM subtests significantly correlated with the change in overall cognitive function in cSLE (baseline vs. 18 month; Spearman correlation coefficient > ±0.4; p<0.05, n=24).
The Ped-ANAM has moderate to substantial reproducibility, criterion and construct validity and may be responsive to change in cSLE. Additional research is required to confirm the Ped-ANAM's outstanding accuracy in identifying cognitive impairment and its usefulness in detecting clinically relevant changes in cognition over time.
PMCID: PMC3519977  PMID: 22933364
SLE; cognitive dysfunction; SLE; children; Ped-ANAM; ANAM
11.  High sensitivity C-reactive protein, disease activity and cardiovascular risk factors in systemic lupus erythematosus 
Arthritis care & research  2013;65(3):441-447.
To study the level of high-sensitivity C-reactive protein (hsCRP) and its relationship with disease activity, damage and cardiovascular risk factors in patients with systemic lupus erythematosus (SLE).
Consecutive patients who fulfilled ≥4 ACR criteria for SLE but did not have concurrent infection were recruited. Blood was assayed for hsCRP and disease activity, organ damage of SLE and cardiovascular risk factors were assessed. Linear regression was performed for the relationship among hsCRP, SLE activity, damage and cardiovascular risk factors.
289 patients were studied (94% women; age 39.0±13.1 years; SLE duration 7.8±6.7 years). The mean SLEDAI score was 4.9±5.6 and clinically active SLE was present in 122(42%) patients. The mean hsCRP level was 4.87±12.7mg/L, and 28(23%) patients with active SLE had undetectable hsCRP (<0.3mg/L). Linear regression revealed a significant correlation between hsCRP and musculoskeletal (Beta=0.21), hematological (Beta=0.19), serosal (Beta=0.46) and clinical SLEDAI score (Beta=0.24), adjusting for age, sex, body mass index, creatinine and the use of various medications (p<0.005 in all). Levels of hsCRP correlated significantly with anti-dsDNA titer (Beta=0.33;p<0.001) but not with complement C3 (Beta=0.07;p=0.26). Significantly more patients with hsCRP >3.0mg/L were men and chronic smokers, and had diabetes mellitus, higher atherogenic index and history of arterial thrombosis. hsCRP levels correlated significantly with pulmonary and endocrine damage score.
hsCRP is detectable in 77% of SLE patients with clinically active disease and correlates with SLEDAI scores, particularly serositis and in the musculoskeletal and hematological systems. Elevated hsCRP in SLE is associated with certain cardiovascular risk factors and history of arterial thromboembolism.
PMCID: PMC3528823  PMID: 22949303
C-reactive protein; acute phase; disease activity; cardiovascular; damage; outcome
12.  Physical activity monitoring in adolescents with juvenile fibromyalgia: findings from a clinical trial of cognitive behavioral therapy 
Arthritis care & research  2013;65(3):398-405.
Juvenile fibromyalgia (JFM) is a chronic musculoskeletal pain condition that is associated with reduced physical function. Recent research has demonstrated that cognitive-behavioral therapy (CBT) is effective in improving daily functioning among adolescents with JFM. However, it is not known whether these improvements were accompanied by increased physical activity levels.
To analyze secondary data from a randomized clinical trial of CBT to examine if CBT was associated with improvement in objectively measured physical activity and whether actigraphy indices corresponded with self-reported functioning among adolescents with JFM.
Participants were 114 adolescents (ages 11–18) recruited from pediatric rheumatology clinics that met criteria for JFM and were enrolled in a clinical trial. Subjects were randomly (1:1) assigned to receive either CBT or fibromyalgia education (FE). Participants wore a hip-mounted accelerometer for one week as part of their baseline and post-treatment assessments.
The final sample included 68 subjects (94% female; mean age = 15.2 years) for whom complete actigraphy data was obtained. Actigraphy measures were not found to correspond with self-reported improvements in functioning. While self-reported functioning improved in the CBT condition compared to FE, no significant changes were seen in either group for activity counts, sedentary, moderate or vigorous activity. The CBT group had significantly lower peak and light activity at post-treatment.
Actigraphy monitoring provides a unique source of information about patient outcomes. CBT intervention was not associated with increased physical activity in adolescents with JFM indicating that combining CBT with interventions to increase physical activity may enhance treatment effects.
PMCID: PMC3535015  PMID: 22972753
actigraphy; physical activity; cognitive-behavioral therapy; juvenile fibromyalgia
13.  Perception and Presentation of Function in Patients with Unilateral Versus Bilateral Knee Osteoarthritis 
Arthritis care & research  2013;65(3):406-413.
Lower extremity functional performance and perception of functional abilities influence clinical management in people diagnosed with unilateral or bilateral knee osteoarthritis. The purpose of this study was to determine if there were differences in perception of function and performance during functional tasks between individuals with unilateral and bilateral knee osteoarthritis.
The functional abilities of patients with symptomatic and radiographic diagnosed unilateral (N=84) or bilateral (N=68) knee osteoarthritis were evaluated with self-reports and performance-based tests. Self reports included the Knee Outcome Survey (KOS), Global Rating Scale (GRS), and Physical Component of Short Form-36 (PCS); functional tests included Timed Up-and-Go (TUG), Stair Climbing Test (SCT), and 6-minute Walk (6MW). Separate MANOVAs were performed separately for men and women to determine if perception (self-reports) and performance (functional tests) were dependent on the number of involved knees.
No significant main effects were observed in functional performance between groups for either sex. Similarly, the perception measures did not differ between groups. In general, individuals diagnosed with unilateral and bilateral knee osteoarthritis both performed functional tasks and perceived their functional ability similarly. Conclusion. Regardless of the number of involved knees, individuals with knee osteoarthritis perform and perceive their functional ability similarly, which suggests that clinicians need to consider other factors, such as include how long the disease has been progressing or how functional abilities have changed when treating patients with knee osteoarthritis.
PMCID: PMC3537858  PMID: 22933450
14.  The Relationship between Perceived Cognitive Dysfunction and Objective Neuropsychological Performance in Persons with Rheumatoid Arthritis 
Arthritis care & research  2013;65(3):481-486.
Research shows a gap between perceived cognitive dysfunction and objective neuropsychological performance in persons with chronic diseases. We explored this relationship in persons with rheumatoid arthritis (RA).
Individuals from a longitudinal cohort study of RA participated in a study visit that included physical, psychosocial, and biological metrics. Subjective cognitive dysfunction was assessed using the Perceived Deficits Questionnaire (PDQ; 0–20, higher scores = greater perceived impairment). Objective cognitive impairment was assessed using a battery of 12 standardized neuropsychological measures yielding 16 indices. On each test, subjects were classified as ‘impaired’ if they performed 1 SD below age-based population norms. Total cognitive function scores were calculated by summing the transformed scores (0–16, higher scores = greater impairment). Multiple linear regression analyses determined the relationship of total cognitive function score with PDQ score, controlling for gender, race, marital status, income, education, disease duration, disease severity, depression, and fatigue.
120 subjects (mean ± SD age: 58.5 ± 11.0 years) were included. Mean ± SD scores of total cognitive function and PDQ were 2.5 ± 2.2 (0–10) and 5.8 ± 3.8 (0–16), respectively. In multivariate analysis, there was no significant relationship between total cognitive function score and PDQ score. However, depression and fatigue (β = 0.31, p < 0.001; β = 0.31, p = 0.001) were significantly associated with PDQ score.
The findings emphasize the gap between subjective and objective measures of cognitive impairment and the importance of considering psychological factors within the context of cognitive complaints in clinical settings.
PMCID: PMC3786333  PMID: 22899659
15.  Patient Race and Surgical Outcomes after Total Knee Arthroplasty: An analysis of a large regional database 
Arthritis care & research  2013;65(3):10.1002/acr.21834.
To examine racial differences in surgical complications, mortality and revision rates after total knee arthroplasty.
We studied patients undergoing primary total knee arthroplasty using 2001–2007 Pennsylvania Health Care Cost Containment Council data. We conducted bivariate analyses to assess the risk of complications: myocardial infarction, venous thromboembolism, wound infections, and failure of prosthesis, and 30-day and one year overall mortality after elective total knee arthroplasty between racial groups. We estimated Kaplan-Meier one and five year surgical revision rates, and fit multivariable Cox proportional hazard models to compare surgical revision by race, incorporating 5 years of follow up. We adjusted for patient age, sex, length of hospital stay, surgical risk of death, type of health insurance, hospital surgical volume and hospital teaching status.
In unadjusted analyses, there were no significant differences by racial group for either overall 30-day or in hospital complication rates, or 30-day and one year mortality rates. Adjusted Cox models incorporating five years of follow up showed an increased risk of revisions for black patients [hazard ratios (95% confidence intervals)]: [1.39 (1.08–1.80)], younger patients [2.30 (1.96–2.69)], and lower risk for female patients [0.81 (0.71–0.92)].
In this sample of patients who underwent knee arthroplasty, we found no significant racial differences in major complication rates or mortality. However, black patients, younger patients, and male patients all had significantly higher rates of revision based on five years of follow up.
PMCID: PMC3833861  PMID: 22933341
16.  Self-Rated Health and Symptomatic Knee Osteoarthritis Over Three Years: Data from the Osteoarthritis Initiative 
Arthritis care & research  2013;65(2):169-176.
To determine if a previously published model of the influence of self-rated health on physical, mental and social health among patients with joint replacement surgery could be generalized to persons with symptomatic knee OA. Our second purpose was to determine if self-rated health mediated changes in physical, mental and social health.
Persons with symptomatic knee OA (n = 1,127) who participated in the Osteoarthritis Initiative completed the required measures at baseline, 1-, 2-, and 3-year intervals. The key variable of interest was a single-item self-rated health measure. In addition, measures of physical, mental and social health and a set of covariate measures over the 3-year period were analyzed. Structural equation modeling was used to test interrelationships among variables as well as predictive and mediational relationships among self-rated health and mental, physical and social health after adjusting for baseline covariates.
The full model demonstrated good statistical fit. Prior self-rated health consistently predicted current mental health and social health. Prior social health predicted current self-rated health. Self-rated health also mediated changes in mental health and social health. Only social health changes were mediated by self-rated health over all time periods.
Self-rated health predicts a variety of outcomes of symptomatic knee OA. In addition, self-rated health mediates changes in social health and mental health. The use of self-rated health as a simple and efficient clinical assessment has potential for clinical utility because of its predictive capability and association with multiple health domains.
PMCID: PMC3386372  PMID: 22392799
17.  Use of a Disease Risk Score to Compare Serious Infections Associated with Anti-TNF Therapy among High versus Lower Risk Rheumatoid Arthritis Patients 
Arthritis care & research  2013;65(2):235-243.
To evaluate whether rates of serious infection with anti-TNF therapy in rheumatoid arthritis (RA) patients differ in magnitude by specific drugs and patient characteristics.
Among new non-biologic disease modifying anti-rheumatic drug (DMARD) users enrolled in Medicare/Medicaid or a large U.S. commercial health plan, we created and validated a person-specific infection risk score based upon age, demographics, insurance, glucocorticoid dose, and comorbidities to identify patients at high risk for hospitalized infections. We then applied this risk score to new users of infliximab, etanercept, and adalimumab and compared the observed one-year rate of infection to each other and to the predicted infection risk score estimated in the absence of anti-TNF exposure.
Among 11,657 RA patients initiating anti-TNF therapy, the observed one year rate of infection was 14.2 per 100 person-years in older patients (>= 65 years) and 4.8 in younger patients (< 65 years). There was a relatively constant rate difference of 1–4 infections per 100 person-years associated with anti-TNF therapy across the range of the infection risk score. Infliximab had a significantly greater adjusted rate of infection compared to etanercept and adalimumab in both high and lower risk RA patients.
The rate of serious infections for anti-TNF agents was incrementally increased by a fixed absolute difference irrespective of age, comorbidities, and other factors that contributed to infections. Older patients and those with high comorbidity burdens should be reassured that the magnitude of incremental risk with anti-TNF agents is not greater for them than for lower risk patients.
PMCID: PMC3414685  PMID: 22556118
rheumatoid arthritis; infection; anti-TNF; DMARD; prediction
18.  Preferences for Arthritis Interventions: Identifying Similarities and Differences among Blacks and Whites with Osteoarthritis 
Arthritis care & research  2013;65(2):203-211.
To determine if there are differences or similarities in arthritis intervention preferences and barriers to participation between Blacks and Whites with osteoarthritis (OA).
Using a needs assessment survey, intervention preferences and barriers to participation in arthritis interventions among Black (n=60) and White (n=55) adults with self-reported doctor-diagnosed OA were examined. T-tests, chi-square tests, and multiple regression analyses adjusting for covariates were examined to determine race effects.
While there were many similarities, Blacks were more likely to report cost (p<.01), lack of trust (p=.04), fear of being the only person of their race (p<.001), lack of recommendation from their doctor (p=.04), and lack of recommendation of a family member or friend (p=.02) as barriers to participating in a community-based self-management arthritis intervention. After adjusting for covariates, Blacks preferred interventions that provide information on arthritis-related internet sources (p=.04), solving arthritis-related problems (p=.04), and talking to family and friends about their condition (p=.02) in comparison to Whites. Blacks also preferred an intervention with child care services provided (p<.01), instructors and participants of the same race (p<.01; p<.001) or gender (p<.001; p=.03), allows a friend (p=.001) or family (p=.02) to attend, offered at a local church (p=.01), clinic (p<.01) or mailed (p<.01).
Findings suggest that similar interventions are preferred across racial groups, but some practical adaptations could be made to existing arthritis interventions to minimize barriers, increase cultural sensitivity, and offer programs that would be appealing to Blacks and Whites with arthritis.
PMCID: PMC3470731  PMID: 22745029
19.  Association of Systemic Lupus Erythematosus with Angiographically-defined Coronary Artery Disease: A Retrospective Cohort Study 
Arthritis care & research  2013;65(2):266-273.
To determine if systemic lupus erythematosus (SLE) is associated with a higher prevalence of coronary artery disease (CAD) in selected patients undergoing coronary angiography, we compared the extent of angiographic abnormalities, CAD risk factors, and all-cause mortality in SLE patients with non-SLE controls.
We identified SLE patients (N=86) and controls matched by sex and year of cardiac catheterization (N=258) undergoing cardiac catheterization for the evaluation of CAD (median follow up of 4.3 years). Multivariable logistic regression was used to determine if SLE was associated with obstructive CAD defined as ≥ 70% stenosis in a major epicardial coronary artery. Risk adjusted survival differences between the two groups were assessed using Cox proportional hazards modeling.
SLE patients (85% female) were younger than non-SLE patients (median age 49 years vs. 70 years, p<0.001) and were less likely to have diabetes and hyperlipidemia, but had similar rates of hypertension (70% vs.71%, p=0.892). In unadjusted analyses, SLE patients and non-SLE patients had similar rates of obstructive CAD by angiography (52% vs. 62% overall p=0.11). After adjustment for known CAD risk factors, SLE was associated with a significantly increased likelihood of CAD (OR 2.24, 95% CI: 1.08, 4.67). SLE was also associated with a non-significant increase in all-cause mortality (HR 1.683, 95% CI: 0.98, 2.89 p=0.060).
In this selected population, SLE was significantly associated with the presence of CAD as defined by coronary angiography, the gold standard for assessing flow-limiting lesions in this disease. The patients with SLE showed a similar severity of CAD as the controls despite having less than half the rate of diabetes and being 20 years younger.
PMCID: PMC3496832  PMID: 22745037
20.  Racial/Ethnic Differences in Physical Activity Guideline Attainment among Participants in the Osteoarthritis Initiative 
Arthritis care & research  2013;65(2):195-202.
This cross-sectional study examined racial/ethnic differences in meeting the 2008 U.S. Department of Health and Human Services Physical Activity Guidelines aerobic component (≥ 150 moderate-to-vigorous (MV) minutes/week in bouts ≥ 10 minutes) among persons with or at risk for radiographic knee osteoarthritis (RKOA).
We evaluated African American versus White differences in Guideline attainment using multiple logistic regression adjusting for socio-demographic (age, gender, site, income, education) and health factors (comorbidity, depressive symptoms, overweight/obesity, knee pain). Our analyses included adults aged 49–84 who participated in accelerometer monitoring at the Osteoarthritis Initiative 48-month visit (1142 with and 747 at risk for RKOA).
2.0% of African Americans and 13.0% of Whites met Guidelines. For adults with and at risk for RKOA, significantly lower rates of Guideline attainment among African Americans compared to Whites were partially attenuated by health factor differences, particularly overweight/obesity and knee pain (RKOA: adjusted odds ratio [OR] = 0.24, 95% confidence interval [CI] = [0.08, 0.72]; at risk for RKOA: OR = 0.28, 95% CI = [0.07, 1.05]).
Despite known benefits from physical activity, attainment of Physical Activity Guidelines among persons with and at risk for RKOA was low. African Americans were 72–76% less likely than Whites to meet Guidelines. Culturally-relevant interventions and environmental strategies in the African American community targeting overweight/obesity and knee pain may reduce future racial/ethnic differences in physical activity and improve health outcomes.
PMCID: PMC3502693  PMID: 22807352
21.  Is symptomatic knee osteoarthritis a risk factor for a fast decline in gait speed? Results from the Osteoarthritis Initiative 
Arthritis care & research  2013;65(2):187-194.
Gait speed is an important marker of health in adults and slows with aging. While knee osteoarthritis (OA) can result in difficulty walking, it is not known if radiographic knee OA (ROA) and/or knee pain are associated with a fast decline trajectory of gait speed over time.
Gait speed trajectories were constructed using a multinomial modeling strategy from repeated 20-meter walk tests measured annually over four years among participants from the Osteoarthritis Initiative (OAI), a prospective cohort study of adults with or at high risk of knee OA aged 45 to 79 at baseline. We grouped participants into four knee OA categories (having neither ROA nor knee pain, ROA only, knee pain only, or symptomatic knee OA (ROA and pain)) and examined their association with trajectories of gait speed using a multivariable polytomous regression model adjusting for age and other potential confounders.
Of the 4179 participants (mean age (sd) = 61.1 (9.1), women =57.6%, mean BMI =28.5 (4.8) kg/m2), 5% (n=205) were in a fast decline trajectory slowing 2.75%/year. People with symptomatic knee OA had almost a 9-fold risk (OR = 8.9, 95% CI [3.1, 25.5]) of being in a fast decline trajectory compared with those with neither pain nor ROA. Participants with knee pain had 4.5 times the odds of fast decline (95% CI [1.4, 14.6]) and those with ROA only had a slight but non-statistically significant increased risk.
People with symptomatic knee OA have the highest risk of fast decline trajectory of gait speed compared with people with ROA or pain alone.
PMCID: PMC3529801  PMID: 22899342
Gait speed; Knee Osteoarthritis; Trajectory
Arthritis care & research  2013;65(2):257-265.
Radiographic damage and functional limitations both increase with the duration of ankylosing spondylitis (AS). We examined whether radiographic damage contributed more to functional limitations in late AS than in early AS, and if the strength of association varied with the anatomic region of damage.
In this cross-sectional study of 801 patients with AS, we examined associations of the lumbar modified Stoke AS Spine Score (mSASSS), cervical mSASSS, lumbar posterior fusion, cervical posterior fusion, and hip arthritis with the Bath AS Functional Index (BASFI) and the Health Assessment Questionnaire (HAQ-S).
Higher lumbar and cervical mSASSS were associated with more functional limitations, but there was an interaction between mSASSS and the duration of AS such that the strength of their association with functional limitations decreased with increasing duration of AS. Cervical posterior fusion was associated with worse functioning independent of mSASSS. Hip arthritis was significantly associated with functional limitations independent of measures of spinal damage. Among patients with AS ≥ 40 years, the number of comorbid conditions accounted for most of the variation in functioning. Results were similar for both the BASFI and HAQ-S.
Although both radiographic damage and functional limitations increase over time in AS, the relative contribution of radiographic damage to functional limitations is lower among patients with longstanding AS than early AS, suggesting patients may accommodate to limited flexibility. Damage in different skeletal regions impacts functioning over the duration of AS. Functional limitations due to comorbidity supervene in late AS.
PMCID: PMC3541454  PMID: 23042639
Ankylosing spondylitis; radiographic damage; functional limitations
23.  Risk Factors for Falls in Adults With Rheumatoid Arthritis: A Prospective Study 
Arthritis Care & Research  2013;65(8):1251-1258.
Objective: To investigate the association between potential risk factors and falls in community-dwelling adults with rheumatoid arthritis (RA).
Methods: We followed patients for 1 year of followup in a prospective cohort study with monthly falls calendars and telephone calls. Lower extremity muscle strength, postural stability, number of swollen and tender joints, functional status, history of falling, fear of falling, pain, fatigue, medication, and use of steroids were assessed as risk factors for falls.
Results: A total of 386 women and 173 men with RA (n = 559) ages 18–88 years completed baseline assessments and 535 participants (96%) completed 1-year followup. Bivariate logistic regression showed that falls risk was not associated with age or sex. Multivariate logistic regression revealed that a history of multiple falls in the previous 12 months was the most significant predictive risk factor (odds ratio [OR] 5.3, 95% confidence interval [95% CI] 2.3–12.3). The most significant modifiable risk factors were swollen and tender lower extremity joints (OR 1.7, 95% CI 1.1–2.7), psychotropic medication (OR 1.8, 95% CI 1.1–3.1), and fatigue (OR 1.13, 95% CI 1.02–1.2).
Conclusion: Adults with RA are at high risk of falls. In clinical practice, high-risk fall patients with RA can be identified by asking whether patients have fallen in the past year. Important risk factors highlighted in this study include swollen and tender lower extremity joints, fatigue, and use of psychotropic medications.
PMCID: PMC3881513  PMID: 23436687
24.  Measures of Anxiety 
Arthritis care & research  2011;63(0 11):10.1002/acr.20561.
PMCID: PMC3879951  PMID: 22588767
25.  Body weight changes and corresponding changes in pain and function in persons with symptomatic knee osteoarthritis. A cohort study 
Arthritis care & research  2013;65(1):15-22.
To determine if a dose-response relationship exists between percentage body weight changes in persons with symptomatic knee osteoarthritis (OA) and self reported pain and function.
Data from persons in the Osteoarthritis Initiative (OAI) and the Multicenter Osteoarthritis (MOST) datasets (n=1,410) with symptomatic function limiting knee OA were studied. For the OAI, we used baseline and 3-year follow-up data while for the MOST, baseline and 30-month data were used. Key outcome variables were WOMAC Physical Function and Pain change scores. In addition to covariates, the predictor variable of interest was the extent of weight change over the study period and divided into 5 categories representing different percentages of body weight change.
A significant dose-response relationship (p< 0.003) was found between the extent of percentage change in body weight and the extent of change in WOMAC Physical Function and WOMAC Pain. For example, persons who gained ≥10% of body weight had WOMAC Physical Function score changes of −5.4 (95%CI, −8.7, −2.00) points indicating worsening relative to the reference group of persons with weight changes of between <5% weight gain and <5% weight reduction.
Our data suggest a dose-response relationship exists between changes in body weight and corresponding changes in pain and function. The threshold for this response gradient appears to be ≥10% body weight shifts. Weight changes of ≥10% have potential to lead to important changes in pain and function for patient groups as well as individual patients.
PMCID: PMC3401342  PMID: 22505346

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