Dupuytren's Disease Predicts Increased All-Cause and Cancer-Specific Mortality: Analysis of a Large Cohort from the U.K. Clinical Practice Research Datalink

Mortality in patients with Dupuytren's disease in the first 5 years after diagnosis: a population-based survival analysis

Previous studies suggest that Dupuytren's disease is associated with increased mortality, but most studies failed to account for important confounders. In this population-based cohort study, general practitioners' (GP) data were linked to Statistics Netherlands to register all-cause and disease-specific mortality. Patients with Dupuytren's disease were identified using the corresponding diagnosis code and assessing free-text fields from GP consultations. Multiple imputations were performed to estimate missing values of covariates, followed by 1:7 propensity score matching to balance cases with controls on confounding factors. A frailty proportional hazard model was used to compare mortality between both groups. Out of 209,966 individuals, 2561 patients with Dupuytren's disease were identified and matched to at least four controls. After a median follow-up of 5 years, mortality was found to be actually reduced in patients with Dupuytren's disease. There was no difference in mortality secondary to cancer or cardiovascular disease. Future studies with longer average follow-up using longitudinal data should clarify these associations in the longer term.Level of evidence: III.

Modifiable Risk Factors for Prevention in Dupuytren Disease: A UK Biobank Case-Control Study

BACKGROUND

Dupuytren disease is associated with significant comorbidity and mortality, and it has no existing prevention strategies. It is unclear which modifiable risk factors are most amenable for prevention. This study aimed to determine the strength of modifiable risk factors for Dupuytren disease, and to investigate associations with other diseases.

METHODS

Using UK Biobank data, this case-control study analyzed the association between phenotypic variables and Dupuytren disease through multivariable logistic regression. Exposures assessed were age, sex, body mass index, waist-to-hip ratio, Townsend deprivation index, smoking status, alcohol intake, diabetes mellitus, hypertension, cancer, liver disease, respiratory disease, rheumatoid arthritis, epilepsy, psoriasis, and gout.

RESULTS

There were 4148 cases and 397,425 controls. Male sex (OR, 3.23; 95% CI, 2.90 to 3.60; P = 1.07 × 10 -100 ), increasing age (OR, 1.08; 95% CI, 1.07 to 1.08; P = 6.78 × 10 -167 ), material deprivation (OR, 1.01; 95% CI, 1.00 to 1.02; P = 0.0305), high-density lipoprotein cholesterol (OR, 1.76; 95% CI, 1.58 to 1.96; P = 3.35 × 10 -24 ), smoking exposure, and alcohol intake were all associated with increased odds of Dupuytren disease. With increasing obesity class, there was approximately 25% decreased odds (OR, 0.774; 95% CI, 0.734 to 0.816; P = 4.71 × 10 -21 ). Diabetes with microvascular or end-organ complications was associated with more than 2.5 times increased odds of Dupuytren disease (OR, 2.59; 95% CI, 1.92 to 3.44; P = 1.92 × 10 -10 ). Within this group, increasing hemoglobin A1c values by 10 mmol/mol, or 0.9%, increased the odds by 31% (OR, 1.31; 95% CI, 1.13 to 1.51; P = 2.19 × 10 -4 ).

CONCLUSION

Diabetes and poor glycemic control are major risk factors for Dupuytren disease, which present an opportunity for prevention.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

A genome-wide association meta-analysis implicates Hedgehog and Notch signaling in Dupuytren's disease

Dupuytren's disease (DD) is a highly heritable fibrotic disorder of the hand with incompletely understood etiology. A number of genetic loci, including Wnt signaling members, have been previously identified. Our overall aim was to identify novel genetic loci, to prioritize genes within the loci for functional studies, and to assess genetic correlation with associated disorders. We performed a meta-analysis of six DD genome-wide association studies from three European countries and extensive bioinformatic follow-up analyses. Leveraging 11,320 cases and 47,023 controls, we identified 85 genome-wide significant single nucleotide polymorphisms in 56 loci, of which 11 were novel, explaining 13.3-38.1% of disease variance. Gene prioritization implicated the Hedgehog and Notch signaling pathways. We also identified a significant genetic correlation with frozen shoulder. The pathways identified highlight the potential for new therapeutic targets and provide a basis for additional mechanistic studies for a common disorder that can severely impact hand function.

Dupuytren Disease: Prevalence, Incidence, and Lifetime Risk of Surgical Intervention. A Population-Based Cohort Analysis

BACKGROUND

Health care burden attributable to Dupuytren disease (DD) is largely unknown. The authors determined (1) the prevalence and incidence of DD, (2) the incidence of first surgical intervention, and (3) the lifetime risk of surgical intervention in the United Kingdom National Healthcare Service.

METHODS

In this population-based dynamic cohort analysis, data of the Clinical Practice Research Datalink was linked to Hospital Episode Statistics, to characterize the diagnosis and surgical treatment of DD. Secular trends of incidence of DD diagnosis and first surgical treatment were calculated for 2000 to 2013. A multistate Markov model was designed to estimate the lifetime risk of first surgical intervention.

RESULTS

A total of 10,553,454 subjects were included in the analyses, 5,502,879 (52%) of whom were women. Of these, 38,707 DD patients were identified. Point prevalence in 2013 was 0.67% (99% CI, 0.66 to 0.68). The incidence of DD almost doubled from 0.30 (99% CI, 0.28 to 0.33) per 1000 person-years in 2000, to 0.59 (99% CI, 0.56 to 0.62) per 1000 person-years in 2013. The incidence of first surgical intervention similarly increased from 0.29 (99% CI, 0.23 to 0.37) to 0.88 (99% CI, 0.77 to 1.00) in the same period. A man or woman newly diagnosed with DD at age 65 has a lifetime risk of surgical intervention of 23% and 13%, respectively, showing only a very subtle decrease when diagnosed later in life.

CONCLUSIONS

DD is an important health condition in the older population, because prevalence and incidence rates have almost doubled in the past decade. Estimated lifetime risk of surgical treatment is relatively low, but almost twice in men compared with women.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

Dupuytren's disease is a work-related disorder: results of a population-based cohort study

OBJECTIVES

Dupuytren's disease (DD) is a fibroproliferative disorder of the hands, characterised by the development of fibrous nodules and cords that may cause disabling contractures of the fingers. The role of manual work exposure in the aetiology of DD is controversial. We investigated whether current occupational exposure to manual work is associated with DD, and if there is a dose-response relationship.

METHODS

In this population-based cohort analysis, we used data from the UK Biobank cohort. Our primary outcome was the presence of DD. The exposure of interest was manual work, measured for each participant in two different ways to allow two independent analyses to be undertaken: (1) the current manual work status of the occupation at the time of recruitment, and (2) a cumulative manual work exposure score, calculated based on the occupational history. We performed propensity score matching and applied a logistic regression model.

RESULTS

We included 196 265 participants for the current manual work analysis, and 96 563 participants for the dose-response analysis. Participants whose current occupation usually/always involved manual work were more often affected with DD than participants whose occupation sometimes/never involved manual work (OR 1.29, 95% CI 1.12 to 1.49, p<0.001). There was a positive dose-response relationship between cumulative manual work exposure score and DD. Each increment in cumulative work exposure score increased the odds by 17% (OR 1.17, 95% CI 1.08 to 1.27, p<0.001).

CONCLUSIONS

Manual work exposure is a risk factor for DD, with a clear dose-response relationship. Physicians treating patients should recognise DD as a work-related disorder and inform patients accordingly.

Cost-effectiveness of adalimumab for early-stage Dupuytren’s disease

Aims

To estimate the potential cost-effectiveness of adalimumab compared with standard care alone for the treatment of early-stage Dupuytren’s disease (DD) and the value of further research from an NHS perspective.

Methods

We used data from the Repurposing anti-TNF for Dupuytren’s disease (RIDD) randomized controlled trial of intranodular adalimumab injections in patients with early-stage progressive DD. RIDD found that intranodular adalimumab injections reduced nodule hardness and size in patients with early-stage DD, indicating the potential to control disease progression. A within-trial cost-utility analysis compared four adalimumab injections with no further treatment against standard care alone, taking a 12-month time horizon and using prospective data on EuroQol five-dimension five-level questionnaire (EQ-5D-5L) and resource use from the RIDD trial. We also developed a patient-level simulation model similar to a Markov model to extrapolate trial outcomes over a lifetime using data from the RIDD trial and a literature review. This also evaluated repeated courses of adalimumab each time the nodule reactivated (every three years) in patients who initially responded.

Results

The within-trial economic evaluation found that adalimumab plus standard care cost £503,410 per quality-adjusted life year (QALY) gained versus standard care alone over a 12-month time horizon. The model-based extrapolation suggested that, over a lifetime, repeated courses of adalimumab could cost £14,593 (95% confidence interval £7,534 to £42,698) per QALY gained versus standard care alone. If the NHS was willing to pay £20,000/QALY gained, there is a 77% probability that adalimumab with retreatment is the best value for money.

Conclusion

Repeated courses of adalimumab are likely to be a cost-effective treatment for progressive early-stage DD. The value of perfect parameter information that would eliminate all uncertainty around the parameters estimated in RIDD and the duration of quiescence was estimated to be £105 per patient or £272 million for all 2,584,411 prevalent cases in the UK. Cite this article: Bone Jt Open 2022;3(11):898–906.

The association of bariatric surgery and Dupuytren's disease: a propensity score-matched cohort study

We aimed to assess the association between bariatric surgery and incident Dupuytren's disease (DD) using propensity score-matched cohort studies among Swedish nationwide healthcare registries. Patients aged 30-79 years who underwent bariatric surgery 2006-2019 were matched on their propensity scores, up to two obese bariatric surgery-free (unexposed) patients. We applied Cox proportional hazard regression to calculate hazard ratios (HR) with 95% confidence intervals (CI) for the risk of DD overall, in subgroups of age, sex, bariatric surgery type and duration of follow-up. Among 34,959 bariatric surgery patients and 54,769 propensity score-matched obese patients, the risk of DD was increased in bariatric surgery patients compared with obese unexposed patients (HR 1.30, 95% CI 1.02-1.65), among women (HR 1.36; 1.00-1.84); those undergoing gastric bypass (HR 1.33; 1.04-1.71) and those with >5 years follow-up (HR 1.63; 1.14-2.34). Our results suggest that substantial weight loss is associated with an increased risk of DD in an obese population.Level of evidence: III.

EPIDEMIOLOGICAL ASPECTS OF DUPUYTREN'S DISEASE IN BRAZIL

Objectives:

The purpose of this study is to describe associated factors and epidemiological aspects of Dupuytren’s Disease in patients followed up in a Brazilian tertiary public hospital, at the Hand Surgery service.

Methods:

A cross-sectional study was performed from 2014 to 2019.

Data collected included:

age, gender, ancestry, associated comorbidity presence, phenobarbital, tobacco, and alcohol use, family history of Dupuytren’s Disease and associated fibrotic diseases. Then, the patients underwent a clinical examination to identify and characterize the involvement of the fingers. The patients were also assessed in regard to whether they presented Dupuytren’s Disease severity factors.

Results:

140 patients were included, 70.7% men and 29.3% women. Only 42.3% reported being of European ancestry; 20% had first-degree relatives with the disease; 59.3% presented comorbidities, including hypertension, diabetes, chronic heart disease, dyslipidemia, epilepsy, and HIV infection; 15.8% had Ledderhose disease, 7.1% had Peyronie’s disease. 31% were smokers, 16.6% were alcoholic, and 37.1% were phenobarbital users; 40% presented with a severe form of DD.

Conclusion:

The population studied was composed of Brazilians, most of whom did not report European ancestry; still, they presented several characteristics similar to those described in literature worldwide. Level of Evidence II; Prognostic Studies; Investigating the effect of a patient characteristic on the outcome of a disease .

A common SNP risk variant MT1-MMP causative for Dupuytren's disease has a specific defect in collagenolytic activity

Dupuytren's Disease (DD) is a common fibroproliferative disease of the palmar fascia. We previously identified a causal association with a non-synonymous variant (rs1042704, p.D273N) in MMP14 (encoding MT1-MMP). In this study, we investigated the functional consequences of this variant, and demonstrated that the variant MT1-MMP (MT1-N273) exhibits only 17% of cell surface collagenolytic activity compared to the ancestral enzyme (MT1-D273). Cells expressing both MT1-D273 and MT1-N273 in a 1:1 ratio, mimicking the heterozygous state, possess 38% of the collagenolytic activity compared to the cells expressing MT1-D273, suggesting that MT1-N273 acts in a dominant negative manner. Consistent with the above observation, patient-derived DD myofibroblasts with the alternate allele demonstrated around 30% of full collagenolytic activity detected in ancestral G/G genotype cells, regardless of the heterozygous (G/A) or homozygous (A/A) state. Small angle X-ray scattering analysis of purified soluble Fc-fusion enzymes allowed us to construct a 3D-molecular envelope of MT1-D273 and MT1-N273, and demonstrate altered flexibility and conformation of the ectodomains due to D273 to N substitution. Taking together, rs1042704 significantly reduces collagen catabolism in tissue, which tips the balance of homeostasis of collagen in tissue, contributing to the fibrotic phenotype of DD. Since around 30% of the worldwide population have at least one copy of the low collagenolytic alternate allele, further investigation of rs1042704 across multiple pathologies is needed.