Objective. To determine whether patients with knee or hip osteoarthritis (OA) who have worse physical function preoperatively achieve a postoperative status that is similar to that of patients with better preoperative function.Methods. This study surveyed an observational cohort of 379 consecutive patients with definite OA who were without other inflammatory joint diseases and were undergoing either total hip or knee replacement in a US (Boston) and a Canadian (Montreal) referral center. Questionnaires on health status (the Short Form 36 and Western Ontario and McMaster Universities Osteoarthritis Index) were administered preoperatively and at 3 and 6 months postoperatively. Physical function and pain due to OA were deemed the most significant outcomes to study.Results. Two hundred twenty-two patients returned their questionnaires. Patients in the 2 centers were comparable in age, sex, time to surgery, and proportion of hip/knee surgery. The Boston group had more education, lower comorbidity, and more cemented knee prostheses. Patients undergoing hip or knee replacement in Montreal had lower preoperative physical function and more pain than their Boston counterparts. In patients with lower preoperative physical function, function and pain were not improved postoperatively to the level achieved by those with higher preoperative function. This was most striking in patients undergoing total knee replacement.Conclusion. Surgery performed later in the natural history of functional decline due to OA of the knee, and possibly of the hip, results in worse postoperative functional status.

Objective. To determine the predictors of outcome in patients with osteoarthritis 2 years after receiving total hip or knee replacement.Methods. A prospective cohort study of 222 osteoarthritis patients undergoing total hip or knee replacement in Boston and Montreal was done. Their postoperative outcomes at 6 months were previously reported. This followup reports on the outcomes after 2 years among the 165 patients (74%) who remained. The subjects were divided into 2 groups according to the median value of their preoperative Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) function score. The Short Form 36-item physical function subscale and the WOMAC pain and function subscale scores were collected at baseline and at 3, 6, and 24 months postoperatively. Clinical outcomes were analyzed at 2 years, using descriptive and multiple regression analyses.Results. Improvements in pain and function at 2 years were similar to those observed at 6 months. Those subjects with the worst function and pain at the time of surgery (baseline) had comparatively worse function 2 years after surgery.Conclusion. In this comparison, the poor outcomes observed at 6 months following total joint replacement in patients with worse baseline functional status persisted after 2 years. Although there are no validated indications for when a patient should optimally have total joint replacement, these data suggest that timing of surgery may be more important than previously realized and, specifically, that performing surgery earlier in the course of functional decline may be associated with better outcome.Total hip replacement (THR) and total knee replacement (TKR) are both highly successful and costeffective procedures for end-stage joint disease. The influence of the timing of these two procedures on patient outcomes has not been studied formally. In a natural experiment, 2 cohorts of patients treated in academic health centers in Boston and Montreal were studied. Although all patients showed improvement at 6 months postoperatively, those with the worst function and pain at the time of surgery (baseline) had comparatively poorer function at followup (1). In this study, we examined whether these results persisted up to 2 years after surgery, when the majority of patients have achieved optimal postoperative results. PATIENTS AND METHODSPopulation. We performed a prospective cohort study of 222 consecutive persons undergoing elective THR and TKR for osteoarthritis at a Boston and a Montreal teaching hospital. At 2 years postoperatively, followup information was available on 165 patients.

Objective. To evaluate treatment with methotrexate (MTX) in patients with newly diagnosed giant cell arteritis (GCA) to determine if MTX reduces GCA relapses and cumulative corticosteroid (CS) requirements and diminishes disease-and treatment-related morbidity.Methods. This was a multicenter, randomized, double-blind study. Over 4 years, 16 centers from the International Network for the Study of Systemic Vasculitides enrolled patients with unequivocal GCA. The initial treatment was 1 mg/kg/day (<60 mg every day) prednisone, plus either 0.15 mg/kg/week MTX (increased to 0.25 mg/kg/week, for a maximum weekly dosage of 15 mg) or placebo. Two physicians, both blinded to treatment allocation, evaluated each patient at every trial visit. One physician was responsible for providing global medical care. The other assessed GCA status according to a standard protocol. Treatment

Objective. To assess the potential benefits of methotrexate in patients with systemic lupus erythematosus (SLE).Methods. A 12-month, double-blind, placebo-controlled trial of methotrexate with folic acid was conducted. Intent-totreat analyses were performed with mixed linear models and ␣ ‫؍‬ 0.04 (96% confidence interval [96% CI]) to account for interim analysis of longitudinal data to assess the treatment effects on lupus disease activity and daily steroid dose across monthly measurements, and to test if the treatment effects depended on selected participant characteristics. Results. Of 215 participants screened, 94 were excluded, 35 declined, and 86 were randomized (methotrexate ‫؍‬ 41, placebo ‫؍‬ 45). The groups were balanced for demographic and disease characteristics. Antimalarial use was more frequent in the placebo group, which was adjusted for in multivariable analyses. Sixty participants (27 methotrexate, 33 placebo) completed the study and 26 terminated early. Among participants who had the same baseline prednisone dose, those taking methotrexate received, on average, 1.33 mg/day less prednisone during the trial period (96% CI 0.06, 2.72 mg/day; a 22% reduction of their average-during-trial daily dose) compared with those in the placebo group. For the primary measure of disease activity (revised Systemic Lupus Activity Measure), methotrexate use was also associated with a marginally significant reduction in the mean during-trial score of 0.86 units (96% CI 0.01, 1.71; P ‫؍‬ 0.039). A significant interaction between treatment and baseline damage was found (P ‫؍‬ 0.001). Conclusion. Methotrexate conferred a significant advantage in participants with moderately active lupus by lowering daily prednisone dose and slightly decreasing lupus disease activity. As a therapeutic option in moderate SLE, methotrexate can be considered to be steroid sparing.