Prevalence of Frailty in Ankylosing Spondylitis, Psoriatic Arthritis, and Rheumatoid Arthritis: Data from a National Claims Dataset

Assessing a revised-risk analysis index for morbidity and mortality after spine surgery for metastatic spinal tumors

BACKGROUND

Risk Analysis Index (RAI) has been increasingly used to assess surgical frailty in various procedures, but its effectiveness in predicting mortality or in-patient hospital outcomes for spine surgery in metastatic disease remains unclear. The aim of this study was to compare the predictive values of the revised RAI (RAI-rev), the modified frailty index-5 (mFI-5), and advanced age for extended length of stay, 30-day readmission, complications, and mortality among patients undergoing spine surgery for metastatic spinal tumors.

METHODS

A retrospective cohort study was performed using the 2012-2022 ACS NSQIP database to identify adult patients who underwent spinal surgery for metastatic spinal pathologies. Using receiver operating characteristic (ROC) and multivariable analyses, we compared the discriminative thresholds and independent associations of RAI-rev, mFI-5, and greater patient age with extended length of stay (LOS), 30-day complications, hospital readmission, and mortality.

RESULTS

A total of 1,796 patients were identified, of which 1,116 (62.1%) were male and 1,008 (70.7%) were non-Hispanic White. RAI-rev identified 1,291 (71.9%) frail and 208 (11.6%) very frail patients, while mFI-5 identified 272 (15.1%) frail and 49 (2.7%) very frail patients. In the ROC analysis for extended LOS, both RAI-rev and mFI-5 showed modest predictive capabilities with area under the curve (AUC) values of 0.5477 and 0.5329, respectively, and no significant difference in their predictive abilities (p = 0.446). When compared to age, RAI-rev demonstrated superior prediction (p = 0.015). With respect to predicting 30-day readmission, no significant difference was observed between RAI-rev and mFI-5 (AUC 0.5394 l respectively, p = 0.354). However, RAI-rev outperformed age (p = 0.001). When assessing the risk of 30-day complications, RAI-rev significantly outperformed mFI-5 (AUC: 0.6016 and 0.5542 respectively, p = 0.022) but not age. Notably, RAI-rev demonstrated superior ability for predicting 30-day mortality compared to mFI-5 and age (AUC: 0.6541, 0.5652, and 0.5515 respectively, p < 0.001). Multivariate analysis revealed RAI-rev as a significant predictor of extended LOS [aOR: 1.96, 95% CI: 1.13-3.38, p = 0.016] and 30-day mortality [aOR: 5.27, 95% CI: 1.73-16.06, p = 0.003] for very frail patients. Similarly, the RAI-rev significantly predicted 30-day complications for frail [aOR: 2.63, 95% CI: 1.21-5.72, p = 0.015] and very frail [aOR: 3.69, 95% CI: 1.60-8.51, p = 0.002] patients. However, the RAI did not significantly predict 30-day readmission [Very Frail aOR: 1.52, 95% CI: 0.75-3.07, p = 0.245; Frail aOR: 1.46, 95% CI: 0.79-2.68, p = 0.225].

CONCLUSION

Our study demonstrates the utility of RAI-rev in predicting morbidity and mortality in patients undergoing spine surgery for metastatic spinal pathologies. Particularly, the superiority that RAI-rev has in predicting 30-day mortality may have significant implications in multidisciplinary decision making.

Exploring the causal association between frailty index with the common types of arthritis: a Mendelian randomization analysis

BACKGROUND

Previous observational studies indicated a complex association between frailty and arthritis.

AIMS

To investigate the genetic causal relationship between the frailty index and the risk of common arthritis.

METHODS

We performed a large-scale Mendelian randomization (MR) analysis to assess frailty index associations with the risk of common arthritis in the UK Biobank (UKB), and the FinnGen Biobank. Summary genome-wide association statistics for frailty, as defined by the frailty index, and common arthritis including rheumatoid arthritis (RA), osteoarthritis (OA), psoriatic arthritis (PSA), and ankylosing spondylitis (AS). The inverse-variance weight (IVW) method served as the primary MR analysis. Heterogeneity testing and sensitivity analysis were also conducted.

RESULTS

Our results denoted a genetic association between the frailty index with an increased risk of OA, the odds ratio (OR)IVW in the UKB was 1.03 (95% confidence interval [CI]: 1.01-1.05; P = 0.007), and ORIVW was 1.55 (95% CI: 1.16-2.07; P = 0.003) in the FinnGen. For RA, the ORIVW from UKB and FinnGen were 1.03 (1.01-1.05, P = 0.006) and 4.57 (1.35-96.49; P = 0.025) respectively. For PSA, the frailty index was associated with PSA (ORIVW = 4.22 (1.21-14.67), P = 0.023) in FinnGen, not in UKB (P > 0.05). However, no association was found between frailty index and AS (P > 0.05). These results remained consistent across sensitivity assessments.

CONCLUSION

This study demonstrated a potential causal relationship that genetic predisposition to frailty index was associated with the risk of arthritis, especially RA, OA, and PSA, not but AS. Our findings enrich the existing body of knowledge on the subject matter.

Frailty and Risk of Serious Infections in Patients With Rheumatoid Arthritis Treated With Biologic or Targeted-Synthetic Disease-Modifying Antirheumatic Drugs

OBJECTIVE

It remains unknown whether frailty status portends an increased risk of adverse outcomes in patients with rheumatoid arthritis (RA) initiating biologic or targeted-synthetic (b/ts) disease-modifying antirheumatic drugs (DMARDs). The objective of our study was to evaluate the association between frailty and serious infections in a younger population of patients (<65 years old) with RA who initiated b/tsDMARDs.

METHODS

Using MarketScan data, we identified new users of tumor necrosis factor inhibitors (TNFi), non-TNFi biologic DMARDs, or Janus kinase inhibitors (JAKi) between 2008 and 2019 among those with RA. Patients' baseline frailty risk score was calculated using a Claims-Based Frailty Index (≥0.2 defined as frail) 12 months prior to drug initiation. The primary outcome was time to serious infection; secondarily, we examined time-to-any infection and all-cause hospitalizations. We used Cox proportional hazards to estimate adjusted hazard ratios and 95% confidence intervals (95% CIs) and assessed the significance of interaction terms between frailty status and drug class.

RESULTS

A total of 57,980 patients, mean (±SD) age 48.1 ± 10.1 were included; 48,139 (83%) started TNFi, 8,111 (14%) non-TNFi biologics, and 1,730 (3%) JAKi. Among these, 3,560 (6%) were categorized as frail. Frailty was associated with a 50% increased risk of serious infections (adjusted hazard ratio [95% CI] 1.5, 1.2-1.9) and 40% higher risk of inpatient admissions (1.4 [1.3-1.6]) compared with nonfrail patients among those who initiated TNFi. Frailty was also associated with a higher risk of any infection relative to nonfrail patients among those on TNFi (1.2 [1.1-1.3]) or non-TNFi (1.2 [1.0-1.4]) or JAKi (1.4 [1.0-2.0]).

CONCLUSION

Frailty is an important predictor for the risk of adverse outcomes among patients with RA treated with biologic or targeted-synthetic DMARDs.

Implications of Frailty on Postoperative Health Care Resource Utilization in Ankylosing Spondylitis Patients Undergoing Spine Surgery for Spinal Fractures

OBJECTIVE

The rise of spinal surgery for ankylosing spondylitis (AS) necessitates balancing health care costs with quality patient care. Frailty has been independently associated with adverse outcomes and increased costs. This study investigates whether frailty is an independent predictor of poor outcomes after elective surgery for AS.

METHODS

Using the National Inpatient Sample (NIS) database, a retrospective study was conducted on adult patients with AS who underwent posterior spinal fusion for fracture between 2016 and 2019. Each patient was assigned a modified frailty index (mFI) score and categorized as prefrail (mFI = 0 or 1), moderately frail (mFI = 2), and highly frail (mFI≥3). Multivariate logistic regression analyses were used to identify independent predictors of extended length of stay, non-routine discharge (NRD), and exorbitant admission costs.

RESULTS

Of the 1910 patients, 35.3% were prefrail, 31.2% moderately frail, and 33.5% highly frail. Age was significantly different across groups (P < 0.001), and frailty was associated with increased comorbidities (P < 0.001). Mean length of stay (P = 0.007), NRD rate (P < 0.001), and mean cost of admission (P = 0.002) all significantly increased with increasing frailty. However, frailty was not an independent predictor of extended hospital stay, NRD, or higher costs on multivariate analysis. Instead, predictors included multiple adverse events, number of comorbidities, and race.

CONCLUSIONS

While frailty in patients with AS is associated with older age, greater comorbidities, and increased adverse events, it was not an independent predictor of extended hospital stay, NRD, or higher hospital costs. Further research is required to understand the full impact of frailty on surgical outcomes and develop effective interventions.

Identifying frailty and its associated factors in patients with axial spondyloarthritis

BACKGROUND AND AIM

Frailty is an elderly people phenomenon; however, younger adults with comorbidities may show a higher trajectory of frailty toward older age. The frailty status of middle-aged patients with axial spondyloarthritis (axSpA) remains little researched. We aimed to identify frailty status and to investigate the association of clinical, sociodemographic, and psychosocial factors with frailty.

METHODS

This study included 114 patients aged between 40 and 65 years. The patients were classified as frail, pre-frail, and robust according to Fried's phenotype and the Kihon Checklist (KCL). Physical function, quality of life, depression, anxiety, and disease-related factors were assessed. Between-group comparisons and multinomial logistic regression analysis were performed.

RESULTS

Frailty and pre-frailty prevalences were 20.2% and 49.1% for Fried's phenotype and 36.0% and 33.3% for the KCL. Frail adults had impaired physical function and increased disease activity compared to pre-frail and robust patients. Adjusted multinomial logistic regression analysis revealed that disease activity (odds ratio [OR] = 1.62, 95% CI = 1.12-2.34) and Short Physical Performance Battery (OR = 0.32, 95% CI = 0.18-0.56) were associated with Fried's phenotype-determined frailty. Disease activity (OR = 1.91, 95% CI = 1.11-3.26), Bath Ankylosing Spondylitis Functional Index (OR = 2.70, 95% CI = 1.56-4.67), and depression (OR = 1.55, 95% CI = 1.18-2.02) were associated with the KCL determined frailty.

CONCLUSION

Frailty and pre-frailty are commonly detected in middle-aged individuals with axSpA. Our findings highlight a possible need for frailty screening and preventive programs targeting middle-aged axSpA patients.

Therapeutic Potential of Zeolites/Vitamin B12 Nanocomposite on Complete Freund's Adjuvant-Induced Arthritis as a Bone Disorder: In Vivo Study and Bio-Molecular Investigations

Rheumatoid arthritis (RA) is a long-term autoimmune disease. As nanotechnology has advanced, a growing number of nanodrugs have been used in the treatment of RA due to their unique physical and chemical properties. The purpose of this study was to assess the therapeutic potential of a novel zeolite/vitamin B12 nanocomposite (Nano ZT/Vit B12) formulation in complete Freund's adjuvant (CFA)-induced arthritis. The newly synthesized Nano ZT/Vit B12 was fully characterized using various techniques such as XRD, FT-IR, BET analysis, HERTEM, SEM, practical size, zeta potential, XRF, and EDX. The anti-arthritic, anti-inflammatory, and antioxidant activities as well as the immunomodulation effect of Nano ZT/Vit B12 on the CFA rat model of arthritis were examined. Histopathologic ankle joint injuries caused by CFA intrapedal injection included synovium hyperplasia, inflammatory cell infiltration, and extensive cartilage deterioration. The arthritic rats' Nano ZT/Vit B12 supplementation significantly improved these effects. Furthermore, in arthritic rats, Nano ZT/Vit B12 significantly reduced serum levels of RF and CRP, as well as the levels of IL-1β, TNF-α, IL-17, and ADAMTS-5, while increasing IL-4 and TIMP-3 levels. Nano-ZT/Vit B12 significantly declined the LPO level and increased antioxidant activities, such as GSH content and GST activity, in the arthritic rats. In arthritic rats, Nano ZT/Vit B12 also reduced TGF-β mRNA gene expression and MMP-13 protein levels. Collectively, Nano ZT/Vit B12 seems to have anti-arthritic, anti-inflammatory, and antioxidant properties, making it a promising option for RA in the future.

Diosmin and Trolox Have Anti-Arthritic, Anti-Inflammatory and Antioxidant Potencies in Complete Freund’s Adjuvant-Induced Arthritic Male Wistar Rats: Roles of NF-κB, iNOS, Nrf2 and MMPs

Rheumatoid arthritis (RA) is a chronic, progressive, autoimmune disease caused by a malfunction of the immune system. The aim of this study was to examine the anti-arthritic effects and suggest the mechanisms of actions of diosmin and trolox in male Wistar rats. Complete Freund’s adjuvant (CFA) was used to establish RA in the animals by subcutaneous injection of 100 µL CFA/rat into plantar region of right hind leg in two consecutive days. Diosmin and/or trolox were administered orally at a dosage of 20 mg/kg/day to CFA-induced arthritic rats for 2 weeks. The normal and arthritic control groups were orally given the same equivalent volume of a vehicle (1% carboxymethyl cellulose) in which treatment agents were dissolved. At the end of the experiment, blood samples were collected from the jugular vein for the detection of the total leukocyte count (TLC) and differential leukocyte count (DLC) in blood and the detection of rheumatoid factor (RF), anti-citrullinated protein antibodies (ACPA), tumor necrosis factor-α (TNF-α), interleukin-13 (IL-13), and interleukin-17 (IL-17) levels by enzyme-linked immunosorbent assay (ELISA), as well as markers of oxidative stress and the antioxidant defense system in serum. The right hind ankle regions of three rats from each group were dissected out and fixed in 10% neutral-buffered formalin for histological examination and the other three were kept at −30 °C for Western blot analysis of nuclear factor-kappa B (NF-κB) protein 50 (NF-κB p50), NF-κB p65, inducible nitric oxide synthase (iNOS), nuclear factor erythroid-2-related factor 2 (Nrf2), and matrix metalloproteinase (MMP)-1 (MMP-1), MMP-3, and MMP-9. The CFA injection was deleterious to the ankle joint’s histological architecture, manifesting as infiltration of inflammatory cells into the articular cartilage, hyperplasia of the synovium, and erosion of the cartilage. All these effects were ameliorated by diosmin and/or trolox, with the combined dose being the most effective. The two compounds significantly lowered the elevated serum levels of RF, ACPA, TNF-α, and IL-17, as well as other pro-inflammatory mediators, such as NF-κB p50, NF-κB p65, iNOS, MMP-1, MMP-3 and MMP-9. They also increased the levels of the anti-inflammatory cytokine, IL-13, and the cytoprotective transcription factor Nrf2. The compounds stimulated higher activities of antioxidants, such as glutathione, glutathione-S-transferase, catalase, and superoxide dismutase, and reduced lipid peroxidation in the serum of arthritic rats. In conclusion, diosmin, trolox, and their combination, which was the most potent, exerted anti-arthritic, anti-inflammatory and antioxidant effects by suppressing NF-κB signaling, inhibiting matrix metalloproteinases, and activating Nrf2.