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Lai Y, Huang C, Cai Y, Ding Z, Fan J, Luo Z, Zhou Z. Perioperative Short-Term Glucocorticoids Do Not Increase Incidence of Complications after Total Joint Arthroplasty in Patients with Rheumatoid Arthritis. Orthop Surg 2024; 16:1974-1979. [PMID: 38946692 PMCID: PMC11293911 DOI: 10.1111/os.14150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Revised: 06/05/2024] [Accepted: 06/10/2024] [Indexed: 07/02/2024] Open
Abstract
OBJECTIVES The safety and analgesic efficacy of perioperative glucocorticoids have been established for patients without rheumatoid arthritis. Therefore, our study aims to investigate whether similar benefits can be observed in patients with rheumatoid arthritis undergoing total joint arthroplasty. Specifically, we aim to explore the impact of perioperative glucocorticoid use on postoperative complications, opioid consumption, incidence of hypotension, hyperglycemia, 30-day mortality, and 90-day re-admission in this patient population. METHODS Approval for the study protocol was obtained from the Medical Research Ethics Committee at Sichuan University, aligning with the principles outlined in the Declaration of Helsinki. We retrospectively analyzed a consecutive series of patients with rheumatoid arthritis who underwent total joint arthroplasty at our medical center between November 2009 and April 2021 and who were not on chronic glucocorticoid therapy before surgery. Those who received glucocorticoids at any time during hospitalization were compared to those who did not in terms of acute complications within 90 days after surgery as well as postoperative rescue opioid consumption, hypotension, and hyperglycemia during hospitalization. The two groups were also compared in terms of overall duration of hospitalization, all-cause mortality within 30 days, and readmission for any reason within 90 days. Continuous data were assessed for significance using the independent-samples t test. Categorical data were assessed using the Pearson chi-squared test. RESULTS Of the 849 patients included in the analysis, 598 administered perioperative glucocorticoids and 251 did not. Prior to surgery, the two groups did not differ significantly in any clinicodemographic variable that we examined. The incidence of acute postoperative complications (2.3% vs. 4.0%, p = 0.187) and acute postoperative infection (2.0% vs. 2.8%, p = 0.482) was comparable between those who received perioperative glucocorticoids and those who did not, but the former group exhibited a significantly lower incidence of rescue opioid use (17.9% vs. 44.6%, p < 0.001) as well as significantly lower total rescue opioid consumption (4.7 ± 2.1 mg vs. 8.9 ± 4.6 mg, p < 0.001). However, the two groups showed similar incidences of postoperative hypotension, hyperglycemia, 30-day mortality, and 90-day re-admission. CONCLUSION Perioperative glucocorticoids may reduce the need for rescue opioids after total joint arthroplasty of rheumatoid arthritis patients, without increasing the incidence of acute complications, hypotension or hyperglycemia.
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Affiliation(s)
- Yahao Lai
- Department of Orthopaedic SurgeryWest China Hospital of Sichuan UniversityChengduChina
| | - Chao Huang
- Department of Orthopaedic SurgeryWest China Hospital of Sichuan UniversityChengduChina
| | - Yongrui Cai
- Department of Orthopaedic SurgeryWest China Hospital of Sichuan UniversityChengduChina
| | - Zichuan Ding
- Department of Orthopaedic SurgeryWest China Hospital of Sichuan UniversityChengduChina
| | - Jiaxuan Fan
- Department of Orthopaedic SurgeryWest China Hospital of Sichuan UniversityChengduChina
| | - Zeyu Luo
- Department of Orthopaedic SurgeryWest China Hospital of Sichuan UniversityChengduChina
| | - Zongke Zhou
- Department of Orthopaedic SurgeryWest China Hospital of Sichuan UniversityChengduChina
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Koh YR, Cummings KC. Newer Immunosuppressants for Rheumatologic Disease: Preoperative Considerations. Rheum Dis Clin North Am 2024; 50:545-557. [PMID: 38942584 DOI: 10.1016/j.rdc.2024.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/30/2024]
Abstract
With the advent of small-molecule immune modulators, recombinant fusion proteins, and monoclonal antibodies, treatment options for patients with rheumatic diseases are now broad. These agents carry significant risks and an individualized approach to each patient, balancing known risks and benefits, remains the most prudent course. This review summarizes the available immunosuppressant treatments, discusses their perioperative implications, and provides recommendations for their perioperative management.
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Affiliation(s)
- Ye Rin Koh
- Anesthesiology Institute, Cleveland Clinic, 9500 Euclid Avenue, E-31, Cleveland, OH 44195, USA
| | - Kenneth C Cummings
- Anesthesiology Institute, Cleveland Clinic, 9500 Euclid Avenue, E-31, Cleveland, OH 44195, USA.
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Tang J, Wang X, Lin X, Wu C. Mesenchymal stem cell-derived extracellular vesicles: a regulator and carrier for targeting bone-related diseases. Cell Death Discov 2024; 10:212. [PMID: 38697996 PMCID: PMC11066013 DOI: 10.1038/s41420-024-01973-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Revised: 04/16/2024] [Accepted: 04/17/2024] [Indexed: 05/05/2024] Open
Abstract
The escalating threat of bone-related diseases poses a significant challenge to human health. Mesenchymal stem cell (MSC)-derived extracellular vesicles (MSC-EVs), as inherent cell-secreted natural products, have emerged as promising treatments for bone-related diseases. Leveraging outstanding features such as high biocompatibility, low immunogenicity, superior biological barrier penetration, and extended circulating half-life, MSC-EVs serve as potent carriers for microRNAs (miRNAs), long no-code RNAs (lncRNAs), and other biomolecules. These cargo molecules play pivotal roles in orchestrating bone metabolism and vascularity through diverse mechanisms, thereby contributing to the amelioration of bone diseases. Additionally, engineering modifications enhance the bone-targeting ability of MSC-EVs, mitigating systemic side effects and bolstering their clinical translational potential. This review comprehensively explores the mechanisms through which MSC-EVs regulate bone-related disease progression. It delves into the therapeutic potential of MSC-EVs as adept drug carriers, augmented by engineered modification strategies tailored for osteoarthritis (OA), rheumatoid arthritis (RA), osteoporosis, and osteosarcoma. In conclusion, the exceptional promise exhibited by MSC-EVs positions them as an excellent solution with considerable translational applications in clinical orthopedics.
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Affiliation(s)
- Jiandong Tang
- Orthopaedics Center, Zigong Fourth People's Hospital, Tan mu lin Street 19#, Zigong, 643099, Sichuan Province, China
| | - Xiangyu Wang
- Orthopaedics Center, Zigong Fourth People's Hospital, Tan mu lin Street 19#, Zigong, 643099, Sichuan Province, China
| | - Xu Lin
- Orthopaedics Center, Zigong Fourth People's Hospital, Tan mu lin Street 19#, Zigong, 643099, Sichuan Province, China
| | - Chao Wu
- Orthopaedics Center, Zigong Fourth People's Hospital, Tan mu lin Street 19#, Zigong, 643099, Sichuan Province, China.
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Elsaid MI, Li N, Firkins SA, Rustgi VK, Paskett ED, Acharya C, Reddy KR, Chiang CW, Mumtaz K. Impacts of glucagon-like peptide-1 receptor agonists on the risk of adverse liver outcomes in patients with metabolic dysfunction-associated steatotic liver disease cirrhosis and type 2 diabetes. Aliment Pharmacol Ther 2024; 59:1096-1110. [PMID: 38538967 DOI: 10.1111/apt.17925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 01/05/2024] [Accepted: 02/15/2024] [Indexed: 04/10/2024]
Abstract
BACKGROUND/AIMS We examined the effects of glucagon-like peptide-1 receptor agonists (GLP-1RAs) initiation on long-term Adverse Liver Outcomes (ALO) in patients with Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD) cirrhosis and type 2 diabetes using real-world data from the MarketScan database. METHODS We conducted a retrospective cohort study of patients with MASLD cirrhosis and type 2 diabetes between 2012 and 2020. Cox proportional hazard models examine the association between GLP-1RAs initiation, modelled as time-dependent, and the risk of ALO, a composite endpoint defined by the first occurrence of hepatic decompensation(s), portal hypertension, hepatocellular carcinoma (HCC) or liver transplantation (LT). We used Overlap Propensity Score Weighting (OPSW) to account for confounding. The study included 459 GLP-1RAs and 4837 non-GLP-1RAs patients. RESULTS The non-GLP-1RAs patients presented with 1411 (29%) ALO over 7431.7 person years, while GLP-1RAs patients had 32 (7%) ALO over 586.6 person years - risk rate difference 13.5 (95% CI: 11.4-15.7) per 100 person-years. The OPSW-adjusted risk of ALO was reduced by 36% (hazard ratio [HR]: 0.64; 95% CI: 0.54-0.76) in patients with vs. without GLP-1RAs initiation. GLP-1RAs initiation was associated with significant reductions in the adjusted risk of hepatic decompensation (HR: 0.74; 95% CI: 0.61-0.88), portal hypertension (HR: 0.73; 95% CI: 0.60-0.88), HCC (HR: 0.37; 95% CI: 0.20-0.63) and LT (HR: 0.24; 95% CI: 0.12-0.43). CONCLUSION The use of GLP-1RAs was associated with significant risk reductions in long-term adverse liver outcomes, including hepatic decompensation, portal hypertension, HCC and LT, in MASLD cirrhosis patients with type 2 diabetes.
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Affiliation(s)
- Mohamed I Elsaid
- Department of Biomedical Informatics, College of Medicine, The Ohio State University, Columbus, Ohio, USA
- Center for Biostatistics, College of Medicine, The Ohio State University, Columbus, Ohio, USA
- Department of Internal Medicine, Division of Medical Oncology, College of Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Na Li
- Department of Internal Medicine, Division of Gastroenterology, Hepatology & Nutrition, College of Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Stephen A Firkins
- Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Vinod K Rustgi
- Division of Gastroenterology and Hepatology, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
- Center for Liver Diseases and Masses, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Electra D Paskett
- Division of Population Sciences, The Ohio State University Comprehensive Cancer Center, Columbus, Ohio, USA
- Department of Internal Medicine, Division of Cancer Prevention and Control, College of Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Chathur Acharya
- Department of Internal Medicine, Division of Gastroenterology, Hepatology & Nutrition, College of Medicine, The Ohio State University, Columbus, Ohio, USA
| | - K Rajender Reddy
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Chien Wei Chiang
- Department of Biomedical Informatics, College of Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Khalid Mumtaz
- Department of Internal Medicine, Division of Gastroenterology, Hepatology & Nutrition, College of Medicine, The Ohio State University, Columbus, Ohio, USA
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Koh YR, Cummings KC. Newer Immunosuppressants for Rheumatologic Disease: Preoperative Considerations. Anesthesiol Clin 2024; 42:131-143. [PMID: 38278585 DOI: 10.1016/j.anclin.2023.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2024]
Abstract
With the advent of small-molecule immune modulators, recombinant fusion proteins, and monoclonal antibodies, treatment options for patients with rheumatic diseases are now broad. These agents carry significant risks and an individualized approach to each patient, balancing known risks and benefits, remains the most prudent course. This review summarizes the available immunosuppressant treatments, discusses their perioperative implications, and provides recommendations for their perioperative management.
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Affiliation(s)
- Ye Rin Koh
- Anesthesiology Institute, Cleveland Clinic, 9500 Euclid Avenue, E-31, Cleveland, OH 44195, USA
| | - Kenneth C Cummings
- Anesthesiology Institute, Cleveland Clinic, 9500 Euclid Avenue, E-31, Cleveland, OH 44195, USA.
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Blum CA, Roethlisberger EA, Cesana-Nigro N, Winzeler B, Rodondi N, Blum MR, Briel M, Mueller B, Christ-Crain M, Schuetz P. Adjunct prednisone in community-acquired pneumonia: 180-day outcome of a multicentre, double-blind, randomized, placebo-controlled trial. BMC Pulm Med 2023; 23:500. [PMID: 38082273 PMCID: PMC10712075 DOI: 10.1186/s12890-023-02794-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Accepted: 11/28/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND Several trials and meta-analyses found a benefit of adjunct corticosteroids for community-acquired pneumonia with respect to short-term outcome, but there is uncertainty about longer-term health effects. Herein, we evaluated clinical outcomes at long term in patients participating in the STEP trial (Corticosteroid Treatment for Community-Acquired Pneumonia). METHODS This predefined secondary analysis investigated 180-day outcomes in 785 adult patients hospitalized with community-acquired pneumonia included in STEP, a randomised, placebo-controlled, double-blind trial. The primary endpoint was time to death from any cause at 180 days verified by telephone interview. Additional secondary endpoints included pneumonia-related death, readmission, recurrent pneumonia, secondary infections, new hypertension, and new insulin dependence. RESULTS From the originally included 785 patients, 727 were available for intention-to-treat analysis at day 180. There was no difference between groups with respect to time to death from any cause (HR for corticosteroid use 1.15, 95% CI 0.68 to 1.95, p = 0.601). Compared to placebo, corticosteroid-treated patients had significantly higher risks for recurrent pneumonia (OR 2.57, 95% CI 1.29 to 5.12, p = 0.007), secondary infections (OR 1.94, 95% CI 1.25 to 3.03, p = 0.003) and new insulin dependence (OR 8.73, 95% CI 1.10 to 69.62, p = 0.041). There was no difference regarding pneumonia-related death, readmission and new hypertension. CONCLUSIONS In patients with community-acquired pneumonia, corticosteroid use was associated with an increased risk for recurrent pneumonia, secondary infections and new insulin dependence at 180 days. Currently, it is uncertain whether these long-term adverse effects outweigh the short-term effects of corticosteroids in moderate CAP. TRIAL REGISTRATION This trial was registered with ClinicalTrials. gov, number NCT00973154 before the recruitment of the first patient. First posted: September 9, 2009. Last update posted: April 21, 2015.
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Affiliation(s)
- Claudine A Blum
- Endocrinology, Diabetology and Metabolism, Department of Internal Medicine and Department of Clinical Research, University Hospital Basel, 4031, Basel, Switzerland.
- Medical University Clinic, Division of General Internal & Emergency Medicine and Division of Endocrinology, Diabetology and Metabolism, Kantonsspital Aarau, 5001, Aarau, Switzerland.
- Hormonpraxis Aarau, 5000, Aarau, Switzerland.
| | - Eva A Roethlisberger
- Medical University Clinic, Division of General Internal & Emergency Medicine and Division of Endocrinology, Diabetology and Metabolism, Kantonsspital Aarau, 5001, Aarau, Switzerland
| | - Nicole Cesana-Nigro
- Endocrinology, Diabetology and Metabolism, Department of Internal Medicine and Department of Clinical Research, University Hospital Basel, 4031, Basel, Switzerland
- Stoffwechselzentrum, Bürgerspital, 4500, Solothurn, Switzerland
| | - Bettina Winzeler
- Endocrinology, Diabetology and Metabolism, Department of Internal Medicine and Department of Clinical Research, University Hospital Basel, 4031, Basel, Switzerland
| | - Nicolas Rodondi
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, 3010, Bern, Switzerland
| | - Manuel R Blum
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, 3010, Bern, Switzerland
| | - Matthias Briel
- CLEAR-Methods Center, Division of Clinical Epidemiology, Department of Clinical Research, University Hospital Basel and University of Basel, 4031, Basel, Switzerland
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Beat Mueller
- Medical University Clinic, Division of General Internal & Emergency Medicine and Division of Endocrinology, Diabetology and Metabolism, Kantonsspital Aarau, 5001, Aarau, Switzerland
| | - Mirjam Christ-Crain
- Endocrinology, Diabetology and Metabolism, Department of Internal Medicine and Department of Clinical Research, University Hospital Basel, 4031, Basel, Switzerland
| | - Philipp Schuetz
- Medical University Clinic, Division of General Internal & Emergency Medicine and Division of Endocrinology, Diabetology and Metabolism, Kantonsspital Aarau, 5001, Aarau, Switzerland
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Cohen BL, Lincango E, Holubar SD. How to Manage Targeted Immune Suppressants (Biologics and Oral Small-molecule Drugs) Perioperatively for Inflammatory Bowel Disease and non-Inflammatory Bowel Disease surgery. Clin Gastroenterol Hepatol 2023; 21:1148-1151.e1. [PMID: 36934049 DOI: 10.1016/j.cgh.2023.01.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 01/09/2023] [Accepted: 01/17/2023] [Indexed: 03/20/2023]
Affiliation(s)
- Benjamin L Cohen
- Department of Gastroenterology, Hepatology, and Nutrition, Cleveland Clinic, Cleveland, OH.
| | - Eddy Lincango
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, OH
| | - Stefan D Holubar
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, OH
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Jiang W, Jiang X, Xu H, Liu H, Huang Q, Huang Z, Zhou Z, Pei F. The Impact of Perioperative Use of Nonbiologic Disease-Modifying Anti-rheumatic Drugs on Perioperative Blood Loss and Complications in Patients Who Have Rheumatoid Arthritis Undergoing Total Knee Arthroplasty. J Arthroplasty 2023:S0883-5403(23)00079-7. [PMID: 36764400 DOI: 10.1016/j.arth.2023.01.059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 01/25/2023] [Accepted: 01/31/2023] [Indexed: 02/12/2023] Open
Abstract
BACKGROUND The use of disease-modifying antirheumatic drugs (DMARDs) before total knee arthroplasty (TKA) was associated with increased risk of postoperative periprosthetic joint and wound infections as well as worse platelet function in patients who have knee rheumatoid arthritis (RA). This study investigated the effects of DMARDS on perioperative blood loss, complications, and blood transfusion in patients undergoing TKA for knee RA. METHODS We retrospectively enrolled patients undergoing TKA for knee RA at our hospital between 2017 and 2021 who received DMARDs (n = 73) or not (n = 84). Every RA patient was matched with patients who had osteoarthritis (OA) in a ratio of 1:1 or 1:2. Primary outcomes were intraoperative and perioperative blood losses, while secondary outcomes were complications and allogeneic transfusions. RESULTS The mean total (804 versus 728 mL (mL), P = .114), mean intraoperative (113 versus 101 mL, P = .488), or hidden blood losses (705 versus 640 mL, P = .340) did not differ statistically between RA patients who received DMARDs versus those who did not. RA patients who received DMARDs showed significantly greater mean total (804 versus 654 mL, P = .001), intraoperative (113 versus 75 mL, P = .002), and hidden blood losses (705 versus 560 mL, P = .016) than OA patients. No statistical differences were found in complications or allogeneic transfusions. CONCLUSION Although RA patients experienced greater perioperative blood loss than OA patients, there was no statistical difference in perioperative blood loss, complications, or allogeneic transfusions between RA patients who received DMARDs and those who did not.
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Affiliation(s)
- Wenyu Jiang
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, Sichuan, People's Republic of China
| | - Xue Jiang
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, Sichuan, People's Republic of China
| | - Hong Xu
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, Sichuan, People's Republic of China
| | - Huansheng Liu
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, Sichuan, People's Republic of China
| | - Qiang Huang
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, Sichuan, People's Republic of China
| | - Zeyu Huang
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, Sichuan, People's Republic of China
| | - Zongke Zhou
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, Sichuan, People's Republic of China
| | - Fuxing Pei
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, Sichuan, People's Republic of China
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Elsaid MI, Li Y, Bridges JFP, Brock G, Minacapelli CD, Rustgi VK. Association of Bariatric Surgery With Cardiovascular Outcomes in Adults With Severe Obesity and Nonalcoholic Fatty Liver Disease. JAMA Netw Open 2022; 5:e2235003. [PMID: 36205997 PMCID: PMC9547320 DOI: 10.1001/jamanetworkopen.2022.35003] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
IMPORTANCE There are no approved treatments for nonalcoholic fatty liver disease (NAFLD) despite its association with obesity and increased risk of cardiovascular disease (CVD). OBJECTIVE To examine the association between bariatric surgery and CVD risk in individuals with severe obesity and NAFLD. DESIGN, SETTING, AND PARTICIPANTS This large, population-based retrospective cohort study obtained data from the MarketScan Commercial Claims and Encounters database from January 1, 2007, to December 31, 2017. Participants included insured adults aged 18 to 64 years with NAFLD and severe obesity (body mass index ≥40) without a history of bariatric surgery or CVD before NAFLD diagnosis. Baseline characteristics were balanced between individuals who underwent surgery (surgical group) and those who did not (nonsurgical group) using inverse probability of treatment weighting. Data were analyzed from March 2020 to April 2021. EXPOSURES Bariatric surgery (Roux-en-Y gastric bypass, sleeve gastrectomy, and other bariatric procedures) vs nonsurgical care. MAIN OUTCOMES AND MEASURES The main outcome was the incidence of cardiovascular events (primary or secondary composite CVD outcomes). The primary composite outcome included myocardial infarction, heart failure, or ischemic stroke, and the secondary composite outcome included secondary ischemic heart events, transient ischemic attack, secondary cerebrovascular events, arterial embolism and thrombosis, or atherosclerosis. Cox proportional hazards regression models with inverse probability treatment weighting were used to examine the associations between bariatric surgery, modeled as time varying, and all outcomes. RESULTS The study included 86 964 adults (mean [SD] age, 44.3 [10.9] years; 59 773 women [68.7%]). Of these individuals, 30 300 (34.8%) underwent bariatric surgery and 56 664 (65.2%) received nonsurgical care. All baseline covariates were balanced after applying inverse probability treatment weighting. In the surgical group, 1568 individuals experienced incident cardiovascular events compared with 7215 individuals in the nonsurgical group (incidence rate difference, 4.8 [95% CI, 4.5-5.0] per 100 person-years). At the end of the study, bariatric surgery was associated with a 49% lower risk of CVD (adjusted hazard ratio [aHR], 0.51; 95% CI, 0.48-0.54) compared with nonsurgical care. The risk of primary composite CVD outcomes was reduced by 47% (aHR, 0.53 [95% CI, 0.48-0.59), and the risk of secondary composite CVD outcomes decreased by 50% (aHR, 0.50; 95% CI, 0.46-0.53) in individuals with vs without surgery. CONCLUSIONS AND RELEVANCE Results of this study suggest that, compared with nonsurgical care, bariatric surgery was associated with significant reduction in CVD risk in individuals with severe obesity and NAFLD.
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Affiliation(s)
- Mohamed I. Elsaid
- Department of Biomedical Informatics, College of Medicine, The Ohio State University, Columbus
- Secondary Data Core, Center for Biostatistics, College of Medicine, The Ohio State University, Columbus
| | - You Li
- Division of Gastroenterology and Hepatology, Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - John F. P. Bridges
- Department of Biomedical Informatics, College of Medicine, The Ohio State University, Columbus
- Department of Surgery, College of Medicine, The Ohio State University, Columbus
| | - Guy Brock
- Department of Biomedical Informatics, College of Medicine, The Ohio State University, Columbus
- Secondary Data Core, Center for Biostatistics, College of Medicine, The Ohio State University, Columbus
| | - Carlos D. Minacapelli
- Division of Gastroenterology and Hepatology, Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Vinod K. Rustgi
- Division of Gastroenterology and Hepatology, Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
- Center for Liver Diseases and Masses, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
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Davila A, Magee R, France K. A retrospective, single-center cohort study on complications after dental extractions in patients taking biologic agents. J Am Dent Assoc 2022; 153:1060-1069.e5. [PMID: 36115715 DOI: 10.1016/j.adaj.2022.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 07/18/2022] [Accepted: 07/27/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND Although biologic agents represent a growing class of therapeutics, little is known about how these agents affect the provision of dental treatment. METHODS This retrospective case-control study analyzed patients undergoing dental extraction treated with biologic agents from 2017 through 2020. Complications within 30 days postextraction were recorded. RESULTS One-hundred twenty-one patients were treated during 147 encounters. Fifteen patients experienced complications during 16 encounters. Notable or excessive pain was most common (14/16; 88%). Patients who experienced complications were treated with 7 biologic agents: dulaglutide, belimumab, adalimumab, aflibercept, tofacitinib, ranibizumab, and ixekizumab. Complication after extraction-specifically, pain-was elevated for patients receiving aflibercept and ranibizumab. When grouped by class, complications were more common with vascular endothelial growth factor antagonism. CONCLUSIONS The impact of biologics on the provision of and recovery after dental treatment remains unknown. Pain was most commonly reported. Patients treated with vascular endothelial growth factor antagonists experienced an elevated rate of complications. PRACTICAL IMPLICATIONS This study provides preliminary data on how patients taking biologic agents heal after dental extraction. It is limited by small sample sizes. Further work will build on this data to determine appropriate management of patients taking biologics in the dental setting.
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Royzman D, Andreev D, Stich L, Peckert-Maier K, Wild AB, Zinser E, Mühl-Zürbes P, Jones E, Adam S, Frey S, Fuchs M, Kunz M, Bäuerle T, Nagel L, Schett G, Bozec A, Steinkasserer A. The soluble CD83 protein prevents bone destruction by inhibiting the formation of osteoclasts and inducing resolution of inflammation in arthritis. Front Immunol 2022; 13:936995. [PMID: 36003376 PMCID: PMC9393726 DOI: 10.3389/fimmu.2022.936995] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Accepted: 07/08/2022] [Indexed: 12/29/2022] Open
Abstract
Here we show that soluble CD83 induces the resolution of inflammation in an antigen-induced arthritis (AIA) model. Joint swelling and the arthritis-related expression levels of IL-1β, IL-6, RANKL, MMP9, and OC-Stamp were strongly reduced, while Foxp3 was induced. In addition, we observed a significant inhibition of TRAP+ osteoclast formation, correlating with the reduced arthritic disease score. In contrast, cell-specific deletion of CD83 in human and murine precursor cells resulted in an enhanced formation of mature osteoclasts. RNA sequencing analyses, comparing sCD83- with mock treated cells, revealed a strong downregulation of osteoclastogenic factors, such as Oc-Stamp, Mmp9 and Nfatc1, Ctsk, and Trap. Concomitantly, transcripts typical for pro-resolving macrophages, e.g., Mrc1/2, Marco, Klf4, and Mertk, were upregulated. Interestingly, members of the metallothionein (MT) family, which have been associated with a reduced arthritic disease severity, were also highly induced by sCD83 in samples derived from RA patients. Finally, we elucidated the sCD83-induced signaling cascade downstream to its binding to the Toll-like receptor 4/(TLR4/MD2) receptor complex using CRISPR/Cas9-induced knockdowns of TLR4/MyD88/TRIF and MTs, revealing that sCD83 acts via the TRIF-signaling cascade. In conclusion, sCD83 represents a promising therapeutic approach to induce the resolution of inflammation and to prevent bone erosion in autoimmune arthritis.
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Affiliation(s)
- Dmytro Royzman
- Department of Immune Modulation, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Erlangen, Germany
- *Correspondence: Dmytro Royzman, ; Alexander Steinkasserer,
| | - Darja Andreev
- Department of Internal Medicine 3, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Erlangen, Germany
| | - Lena Stich
- Department of Immune Modulation, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Erlangen, Germany
| | - Katrin Peckert-Maier
- Department of Immune Modulation, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Erlangen, Germany
| | - Andreas B. Wild
- Department of Immune Modulation, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Erlangen, Germany
| | - Elisabeth Zinser
- Department of Immune Modulation, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Erlangen, Germany
| | - Petra Mühl-Zürbes
- Department of Immune Modulation, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Erlangen, Germany
| | - Evan Jones
- Department of Immune Modulation, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Erlangen, Germany
| | - Susanne Adam
- Department of Internal Medicine 3, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Erlangen, Germany
| | - Silke Frey
- Department of Internal Medicine 3, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Erlangen, Germany
| | - Maximilian Fuchs
- Fraunhofer Institute for Toxicology and Experimental Medicine (ITEM), Hannover, Germany
| | - Meik Kunz
- Fraunhofer Institute for Toxicology and Experimental Medicine (ITEM), Hannover, Germany
- Department of Medical Informatics, Friedrich-Alexander University (FAU) of Erlangen-Nürnberg, Erlangen, Germany
| | - Tobias Bäuerle
- Institute of Radiology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Erlangen, Germany
| | - Lisa Nagel
- Institute of Radiology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Erlangen, Germany
| | - Georg Schett
- Department of Internal Medicine 3, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Erlangen, Germany
| | - Aline Bozec
- Department of Internal Medicine 3, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Erlangen, Germany
| | - Alexander Steinkasserer
- Department of Immune Modulation, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Erlangen, Germany
- *Correspondence: Dmytro Royzman, ; Alexander Steinkasserer,
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12
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Zisa D, Goodman SM. Perioperative Management of Rheumatic Disease and Therapies. Rheum Dis Clin North Am 2022; 48:455-466. [PMID: 35400371 DOI: 10.1016/j.rdc.2022.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Patients with rheumatic disease, including those with systemic lupus erythematous, rheumatoid arthritis, and spondyloarthritis, use total hip and knee arthroplasties at high rates. They represent a particularly vulnerable population in the perioperative setting because of their diseases and the immunosuppressant therapies used to treat them. Careful planning among internists, medical specialists, and the surgical team must therefore occur preoperatively to minimize risks in the postoperative period, particularly infection. Management of immunosuppressant medications, such as conventional synthetic disease-modifying antirheumatic drugs and targeted therapies including biologics, is one avenue by which this infectious risk can be mitigated.
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Affiliation(s)
- Diane Zisa
- Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
| | - Susan M Goodman
- Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA; Hospital for Special Surgery, Weill Cornell Medicine, 535 East 70th Street, New York, NY 10021, USA.
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13
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Hong M, Zhang ZY, Sun XW, Wang WG, Zhang QD, Guo WS. Pneumocystis jiroveci pneumonia after total hip arthroplasty in a dermatomyositis patient: A case report. World J Clin Cases 2022; 10:3313-3320. [PMID: 35603336 PMCID: PMC9082693 DOI: 10.12998/wjcc.v10.i10.3313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 01/26/2022] [Accepted: 02/20/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Pneumocystis jiroveci pneumonia (PJP) is a serious opportunistic infection that occurs mostly in patients with immunodeficiency and long-term immunosuppressive therapy. In non-human immunodeficiency virus-infected patients, the most important risk factor for PJP is the use of glucocorticoids in combination with other immunosuppressive treatments. The management of glucocorticoids during the perioperative period in patients with dermatomyositis requires special care.
CASE SUMMARY We report a case of PJP in the perioperative period. A 61-year-old woman with a history of anti-melanoma differentiation-associated gene 5 (MDA5)-positive dermatomyositis and interstitial pneumonia was administered with long-term oral methylprednisolone and cyclosporine. The patient underwent right total hip arthroplasty in the orthopaedic department for bilateral osteonecrosis of the femoral head. She was given intravenous drip hydrocortisone before anesthesia and on the first day after surgery and resumed oral methylprednisolone on the second postoperative day. On the fifth day after surgery, the patient suddenly developed dyspnea. The computed tomography scan showed diffuse grid shadows and ground glass shadows in both lungs. Polymerase chain reaction testing of bronchoalveolar lavage fluid was positive for Pneumocystis jiroveci. The patient was eventually diagnosed with PJP and was administered with oral trimethoprim-sulfamethoxazole. At the 6-mo review, there was no recurrence or progression.
CONCLUSION Continued perioperative glucocorticoid use in patients with anti-MDA5-positive dermatomyositis may increase the risk of PJP.
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Affiliation(s)
- Mao Hong
- Beijing University of Chinese Medicine, Beijing 100029, China
- Department of Orthopaedic Surgery, Beijing Key Lab Immune-Mediated Inflammatory Diseases, China-Japan Friendship Hospital, Beijing 100029, China
| | - Zi-Yu Zhang
- Beijing University of Chinese Medicine, Beijing 100029, China
| | - Xiao-Wei Sun
- Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing 100029, China
| | - Wei-Guo Wang
- Department of Orthopaedic Surgery, Beijing Key Lab Immune-Mediated Inflammatory Diseases, China-Japan Friendship Hospital, Beijing 100029, China
| | - Qi-Dong Zhang
- Department of Orthopaedic Surgery, Beijing Key Lab Immune-Mediated Inflammatory Diseases, China-Japan Friendship Hospital, Beijing 100029, China
| | - Wan-Shou Guo
- Department of Orthopaedic Surgery, Beijing Key Lab Immune-Mediated Inflammatory Diseases, China-Japan Friendship Hospital, Beijing 100029, China
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14
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Perioperative Management of Immunosuppressive Medications for Rheumatoid Arthritis. J Hand Surg Am 2022; 47:370-378. [PMID: 35184919 DOI: 10.1016/j.jhsa.2021.09.038] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 07/09/2021] [Accepted: 09/17/2021] [Indexed: 02/02/2023]
Abstract
Operations in patients with rheumatoid arthritis are complicated by the fact that most drugs used in medical management have immunosuppressive mechanisms of action, including corticosteroids and conventional synthetic and biologic disease-modifying antirheumatic drugs. In deciding to continue or discontinue these medications perioperatively, surgeons must weigh the relative risk of infection from immunosuppression against the risk of rheumatoid arthritis symptom flares from reduced medical disease control. The objective of this article is to review the existing evidence regarding perioperative management of immunosuppressive rheumatoid arthritis medications, with a specific focus on relevance to hand and upper-extremity procedures.
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15
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Ito H, Murata K, Sobue Y, Kojima T, Nishida K, Matsushita I, Kawahito Y, Kojima M, Hirata S, Kaneko Y, Kishimoto M, Kohno M, Mori M, Morinobu A, Murashima A, Seto Y, Sugihara T, Tanaka E, Nakayama T, Harigai M. Comprehensive risk analysis of postoperative complications in patients with rheumatoid arthritis for the 2020 update of the Japan College of Rheumatology clinical practice guidelines for the management of rheumatoid arthritis. Mod Rheumatol 2022; 32:296-306. [PMID: 33855932 DOI: 10.1080/14397595.2021.1913824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 04/01/2019] [Indexed: 10/21/2022]
Abstract
OBJECTIVES To examine the risk factors of surgical site infection (SSI), delayed wound healing, and death after orthopedic surgery in patients with rheumatoid arthritis (RA). METHODS We identified articles indexed in the Cochrane Library, PubMed, and Japan Centra Revuo Medicina Web published from 2013 to 2019 and other articles. Articles fulfilling the predefined inclusion criteria were reviewed systematically and their quality was appraised according to the Grading of Recommendations Assessment, Development, and Evaluation system with some modifications. RESULTS After inclusion and exclusion by full-text review, 29 articles were analyzed. Use of biological disease modifying antirheumatic drugs was a risk factor of SSI (risk ratio 1.66, 95% confidence interval 1.25-2.19), but not of delayed wound healing. RA itself was a risk factor of SSI, and oral glucocorticoid use was a risk factor of SSI in three of the four studies analyzed and of postoperative death. Age, male sex, comorbidities such as diabetes mellitus and chronic obstructive pulmonary disease, surgical factors such as foot/ankle and spine surgery and longer operative time were risk factors of those postoperative complications. CONCLUSION Patients with those factors should be dealt with appropriate cautions to strike a risk-benefit balance of orthopedic surgeries.
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Affiliation(s)
- Hiromu Ito
- Department of Advanced Medicine for Rheumatic Diseases and Department of Orthopaedic Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Koichi Murata
- Department of Advanced Medicine for Rheumatic Diseases and Department of Orthopaedic Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Yasumori Sobue
- Department of Orthopedic Surgery, Japanese Red Cross Nagoya Daiichi Hospital, Nagoya, Japan
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Toshihisa Kojima
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Keiichiro Nishida
- Department of Orthopaedic Surgery, Okayama University Graduate School of Medicine, Density and Pharmaceutical Sciences, Okayama, Japan
| | - Isao Matsushita
- Department of Rehabilitation Medicine, Kanazawa Medical University, Ishikawa, Japan
| | - Yutaka Kawahito
- Inflammation and Immunology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Masayo Kojima
- Center for Gerontology and Social Science, National Center for Geriatrics and Gerontology, Aichi, Japan
| | - Shintaro Hirata
- Department of Clinical Immunology and Rheumatology, Hiroshima University Hospital, Hiroshima, Japan
| | - Yuko Kaneko
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Mitsumasa Kishimoto
- Department of Nephrology and Rheumatology, Kyorin University School of Medicine, Tokyo, Japan
| | - Masataka Kohno
- Inflammation and Immunology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Masaaki Mori
- Department of Lifetime Clinical Immunology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Akio Morinobu
- Department of Rheumatology and Clinical Immunology, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Atsuko Murashima
- Center for Maternal-Fetal, Neonatal and Reproductive Medicine/Japan Drug Information Institute in Pregnancy, National Center for Child Health and Development, Tokyo, Japan
| | - Yohei Seto
- Department of Rheumatology, Yachiyo Medical Center, Tokyo Women's Medical University, Chiba, Japan
| | - Takahiko Sugihara
- Department of Lifetime Clinical Immunology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University
| | - Eiichi Tanaka
- Department of Rheumatology, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Takeo Nakayama
- Department of Health Informatics, Kyoto University School of Public Health, Kyoto, Japan
| | - Masayoshi Harigai
- Department of Rheumatology, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
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16
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Wang S, Hou Y, Li X, Meng X, Zhang Y, Wang X. Practical Implementation of Artificial Intelligence-Based Deep Learning and Cloud Computing on the Application of Traditional Medicine and Western Medicine in the Diagnosis and Treatment of Rheumatoid Arthritis. Front Pharmacol 2022; 12:765435. [PMID: 35002704 PMCID: PMC8733656 DOI: 10.3389/fphar.2021.765435] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Accepted: 12/09/2021] [Indexed: 12/23/2022] Open
Abstract
Rheumatoid arthritis (RA), an autoimmune disease of unknown etiology, is a serious threat to the health of middle-aged and elderly people. Although western medicine, traditional medicine such as traditional Chinese medicine, Tibetan medicine and other ethnic medicine have shown certain advantages in the diagnosis and treatment of RA, there are still some practical shortcomings, such as delayed diagnosis, improper treatment scheme and unclear drug mechanism. At present, the applications of artificial intelligence (AI)-based deep learning and cloud computing has aroused wide attention in the medical and health field, especially in screening potential active ingredients, targets and action pathways of single drugs or prescriptions in traditional medicine and optimizing disease diagnosis and treatment models. Integrated information and analysis of RA patients based on AI and medical big data will unquestionably benefit more RA patients worldwide. In this review, we mainly elaborated the application status and prospect of AI-assisted deep learning and cloud computation-oriented western medicine and traditional medicine on the diagnosis and treatment of RA in different stages. It can be predicted that with the help of AI, more pharmacological mechanisms of effective ethnic drugs against RA will be elucidated and more accurate solutions will be provided for the treatment and diagnosis of RA in the future.
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Affiliation(s)
- Shaohui Wang
- School of Ethnic Medicine, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Ya Hou
- School of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Xuanhao Li
- Chengdu Second People's Hospital, Chengdu, China
| | - Xianli Meng
- State Key Laboratory of Southwestern Chinese Medicine Resources, Innovative Institute of Chinese Medicine and Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Yi Zhang
- School of Ethnic Medicine, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Xiaobo Wang
- State Key Laboratory of Southwestern Chinese Medicine Resources, Innovative Institute of Chinese Medicine and Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu, China
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17
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Hu Q, Zhong X, Tian H, Liao P. The Efficacy of Denosumab in Patients With Rheumatoid Arthritis: A Systematic Review and Pooled Analysis of Randomized or Matched Data. Front Immunol 2022; 12:799575. [PMID: 35069583 PMCID: PMC8766643 DOI: 10.3389/fimmu.2021.799575] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 12/13/2021] [Indexed: 12/19/2022] Open
Abstract
Objective The purpose of this study was to evaluate the efficacy of denosumab treatment in patients with rheumatoid arthritis (RA). Methods The Medline, Embase and Cochrane Library databases were searched for relevant clinical studies. Studies that assessed the efficacy of denosumab in patients with RA were identified. The primary endpoints were the percent changes in bone mineral density (BMD), and the changes in modified total Sharp score (mTSS), modified Sharp erosion score and joint space narrowing (JSN) score. Pooled analyses were calculated using random-effect models. Results After searching the literature and performing further detailed assessments, 10 studies with a total of 1758 patients were included in the quantitative analysis. Pooled analyses showed that denosumab treatment significantly increased the percent changes in lumbar spine BMD [mean difference (MD): 5.12, confidence intervals (CI): 4.15 to 6.09], total hip BMD (MD: 2.72, 95% CI: 1.80 to 3.64) and femoral neck BMD (MD: 2.20, 95% CI: 0.94 to 3.46) compared with controls. Moreover, denosumab treatment significantly decreased the changes in mTSS (MD: -0.63, 95% CI: -0.86 to -0.41) and modified Sharp erosion score (MD: -0.62, 95% CI: -0.88 to -0.35). Subgroup analysis indicated that denosumab was superior to bisphosphonates for the improvement of BMD and the mitigation of joint destruction. Conclusion Denosumab treatment was associated with increased BMD and alleviated progression of joint destruction in RA patients, even when compared with bisphosphonates.
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Affiliation(s)
- Qiongwen Hu
- Department of Medical Laboratory, Chongqing General Hospital, University of Chinese Academy of Sciences, Chongqing, China
| | - Xue Zhong
- Department of Nephrology, Chongqing General Hospital, University of Chinese Academy of Sciences, Chongqing, China
| | - Hua Tian
- Department of Medical Laboratory, Chongqing General Hospital, University of Chinese Academy of Sciences, Chongqing, China
| | - Pu Liao
- Department of Medical Laboratory, Chongqing General Hospital, University of Chinese Academy of Sciences, Chongqing, China
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18
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Zhou P, Chen J, He J, Zheng T, Yunis J, Makota V, Alexandre YO, Gong F, Zhang X, Xie W, Li Y, Shao M, Zhu Y, Sinclair JE, Miao M, Chen Y, Short KR, Mueller SN, Sun X, Yu D, Li Z. Low-dose IL-2 therapy invigorates CD8+ T cells for viral control in systemic lupus erythematosus. PLoS Pathog 2021; 17:e1009858. [PMID: 34618873 PMCID: PMC8525737 DOI: 10.1371/journal.ppat.1009858] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 10/19/2021] [Accepted: 07/30/2021] [Indexed: 01/10/2023] Open
Abstract
Autoimmune diseases are often treated by glucocorticoids and immunosuppressive drugs that could increase the risk for infection, which in turn deteriorate disease and cause mortality. Low-dose IL-2 (Ld-IL2) therapy emerges as a new treatment for a wide range of autoimmune diseases. To examine its influence on infection, we retrospectively studied 665 patients with systemic lupus erythematosus (SLE) including about one third receiving Ld-IL2 therapy, where Ld-IL2 therapy was found beneficial in reducing the incidence of infections. In line with this clinical observation, IL-2 treatment accelerated viral clearance in mice infected with influenza A virus or lymphocytic choriomeningitis virus (LCMV). Noticeably, despite enhancing anti-viral immunity in LCMV infection, IL-2 treatment exacerbated CD8+ T cell-mediated immunopathology. In summary, Ld-IL2 therapy reduced the risk of infections in SLE patients and enhanced the control of viral infection, but caution should be taken to avoid potential CD8+ T cell-mediated immunopathology.
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Affiliation(s)
- Pengcheng Zhou
- Department of Immunology and Infectious Disease, The John Curtin School of Medical Research, The Australian National University, Canberra, ACT, Australia
- The University of Queensland Diamantina Institute, Translational Research Institute, Brisbane, Australia
| | - Jiali Chen
- Department of Rheumatology and Immunology, Peking University People’s Hospital, Beijing Key Laboratory for Rheumatism Mechanism and Immune Diagnosis (BZ0135), Beijing, China
| | - Jing He
- Department of Rheumatology and Immunology, Peking University People’s Hospital, Beijing Key Laboratory for Rheumatism Mechanism and Immune Diagnosis (BZ0135), Beijing, China
| | - Ting Zheng
- Laboratory of Immunology for Environment and Health, Shandong Analysis and Test Center, Qilu University of Technology (Shandong Academy of Sciences), Jinan, China
| | - Joseph Yunis
- The University of Queensland Diamantina Institute, Translational Research Institute, Brisbane, Australia
| | - Victor Makota
- Department of Immunology and Infectious Disease, The John Curtin School of Medical Research, The Australian National University, Canberra, ACT, Australia
| | - Yannick O. Alexandre
- Department of Microbiology and Immunology, The University of Melbourne, The Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | - Fang Gong
- Department of Laboratory Medicine, Affiliated Hospital of Jiangnan University, Wuxi, China
| | - Xia Zhang
- Department of Rheumatology and Immunology, Peking University People’s Hospital, Beijing Key Laboratory for Rheumatism Mechanism and Immune Diagnosis (BZ0135), Beijing, China
| | - Wuxiang Xie
- Peking University Clinical Research Institute, Peking University Health Science Center, Beijing, China
| | - Yuhui Li
- Department of Rheumatology and Immunology, Peking University People’s Hospital, Beijing Key Laboratory for Rheumatism Mechanism and Immune Diagnosis (BZ0135), Beijing, China
| | - Miao Shao
- Department of Rheumatology and Immunology, Peking University People’s Hospital, Beijing Key Laboratory for Rheumatism Mechanism and Immune Diagnosis (BZ0135), Beijing, China
| | - Yanshan Zhu
- School of Chemistry and Molecular Biosciences, The University of Queensland, Brisbane, Australia
| | - Jane E. Sinclair
- School of Chemistry and Molecular Biosciences, The University of Queensland, Brisbane, Australia
| | - Miao Miao
- Department of Rheumatology and Immunology, Peking University People’s Hospital, Beijing Key Laboratory for Rheumatism Mechanism and Immune Diagnosis (BZ0135), Beijing, China
| | - Yaping Chen
- Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, VIC, Australia
| | - Kirsty R. Short
- School of Chemistry and Molecular Biosciences, The University of Queensland, Brisbane, Australia
| | - Scott N. Mueller
- Department of Microbiology and Immunology, The University of Melbourne, The Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | - Xiaolin Sun
- Department of Rheumatology and Immunology, Peking University People’s Hospital, Beijing Key Laboratory for Rheumatism Mechanism and Immune Diagnosis (BZ0135), Beijing, China
| | - Di Yu
- Department of Immunology and Infectious Disease, The John Curtin School of Medical Research, The Australian National University, Canberra, ACT, Australia
- The University of Queensland Diamantina Institute, Translational Research Institute, Brisbane, Australia
- Laboratory of Immunology for Environment and Health, Shandong Analysis and Test Center, Qilu University of Technology (Shandong Academy of Sciences), Jinan, China
| | - Zhanguo Li
- Department of Rheumatology and Immunology, Peking University People’s Hospital, Beijing Key Laboratory for Rheumatism Mechanism and Immune Diagnosis (BZ0135), Beijing, China
- Peking-Tsinghua Center for Life Sciences, Beijing, China
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19
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Yazdanyar A, Donato A, Wasko MC, Ward MM. Risk of 30-day Readmission after Knee or Hip Replacement in Rheumatoid Arthritis and Osteoarthritis by non-Medicare and Medicare Payer Status. J Rheumatol 2021; 49:205-212. [PMID: 34599044 DOI: 10.3899/jrheum.201370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/15/2021] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To determine the indication and risk of 30-day rehospitalization after hip or knee replacement among rheumatoid arthritis (RA) and osteoarthritis (OA) by Medicare and non-Medicare status. METHODS Using the Nationwide Readmission Database (2010-2014), we defined an Index hospitalization as an elective hospitalization with a principal procedure of total hip or knee replacement among adults aged ≥18 years. Primary payer was categorized as Medicare or non- Medicare. Survey logistic regression provided the odds of 30-day rehospitalization in RA relative to OA. We calculated the rates for principal diagnoses leading to rehospitalization. RESULTS Overall, 3.53% of 2,190,745 index hospitalization had a 30-day rehospitalization. Patients with RA had a higher adjusted risk of rehospitalization after TKR (Odds Ratio [OR], 1.11; 95% Confidence Interval [CI], 1.02 to 1.21) and THR (OR, 1.39; 95% CI, 1.19 to 1.62). Persons with RA and OA did not differ with respect to rates of infections, cardiac events, or postoperative complications leading to the rehospitalization. After TKR, RA patients with Medicare had a lower VTE risk (OR, 0.58;95% CI, 0.58 to 0.88) while post-THR those with RA had a greater VTE risk (OR, 2.41;95% CI, 1.04 to 5.57). CONCLUSION RA patients had a higher 30-day rehospitalization than OA after TKR and THR regardless of payer type. While infections, postoperative complications, cardiac did not differ, there was a significant difference in venous thromboembolism as the rehospitalization's principal diagnosis.
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Affiliation(s)
- Ali Yazdanyar
- Department of Emergency and Hospital Medicine, Lehigh Valley Hospital-Cedar Crest, Allentown, PA; Morsani College of Medicine, University of South Florida, Tampa, FL; Department of Medicine, Reading Hospital-Tower Health, Reading, PA; Department of Medicine/Rheumatology, Allegheny Health Network-West Penn Hospital, Division of Rheumatology, Pittsburgh, PA; National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD. Funding: Michael M Ward, MD MPH was funded by the Intramural Research Program, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health. Conflicts of Interest: No conflict of interest to report by any of the authors of this manuscript. Corresponding Author: Ali Yazdanyar, DO PhD MS, Lehigh Valley Hospital-Cedar Crest, Department of Emergency and Hospital Medicine, 1200 South Cedar Crest Blvd, 3rd Floor, Anderson Wing, Allentown, PA 18103.
| | - Anthony Donato
- Department of Emergency and Hospital Medicine, Lehigh Valley Hospital-Cedar Crest, Allentown, PA; Morsani College of Medicine, University of South Florida, Tampa, FL; Department of Medicine, Reading Hospital-Tower Health, Reading, PA; Department of Medicine/Rheumatology, Allegheny Health Network-West Penn Hospital, Division of Rheumatology, Pittsburgh, PA; National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD. Funding: Michael M Ward, MD MPH was funded by the Intramural Research Program, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health. Conflicts of Interest: No conflict of interest to report by any of the authors of this manuscript. Corresponding Author: Ali Yazdanyar, DO PhD MS, Lehigh Valley Hospital-Cedar Crest, Department of Emergency and Hospital Medicine, 1200 South Cedar Crest Blvd, 3rd Floor, Anderson Wing, Allentown, PA 18103.
| | - Mary Chester Wasko
- Department of Emergency and Hospital Medicine, Lehigh Valley Hospital-Cedar Crest, Allentown, PA; Morsani College of Medicine, University of South Florida, Tampa, FL; Department of Medicine, Reading Hospital-Tower Health, Reading, PA; Department of Medicine/Rheumatology, Allegheny Health Network-West Penn Hospital, Division of Rheumatology, Pittsburgh, PA; National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD. Funding: Michael M Ward, MD MPH was funded by the Intramural Research Program, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health. Conflicts of Interest: No conflict of interest to report by any of the authors of this manuscript. Corresponding Author: Ali Yazdanyar, DO PhD MS, Lehigh Valley Hospital-Cedar Crest, Department of Emergency and Hospital Medicine, 1200 South Cedar Crest Blvd, 3rd Floor, Anderson Wing, Allentown, PA 18103.
| | - Michael M Ward
- Department of Emergency and Hospital Medicine, Lehigh Valley Hospital-Cedar Crest, Allentown, PA; Morsani College of Medicine, University of South Florida, Tampa, FL; Department of Medicine, Reading Hospital-Tower Health, Reading, PA; Department of Medicine/Rheumatology, Allegheny Health Network-West Penn Hospital, Division of Rheumatology, Pittsburgh, PA; National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD. Funding: Michael M Ward, MD MPH was funded by the Intramural Research Program, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health. Conflicts of Interest: No conflict of interest to report by any of the authors of this manuscript. Corresponding Author: Ali Yazdanyar, DO PhD MS, Lehigh Valley Hospital-Cedar Crest, Department of Emergency and Hospital Medicine, 1200 South Cedar Crest Blvd, 3rd Floor, Anderson Wing, Allentown, PA 18103.
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20
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Sellam J, Morel J, Tournadre A, Bouhnik Y, Cornec D, Devauchelle-Pensec V, Dieudé P, Goupille P, Jullien D, Kluger N, Lazaro E, Le Goff B, de Lédinghen V, Lequerré T, Nocturne G, Seror R, Truchetet ME, Verhoeven F, Pham T, Richez C. PRACTICAL MANAGEMENT of patients on anti-TNF therapy: Practical guidelines drawn up by the Club Rhumatismes et Inflammation (CRI). Joint Bone Spine 2021; 88:105174. [PMID: 33992225 DOI: 10.1016/j.jbspin.2021.105174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Jérémie Sellam
- Service de Rhumatologie, CHU Saint-Antoine, Paris, France
| | - Jacques Morel
- Service de Rhumatologie, CHU Montpellier, Montpellier, France
| | - Anne Tournadre
- Service de Rhumatologie, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Yoram Bouhnik
- Service de Gastro-entérologie, CHU Hôpital Beaujon, Clichy, France
| | - Divi Cornec
- Service de Rhumatologie, CHRU La Cavale Blanche, Brest, France
| | | | - Philippe Dieudé
- Service de Rhumatologie, CHU Bichat-Claude Bernard, Paris, France
| | | | | | - Nicolas Kluger
- Dpt Dermatology, Helsinki, Finland; Service de Dermatologie, CHU Bichat-Claude Bernard, Paris, France
| | - Estibaliz Lazaro
- Service de Médecine interne, Hôpital Haut-Lévêque, CHU Bordeaux, Pessac, France
| | | | - Victor de Lédinghen
- Unité d'Hépatologie et transplantation hépatique, Hôpital Haut-Lévêque, CHU Bordeaux, Pessac, France
| | | | | | - Raphaèle Seror
- Service de Rhumatologie, Bicêtre, Le Kremlin-Bicêtre, France
| | | | | | - Thao Pham
- Service de Rhumatologie, CHU Sainte-Marguerite, Marseille, France
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21
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Morel J, Tournadre A, Sellam J, Bouhnik Y, Cornec D, Devauchelle-Pensec V, Dieudé P, Goupille P, Kluger N, Lazaro E, Le Goff B, de Lédinghen V, Lequerré T, Nocturne G, Seror R, Truchetet ME, Verhoeven F, Pham T, Richez C. Practical Management of patients on anti-IL6R therapy: Practical guidelines drawn up by the Club Rhumatismes et Inflammation (CRI). Joint Bone Spine 2021; 88:105221. [PMID: 34183155 DOI: 10.1016/j.jbspin.2021.105221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Jacques Morel
- Service de Rhumatologie, CHU Montpellier, Montpellier, France
| | - Anne Tournadre
- Service de Rhumatologie, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Jérémie Sellam
- Service de Rhumatologie, CHU Saint-Antoine, Paris, France
| | - Yoram Bouhnik
- Service de Gastro-entérologie, CHU Hôpital Beaujon, Clichy, France
| | - Divi Cornec
- Service de Rhumatologie, CHRU La Cavale Blanche, Brest, France
| | | | - Philippe Dieudé
- Service de Rhumatologie, CHU Bichat-Claude Bernard, Paris, France
| | | | - Nicolas Kluger
- Dpt Dermatology, Helsinki, Finland & Service de Dermatologie, CHU Bichat-Claude Bernard, Paris, France
| | - Estibaliz Lazaro
- Service de Médecine interne, Hôpital Haut-Lévêque, CHU Bordeaux, Pessac, France
| | | | - Victor de Lédinghen
- Unité d'Hépatologie et transplantation hépatique, Hôpital Haut-Lévêque, CHU Bordeaux, Pessac, France
| | | | | | - Raphaèle Seror
- Service de Rhumatologie, Bicêtre, Le Kremlin-Bicêtre, France
| | | | | | - Thao Pham
- Service de Rhumatologie, CHU Sainte-Marguerite, Marseille, France
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22
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Fraenkel L, Bathon JM, England BR, St.Clair EW, Arayssi T, Carandang K, Deane KD, Genovese M, Huston KK, Kerr G, Kremer J, Nakamura MC, Russell LA, Singh JA, Smith BJ, Sparks JA, Venkatachalam S, Weinblatt ME, Al-Gibbawi M, Baker JF, Barbour KE, Barton JL, Cappelli L, Chamseddine F, George M, Johnson SR, Kahale L, Karam BS, Khamis AM, Navarro-Millán I, Mirza R, Schwab P, Singh N, Turgunbaev M, Turner AS, Yaacoub S, Akl EA. 2021 American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis. Arthritis Care Res (Hoboken) 2021; 73:924-939. [PMID: 34101387 PMCID: PMC9273041 DOI: 10.1002/acr.24596] [Citation(s) in RCA: 375] [Impact Index Per Article: 125.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 03/15/2021] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To develop updated guidelines for the pharmacologic management of rheumatoid arthritis. METHODS We developed clinically relevant population, intervention, comparator, and outcomes (PICO) questions. After conducting a systematic literature review, the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to rate the certainty of evidence. A voting panel comprising clinicians and patients achieved consensus on the direction (for or against) and strength (strong or conditional) of recommendations. RESULTS The guideline addresses treatment with disease-modifying antirheumatic drugs (DMARDs), including conventional synthetic DMARDs, biologic DMARDs, and targeted synthetic DMARDs, use of glucocorticoids, and use of DMARDs in certain high-risk populations (i.e., those with liver disease, heart failure, lymphoproliferative disorders, previous serious infections, and nontuberculous mycobacterial lung disease). The guideline includes 44 recommendations (7 strong and 37 conditional). CONCLUSION This clinical practice guideline is intended to serve as a tool to support clinician and patient decision-making. Recommendations are not prescriptive, and individual treatment decisions should be made through a shared decision-making process based on patients' values, goals, preferences, and comorbidities.
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Affiliation(s)
- Liana Fraenkel
- Berkshire Medical Center, Pittsfield, Massachusetts, and Yale University School of Medicine, New Haven, Connecticut
| | - Joan M. Bathon
- Columbia University Irving Medical Center, New York Presbyterian Hospital, New York, New York
| | - Bryant R. England
- University of Nebraska Medical Center and VA Nebraska–Western Iowa Health Care System, Omaha, Nebraska
| | | | | | | | | | - Mark Genovese
- Stanford University Medical Center, Palo Alto, California
| | - Kent Kwas Huston
- The Center for Rheumatic Disease/Allergy and Immunology, Kansas City, Missouri
| | - Gail Kerr
- Veterans Affairs Medical Center, Georgetown and Howard University, Washington, DC
| | - Joel Kremer
- Albany Medical College and The Center for Rheumatology, Albany, New York
| | | | | | - Jasvinder A. Singh
- University of Alabama at Birmingham and Birmingham Veterans Affairs Medical Center, Birmingham, Alabama
| | - Benjamin J. Smith
- State University College of Medicine School of Physician Assistant Practice, Tallahassee
| | - Jeffrey A. Sparks
- Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | | | | | | | - Joshua F. Baker
- Corporal Michael J. Crescenz VA Medical Center and the University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Jennifer L. Barton
- Oregon Health & Science University and VA Portland Health Care System, Portland, Oregon
| | | | | | | | - Sindhu R. Johnson
- Toronto Western Hospital, Mount Sinai Hospital, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Lara Kahale
- American University of Beirut, Beirut, Lebanon
| | | | | | | | - Reza Mirza
- University of Toronto, Toronto, Ontario, Canada
| | - Pascale Schwab
- Oregon Health & Science University and VA Portland Health Care System, Portland, Oregon
| | | | | | | | | | - Elie A. Akl
- American University of Beirut, Beirut, Lebanon
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Rustgi VK, Li Y, Gupta K, Minacapelli CD, Bhurwal A, Catalano C, Elsaid MI. Bariatric Surgery Reduces Cancer Risk in Adults With Nonalcoholic Fatty Liver Disease and Severe Obesity. Gastroenterology 2021; 161:171-184.e10. [PMID: 33744305 DOI: 10.1053/j.gastro.2021.03.021] [Citation(s) in RCA: 74] [Impact Index Per Article: 24.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 02/23/2021] [Accepted: 03/13/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND & AIMS Nonalcoholic fatty liver disease (NAFLD) is associated with obesity and increased risk of cancer. The impacts of bariatric surgery on cancer risk in NAFLD patients are unknown. We investigated the effect of bariatric surgery on cancer risk in patients with NAFLD and severe obesity using the MarketScan database. METHODS We conducted a retrospective cohort study of 18 to 64 years old newly diagnosed NAFLD patients with severe obesity between 2007 and 2017. We used Cox proportional hazard models to examine the association between bariatric surgery, modeled as a time-varying covariate, and the risks of any cancer and obesity-related cancer, while accounting for confounding using inverse probability of treatment weighting (IPTW). RESULTS A total of 98,090 patients were included in the study, 33,435 (34.1%) received bariatric surgery. In those without surgery, 1898 incident cases of cancer occurred over 115,890.11 person-years of follow-up, compared with 925 cancer cases over 67,389.82 person-years among surgery patients (crude rate ratio, 0.84; 95% CI, 0.77- 0.91). The IPTW-adjusted risk of any cancer and obesity-related cancer was reduced by 18% (hazard ratio, 0.82; 95% CI, 0.76-0.89) and 25% (hazard ratio, 0.65; 95% CI, 0.56-0.75), respectively, in patients with versus without bariatric surgery. The adjusted risks of any cancer and obesity-related cancer were significantly lower in cirrhotic versus non-cirrhotic patients who underwent surgery. In cancer-specific models, bariatric surgery was associated with significant risk reductions for colorectal, pancreatic, endometrial, thyroid cancers, hepatocellular carcinoma, and multiple myeloma. CONCLUSION Bariatric surgery was associated with significant reductions in the risks of any cancer and obesity-related cancer in NAFLD patients with severe obesity.
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Affiliation(s)
- Vinod K Rustgi
- Division of Gastroenterology and Hepatology, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey; Center for Liver Diseases and Masses, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey.
| | - You Li
- Division of Gastroenterology and Hepatology, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey; Center for Liver Diseases and Masses, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Kapil Gupta
- Division of Gastroenterology and Hepatology, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey; Center for Liver Diseases and Masses, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Carlos D Minacapelli
- Division of Gastroenterology and Hepatology, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey; Center for Liver Diseases and Masses, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Abhishek Bhurwal
- Division of Gastroenterology and Hepatology, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey; Center for Liver Diseases and Masses, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Carolyn Catalano
- Division of Gastroenterology and Hepatology, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey; Center for Liver Diseases and Masses, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Mohamed I Elsaid
- Division of Gastroenterology and Hepatology, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey; Center for Liver Diseases and Masses, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
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24
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Goodman SM, George MD. 'Should we stop or continue conventional synthetic (including glucocorticoids) and targeted DMARDs before surgery in patients with inflammatory rheumatic diseases?'. RMD Open 2021; 6:rmdopen-2020-001214. [PMID: 32719151 PMCID: PMC7722271 DOI: 10.1136/rmdopen-2020-001214] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 06/03/2020] [Accepted: 06/05/2020] [Indexed: 12/14/2022] Open
Abstract
Total hip and total knee arthroplasty) remain important interventions to treat symptomatic knee and hip damage in patients with rheumatoid arthritis, with little change in utilisation rates despite the increasingly widespread use of potent conventional synthetic disease-modifying anti-rheumatic drugs (csDMARDs) and targeted DMARDs including Janus kinase inhibitors and biologics. The majority of patients are receiving these immunosuppressing medications and glucocorticoids at the time they present for arthroplasty. There is minimal randomised controlled trial data addressing the use of DMARDs in the perioperative period, yet patients and their physicians face these decisions daily. This paper reviews what is known regarding perioperative management of targeted and csDMARDs and glucocorticoids.
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Affiliation(s)
- Susan M Goodman
- Department of Medicine, Hospital for Special Surgery, Weill Cornell Medicine, New York, USA
| | - Michael D George
- Department of Biostatistics, Epidemiology and Informatics, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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25
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Fraenkel L, Bathon JM, England BR, St Clair EW, Arayssi T, Carandang K, Deane KD, Genovese M, Huston KK, Kerr G, Kremer J, Nakamura MC, Russell LA, Singh JA, Smith BJ, Sparks JA, Venkatachalam S, Weinblatt ME, Al-Gibbawi M, Baker JF, Barbour KE, Barton JL, Cappelli L, Chamseddine F, George M, Johnson SR, Kahale L, Karam BS, Khamis AM, Navarro-Millán I, Mirza R, Schwab P, Singh N, Turgunbaev M, Turner AS, Yaacoub S, Akl EA. 2021 American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis. Arthritis Rheumatol 2021; 73:1108-1123. [PMID: 34101376 DOI: 10.1002/art.41752] [Citation(s) in RCA: 310] [Impact Index Per Article: 103.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 03/15/2021] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To develop updated guidelines for the pharmacologic management of rheumatoid arthritis. METHODS We developed clinically relevant population, intervention, comparator, and outcomes (PICO) questions. After conducting a systematic literature review, the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to rate the certainty of evidence. A voting panel comprising clinicians and patients achieved consensus on the direction (for or against) and strength (strong or conditional) of recommendations. RESULTS The guideline addresses treatment with disease-modifying antirheumatic drugs (DMARDs), including conventional synthetic DMARDs, biologic DMARDs, and targeted synthetic DMARDs, use of glucocorticoids, and use of DMARDs in certain high-risk populations (i.e., those with liver disease, heart failure, lymphoproliferative disorders, previous serious infections, and nontuberculous mycobacterial lung disease). The guideline includes 44 recommendations (7 strong and 37 conditional). CONCLUSION This clinical practice guideline is intended to serve as a tool to support clinician and patient decision-making. Recommendations are not prescriptive, and individual treatment decisions should be made through a shared decision-making process based on patients' values, goals, preferences, and comorbidities.
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Affiliation(s)
- Liana Fraenkel
- Berkshire Medical Center, Pittsfield, Massachusetts, and Yale University School of Medicine, New Haven, Connecticut, United States
| | - Joan M Bathon
- Columbia University Irving Medical Center, New York Presbyterian Hospital, New York, New York, United States
| | - Bryant R England
- University of Nebraska Medical Center and VA Nebraska-Western Iowa Health Care System, Omaha, Nebraska, United States
| | | | | | | | | | - Mark Genovese
- Stanford University Medical Center, Palo Alto, California, United States
| | - Kent Kwas Huston
- The Center for Rheumatic Disease/Allergy and Immunology, Kansas City, Missouri, United States
| | - Gail Kerr
- Veterans Affairs Medical Center, Georgetown and Howard University, Washington, DC, United States
| | - Joel Kremer
- Albany Medical College and The Center for Rheumatology, Albany, New York, United States
| | | | - Linda A Russell
- Hospital for Special Surgery, New York, New York, United States
| | - Jasvinder A Singh
- University of Alabama at Birmingham and Birmingham Veterans Affairs Medical Center, Birmingham, Alabama, United States
| | - Benjamin J Smith
- Florida State University College of Medicine School of Physician Assistant Practice, Tallahassee
| | - Jeffrey A Sparks
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, United States
| | | | - Michael E Weinblatt
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, United States
| | | | - Joshua F Baker
- Corporal Michael J. Crescenz VA Medical Center and the University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - Kamil E Barbour
- Centers for Disease Control and Prevention, Atlanta, Georgia, United States
| | - Jennifer L Barton
- Oregon Health & Science University and VA Portland Health Care System, Portland, Oregon, United States
| | - Laura Cappelli
- Johns Hopkins Medicine, Baltimore, Maryland, United States
| | | | | | - Sindhu R Johnson
- Toronto Western Hospital, Mount Sinai Hospital, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Lara Kahale
- American University of Beirut, Beirut, Lebanon
| | | | | | | | - Reza Mirza
- University of Toronto, Toronto, Ontario, Canada
| | - Pascale Schwab
- Oregon Health & Science University and VA Portland Health Care System, Portland, Oregon, United States
| | | | - Marat Turgunbaev
- American College of Rheumatology, Atlanta, Georgia, United States
| | - Amy S Turner
- American College of Rheumatology, Atlanta, Georgia, United States
| | | | - Elie A Akl
- American University of Beirut, Beirut, Lebanon
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26
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Portney DA, Baker HP, Boyle MM, Barbosa VH, Luu HH. Drug Reaction with Eosinophilia and Systemic Syndrome in Revision Arthroplasty for a Prosthetic Knee Infection: A Case Report. JBJS Case Connect 2021; 11:e20.00805. [PMID: 34038391 DOI: 10.2106/jbjs.cc.20.00805] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CASE A 51-year-old woman underwent stage I of a 2-stage revision for a prosthetic knee infection with a vancomycin-impregnated articulating cement spacer followed by IV vancomycin and ceftriaxone. Four weeks later, she developed fevers, a diffuse cutaneous eruption, lymphadenopathy, transaminitis, and acute renal tubular necrosis before being diagnosed with drug reaction with eosinophilia and systemic syndrome (DRESS). CONCLUSION DRESS is a rare, potentially life-threatening adverse drug reaction with cutaneous manifestations and multiorgan involvement. Although rare, its incidence in orthopaedic patients is likely to increase with the aging population. It must be recognized early to minimize end-stage organ dysfunction and mortality.
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Affiliation(s)
- Daniel A Portney
- Department of Orthopaedic Surgery, University of Chicago, Chicago, Illinois
| | - Hayden P Baker
- Department of Orthopaedic Surgery, University of Chicago, Chicago, Illinois
| | - Margaret M Boyle
- Department of Dermatology, University of Chicago, Chicago, Illinois
| | | | - Hue H Luu
- Department of Orthopaedic Surgery, University of Chicago, Chicago, Illinois
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27
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Dubourg S, Huck O, Jung S. Implant-based oral rehabilitation in systemic sclerosis patients: a systematic review. J ORAL IMPLANTOL 2021; 48:251-260. [PMID: 33945625 DOI: 10.1563/aaid-joi-d-20-00384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Systemic sclerosis is a rare multisystem autoimmune disorder that significantly impacts the orofacial region. Several oral features including microstomia and increased tooth loss contribute to the mouth-related disability. Prosthetic rehabilitation is very challenging in these patients. As the spectrum of dental implants indications has been recently extended to patients with various systemic disorders, the aim of this systematic review was to evaluate the outcome of dental implants in patients with systemic sclerosis. A literature search was conducted in Medline/PubMed database to identify eligible case-reports. 10 publications were included in qualitative synthesis. A total of 71 implants have been reported in 10 patients with systemic sclerosis with a mean of 7.1 +/- 3.8 implants per patient. Pre-implant surgeries have been described for 3 patients. Implant survival rates were higher than 98% but the mean follow-up time was only 28.3 +/- 18.6 months. Complications have been observed in 3 patients with 1 implant failure and peri-implant bone resorption in 2 patients. Although implant survival rates were high, an individualized assessment of risk-benefit balance is mandatory before indicating implant-based rehabilitation in patients suffering from systemic sclerosis and a scrupulous maintenance program has to be implemented. Further studies are strongly required to establish clinical guidelines.
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Affiliation(s)
- Sarah Dubourg
- Hôpitaux Universitaires de Strasbourg, Centre de Référence Maladies Rares Orales et Dentaires (O-Rares), Pôle de Médecine et de Chirurgie Bucco-Dentaires - Strasbourg, France
| | - Olivier Huck
- Université de Strasbourg, Faculté de Chirurgie Dentaire - Hôpitaux Universitaires de Strasbourg, Service de Parodontologie et Centre de Référence Maladies Rares Orales et Dentaires - INSERM UMR 1260 - Strasbourg, France
| | - Sophie Jung
- Universite de Strasbourg 1: Universite de Strasbourg Faculté de Chirurgie Dentaire 8 rue Sainte Elisabeth FRANCE STRASBOURG Alsace 67000 Université de Strasbourg, Faculté de Chirurgie Dentaire - Hôpitaux Universitaires de Strasbourg, Centre de Référence Maladies Rares Orales et Dentaires - INSERM UMR_S 1109 - Strasbourg, France
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28
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Shoor S. Risk of Serious Infection Associated with Agents that Target T-Cell Activation and Interleukin-17 and Interleukin-23 Cytokines. Infect Dis Clin North Am 2021; 34:179-189. [PMID: 32444009 DOI: 10.1016/j.idc.2020.02.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Co-stimulatory T-cell inhibitors are used in the treatment of rheumatoid arthritis and to prevent rejection of renal transplants. Inhibitors of the intereukin (IL-17) cytokine are indicated for psoriasis, psoriatic arthritis and ankylosing spondylitis and anti- IL-23 drugs for psoriasis. Serious infections occur in 4.2% to 25.0% of co-stimulatory inhibitors and 1.0% to 2.0% with IL-17 or IL-23 inhibitors. Underlying disease, steroid dose greater than 7.5 to 10.0 mg, and comorbidities influence risk in individual patients. Opportunistic infections or reactivation of tuberculosis are rare.
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Affiliation(s)
- Stanford Shoor
- Stanford University, 1000 Welch Road Suite 203, Palo Alto, CA 94304, USA.
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29
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Abstract
Patients with rheumatic disease, including those with systemic lupus erythematous, rheumatoid arthritis, and spondyloarthritis, use total hip and knee arthroplasties at high rates. They represent a particularly vulnerable population in the perioperative setting because of their diseases and the immunosuppressant therapies used to treat them. Careful planning among internists, medical specialists, and the surgical team must therefore occur preoperatively to minimize risks in the postoperative period, particularly infection. Management of immunosuppressant medications, such as conventional synthetic disease-modifying antirheumatic drugs and targeted therapies including biologics, is one avenue by which this infectious risk can be mitigated.
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Affiliation(s)
- Diane Zisa
- Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
| | - Susan M Goodman
- Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA; Hospital for Special Surgery, Weill Cornell Medicine, 535 East 70th Street, New York, NY 10021, USA.
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30
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England BR, Roul P, Yang Y, Sayles H, Yu F, Michaud K, Xie F, Curtis JR, Mikuls TR. Burden and trajectory of multimorbidity in rheumatoid arthritis: a matched cohort study from 2006 to 2015. Ann Rheum Dis 2021; 80:286-292. [PMID: 33032999 PMCID: PMC10658760 DOI: 10.1136/annrheumdis-2020-218282] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 09/11/2020] [Accepted: 09/15/2020] [Indexed: 12/31/2022]
Abstract
OBJECTIVES To compare the onset and trajectory of multimorbidity between individuals with and without rheumatoid arthritis (RA). METHODS A matched, retrospective cohort study was completed in a large, US commercial insurance database (MarketScan) from 2006 to 2015. Using validated algorithms, patients with RA (overall and incident) were age-matched and sex-matched to patients without RA. Diagnostic codes for 44 preidentified chronic conditions were selected to determine the presence (≥2 conditions) and burden (count) of multimorbidity. Cross-sectional comparisons were completed using the overall RA cohort and conditional logistic and negative binomial regression models. Trajectories of multimorbidity were assessed within the incident RA subcohort using generalised estimating equations. RESULTS The overall cohort (n=277 782) and incident subcohort (n=61 124) were female predominant (76.5%, 74.1%) with a mean age of 55.6 years and 54.5 years, respectively. The cross-sectional prevalence (OR 2.29, 95% CI 2.25 to 2.34) and burden (ratio of conditions 1.68, 95% CI 1.66 to 1.70) of multimorbidity were significantly higher in RA than non-RA in the overall cohort. Within the incident RA cohort, patients with RA had more chronic conditions than non-RA (β 1.13, 95% CI 1.10 to 1.17), and the rate of accruing chronic conditions was significantly higher in RA compared with non-RA (RA × follow-up year, β 0.21, 95% CI 0.20 to 0.21, p<0.001). Results were similar when including the pre-RA period and in several sensitivity analyses. CONCLUSIONS Multimorbidity is highly prevalent in RA and progresses more rapidly in patients with RA than in patients without RA during and immediately following RA onset. Therefore, multimorbidity should be aggressively identified and targeted early in the RA disease course.
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Affiliation(s)
- Bryant R England
- Division of Rheumatology & Immunology, University of Nebraska Medical Center, Omaha, Nebraska, USA
- VA Nebraska-Western Iowa Health Care System, Omaha, Nebraska, USA
| | - Punyasha Roul
- Division of Rheumatology & Immunology, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Yangyuna Yang
- Division of Rheumatology & Immunology, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Harlan Sayles
- Department of Biostatistics, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Fang Yu
- Department of Biostatistics, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Kaleb Michaud
- Division of Rheumatology & Immunology, University of Nebraska Medical Center, Omaha, Nebraska, USA
- National Data Bank for Rheumatic Diseases, Wichita, Kansas, USA
| | - Fenglong Xie
- Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Jeffrey R Curtis
- Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Ted R Mikuls
- Division of Rheumatology & Immunology, University of Nebraska Medical Center, Omaha, Nebraska, USA
- VA Nebraska-Western Iowa Health Care System, Omaha, Nebraska, USA
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Ward MM, Dasgupta A. Pre-operative withholding of infliximab and the risk of infections after major surgery in patients with rheumatoid arthritis. Rheumatology (Oxford) 2020; 59:3917-3926. [PMID: 32710102 DOI: 10.1093/rheumatology/keaa291] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 04/04/2020] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Withholding TNF inhibitors (TNFI) before surgery has been recommended due to concern for post-operative infection. We examined the risks of post-operative infections and mortality in patients with RA in relation to the pre-operative timing of infliximab infusion. METHODS In this population-based retrospective cohort study, we used US Medicare claims data from 2007 to 2015 to identify patients with RA who underwent coronary artery bypass grafting (CABG), aortic or vascular surgery, or bowel resection, and who were treated with infliximab in the 90 days prior to surgery. We examined associations between the timing of infusion and infections and mortality in the 30 days after surgery. We adjusted for the predicted probability of post-operative infection or death, demographic characteristics, use of MTX, post-operative blood transfusion and hospital volume. RESULTS We studied 712 patients with CABG, 244 patients with vascular surgery and 862 patients with bowel resections. Post-operative pneumonia occurred in 7.4-11.9%, urinary tract infection in 9.0-15.2%, surgical site infection in 3.2-18.9%, sepsis in 4.2-9.6% and death in 3.5-7.0% among surgery cohorts. There was no association between the time from last infliximab dose to surgery and the risk of post-operative infection or mortality in any surgical cohort. No subgroups were identified that had an increased risk of infection with more proximate use of infliximab. CONCLUSION Among elderly patients with RA, risks of infection and mortality after major surgery were not related to the pre-operative timing of infliximab infusion.
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Affiliation(s)
- Michael M Ward
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Abhijit Dasgupta
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD, USA
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Taylor-Williams O, Nossent J, Inderjeeth CA. Incidence and Complication Rates for Total Hip Arthroplasty in Rheumatoid Arthritis: A Systematic Review and Meta-Analysis Across Four Decades. Rheumatol Ther 2020; 7:685-702. [PMID: 33000421 PMCID: PMC7695804 DOI: 10.1007/s40744-020-00238-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 09/19/2020] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION Over the past several decades, management of rheumatoid arthritis (RA) has evolved significantly, but few studies have examined the real-world impact of these changes on orthopaedic surgery in patients with RA. This systematic review assessed total hip arthroplasty (THA) incidence and postoperative complication rates across the past four decades. METHODS This is a systematic literature review sourcing data on THA in patients with RA from the electronic databases MEDLINE, EMBASE, Scopus, and Cochrane between January 1, 1980 and December 31, 2019. RESULTS The search retrieved 1715 articles of which 44 were included for quantitative synthesis. The rate for THA decreased by almost 40% from 11/1000 patient years (PY) in the 2000s to 7/1000 PY in the 2010s, while the overall complication rate decreased from 9.9% in the 1990s to 5.3% in the 2010s. Throughout the duration of the study, THA incidence and overall complication rate decreased. However, not all individual complication rates decreased. For example, revision and periprosthetic fracture decreased, infection and aseptic loosening remained constant, and dislocation increased. CONCLUSION Medical management of patients with RA has reduced the need for THA, while postoperative medical and surgical management has improved some postoperative outcomes. Nevertheless, there remains room for further improvement to postoperative outcomes through RA-specific management.
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Affiliation(s)
| | - Johannes Nossent
- School of Medicine, The University of Western Australia, Perth, Australia.
- Sir Charles Gairdner and Osborne Park Health Care Group, Perth, Australia.
| | - Charles A Inderjeeth
- School of Medicine, The University of Western Australia, Perth, Australia.
- Sir Charles Gairdner and Osborne Park Health Care Group, Perth, Australia.
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Delaney-Nelson KL, Henry SM, Siva C. Rheumatoid arthritis in a patient with cystic fibrosis: challenging treatment options. BMJ Case Rep 2020; 13:13/9/e234305. [PMID: 32895251 DOI: 10.1136/bcr-2020-234305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 26-year-old Caucasian male patient with a history of cystic fibrosis presented with a 6-month history of diffuse joint pain and swelling. He was found to have active synovitis in bilateral wrists and proximal interphalangeal joints of the hands on physical examination. He was diagnosed with seropositive rheumatoid arthritis since he had positive anti-cyclic citrullinated peptide antibodies and erosions on hand and foot X-rays. The patient has responded well to abatacept which may have less infection risk compared with other biological therapies.
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Affiliation(s)
- Kelly Lynn Delaney-Nelson
- Department of Internal Medicine, Division of Rheumatology, University of Missouri Health System, Columbia, Missouri, USA
| | - Sheena Marie Henry
- Department of Internal Medicine, Division of Rheumatology, University of Missouri Health System, Columbia, Missouri, USA
| | - Chokkalingam Siva
- Department of Internal Medicine, Division of Rheumatology, University of Missouri Health System, Columbia, Missouri, USA
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Prevention of Prosthetic Joint Infection: From Traditional Approaches towards Quality Improvement and Data Mining. J Clin Med 2020; 9:jcm9072190. [PMID: 32664491 PMCID: PMC7408657 DOI: 10.3390/jcm9072190] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 07/08/2020] [Accepted: 07/09/2020] [Indexed: 02/06/2023] Open
Abstract
A projected increased use of total joint arthroplasties will naturally result in a related increase in the number of prosthetic joint infections (PJIs). Suppression of the local peri-implant immune response counters efforts to eradicate bacteria, allowing the formation of biofilms and compromising preventive measures taken in the operating room. For these reasons, the prevention of PJI should focus concurrently on the following targets: (i) identifying at-risk patients; (ii) reducing “bacterial load” perioperatively; (iii) creating an antibacterial/antibiofilm environment at the site of surgery; and (iv) stimulating the local immune response. Despite considerable recent progress made in experimental and clinical research, a large discrepancy persists between proposed and clinically implemented preventative strategies. The ultimate anti-infective strategy lies in an optimal combination of all preventative approaches into a single “clinical pack”, applied rigorously in all settings involving prosthetic joint implantation. In addition, “anti-infective” implants might be a choice in patients who have an increased risk for PJI. However, further progress in the prevention of PJI is not imaginable without a close commitment to using quality improvement tools in combination with continual data mining, reflecting the efficacy of the preventative strategy in a particular clinical setting.
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George MD, Baker JF, Winthrop KL, Goldstein SD, Alemao E, Chen L, Wu Q, Xie F, Curtis JR. Immunosuppression and the risk of readmission and mortality in patients with rheumatoid arthritis undergoing hip fracture, abdominopelvic and cardiac surgery. Ann Rheum Dis 2020; 79:573-580. [PMID: 32209540 PMCID: PMC7171699 DOI: 10.1136/annrheumdis-2019-216802] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 03/04/2020] [Accepted: 03/05/2020] [Indexed: 12/18/2022]
Abstract
OBJECTIVES The impact of immunosuppression on postoperative outcomes has primarily been studied in patients undergoing joint replacement surgery. We aimed to evaluate the impact of biologics and glucocorticoids on outcomes after other major surgeries. METHODS This retrospective cohort study used Medicare data 2006-2015 to identified adults with rheumatoid arthritis undergoing hip fracture repair, abdominopelvic surgery (cholecystectomy, hysterectomy, hernia, appendectomy, colectomy) or cardiac surgery (coronary artery bypass graft, mitral/aortic valve). Logistic regression with propensity-score-based inverse probability weighting compared 90-day mortality and 30-day readmission in patients receiving methotrexate (without a biologic or targeted synthetic disease-modifying antirheumatic drug (tsDMARD)), a tumour necrosis factor inhibitor (TNFi) or a non-TNFi biologic/tsDMARD <8 weeks before surgery. Similar analyses evaluated associations between glucocorticoids and outcomes. RESULTS We identified 10 777 eligible surgeries: 3585 hip fracture, 5025 abdominopelvic and 2167 cardiac surgeries. Compared with patients receiving methotrexate, there was no increase in the risk of 90-day mortality or 30-day readmission among patients receiving a TNFi (mortality adjusted OR (aOR) 0.83 (0.67 to 1.02), readmission aOR 0.86 (0.75 to 0.993)) or non-TNFi biologic/tsDMARD (mortality aOR 0.78 (0.49 to 1.22), readmission aOR 1.02 (0.78 to 1.33)). Analyses stratified by surgery category were similar. Risk of mortality and readmission was higher with 5-10 mg/day of glucocorticoids (mortality aOR 1.41 (1.08 to 1.82), readmission aOR 1.26 (1.05 to 1.52)) or >10 mg/day (mortality aOR 1.64 (1.02 to 2.64), readmission aOR 1.60 (1.15 to 2.24)) versus no glucocorticoids, although results varied when stratifying by surgery category. CONCLUSIONS Recent biologic or tsDMARD use was not associated with a greater risk of mortality or readmission after hip fracture, abdominopelvic or cardiac surgery compared with methotrexate. Higher dose glucocorticoids were associated with greater risk.
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Affiliation(s)
- Michael D George
- Rheumatology and Epidemiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Joshua F Baker
- Rheumatology and Epidemiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Rheumatology, Philadelphia VAMC, Philadelphia, Pennsylvania, USA
| | - Kevin L Winthrop
- Infectious Diseases, Oregon Health & Science University, Portland, Oregon, USA
| | - Seth D Goldstein
- Surgery, Northwestern University, Evanston, Illinois, USA
- Surgery, Ann and Robert H Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - E Alemao
- Bristol-Myers Squibb, Princeton, New Jersey, USA
| | - Lang Chen
- Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Qufei Wu
- Rheumatology and Epidemiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Fenglong Xie
- Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Jeffrey R Curtis
- Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, Alabama, USA
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Campana P, Petraglia L, Leosco D, Conte M, Grieco FV, Perrotta G, Prastaro M, Franzone A, Abete P, Parisi V. Infectious endocarditis after transcatheter aortic valve implantation in a patient on oral therapy with glucocorticoids. Aging Clin Exp Res 2020; 32:539-541. [PMID: 31728844 DOI: 10.1007/s40520-019-01401-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Accepted: 10/28/2019] [Indexed: 10/25/2022]
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Agarwal N, Kamaraj A, McDonnell S, Khan W. Perioperative management of patients with rheumatoid arthritis undergoing orthopaedic surgery. J Perioper Pract 2019; 30:265-270. [PMID: 31694466 DOI: 10.1177/1750458919886186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Rheumatoid arthritis is an autoimmune disease which is characterised by systemic inflammation. In the recent decades, the advent of disease modifying anti-rheumatic drugs have reduced the need for orthopaedic procedures. However, there are numerous patients in which pharmacological treatment fails and these patients require surgical intervention. Complications can arise due to the underlying pathology and multitude of medications these patients can be on, specifically increased infection rates due to use of immunosuppressive agents. An understanding into the disease itself, as well as perioperative management, may improve overall patient outcomes and prevent future complications.
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Affiliation(s)
- Nikhil Agarwal
- Division of Trauma & Orthopaedic Surgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK.,College of Life Sciences and Medicine, University of Aberdeen, Aberdeen, UK
| | - Achi Kamaraj
- Division of Trauma & Orthopaedic Surgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Stephen McDonnell
- Division of Trauma & Orthopaedic Surgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Wasim Khan
- Division of Trauma & Orthopaedic Surgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
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Boers M. Risk of Biologics and Glucocorticoids in Patients With Rheumatoid Arthritis Undergoing Arthroplasty. Ann Intern Med 2019; 171:679-680. [PMID: 31683279 DOI: 10.7326/l19-0527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Maarten Boers
- Amsterdam University Medical Centers, Vrije Universiteit, Amsterdam, the Netherlands (M.B.)
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40
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Ravi B, Hawker G. Elucidating the Risks and Benefits of Withholding Biologics to Optimize Surgical Outcomes. Ann Intern Med 2019; 170:886-887. [PMID: 31108501 DOI: 10.7326/m19-1088] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Bheeshma Ravi
- University of Toronto, Toronto, Ontario, Canada (B.R., G.H.)
| | - Gillian Hawker
- University of Toronto, Toronto, Ontario, Canada (B.R., G.H.)
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Mahase E. Rheumatoid arthritis: glucocorticoids are associated with nearly double infection risk post-surgery. BMJ 2019; 365:l2271. [PMID: 31113781 DOI: 10.1136/bmj.l2271] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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