Milisa Blagojevic-Bucknall

Current evidence on risk factors for knee osteoarthritis in older adults: a systematic review and meta-analysis

Osteoarthritis (OA) is a leading cause of pain and disability and leads to a reduced quality of life. The aim was to determine the current evidence on risk factors for onset of knee pain/OA in those aged 50 and over. A systematic review and meta-analysis was conducted of cohort studies for risk factors for the onset of knee pain. Two authors screened abstracts and papers and completed data extraction. Where possible, pooled odds ratios (OR) were calculated via random effects meta-analysis and population attributable fractions (PAFs) derived. 6554 papers were identified and after screening 46 studies were included. The main factors associated with onset of knee pain were being overweight (pooled OR 1.98, 95% confidence intervals (CI) 1.57-2.20), obesity (pooled OR 2.66 95% CI 2.15-3.28), female gender (pooled OR 1.68, 95% CI 1.37-2.07), previous knee injury (pooled OR 2.83, 95% CI 1.91-4.19). Hand OA (pooled OR 1.30, 95% CI 0.90-1.87) was found to be non-significant. Smoking was found not to be a statistically significant risk or protective factor (pooled OR 0.92, 95% CI 0.83-1.01). PAFs indicated that in patients with new onset of knee pain 5.1% of cases were due to previous knee injury and 24.6% related to being overweight or obese. Clinicians can use the identified risk factors to identify and manage patients at risk of developing or increasing knee pain. Obesity in particular needs to be a major target for prevention of development of knee pain. More research is needed into a number of potential risk factors.

Impact of musculoskeletal pain on insomnia onset: a prospective cohort study

Objective. Pain, the most common manifestation of rheumatological conditions, is highly prevalent among older adults, with worse health outcomes found in those with co-morbid insomnia. Proactive prevention of insomnia may reduce the overall disease burden of pain and rheumatological conditions. To inform such development, this study examined the role of pain, physical limitation and reduced social participation in predicting and mediating insomnia onset. Methods. A prospective cohort study was conducted involving 6676 individuals ≥50 years of age who completed questionnaires at baseline and a 3-year follow-up. Participants were classified into none, some and widespread pain according to the ACR criteria. Logistic regression was used to examine the relationship between baseline pain and insomnia onset at 3 years. Path analysis was used to test for the mediating role of physical limitation and social participation restriction. Results. Some [adjusted odds ratio (AOR) 1.57 (95% CI 1.15, 2.13)] and widespread [2.13 (1.66, 3.20)] pain increased the risk of insomnia onset at 3 years, after adjusting for age, gender, socio-economic class, education, anxiety, depression, sleep and co-morbidity at baseline. The combination of physical limitation and reduced social participation explained up to 68% of the effect of some pain on insomnia onset and 66% of the effect of widespread pain on insomnia onset. Conclusion. There was a dose–response association between the extent of pain at baseline and insomnia onset at 3 years that was substantially mediated by physical limitation and reduced social participation. Targeting physical limitation and social participation in older people with pain may buffer co-morbid insomnia, reducing the overall disease burden.

Reasons why multimorbidity increases the risk of participation restriction in older adults with lower extremity osteoarthritis: a prospective cohort study in primary care.

To determine why multimorbidity causes participation restriction in adults ages ≥50 years who consult primary care with lower extremity osteoarthritis (OA).

Incidence of prostate, breast, lung and colorectal cancer following new consultation for musculoskeletal pain: A cohort study among UK primary care patients

Musculoskeletal pain has been linked with subsequent cancer. The objective was to investigate associations between pain sites and specific cancers, and investigate the hypothesis that musculoskeletal pain is an early marker, rather than cause, of cancer. This was a cohort study in the General Practice Research Database. From a cohort of 46,656 people aged ≥50 years with a recorded musculoskeletal problem in 1996 but not during the previous 2 years, patients with a new consultation for back, neck, shoulder or hip pain in 1996 were selected and compared with 39,253 persons who had had no musculoskeletal consultation between 1994 and 1996. Outcome was incidence of prostate, breast, lung and colorectal cancer up to 10 years after baseline consultation. Strongest associations with prostate cancer were in the first year of follow‐up for males consulting initially with back (adjusted hazard ratio 5.42; 95% CI 3.31, 8.88), hip (6.08; 2.87, 12.85) or neck problems (3.46; 1.58, 7.58). These associations remained for back and neck problems over 10 years. Significant associations existed with breast cancer up to 5 years after consultation in females with hip problems, and with breast and lung cancer in the first year after presentation with back problems. Previously observed links between pain and cancer reflect specific associations between pain sites and certain cancers. One explanation is liability for bony metastases from primary sites, and that pain represents a potential early marker of cancer. However, older patients with uncomplicated musculoskeletal pain seen in clinical practice have a low absolute excess cancer risk.

The epidemiology of self-reported intermenstrual and postcoital bleeding in the perimenopausal years.

To obtain estimates of the rates of occurrence and spontaneous resolution of intermenstrual and postcoital bleeding, and investigate any association with underlying malignancy.

Widespread pain and depression are key modifiable risk factors associated with reduced social participation in older adults: A prospective cohort study in primary care

Abstract In older adults, reduced social participation increases the risk of poor health-related quality of life, increased levels of inflammatory markers and cardiovascular disease, and increased mortality. Older adults frequently present to primary care, which offers the potential to deliver interventions at the point of care to increase social participation. The aim of this prospective study was to identify the key modifiable exposures that were associated with reduced social participation in a primary care population of older adults. The study was a population-based prospective cohort study. Participants (n = 1991) were those aged ≥65 years who had completed questionnaires at baseline, and 3 and 6-year follow-ups. Generalized linear mixed modeling framework was used to test for associations between exposures and decreasing social participation over 6 years. At baseline, 44% of participants reported reduced social participation, increasing to 49% and 55% at 3 and 6-year follow-up. Widespread pain and depression had the strongest independent association with reduced social participation over the 6-year follow-up period. The prevalence of reduced social participation for those with widespread pain was 106% (adjusted incidence rate ratio 2.06, 95% confidence interval 1.72, 2.46), higher than for those with no pain. Those with depression had an increased prevalence of 82% (adjusted incidence rate ratio 1.82, 95% confidence interval 1.62, 2.06). These associations persisted in multivariate analysis. Population ageing will be accompanied by increasing numbers of older adults with pain and depression. Future trials should assess whether screening for widespread pain and depression, and targeting appropriate treatment in primary care, increase social participation in older people.

What does a primary care annual review for RA include? A national GP survey

Sir Patients with rheumatoid arthritis (RA) are at increased risk of comorbidities particularly cardiovascular disease and osteoporosis [1, 2]. NICE standards of care for rheumatoid arthritis (RA) recommend patients should receive a holistic annual review that should include an assessment of disease activity and severity, active screening for and management of comorbidities [3] and assessment of the impact of RA on quality of life. In 2013, RA was included in the Quality Outcomes Framework (QOF) of the UK general practice contract. General practitioners (GPs) were incentivised to provide a face to face annual review for RA patients, including cardiovascular and fracture risk screening, mirroring the routine care for patients with other long-term conditions such as diabetes—a model which improves quality of care and clinically important outcomes [4]. The aims of this study were to investigate what domains GPs report including in their annual review for patients with RA and to determine the role of the multidisciplinary team in providing these reviews. We conducted a national cross-sectional survey in 2013 to investigate the primary care management of RA. Five thousand randomly selected GPs were asked to complete a brief questionnaire investigating their management strategies for patients with RA. Participants were presented with a predefined list of 12 measures that could be included in an annual review (presented in Table 1: including cardiovascular disease, osteoporosis and depression screening) and asked to indicate which measures they routinely included. Furthermore, GPs were asked which screening tools they used for cardiovascular disease and osteoporosis screening and which members of the multidisciplinary team conducted these reviews. One thousand three hundred eighty-eight (27.8 %) completed questionnaires were returned. The majority (1052, 75.6 %) of responders were GP partners, with a mean (SD) age of 47 (9.4) years. Seven hundred five participants (50.8%) were female. The majority of responding GPs (1083, 80.4 %) felt that a primary care annual review was of benefit to their RA patients, although only 712 (51.2 %) GPs felt that RA should be included in the QOF component of the GP contract. Nine hundred thirty-nine (67.7 %) GPs indicated they were aware of the NICE Standards of Care for RA, although only half (693, 49.9 %) felt they impacted on their clinical practice. Only 767 (55.3 %) GPs thought their patients had access to an annual review in secondary care. The individual measures that GPs reported including in their annual review are detailed in Table 1. The most frequently incorporated components were medication review (1232, 88.8 %), followed by cardiovascular risk assessment (1139, 82.1 %). The latter was most commonly performed by practice nurses using QRISK (1214, 87.5 %). Osteoporosis risk assessment was also commonly performed (1118, 80.5 %), usually by GPs themselves (1023, 73.7 %), with a minority of GPs thought osteoporosis screening for their patients was * S. L. Hider s.hider@keele.ac.uk

Incident acute pseudogout and prior bisphosphonate use: Matched case–control study in the UK-Clinical Practice Research Datalink

Abstract Oral bisphosphonates are the most commonly used drugs to treat postmenopausal osteoporosis. Acute pseudogout is anecdotally reported to occur following bisphosphonate initiation but empirical data are lacking. We investigated whether treatment with oral bisphosphonates is a risk factor for incident acute pseudogout. A matched case–control study was undertaken using data from the UK-Clinical Practice Research Datalink. Adults who consulted for incident acute pseudogout between 1987 and 2012 were each matched for gender, age at pseudogout diagnosis, and general practice to up to 4 control subjects without pseudogout. The exposure of interest was a prescription for an oral bisphosphonate issued within the 60-day period prior to the date of incident acute pseudogout. Associations between incident acute pseudogout and prior bisphosphonate prescription were examined using conditional logistic regression, adjusting for hyperparathyroidism, osteoarthritis, rheumatoid arthritis, hemochromatosis, hypophosphatasia, and prescriptions for diuretics and oral corticosteroids. Two thousand eleven acute pseudogout cases were compared with 8013 matched controls without acute pseudogout (mean age [standard deviation] 72 years [14]; 52% male). One hundred twenty-three cases (6.1%) had received an oral bisphosphonate prescription in the 60-day exposure period compared with 305 controls (3.8%) (adjusted incidence rate ratio [IRR] 1.33; 95% confidence interval [CI] 1.05–1.69). This association was stronger in females (adjusted IRR 1.49; 95% CI 1.15–1.94) and was nonsignificant in males (0.83; 0.48–1.44). Incident acute pseudogout was associated with prescription of an oral bisphosphonate in the preceding 60 days. Prescribers should be aware of acute pseudogout as a possible side effect of bisphosphonate treatment. Further research is needed to explore the risks conferred by different bisphosphonates and the mechanism underlying this association.

The association between GP consultations for non-specific physical symptoms in children and parents: a case-control study

Background Non-specific physical symptoms (NSPS) such as abdominal pain, headache and musculoskeletal pain are widespread in the community, and are common reasons for visiting a general practitioner (GP). Causes of NSPS are multifactorial, but may include parental influences. Objective To investigate associations between GP consultations for NSPS in parents and their children. Methods Matched case-control study using GP consultation data from 12 GP practices in the United Kingdom. Participants were 1328 children who consulted a GP for NSPS in 2009 (cases), 3980 controls who consulted a GP in 2009 but not for NSPS, plus parents of cases and controls (n = 8354). Primary outcome measure: child consultation status for NSPS. Results Maternal consultation for NSPS was associated with significantly increased odds of their child consulting for NSPS (odds ratio (OR) 1.51, 95% confidence intervals (CI) 1.33, 1.73); there was no significant association with paternal consultations (OR 0.87, 95% CI 0.71, 1.08). Each additional maternal consultation for NSPS was associated with an increase in the rate ratio for number of consultations for NSPS in the child by 1.03 (95% CI 1.01, 1.05). This overall association was clearest in maternal-child consultations for painful NSPS and for specific bodily systems including gastrointestinal, musculoskeletal and neurologic symptoms. Conclusions Maternal GP consultation for NSPS is associated with increased odds of GP consultations for NSPS in children. This study included a large sample of children and parents and used medical records data which is not subject to recall bias. However, analysis was based on medical records, thus the presence of NSPS not leading to consultations is unknown. Medical practitioners managing children with NSPS need to be aware of this association.

Health-related Quality of Life in Gout in Primary Care: Baseline Findings From a Cohort Study

Objectives To examine gout-related, comorbid, and sociodemographic characteristics associated with generic and disease-specific health-related quality of life (HRQOL) in gout. Methods Adults with gout from 20 general practices were mailed a questionnaire containing the Health Assessment Questionnaire-Disability Index (HAQ-DI), Short-Form-36 Physical Function subscale (PF-10), Gout Impact Scale (GIS), and questions about gout-specific, comorbid and sociodemographic characteristics. Variables associated with HRQOL were examined using multivariable linear regression models. Results A total of 1184 completed questionnaires were received (response 65.9%). Worse generic and gout-specific HRQOL was associated with frequent gout attacks (≥5 attacks PF-10 β = −4.90, HAQ-DI β = 0.14, GIS subscales β = 8.94, 33.26), current attack (HAQ-DI β = 0.15, GIS β = −1.94, 18.89), oligo/polyarticular attacks (HAQ-DI β = 0.11, GIS β = 0.78, 7.86), body pain (PF-10 β = −10.68, HAQ-DI β = 0.29, GIS β = 2.61, 11.89), anxiety (PF-10 β = −1.81, HAQ-DI β = 0.06, GIS β = 0.38, 1.70), depression (PF-10 β = −1.98, HAQ-DI β = 0.06, GIS 0.42, 1.47) and alcohol non-consumption (PF-10 β = −16.10, HAQ-DI β = 0.45). Gout-specific HRQOL was better in Caucasians than non-Caucasians (GIS β = −13.05, −13.48). Poorer generic HRQOL was associated with diabetes mellitus (PF-10 β = −4.33, HAQ-DI β = 0.14), stroke (PF-10 β = −12.21, HAQ-DI β = 0.37), renal failure (PF-10 β = −9.43, HAQ-DI β = 0.21), myocardial infarction (HAQ-DI β = 0.17), female gender (PF-10 β = −17.26, HAQ-DI β = 0.43), deprivation (PF-10 β = −7.80, HAQ-DI β = 0.19), and body mass index ≥35 kg/m2 (PF-10 β = −6.10, HAQ-DI β = 0.21). Conclusions HRQOL in gout is impaired by gout-specific, comorbid, and sociodemographic characteristics, highlighting the importance of comorbidity screening and early urate-lowering therapy. Both gout-specific and generic questionnaires identify the impact of disease-specific features on HRQOL but studies focusing on comorbidity should include generic instruments.