Changes to consultations and diagnosis of osteoarthritis in primary care during the COVID-19 pandemic.

OBJECTIVE: General practitioners (GP) are often the first medical professionals to treat musculoskeletal complaints. Yet the impact of COVID-19 on primary care utilisation for musculoskeletal complaints is largely unknown. This study quantifies the impact of the pandemic on primary care utilisation for musculoskeletal complaints and specifically osteoarthritis (OA) in the Netherlands. DESIGN: We extracted data on GP consultations in 2015-2020 from 118,756 patients over 45 years of age and estimated reductions in consultations in 2020 as compared to 5-year average. Outcomes were GP consultations for: any musculoskeletal complaints, knee and hip OA, knee and hip complaints, and newly diagnosed knee and hip OA/complaints. RESULTS: The relative reductions in consultations ranged from 46.7% (95% confidence intervals (CI): 43.9-49.3%) (all musculoskeletal consultations) to 61.6% (95% CI: 44.7-73.3%) (hip complaints) at the peak of the first wave, and from 9.3% (95% CI: 5.7-12.7%) (all musculoskeletal consultations) to 26.6% (95% CI: 11.5-39.1%) (knee OA) at the peak of the second wave. The reductions for new diagnoses were 87.0% (95% CI: 71.5-94.1%) for knee OA/complaints, and 70.5% (95% CI: 37.7-86.0%) for hip OA/complaints at the peak of the first wave, and not statistically significant at the peak of the second wave. CONCLUSION: We observed 47% reduction in GP consultations for musculoskeletal disorders during the first wave and 9% during the second wave. For hip and knee OA/complaints, the reductions were over 50% during the first, and 10% during the second wave. This disruption may lead to accumulation of patients with severe OA symptoms and more requests for arthroplasty surgery.

Rates of surgical procedures of the knee and hip during the first wave of COVID 19 in Sweden

Background: Many countries imposed lockdowns in March 2020, in anticipation of the first wave of COVID-19 and the massive healthcare resources required to meet its acute medical needs. Sweden adopted a different strategy to contain the epidemic, opting for non-binding recommendations. Nonetheless, elective and acute surgical procedures in health care may have been affected. Objectives: To investigate the effect of the first-wave of COVID-19 and the government's response in Sweden on the rates of total joint replacements (TJR), arthroscopies, and fracture surgeries of the knee and hip. Methods: We used register data for the entire population of Skåne, the southernmost region in Sweden with 1.3 million inhabitants (13% of the total Swedish population). We identified all residents aged ≥18 years who between 1st January 2015 and 31st November 2020 underwent any of the following surgical procedures of the knee or hip: TJR (TJR due to fracture excluded), arthroscopy, and surgery due to fracture (including TJR). To demarcate pre-event and post-event periods, we established a differentiation point corresponding to mid-March 2020, the timepoint at which the the Swedish Public Health Agency began recommending social distancing, working from home, distance learning for secondary schools and universities,. At the aggregate level, we modelled the number of surgeries per 10,000 adults from January 2015 up to September 2020. We did an interrupted time-series (ITSA) analysis using segmented ordinary least-squares regression to estimate changes in the levels and trends of surgical procedures compared to pre-COVID-19 levels, adjusting for seasonal variations. The month of March was treated as a phase-in period to give time for the new recommendations to be implemented. In addition, we estimated the absolute and relative difference (with its 95% confidence interval [CI]) between the predicted and the counterfactual scenario in the monthly number of surgeries from April 2020, where the counterfactual is the rate of surgery that would have been expected if COVID-19 had not happened. To account for the possibility that other co-occurring events may be responsible for the observed changes, we assessed changes in the number of surgeries due to fractures, which are normally treated as emergencies that cannot be cancelled or rescheduled, and thus should be less affected, at least by policies at the hospital level. Results: We identified a total of 20,831 TJRs, 12,156 arthroscopies and 15,041 fracture surgeries of the knee or hip over the study period. The monthly rate of surgeries and ITSAs are presented in Figure 1, with the pre-COVID period starting from February 2019 for readability (Figure 1). The results suggest that in April 2020, there was a decrease of 2.08 (95%CI 1.81;2.35) TJRs per 10,000 adults which corresponds to a decrease of 74% (95%CI 65%;85%) when compared to the counterfactual scenario. This was followed by a positive trend signifying a monthly increase of 0.36 (95%CI 0.31;0.40) TJRs per 10,000 adults. The rate of arthroscopies followed a similar pattern with a decrease of 0.55 (95%CI 0.39;0.71) arthroscopies per 10,000 adults in April, which corresponds to a 49% decrease (95%CI 28%;63%) followed by a positive trend signifying a monthly increase of 0.11 (95%CI 0.07;0.15) arthroscopies per 10,000 adults. The rate of surgery due to knee or hip fractures showed no decrease in April and was followed by a negative trend signifying a monthly decrease of 0.03 (95%CI 0.002;0.04) surgeries per 10,000 adults. Conclusion: In Sweden, we observed a marked decrease in the number of typical elective knee and hip surgeries such as TJRs and arthroscopies, following the government's response to Covid-19. We then observed a slow but steady recovery that brought the rates of procedures towards expected levels by Fall 2020, before the second wave hit the country. The number of acute fracture surgeries showed no sharp drop, instead showing a steady and slow decline potentially due to reduction in commuting and in physical activities l nked to recommendations of social.

Accelerated menopausal changes as disease model for development of osteoarthritis, focum

Purpose: After the age of fifty years, the percentage of females with degenerative disorders, including osteoarthritis (OA), increases rapidly. It has been suggested that menopause, and the change in hormones during menopausal transition, influences the development of these disorders. During menopausal transition, not only the hormone levels change, but also metabolism and inflammatory responses. Investigating the influence of menopausal changes, including protein change, on the development of degenerative disorders is difficult, because these changes occur slowly. However, identifying these changes is crucial to develop novel female-specific prevention strategies and therapies for these disorders. Therefore, we propose the use of an unique and novel human model to investigate the influence of menopause on the development of degenerative disorders by modelling a “sudden menopause”, in which we expect that menopausal-related changes will occur faster: the Females discontinuing Oral Contraceptives Use at Menopausal age (FOCUM) model. This model does not have the limitations in generalizability of animal models. Nor does it have the limitations of subsequent hormonal support, malignancy and its associated treatments that are pertinent to human models with a sudden menopause caused by ovariectomy.The aim of our study is to develop the FOCUM model as a disease model for the development of OA. We want to identify when changes, especially in proteins, occur after a “sudden menopause” and which of these changes are associated with the development of OA after two years. Furthermore, we want to explore if the model can also be used to learn more about the development of cardiovascular diseases, diabetes, osteoporosis and tendinopathies. In this abstract we will report on the feasibility of our inclusion. Our aim is to include 50 female participants from the general population in and nearby Rotterdam within one year. Methods: Our study design is a pilot observational prospective cohort study with two years of follow-up. Our main questions for this pilot study are: will the inclusion of participants be feasible and what are the important time points to find changes in proteins? Females between 50 and 60 years of age, who are currently using a combined oral contraceptive and started oral contraceptive use before the age of 45, are recruited from pharmacies and (if necessary) general practices. In general, females are advised to stop oral contraceptive use at the age of 52. Females who are willing to stop oral contraceptive use at short term are invited to participate. Different measurements are performed before (T0 = 0 to 30 days) and after (T1 = 6 weeks;T2 = 6 months;T3 = 1 year;T4 = 2 years) stopping oral contraceptive use. At every time point of measurements a questionnaire is filled in, a normal photograph of both hands is taken and a sample of blood is drawn to measure hormones, proteins, glucose, cholesterol, DNA-methylation and immunological aspects of cells. At the first and final time point of measurements, also a physical examination, an radiograph of both hands, an MRI scan of one knee, a DXA-scan, and an ultrasound tissue characterization of one Achilles tendon are performed. To establish which time points of measurements are most relevant to find changes in proteins after hormone change, we will examine changes in serum levels of approximately 150 different inflammation and cardiometabolic related proteins by using the Olink-technology at different time points of measurements. At the first stage of this study, we will use the Principal Component Analysis on the change in protein levels over time. Thereafter, we will test for the association between principal components and hormone change. At the second stage of this study, we will relate these principal components to various OA outcomes. Results: In January 2020, we sent invitations to 108 local pharmacies to participate in this study. At that time, a total of 55 pharmacies were willing to participate. The participating pharmacies were asked to search in their own information system to identify all possible eligible subjects, based on age and oral contraceptive use, and to send an invitation letter in their name to these subjects. Unfortunately, due to COVID restrictions we started sending these invitation letters by the end of June 2020, four months later than planned. Until now, we have sent 534 invitations from 26 pharmacies to possible eligible subjects. A total of 107 females replied positively and gave permission to provide them more information about the study. After giving information and screening for in- and exclusion criteria, we now have 25 eligible participants who gave informed consent. Of them, 16 participants have had their first (baseline) measurements of 2,5 hours at the Erasmus MC. With the 29 participating pharmacies left, we expect to reach the targeted number of 50 inclusions by February 2021 and to report about the first stage of this study. Conclusions: At this time, we have included half of our study population. So the inclusion of 50 female participants for this study within one year seems to be feasible. By performing different measurements before and after stopping oral contraceptive use, we will be able to investigate when and which menopausal changes occur and which of these changes can be related to OA. With this model we hope to learn more about the influence of menopause on the development of OA, but also of cardiovascular diseases, diabetes, osteoporosis and tendinopathies, in order to develop new prevention strategies and therapies for these diseases.