Introduction:It is necessary to understand the decision-making dynamics between physicians and families so as to help families better participate in shared decision-making. Methods:A qualitative observational research was conducted. Conversations between physicians and families at a tertiary care hospital from July to December 2022 were audio-recorded. The families were those with critically ill patients lacking decision-making capacity in the intensive care unit. Data were analyzed using an inductive content analysis method. Results:A total of 40 conversations were analyzed. There were 12, 15, and 13 decisions made on the day of hospital admission, when the patient's condition changed, and during the end-of-life situation, respectively. In all decision-making stages, some sharing of information occurred between physicians and families. The degree of sharing differed depending on the decision-making context. In end-of-life situations, decision-making mostly involved families, which might only represent the values and preferences from family members but not patients. Conclusion:Evidence of shared decision-making between physicians and family members was low. The levels of shared decision-making varied according to the context in which decisions were made. The shared decision-making between physicians and families might only represent the values and preferences from family members but not patients. Family members often faced decision-making difficulties and regrets.

ObjectiveTo evaluate the relationship between sleep behaviors and rheumatoid arthritis (RA) risk.MethodsFirst, based on large-scale data from the UK Biobank, we analyzed the associations between multiple sleep factors and RA risk and calculated a poor sleep score (PSS) to assess their combined effect. Then we constructed genetic risk scores (GRS) based on a large genome-wide association study and assessed the interaction or combined effect of sleep and genetic factors on RA risk. Finally, we conducted a case-control study to explore the effect of RA on sleep.ResultsSleep duration, getting up, napping during the day, insomnia, and daytime dozing were associated with the risk of RA, but no associations were observed for chronotype and snoring with RA. Participants in the high genetic risk and high PSS group had a 363.1% higher risk of developing RA compared to those with low genetic risk and low PSS. We also found that women were more likely than men to be affected by the combined effects of PSS and GRS. In the case-control study, there were statistically significant associations of RA with getting up, PSS grade and PSS.ConclusionsUnhealthy sleep patterns were associated with increasing risk of RA among participants with low, intermediate, or high genetic risk.

Purpose:Frailty can impact the prognosis of cancer patients. We aimed to elucidate longitudinal frailty trajectories in cancer patients undergoing immunotherapy and to analyze the factors influencing these trajectories. Methods:A prospective observational cohort study was conducted among cancer patients scheduled for immunotherapy from December 2022 to November 2023. Sociodemographic and disease-related information was collected. The Chinese version of the Tilburg Frailty Indicator, the Activities of Daily Living scale, the Hospital Anxiety and Depression Scale, the Nutritional Risk Screening 2002, and the Social Support Rating Scale were used to assess patients before the first immunotherapy session (T0) and 1 week after each subsequent immunotherapy session until the sixth cycle (T1-T6). A growth mixed model was applied to explore frailty trajectories. Univariate and multivariate logistic regression analyses were performed to identify variables associated with each trajectory. Results:A total of 205 patients completed the treatment cycles and were included in the analysis. The overall frailty score demonstrated significant changes (p = 0.037), with an initial increase followed by a subsequent decrease during the six treatment cycles. Four distinct frailty trajectories were identified: the "persistently non-frail group" (Class 1), the "persistently frail group" (Class 2), the "frailty deterioration-remission group" (Class 3), and the "frailty remission-deterioration group" (Class 4). Compared with Class 1, patients in Class 2 were more likely to have nutritional risk (odds ratio [OR] = 4.173, 95% confidence interval [CI]: 1.637-12.664) and live in rural areas (OR = 6.869, 95% CI: 2.589-18.223), while the likelihood of being male was significantly lower (OR = 0.365, 95%, CI: 0.136-0.982). In Class 3, more patients had depression (OR = 6.663, 95% CI: 2.266-19.592), had low social support (OR = 9.483, 95% CI: 1.493-60.249), and were dependent on their spouses (OR = 5.728, 95% CI: 1.584-20.716) or their children for care (OR = 7.847, 95% CI: 1.994-30.885); however, being male and the presence of anxiety were associated with lower odds (OR = 0.316, 95% CI: 0.122-0.815; OR = 0.281, 95% CI: 0.100-0.789, respectively). Patients with distant tumor metastasis (OR = 12.712, 95% CI: 2.930-53.988), pre-treatment frailty (OR = 8.427, 95% CI: 1.973-36.003), and no history of chemotherapy (OR = 0.182, 95% CI: 0.033-0.994) were more likely to be in Class 4. Conclusions:There was significant heterogeneity in the frailty trajectories of cancer patients undergoing immunotherapy. Identifying factors associated with different frailty trajectories is crucial for implementing targeted interventions to improve prognosis in these patients.

BACKGROUND:The risk factors for skin injuries remain poorly understood in cancer patients with peripherally inserted central catheters (PICC). We herein aimed at exploring the effect of clinical factors on the risk of PICC-related skin injuries. METHODS:We included 1245 cancer patients with PICC from 16 hospitals in Suzhou, China. The study outcome was in-hospital skin injuries, including contact dermatitis, skin (epidermal) stripping, tension injury, allergic dermatitis, skin tear, maceration, folliculitis, and pressure injury. RESULTS:During hospitalization, 274 patients (22.0%) developed skin injuries after prolonged use of an indwelling catheter. Univariable logistic regression analysis identified several risk factors for PICC-related skin injuries; multivariable logistic regression analysis showed that the following factors independently and significantly (p < 0.05) associated with the risk of PICC-related skin injuries: body mass index (BMI, >25 kg/m2 versus <18.5 kg/m2: odds ratio (OR), 1.79; 95% confidence interval (CI), 1.03-3.11), skin condition (humid vs normal: OR, 2.96; 95% CI, 1.62-5.43), skin indentation (OR, 4.67; 95% CI, 3.31-6.58), allergic history (OR, 2.11; 95% CI, 1.21-3.66), history of dermatitis (OR, 3.05; 95% CI, 1.00-9.28), history of eczema (OR, 3.36; 95% CI, 1.20-9.43), catheter insertion site (under elbow vs. upper arm: OR, 3.32; 95% CI, 1.12-9.90), and PICC maintenance interval (4-5 days vs ⩽3 days: OR, 0.06; 95% CI, 0.01-0.50; 5-7 days vs ⩽3 days: OR, 0.07; 95% CI, 0.02-0.31; 7-9 days vs ⩽3 days: OR, 0.10; 95% CI, 0.02-0.57). CONCLUSIONS:BMI, skin condition, skin indentation, allergic history, history of dermatitis, history of eczema, catheter insertion site, and PICC maintenance interval were independent risk factors for PICC-related skin injuries in cancer patients. This knowledge will guide future studies with formulating optimal treatment strategies for improving the skin health of cancer patients with PICC.

Background & Objective: Stroke has a high incidence, disability, and mortality rate, which has a serious impact on the patients’ quality of life. Heart rate (HR) is valuable in the prognostic assessment of stroke patients. Continuous HR tracking helps to detect abnormal indicators and provide interventions timely to avoid disease progression. However, the cuff-based or electrode-based HR monitoring tools commonly used in clinic are not suitable for continuous monitoring in daily life. The aim of this study was to verify the accuracy and reliability of a wristband smartwatch in monitoring HR over 24-hour in stroke patients, including in terms of the circadian rhythm characteristics of HR. Methods: 25 stroke patients underwent 24-hour HR monitoring by wearing a smartwatch and a clinical monitor. We use ambulatory blood pressure monitors and bedside monitors as the gold standard for clinical HR monitoring. The degree of association between the two measurements was compared using Pearson’s correlation coefficient. Bland-Altman analysis showed the accuracy of the smartwatch in HR monitoring. Intraclass correlation coefficients (ICC) and coefficients of variation (CV) were used to verify the reliability of the wristband smartwatch for repeated measurements. Results: A total of 625 heart rate pairs were acquired. The smartwatches had an average error of 0.816 bpm in 24-hour, with no difference from standard monitors (P>0.05), indicating good accuracy. The intraday repeated measures ICC was 0.969 and the interday repeated measures ICC was 0.788, indicating good reliability. Conclusions: The smartwatch is acceptable in detecting 24-hour ambulatory HR in stroke patients, and in the future, long-term HR monitoring with diurnal variations can be performed in daily life.

AIMS AND OBJECTIVES:This systematic review and meta-analysis aimed to compare the incidence of PVC-related complications between catheterisation in the forearm and back of the hand in adult patients. BACKGROUND:A peripheral intravenous catheter (PVC) is often inserted as part of care during patients' hospitalisation. The catheter is typically inserted in the forearm or at the back of the hand in usual practice. Studies have not yet reached a consensus on the optimal insertion site in any clinical setting. DESIGN:We performed a systematic review and meta-analysis based on PRISMA guidelines. METHODS:We searched the following electronic databases: PubMed, Cochrane Library, Embase, and CINAHL. Randomised controlled trials, cohort studies, case-control studies and cross-sectional studies from inception to July 2021 reporting the incidence of PVC-related complications at the forearm and back of the hand were included. Fixed-effects models and random-effects models were used to derive the pooled risk ratios. RESULTS:Twenty-four studies involving 16562 PVCs met our inclusion criteria. The meta-analysis showed that compared with PVC placement in the back of the hand, placement in the forearm was associated with a higher incidence of total complications and infiltration/extravasation. However, the differences between the PVC indwelling sites were not significant (total complications: P = 0.43; phlebitis: P = 0.35; infiltration/extravasation: P = 0.51). Both incidence of total complications and infiltration/extravasation analyses showed high heterogeneity (total complications: I2  = 60%; infiltration/extravasation: I2  = 58%). CONCLUSION:Available evidence suggests that there is no significant difference between PVC placement in the forearm and at the back of the hand in terms of the incidence of complications, thus making both approaches suitable. RELEVANCE TO CLINICAL PRACTICE:For patients who need indwelling PVC, medical staff can choose the best indwelling site, and both forearm and back of the hand are suitable.

Introduction: The novel corona-virus outbreak three years ago has changed people’s lives, with different responses around the world. As the largest developing country, China has taken strict prevention and control measures against this endemic. Although it is not very convenient, people have been used to such prevention and control methods. In December, 2022, China changed the prevention and control measures, a large number of patients were infected in a short period of time. Outpatient department acted as the first line of the hospital, and outpatient nurses acted as fighters, facing great difficulties and psychological pressure.In-depth understanding of the real experience of outpatient nurses after the change of COVID-19 prevention and control measures in China will provide reference for further improving the management level of emergency nursing. Methods: From December 2022 to January 2023, in the initial stage of the change of endemic prevention measures, 16 outpatient nurses from the First Affiliated Hospital of Soochow University conducted semi-structured interviews, and analyzed the interview data by Colaizzi analysis. Results: Based on the real experience of 16 outpatient nurses in this special period, four themes were extracted. The themes were the following:(1)Ethical challenges; (2)Changes in life; (3)Get experience, normalize, and adapt to the endemic; (4)Re-understanding for work and life. The suggestions were the following:(1)Pay more attention to the emotional changes of the outpatient nurses, and give them psychological support; (2)Strengthen the social support system and provide good logistics support; (3)Improve the management system, and pay attention to the suggestions and reflections of medical staff. Conclusion: Through this interview, it was discovered that outpatient nurses demonstrated a strong sense of responsibility and mission during the process of epidemic prevention policy changes. However, they also experienced negative psychological effects due to inadequate understanding of the disease, heavy treatment tasks, and risk of self-infection. Therefore, managers should optimize human resource allocation, promptly alleviate negative emotions among outpatient nurses, and provide them with psychological counseling services.

OBJECTIVE:Ecological momentary assessment (EMA) refers to the repeated sampling of information about an individual's symptoms and behaviours, enabling the capture of ecologically meaningful real-time information in a timely manner. Compliance with EMA is critical in determining the validity of an assessment. However, there is limited evidence related to how the elderly comply with EMA programmes or the factors that are associated with compliance.DESIGN:Systematic review and meta-analysis.DATA SOURCES:PubMed, Embase, the Cochrane Library and Web of Science were searched up to 17 July 2022.ELIGIBILITY CRITERIA:We included observational studies on EMA in the elderly reported in English.DATA EXTRACTION AND SYNTHESIS:Two investigators independently performed screening and data extraction. Discrepancies were resolved by discussion or a third investigator. A systematic review was carried out to characterise the basic characteristics of the participants and EMA programmes. Random-effects meta-analysis was conducted to assess overall compliance and to explore factors associated with differences in compliance among the elderly.RESULTS:A total of 20 studies with 2047 participants were included in the systematic review and meta-analysis. Meta-analysis showed that the combined compliance rate was 86.41% (95% CI: 77.38% to 92.20%; I2=96.4%; p<0.001). Subgroup analysis revealed high levels of heterogeneity in terms of the methods used to assess population classification, assessment method and assessment frequency, although these may not be the sources of heterogeneity. Meta-regression analysis showed that population classification and assessment period might have a significant impact on heterogeneity (p<0.05). Egger's test indicated significant publication bias (p<0.001).CONCLUSIONS:Compliance with EMA programmes is high in the elderly. It is recommended that scholars design reasonable EMA programmes according to the health status of the elderly in the future.

目的 探讨中心静脉通路装置(central venous access device,CAVD)相关性皮肤损伤(CAVD-associated skin impairment,CA-SI)预防方案在门诊经外周静脉置入中心静脉导管(peripherally inserted central catheter,PICC)患者中的应用效果.方法 便利抽样法选取苏州市、无锡市 8 所三级综合医院门诊行PICC维护的 1043 例患者为研究对象并采用整群随机对照试验.其中 4 所医院为对照组,给予PICC常规护理;4 所医院为试验组,在常规护理基础上予以CASI预防方案.干预 6 个月后,比较两组患者CASI发生率、医用粘胶相关性皮肤损伤(medical adhesive-related skin injury,MARSI)及医疗器械相关压力性损伤(medical device related pressure ul-cers,MDRPU)发生率和严重程度、血管导管相关感染率和非计划拔管率的差异.结果 试验组CASI、MARSI及MDRPU发生率均低于对照组(均P＜0.05),两组MARSI、MDRPU严重程度及非计划拔管率无统计学差异(均P＞0.05).两组均未发生血管导管相关感染.结论 实施CASI预防方案有利于降低PICC门诊患者CASI的发生率,为临床护士预防CASI提供实践指导.

With the widespread adoption of ultrasound guidance, Seldinger puncture techniques, and intracardiac electrical positioning technology for the placement of peripherally inserted central catheters in recent years, an increasing number of medical staff and patients now accept peripheral placement of totally implantable venous access devices (TIVADs) in the upper arm. This approach has the advantage of completely avoiding the risks of hemothorax, pneumothorax, and neck and chest scarring. Medical specialties presently engaged in this study in China include internal medicine, surgery, anesthesiology, and interventional departments. However, command over implantation techniques, treatment of complications, and proper use and maintenance of TIVAD remain uneven among different medical units. Moreover, currently, there are no established quality control standards for implantation techniques or specifications for handling complications. Thus, this expert consensus is proposed to improve the success rate of TIVAD implantation via the upper-arm approach, reduce complication rates, and ensure patient safety. This consensus elaborates on the technical indications and contraindications, procedures and technical points, treatment of complications, and the use and maintenance of upper-arm TIVAD, thus providing a practical reference for medical staff.

Traditional symptom management methods are difficult to efficiently and accurately intervene in symptom networks related to mental illness. Bridge symptoms are the most core symptom in the symptom network, and symptom management for bridge symptoms can effectively improve other related symptoms management of mental illness. This paper reviews the overview, identification indicators and methods, characteristics of bridge symptoms, and its application significance in symptom management of mental illness patients, aiming to provide reference for nurses to implement efficient and accurate symptom management for patients with mental illness.

BackgroundAs a novel antineoplastic drug, immune checkpoint inhibitors (ICIs) are associated with a spectrum of autoimmune-related side effects, including acute kidney injury (AKI). Understanding the risk factors for immune-associated acute kidney injury will inform future symptom management measures to reduce this risk. This study aims to identify the risk factors for ICIs-AKI in cancer patients through a systematic review and meta-analysis.MethodsThe systematic search was conducted in The Cochrane Library, Pubmed, Embase, Web of Science, China National Knowledge Infrastructure (CNKI), Wanfang Data, and VIP Database. The related studies published since the establishment of the database to Aug 22, 2022, were screened, data was extracted following the inclusion and exclusion criteria, and the quality of the selected studies was assessed by Newcastle-Ottawa Scale (NOS). The above was performed independently by the two reviewers. The estimated pooled odds ratios (ORs) for risk factors of developing ICIs-AKI were conducted by random-effects meta-analysis.ResultsA total of 8 publications, including 5267 patients, were included. Meta-analysis results showed that extrarenal immune-related adverse events (irAEs), therapy with the cytotoxic T-lymphocyte-associated protein 4 (CTLA-4), male, hypertension, pre-existent use of a diuretic, and a proton pump inhibitor (PPI) were significantly correlated to ICIs-AKI.ConclusionsWe identified extrarenal irAEs, CTLA-4 treatments, males, hypertension, previous use of diuretics, and PPIs are essential predictors of ICIs-AKI. These findings are helpful for healthcare providers to monitor ICIs-AKI for management and timely interventions.

The purpose of this paper is to explore the attitudes of surrogacy and medical service providers toward SDM and to identify the barriers and promoters of SDM in this population. To this end, we conducted a qualitative study of surrogacy and medical service providers in the First Affiliated Hospital of Soochow University using semistructured interviews. Thirty participants (11 agents, 12 ICU physicians, and 7 ICU nurses) were interviewed. The three stakeholders showed different attitudes toward SDM. They reported barriers to SDM, including insufficient cognition of decision-makers, high expectations, negative psychological experiences, previous decision-making experiences, excessive workload, heavy financial burden, and lack of decision AIDS. They reported facilitators of SDM, including trust, effective communication, decision support, value clarification, outcome commitment, and continuous service. This study explored the different attitudes of the three stakeholders and identified various barriers and facilitators of SDM. It highlights the need to develop localised decision AIDS and to involve agents and nurses more in the decision-making process. Therefore, this paper identifies barriers and facilitators of SDM in this population. In addition, the study identified various barriers and facilitators to SDM and highlighted the need to develop localised decision AIDS and involve agents and nurses more in the decision-making process. Finally, the barriers and facilitators of SDM are established. The paper also shows that the development of localized decision AIDS and greater involvement of agents and nurses in the decision-making process are integral to good treatment outcomes.

BACKGROUND:Radiotherapy-induced oral mucositis (RIOM) is the most common toxicity associated with radiotherapy for nasopharyngeal carcinoma (NPC). Patients with RIOM become malnourished, which can affect the delivery and dose of radiotherapy. The value of personalizing nutrition recommendations for cancer prevention and management is increasingly recognized. To investigate the effect of individualized whole course nutrition management on nutritional status and the incidence and severity of RIOM in NPCs.METHODS:This retrospective study included 77 patients who were provided individualized whole course nutrition management during radiotherapy (RT) and a 1-month follow-up. Seventy-one patients were included in the control group.RESULTS:During radiotherapy, severity of RIOM was significantly lower in the intervention group. There were statistically significant differences in oral mucosa recovery time and nutritional status between the two groups (p < 0.05).CONCLUSIONS:Individualized whole course nutrition management had the potential to maintain nutritional status and decrease the adverse effects of radiotherapy in NPCs.

Purpose: The objective of this study was to determine the independent risk factors associated with peripheral venous catheter (PVC) failure and develop a model that can predict PVC failure. Methods: This prospective, multicenter cohort study was carried out in nine tertiary hospitals in Suzhou, China between December 2017 and February 2018. Adult patients undergoing first-time insertion of a PVC were observed from catheter insertion to removal. Logistic regression was used to identify the independent risk factors predicting PVC failure. Results: This study included 5345 patients. The PVC failure rate was 54.05% ( n = 2889/5345), and the most common causes of PVC failure were phlebitis (16.3%) and infiltration/extravasation (13.8%). On multivariate analysis, age (45–59 years: OR, 1.295; 95% CI, 1.074–1.561; 60–74 years: OR, 1.375; 95% CI, 1.143–1.654; ⩾75 years: OR, 1.676; 95% CI, 1.355–2.073); department (surgery OR, 1.229; 95% CI, 1.062–1.423; emergency internal/surgical ward OR, 1.451; 95% CI, 1.082–1.945); history of venous puncture in the last week (OR, 1.298, 95% CI 1.130–1.491); insertion site, number of puncture attempts, irritant fluid infusion, daily infusion time, daily infusion volume, and type of sealing liquid were independent predictors of PVC failure. Receiver operating characteristic curve analysis indicated that a logistic regression model constructed using these variables had moderate accuracy for the prediction of PVC failure (area under the curve, 0.781). The Hosmer-Lemeshow goodness of fit test demonstrated that the model was correctly specified (χ2 = 2.514, p = 0.961). Conclusion: This study should raise awareness among healthcare providers of the risk factors for PVC failure. We recommend that healthcare providers use vascular access device selection tools to select a clinically appropriate device and for the timely detection of complications, and have a list of drugs classified as irritants or vesicants so they can monitor patients receiving fluid infusions containing these drugs more frequently.

传统的评估方法难以对老年人日常生活中的健康行为进行精准评估,生态瞬时评估能够实时监测老年人在自然环境中的行为、情境、情绪、意识等信息,具有生态性和时效性.该文从生态瞬时评估概述、策略(评估内容、评估方法、评估频率及周期)、应用评价等方面进行综述,旨在为护士参与老年人健康行为管理和提高老年人健康行为提供依据.

目的 评价延长维护间隔时间对非治疗期患者输液港相关并发症的影响.方法 检索中国知网、维普数据库、万方数据库、中国生物医学文献数据库、PubMed、Cochrane Library、Embase、Web of Science数据库中关于延长非治疗期患者输液港维护间隔时间的文献,检索时限为建库至2021年10月6日.由2名研究者独立进行文献筛选、资料提取和质量评价后,采用RevMan 5.3软件进行统计分析.结果 共纳入11篇文献,2268例患者.Meta分析结果显示,维护间隔时间>4周与≤4周相比,导管相关并发症总发生率[RR=0.82,95％CI(0.56,1.19),P=0.30]及导管堵塞发生率[RR=0.84,95％CI(0.54,1.31),P=0.44]、导管相关性感染发生率[RR=1.47,95％CI(0.38,5.73),P=0.58]差异均无统计学意义.描述性分析显示,延长维护间隔时间未增加血栓的发生率,并可减少输液港的维护费用.结论 延长非治疗期患者输液港维护间隔时间是安全可行的,不会增加其并发症的发生率,并可减少输液港的维护费用.未来需要更多高质量的随机对照试验验证输液港最佳的维护间隔时间.

Aim: To investigate the effect of implementing a model for continuous quality improvement in the nutritional management of patients with nasopharyngeal carcinoma (NPC) treated with radiotherapy. Design methods: In the intervention group (n = 77), a model for the continuous quality improvement of efforts at nutrition management was implemented. These efforts included the development of a new process for nutrition management, a system to provide nutritional support and the use of targeted intervention plans to improve nutrition. The time from diagnosis to the administration of radiation therapy, the severity of oral mucositis and dietary factors were recorded and considered in the development of targeted nutrition intervention and nutrition education. The control group (n = 71) followed the original procedures for nutrition management. Results: The study found that the CQI model can decrease the severity of oral mucositis caused by radiation and improve nutritional status in affected patients.

通过综述中心静脉通路装置相关性皮肤损伤的国内外研究进展,从皮肤损伤的评估、预防和治疗措施3个方面分析和总结当前研究中存在的问题并提出相应建议,以期为中心静脉通路装置相关皮肤损伤的规范化管理提供参考。

Rheumatoid arthritis (RA) is associated with increased localized and generalized bone loss, but the complex genetic mechanism between them is still unknown. By leveraging large-scale genome-wide association studies summary statistics and individual-level datasets (i.e. UK Biobank), a series of genetic approaches were conducted. Linkage disequilibrium score regression reveals a shared genetic correlation between RA and estimated bone mineral density (eBMD) (r(g)=-0.059, P=0.005). The PLACO analysis has identified 74 lead (8 novel) pleiotropic loci that could be mapped to 99 genes, the genetic functions of which reveal the possible mechanism underlying RA and osteoporosis. In European, genetic risk score (GRS) and comprehensive Mendelian randomization (MR) were utilized to evaluate the causal association between RA and osteoporosis in European and Asian. The increase in GRS of RA could lead to a decrease of eBMD (beta=-0.008, P=3.77E-6) and a higher risk of facture [odds ratio (OR)=1.012, P=0.044]. MR analysis identified that genetically determined RA was causally associated with eBMD (beta=-0.021, P=4.14E-05) and fracture risk (OR=1.036, P=0.004). Similar results were also observed in Asian that osteoporosis risk could be causally increased by RA (OR=1.130, P=1.04E-03) as well as antibodies against citrullinated proteins-positive RA (OR=1.083, P=0.015). Overall, our study reveals complex genetic mechanism between RA and osteoporosis and provides strong evidence for crucial role of RA in pathogenesis of osteoporosis.