Body size shapes song in honeyeaters

Birdsongs are among the most distinctive animal signals. Their evolution is thought to be shaped simultaneously by habitat structure and by the constraints of morphology. Habitat structure affects song transmission and detectability, thus influencing song (the acoustic adaptation hypothesis), while body size and beak size and shape necessarily constrain song characteristics (the morphological constraint hypothesis). Yet, support for the acoustic adaptation and morphological constraint hypotheses remains equivocal, and their simultaneous examination is infrequent. Using a phenotypically diverse Australasian bird clade, the honeyeaters (Aves: Meliphagidae), we compile a dataset consisting of song, environmental, and morphological variables for 163 species and jointly examine predictions of these two hypotheses. Overall, we find that body size constrains song frequency and pace in honeyeaters. Although habitat type and environmental temperature influence aspects of song, that influence is indirect, likely via effects of environmental variation on body size, with some evidence that elevation constrains the evolution of song peak frequency. Our results demonstrate that morphology has an overwhelming influence on birdsong, in support of the morphological constraint hypothesis, with the environment playing a secondary role generally via body size rather than habitat structure. These results suggest that changing body size (a consequence of both global effects such as climate change and local effects such as habitat transformation) will substantially influence the nature of birdsong.

Geographic range size and speciation in honeyeaters

Background

Darwin and others proposed that a species’ geographic range size positively influences speciation likelihood, with the relationship potentially dependent on the mode of speciation and other contributing factors, including geographic setting and species traits. Several alternative proposals for the influence of range size on speciation rate have also been made (e.g. negative or a unimodal relationship with speciation). To examine Darwin’s proposal, we use a range of phylogenetic comparative methods, focusing on a large Australasian bird clade, the honeyeaters (Aves: Meliphagidae).

Results

We consider the influence of range size, shape, and position (latitudinal and longitudinal midpoints, island or continental species), and consider two traits known to influence range size: dispersal ability and body size. Applying several analytical approaches, including phylogenetic Bayesian path analysis, spatiophylogenetic models, and state-dependent speciation and extinction models, we find support for both the positive relationship between range size and speciation rate and the influence of mode of speciation.

Conclusions

Honeyeater speciation rate differs considerably between islands and the continental setting across the clade’s distribution, with range size contributing positively in the continental setting, while dispersal ability influences speciation regardless of setting. These outcomes support Darwin’s original proposal for a positive relationship between range size and speciation likelihood, while extending the evidence for the contribution of dispersal ability to speciation.

Macroevolutionary dynamics of parasite diversification: A reality check

Parasitism is often invoked as a factor explaining the variation in diversification rates across the tree of life, while also representing up to half of Earth's diversity. Yet, patterns and processes of parasite diversification remain mostly unknown. In this study, we assess the patterns of parasite diversification and specifically determine the role of life-history traits (i.e. life cycle complexity and host range) and major coevolutionary events in driving diversification across eight phylogenetic datasets spanning taxonomically different parasite groups. Aware of the degree of incomplete sampling among all parasite phylogenies, we also tested the impact of sampling bias on estimates of diversification. We show that the patterns and rates of parasite diversification differ among taxa according to life cycle complexity and to some extent major host transitions. Only directly transmitted parasites were found to be influenced by an effect of major host transitions on diversification rates. Although parasitism may be a main factor responsible for heterogeneity in diversification among the tree of life, the high degree of incomplete parasite phylogenies remains an obstacle when modelling diversification dynamics. Nevertheless, we provide the first comparative test of parasite diversification, revealing some consistent patterns and insight into the processes that shape it.

The feasibility and acceptability of a physical activity intervention for older people with chronic musculoskeletal pain: The iPOPP pilot trial protocol

INTRODUCTION

This pilot trial will inform the design and methods of a future full-scale randomized controlled trial (RCT) and examine the feasibility, acceptability and fidelity of the Increasing Physical activity in Older People with chronic Pain (iPOPP) intervention, a healthcare assistant (HCA)-supported intervention to promote walking in older adults with chronic musculoskeletal pain in a primary care setting.

METHODS AND ANALYSIS

The iPOPP study is an individually randomized, multicentre, three-parallel-arm pilot RCT. A total of 150 participants aged ≥65 years with chronic pain in one or more index sites will be recruited and randomized using random permuted blocks, stratified by general practice, to: (i) usual care plus written information; (ii) pedometer plus usual care and written information; or (iii) the iPOPP intervention. A theoretically informed mixed-methods approach will be employed using semi-structured interviews, audio recordings of the HCA consultations, self-reported questionnaires, case report forms and objective physical activity data collection (accelerometry). Follow-up will be conducted 12 weeks post-randomization. Collection of the quantitative data and statistical analysis will be performed blinded to treatment allocation, and analysis will be exploratory to inform the design and methods of a future RCT. Analysis of the HCA consultation recordings will focus on the use of a checklist to determine the fidelity of the iPOPP intervention delivery, and the interview data will be analysed using a constant comparison approach in order to generate conceptual themes focused around the acceptability and feasibility of the trial, and then mapped to the Theoretical Domains Framework to understand barriers and facilitators to behaviour change. A triangulation protocol will be used to integrate quantitative and qualitative data and findings.

Incidence, progression and sequence of development of radiographic knee osteoarthritis in a symptomatic population

OBJECTIVES

Symptomatic knee osteoarthritis (OA) is a common disabling condition. Attention has tended to focus on the tibiofemoral joint (TFJ). However, there is evidence that the patellofemoral joint (PFJ) is involved in many cases, but its place in the sequence of development and progression of knee OA is unclear. This study estimates the cumulative incidence, progression and inter-relationship of radiographic changes of OA in the TFJ and the PFJ in symptomatic adults.

METHODS

A population-based observational cohort of 414 adults aged ≥ 50 years with knee pain who had knee x-rays (weight-bearing posteroanterior semiflexed, skyline and lateral views) in 2002-3 and again in 2005-6 (mean interval 36.7 months) was studied. The outcome measure was the development of incident or progressive radiographic OA.

RESULTS

The 3-year cumulative incidences of patellofemoral joint osteoarthritis (PFJOA) and tibiofemoral joint osteoarthritis (TFJOA) were 28.8% and 21.7%, respectively. Corresponding estimates of 3-year cumulative progression were 18.9% and 25.3%. PFJOA at baseline was common and increased the risk of incident TFJOA (adjusted OR 2.2, 95% CI 1.1 to 4.1) but less clearly progression of TFJOA (adjusted OR 1.7, 95% CI 0.3 to 9.0). TFJOA at baseline increased the risk of PFJOA incidence and progression (adjusted OR 3.1, 95% CI 1.2 to 8.4 and OR 4.5, 95% CI 1.8 to 11.2, respectively).

CONCLUSIONS

These results suggest a common sequence in the development of radiographic knee OA in symptomatic adults beginning in the PFJ, with subsequent addition and progression of TFJOA. It is proposed that isolated symptomatic PFJOA may be one marker for the future development of TFJOA and a target for the early management of knee OA.

Integrating physical and psychological approaches to treatment in low back pain: the development and content of the STarT Back trial's 'high-risk' intervention (StarT Back; ISRCTN 37113406)

A new randomised controlled trial of intervention in low back pain has been described recently. In this trial, a screening and targeted approach was found to be more effective and cost-effective than current best practice. Nested within the intervention arm were three different interventions targeting patients identified as 'low', 'medium' or 'high' risk dependent on the presence of (mainly) psychosocial risk factors. In this paper, the development and content of the STarT Back trial's 'high-risk' intervention is described. It offers a systematic approach, termed 'psychologically informed practice', to the integration of physical and psychological approaches to treatment for the management of people with low back pain by physiotherapists. The term 'disability' is used to refer to self-reported pain-associated functional limitations, and 'psychological' is used to refer to the beliefs/expectations, emotional responses and behavioural responses associated with low back pain.

A systematic search and narrative review of radiographic definitions of hand osteoarthritis in population-based studies

OBJECTIVE

Currently there is no agreed "gold standard" definition of radiographic hand osteoarthritis (RHOA) for use in epidemiological studies. We therefore undertook a systematic search and narrative review of community-based epidemiological studies of hand osteoarthritis (OA) to identify (1) grading systems used, (2) definitions of radiographic OA for individual joints and (3) definitions of overall RHOA.

METHODS

The following electronic databases were searched: Medline, Embase, Science Citation Index and Ageline (inception to Dec 2006). The search strategy combined terms for "hand" and specific joint sites, OA and radiography. Inclusion and exclusion criteria were applied. Data were extracted from each paper covering: hand joints studied, grading system used, definitions applied for OA at individual joints and overall RHOA.

RESULTS

Titles and abstracts of 829 publications were reviewed and the full texts of 399 papers were obtained. One hundred fifty-two met the inclusion criteria and 24 additional papers identified from screening references. Kellgren and Lawrence (K&L) was the most frequently applied grading system used in 80% (n=141) of studies. In 71 studies defining OA at the individual joint level 69 (97%) used a definition of K&L grade > or = 2. Only 53 publications defined overall RHOA, using 21 different definitions based on five grading systems.

CONCLUSION

The K&L scheme remains the most frequently used grading system. There is a consistency in defining OA in a single hand joint as K&L grade > or = 2. However, there are substantial variations in the definitions of overall RHOA in epidemiological studies.

A brief pain management program compared with physical therapy for low back pain: Results from an economic analysis alongside a randomized clinical trial

OBJECTIVE

Guidelines for the management of acute low back pain in primary care recommend early intervention to address psychosocial risk factors associated with long-term disability. We assessed the cost utility and cost effectiveness of a brief pain management program (BPM) targeting psychosocial factors compared with physical therapy (PT) for primary care patients with low back pain of <12 weeks' duration.

METHODS

A total of 402 patients were randomly assigned to BPM or PT. We adopted a health care perspective, examining the direct health care costs of low back pain. Outcome measures were quality-adjusted life years (QALYs) and 12-month change scores on the Roland and Morris disability questionnaire. Resource use data related to back pain were collected at 12-month followup. Cost effectiveness was expressed as incremental ratios, with uncertainty assessed using cost-effectiveness planes and acceptability curves.

RESULTS

There were no statistically significant differences in mean health care costs or outcomes between treatments. PT had marginally greater effectiveness at 12 months, albeit with greater health care costs (BPM 142 pounds, PT 195 pounds). The incremental cost-per-QALY ratio was 2,362 pounds. If the UK National Health Service were willing to pay 10,000 pound per additional QALY, there is only a 17% chance that BPM provides the best value for money.

CONCLUSION

PT is a cost-effective primary care management strategy for low back pain. However, the absence of a clinically superior treatment program raises the possibility that BPM could provide an additional primary care approach, administered in fewer sessions, allowing patient and doctor preferences to be considered.

Prevalence of radiographic osteoarthritis--it all depends on your point of view

OBJECTIVES

Knee pain and disability in older people may occur in the apparent absence of radiographic osteoarthritis. However, the view chosen to define radiographic osteoarthritis may be critical. We have investigated the prevalence and compartmental distribution of radiographic osteoarthritis in people with knee pain using different combinations of three separate radiographic views.

METHODS

We performed a population-based study of 819 adults aged 50 yr and over with knee pain (part of the Clinical Assessment Study - Knee [CAS(K)]). Three radiographic views were obtained: weight-bearing posteroanterior (PA) semiflexed/metatarsophalangeal view; supine skyline; and supine lateral.

RESULTS

Complete data for all three views were available on 777 subjects. The distribution of compartmental radiographic osteoarthritis was 314 (40%) combined tibiofemoral/patellofemoral, 186 (24%) isolated patellofemoral, 31 (4%) isolated tibiofemoral and 246 (32%) normal. Hence, the overall prevalence of radiographic osteoarthritis was 531/777 (68.3%) in this symptomatic population. Using a PA view alone (reflecting tibiofemoral osteoarthritis only) would identify 56.7% of the 531, whilst the addition of a skyline or lateral view increased this to 87.0%. When using both skyline and lateral views in addition to the PA view, 98.7% cases of radiographic osteoarthritis were identified. In addition to prevalence, compartmental distribution altered markedly when different combinations of views were used.

CONCLUSIONS

Multiple views detect more radiographic osteoarthritis than single views alone. When different combinations of views are used, the prevalence and compartmental distribution of osteoarthritis changes and this may alter the accepted relationship, or lack of it, between symptoms and radiographic change.

A cost consequences analysis of local corticosteroid injection and physiotherapy for the treatment of new episodes of unilateral shoulder pain in primary care

OBJECTIVE

Local steroid injections and community-based physiotherapy have been shown to be of similar benefit for treating shoulder pain presenting to primary care. This paper presents a cost consequences analysis of a prospective economic evaluation, conducted alongside a randomized clinical trial (RCT) of corticosteroid injections versus physiotherapy for new episodes of unilateral shoulder pain, to determine the economic implications of injection versus physiotherapy.

METHODS

A pragmatic RCT with 207 patients randomized to either physiotherapy (n = 103) or local steroid injection (n = 104) was conducted. The resource inputs required were identified for each treatment arm in terms of capital, staff and consumables. These were measured for the period up to 6 months post-randomization. Outcome measures included shoulder disability, shoulder pain, global assessment of health change and the EQ5D, all at 6 months. A sensitivity analysis was performed around the general practitioner minor surgical fee.

RESULTS

Analysis is presented on the 199 patients for which the general practice record review (101 physiotherapy, 98 injection) was available. The total mean costs, per patient, were 71.28 pound sterling for the injection group and 114.60 pound sterling for the physiotherapy group. The difference in average total cost per patient was 43.32 pound sterling (95% bootstrap confidence interval: 16.21 pound sterling, 68.03 pound sterling ). This is a statistically significant difference in cost. Outcome was similar in both groups across all measures following intervention. Smaller mean differences in cost were observed between the treatment groups in the sensitivity analysis, but the difference remained in favour of injection over physiotherapy.

CONCLUSIONS

This study has shown, given similar clinical outcomes across the treatment groups, that corticosteroid injections were the cost-effective option for patients presenting with new episodes of unilateral shoulder pain in primary care.

Comparison of physical treatments versus a brief pain-management programme for back pain in primary care: a randomised clinical trial in physiotherapy practice

BACKGROUND

Recommendations for the management of low back pain in primary care emphasise the importance of recognising and addressing psychosocial factors at an early stage. We compared the effectiveness of a brief pain-management programme with physiotherapy incorporating manual therapy for the reduction of disability at 12 months in patients consulting primary care with subacute low back pain.

METHODS

For this pragmatic, multicentre, randomised clinical trial, eligible participants consulted primary care with non-specific low back pain of less than 12 weeks' duration. They were randomly assigned either a programme of pain management (n=201) or manual therapy (n=201). The primary outcome was change in the score on the Roland and Morris disability questionnaire at 12 months. Analysis was by intention to treat.

FINDINGS

Of 544 patients assessed for eligibility, 402 were recruited (mean age 40.6 years) and 329 (82%) reached 12-month follow-up. Mean disability scores were 13.8 (SD 4.8) for the pain-management group and 13.3 (4.9) for the manual-therapy group. The mean decreases in disability scores were 8.8 (6.4) and 8.8 (6.1) at 12 months (difference 0 [95% CI -1.3 to 1.4], p=0.99), and median numbers of physiotherapy visits per patient were three (IQR one to five) and four (two to five), respectively (p=0.001). One adverse reaction (an exacerbation of pain after the initial assessment) was recorded.

INTERPRETATION

Brief pain management techniques delivered by appropriately trained clinicians offer an alternative to physiotherapy incorporating manual therapy and could provide a more efficient first-line approach for management of non-specific subacute low back pain in primary care.

A comparison of two primary care trials on tennis elbow: issues of external validity

OBJECTIVE

To assess clinical heterogeneity across two studies with respect to study population, interventions, and outcome measures, and to evaluate the influence of these sources of heterogeneity on the results of the studies.

METHODS

The individual patient data were used from two randomised controlled trials investigating the effectiveness of conservative treatments in patients with tennis elbow in primary care. Patients were allocated at random to treatment with steroid injection, wait and see policy, non-steroidal anti-inflammatory drugs, placebo tablets, or physiotherapy. Outcome measures included severity of the main complaint, inconvenience of the elbow complaints, pain during the day, elbow disability, pain-free grip strength, and global improvement. All outcomes were assessed at 1, 6, and 12 months after randomisation.

RESULTS

The two study populations were similar with respect to age, sex, comorbid neck/shoulder complaints, and baseline scores for the severity of pain. However, significant differences were observed for employment status, duration of elbow complaints, dominant side affected, previous history of elbow complaints, and use of analgesics. Local injections differed between the two studies with respect to volume, number, and steroid preparation. However, after 1, 6, and 12 months, the treatment effects of steroid injections were very similar between the study populations.

CONCLUSIONS

Despite large differences in study population at baseline, the responses to steroid injections were remarkably similar. Also the responses to other conservative interventions and the placebo treatment were very consistent, suggesting a uniform course of a tennis elbow and a lack of influence of clinical heterogeneity.

Two pragmatic trials of treatment for shoulder disorders in primary care: generalisability, course, and prognostic indicators

OBJECTIVE

To investigate predictors of long term prognosis in patients treated for shoulder pain in primary care.

METHODS

Data were taken from two pragmatic randomised clinical trials investigating the effectiveness of conservative treatments for shoulder pain presenting to primary care. Shoulder pain severity, disability, and perceived recovery measured in the long term (UK, 18 months; Netherlands, 12 months) were considered as outcome measures. Prognostic indicators measured before randomisation were determined by linear regression (pain severity and disability) and logistic regression (perceived recovery).

RESULTS

316 adults with a new episode of shoulder pain were recruited (UK, n = 207; Netherlands, n = 109). In multivariate analysis, greater shoulder disability at follow up was associated with higher baseline disability score, concomitant neck pain, and a gradual onset and longer duration of shoulder symptoms. Pain scores at follow up were higher in women and in those with longer baseline duration of symptoms and higher baseline pain or disability scores. Being female, reporting gradual onset of symptoms, and a higher baseline disability score each independently reduced the likelihood of perceived recovery.

CONCLUSIONS

The results suggest that there is no long term difference in outcome between patients with shoulder pain treated with different clinical interventions in different clinical settings, or having different clinical diagnoses. Baseline clinical characteristics of this consulting population, rather than the randomised treatments which they received, were the most powerful predictors of outcome. Whether this highlights the need for earlier intervention or reflects different natural histories of shoulder pain is a topic for further research.

A systematic search and critical review of measures of disability for use in a population survey of hand osteoarthritis (OA)

OBJECTIVE

In order to develop a hand assessment questionnaire for a population survey, a systematic review was undertaken of measures of hand disability. The purpose of this review was to identify valid measures to evaluate hand osteoarthritis (HOA) in the general population and primary care and to perform a quality appraisal of them.

METHOD

Measurement tools were identified from an online search of databases (Medline, CINAHL and Institute for Scientific Information (ISI), 1990-2002) restricted to English language and adult population. Search terms combined "osteoarthritis" and "arthritis" with "hand" and ["function" or "disability" or "outcome"]. Instruments used in the evaluation of HOA were identified following application of strict eligibility criteria. The use of these tools in HOA was rated by pairs of independent reviewers according to criteria developed by the Medical Outcomes Trust.

RESULTS

The initial search yielded a list of articles which were not mutually exclusive (ISI, 127; Medline, 64; CINAHL, 61). Full journal articles were ordered from relevant abstracts (ISI, 28; Medline, 3; CINAHL, 5). Further hand searching of articles produced an additional 34 references. A total of 61 references were identified, 18 measurement tools, 5 of which met the inclusion criteria [Algofunctional Index (FIHOA), Arthritis Impact Measurement Scale 2 (AIMS2), Stanford Health Assessment Questionnaire (HAQ), Australian/Canadian Osteoarthritis Hand Index (AUSCAN), Cochin]. Overall, the AIMS2 and AUSCAN were more highly rated than the FIHOA, Cochin and HAQ.

CONCLUSIONS

The aim of this review was not to recommend any one instrument over another but to provide an overall summary of the robustness of commonly used measures. The choice of instrument will depend on many factors, and will differ from project to project depending on the question asked.

A comparison of four shoulder-specific questionnaires in primary care

OBJECTIVES

To compare the validity, responsiveness to change, and user friendliness of four self completed, shoulder-specific questionnaires in primary care.

METHODS

A cross sectional assessment of validity and a longitudinal assessment of responsiveness to change of four shoulder questionnaires was carried out: the Dutch Shoulder Disability Questionnaire (SDQ-NL); the United Kingdom Shoulder Disability Questionnaire (SDQ-UK); and two American instruments, the Shoulder Pain and Disability Index (SPADI) and the Shoulder Rating Questionnaire (SRQ). 180 primary care consulters with new shoulder region pain each completed two of the questionnaires, as well as EuroQoL and 10 cm visual analogue scales (VAS) for overall pain and difficulty due to the shoulder problem. Each participant was assessed by a standardised clinical schedule. Postal follow up at 6 weeks included baseline measures and self rated assessment of global change of the shoulder problem (seven point Likert scale).

RESULTS

Strongest correlations were found for SDQ-UK with EuroQoL 5 score, and for SPADI and SRQ with shoulder pain and difficulty VAS. All shoulder questionnaires correlated poorly with active movement at the painful shoulder. SPADI and SRQ performed better on ROC analysis than SDQ-NL and SDQ-UK (areas under the curve of 0.87, 0.85, 0.77, and 0.77, respectively). However, SRQ scores changed significantly over time in stable subjects.

CONCLUSIONS

Cross sectional comparison of the four shoulder questionnaires showed they had similar overall validity and patient acceptability. SPADI and SRQ were most responsive to change. Additionally, SPADI was the quickest to complete and scores did not change significantly in stable subjects.

A pragmatic randomised controlled trial of local corticosteroid injection and physiotherapy for the treatment of new episodes of unilateral shoulder pain in primary care

OBJECTIVES

To compare the long term effectiveness of local steroid injections administered by general practitioners with practice based physiotherapy for treating patients presenting in primary care with new episodes of unilateral shoulder pain.

METHODS

Adults consulting with shoulder pain were recruited by their general practitioner. Patients were randomly allocated to receive either corticosteroid injections or community based physiotherapy. Primary outcome was self reported disability from shoulder problems at six months. Secondary outcomes included participant's global assessment of change; pain; function; "main complaint"; range of shoulder movement; co-interventions. A study nurse unaware of the treatment allocation performed baseline and follow up assessments. Analysis was by intention to treat.

RESULTS

Over 22 months 207 participants were randomised, 103 to physiotherapy and 104 to injection. Prognostic variables were similar between the two groups at baseline. Mean (SD) improvements in disability scores at six weeks were 2.56 (5.4) for physiotherapy and 3.03 (6.3) for injection (mean difference=-0.5, 95% confidence interval (95% CI): -2.1 to 1.2) and at six months were 5.97 (5.4) for physiotherapy and 4.55 (5.9) for injection (mean difference=1.4, 95% CI -0.2 to 3.0). A "successful outcome" (a minimum 50% drop in the disability score from baseline) at six months was achieved by 59/99 (60%) in the physiotherapy group and 51/97 (53%) in the injection group (percentage difference=7%, 95% CI -6.8% to 20.4%). Co-interventions were more common in the injection group during follow up.

CONCLUSION

Community physiotherapy and local steroid injections were of similar effectiveness for treating new episodes of unilateral shoulder pain in primary care, but those receiving physiotherapy had fewer co-interventions.

Chronic shoulder pain in the community: a syndrome of disability or distress?

OBJECTIVES

To investigate two questions in a community based population of people with chronic shoulder pain. Firstly, does chronic pain lead to impaired psychological health over time? Secondly, how does restriction of daily activity influence pain perception and psychological health?

METHODS

Two postal surveys, two years apart, were carried out to identify a group of subjects with chronic shoulder pain. The first survey was sent to a random sample of adults (n=40026) registered with a primary care practice, and included a pain manikin, demographic information, and the Hospital Anxiety and Depression scale (HAD). The second survey was sent to those subjects who reported unilateral shoulder region pain in the first survey and it included a shoulder-specific disability scale, pain severity score, and the HAD.

RESULTS

2606 (65.1%) people responded to the initial survey. Of these, 304 (11.7%) reported unilateral shoulder region pain at baseline. In the subsequent survey, there were 234 responders (83.3% adjusted response): 142 of these reported shoulder pain and formed our study group of "subjects with chronic shoulder pain". Within this group there was no significant change in psychological distress scores between baseline and follow up. Both the disability score and psychological distress scores correlated significantly with pain severity (disability v pain r=0.536, p<0.001; psychological distress v pain r=0.269, p=0.002). When the correlation between disability and pain severity was corrected for possible confounders, it remained significant (r=0.490, p<0.001). This was not the case for the correlation between psychological distress and pain (p>0.05). Disability was significantly correlated with psychological distress on univariate (r=0.445, p<0.001) and multivariate analysis (r=0.341, p=0.002).

CONCLUSION

In those with chronic shoulder pain the relation between pain and psychological health seems to be linked to disability. Psychological distress was not explained by persistent pain itself.

Adverse reactions to disease-modifying anti-rheumatic drugs in clinical practice

We analysed computerized records of disease-modifying anti-rheumatic drug (DMARD) monotherapy to determine how long rheumatoid arthritis (RA) patients continued on five commonly prescribed DMARDs, and the incidence and time-course of adverse drug reactions (ADRs) they experienced. We studied the records for 3923 courses of DMARDs given to a cohort of 2170 patients monitored for a total of 9378 treatment-years. Methotrexate (MTX) was the DMARD most likely to be continued long-term; <45% of patients had discontinued the drug after 96 months. For the other DMARDs, the time until 50% discontinued due to ADRs or inefficacy was 43.3 months for sulphasalazine (SAS), 33.9 months for D-penicillamine (DPN) and 26 months for myocrisin. Most monitored ADRs requiring drug discontinuation were seen early in therapy, with a median time to onset of <6 months; the important exceptions to this were haematological ADRs to MTX, where the median delay to neutropenia was 16.9 months, and that to thrombocytopenia was 9.4 months. Monitored ADRs (identified by blood or urine tests) were seen least frequently with SAS (one ADR in every 35 patient-years of monitoring) but this apparent advantage was offset by a high incidence of gastrointestinal ADRs and inefficacy. Overall, one toxicity reaction requiring drug discontinuation was identified for every 15.9 patient-years of monitoring.

Do patients with rheumatoid arthritis established on methotrexate and folic acid 5 mg daily need to continue folic acid supplements long term?

BACKGROUND

It is postulated that some aspects of methotrexate toxicity may be related to its action as an anti-folate. Folic acid (FA) is often given as an adjunct to methotrexate therapy, but there is no conclusive proof that it decreases the toxicity of methotrexate and there is a theoretical risk that it may decrease the efficacy of methotrexate.

OBJECTIVES

To look at the effect of stopping FA supplementation in UK rheumatoid arthritis (RA) patients established on methotrexate <20 mg weekly and FA 5 mg daily, to report all toxicity (including absolute changes in haematological and liver enzyme indices) and to report changes in the efficacy of methotrexate.

METHODS

In a prospective, randomized, double-blind, placebo-controlled study, 75 patients who were established on methotrexate <20 mg weekly and FA 5 mg daily were asked to stop their FA and were randomized to one of two groups: placebo or FA 5 mg daily. Patients were evaluated for treatment toxicity and efficacy before entry and then at intervals of 3 months for 1 yr.

RESULTS

Overall, 25 (33%) patients concluded the study early, eight (21%) in the group remaining on FA and 17 (46%) in the placebo group (P = 0.02). Two patients in the placebo group discontinued because of neutropenia. At 9 months there was an increased incidence of nausea in the placebo group (45 vs. 7%, P = 0.001). The placebo group had significantly lower disease activity on a few of the variables measured, but these were probably not of clinical significance.

CONCLUSIONS

It is important to continue FA supplementation over the long term in patients on methotrexate and FA in order to prevent them discontinuing treatment because of mouth ulcers or nausea and vomiting. Our data suggest that FA supplementation is also helpful in preventing neutropenia, with very little loss of efficacy of methotrexate.

Pragmatic randomised controlled trial of local corticosteroid injection and naproxen for treatment of lateral epicondylitis of elbow in primary care

OBJECTIVE

To compare the clinical effectiveness of local corticosteroid injection, standard non-steroidal anti-inflammatory drugs, and simple analgesics for the early treatment of lateral epicondylitis in primary care.

DESIGN

Multicentre pragmatic randomised controlled trial.

SETTING

23 general practices in North Staffordshire and South Cheshire.

PARTICIPANTS

164 patients aged 18-70 years presenting with a new episode of lateral epicondylitis.

INTERVENTIONS

Local injection of 20 mg methylprednisolone plus lignocaine, naproxen 500 mg twice daily for two weeks, or placebo tablets. All participants received a standard advice sheet and co-codamol as required.

MAIN OUTCOME MEASURES

Participants' global assessment of improvement (five point scale) at four weeks. Pain, function, and "main complaint" measured on 10 point Likert scales at 4 weeks, 6 months, and 12 months.

RESULTS

Over 2 years, 53 subjects were randomised to injection, 53 to naproxen, and 58 to placebo. Prognostic variables were similar between groups at baseline. At 4 weeks, 48 patients (92%) in the injection group were completely better or improved compared with 30 (57%) in the naproxen group (P<0.001) and 28 (50%) in the placebo group (P<0.001). At 12 months, 43 patients (84%) in the injection group had pain scores </=3 compared with 45 (85%) in the naproxen group and 44 (82%) in the placebo group (P>0.05).

CONCLUSIONS

Early local corticosteroid injection is effective for lateral epicondylitis. Outcome at one year was good in all groups, and effective early treatment does not seem to influence this.

Treatment options for regional musculoskeletal pain: what is the evidence?

Decisions about the best treatment options for patients with regional musculoskeletal pain must be made despite a lack of clear diagnostic criteria, an absence of robust outcome measures by which to assess response, and a paucity of evidence from high-quality randomized controlled trials. Although the randomized controlled trial is considered to be the 'gold standard' research design, it does not lend itself easily to the evaluation of all management strategies. This chapter explores these issues from a research perspective and reviews the various types of evidence available to help practitioners make informed decisions. The current evidence from systematic reviews in this area is summarized in the final part of the chapter.

Sjögren's syndrome: a community-based study of prevalence and impact

OBJECTIVE

Using the European Community (EC) criteria for classification Vitali et al. Arthritis Rheum 1993;36:340 7, we report the prevalence estimates of Sjogren's syndrome (SS) from a general population and present the first population data to assess the impact of the syndrome.

METHODS

A cross-sectional population-based survey performed on 1000 adults, aged 18-75 yr, randomly selected from a population register. Responders to the initial postal phase were invited for an interview. The five criteria measured at interview were: (1) the reporting of subjective oral symptoms lasting for > 3 months; (2) the reporting of subjective ocular symptoms lasting for >3 months; (3) Schirmer-I test; (4) unstimulated salivary flow; (5) autoantibodies [Ro (SS-A), La (SS-B), rheumatoid factor (RF), antinuclear antibodies (ANA)]. SS was diagnosed if at least four of these five criteria were positive. The MOS Short-form 36 (SF-36), General Health Questionnaire (GHQ) and the Health and Fatigue Questionnaire (HFQ) were completed by subjects after the interview, and scores were compared between those with and without a diagnosis of SS.

RESULTS

A total of 341 subjects completed both the postal questionnaire and home visit. A diagnosis of SS could be given to 13 subjects. After adjusting for the presence of possible bias due to non-response, our best estimate of the prevalence of SS in the study population was 33 per 1000 subjects (95% CI 22 44). The prevalence of the disorder was higher in females (38; 95% CI 27-52) and for those subjects aged > or = 55 yr (46; 95% CI 34-61). Those subjects diagnosed positively were more impaired for each of the eight dimensions of the SF-36 than those without a diagnosis, and also suffered from higher levels of depression and fatigue.

CONCLUSIONS

SS affects approximately 3-4% of adults and in the general population appears to be associated with a clinically significant impairment of a subject's health and well-being.

Weak association between subjective symptoms or and objective testing for dry eyes and dry mouth: results from a population based study

OBJECTIVES

To determine associations between symptoms of dry eyes and dry mouth and objective evidence of lacrimal and salivary gland dysfunction in a population based sample. To determine associations between these elements and the presence of autoantibodies.

METHODS

A cross sectional population based survey. Subjects were interviewed and examined (Schirmer-1 test and unstimulated salivary flow) for the presence of dry eyes and mouth. Antibodies (anti-Ro [SS-A], anti-La [SS-B], rheumatoid factor, antinuclear antibody) were measured.

RESULTS

341 subjects were examined. Twenty four per cent had dry eye symptoms, 29% dry mouth symptoms, and 14% both. There was only a weak association between the presence of oral or ocular symptoms and their respective test results. Associations were strongest between dry mouth symptoms and positive test results, and in subjects under 55 years of age. There was no association between the presence of autoantibodies and either symptoms or signs of dry eyes or dry mouth.

CONCLUSION

Only weak associations were found between self reported symptoms of dry eyes and dry mouth and objective measures said to define Sjögrens syndrome in the general population. The clinical significance of these symptoms in the community needs reappraisal.

Corticosteroid injections for lateral epicondylitis: a systematic overview

BACKGROUND

Lateral epicondylitis (tennis elbow) is a common complaint, for which corticosteroid injections are a frequently applied therapy. However, there were no up-to-date reviews available that systematically addressed the effectiveness and adverse effects, including questions concerning optimal timing of injections and composition of the injection fluid.

AIM

The aim of the study was to assess the effectiveness of corticosteroid injections in the treatment of lateral epicondylitis (tennis elbow) by systematic review of the available randomized clinical trials.

DATA SOURCES

The data sources used were randomized clinical trials identified by literature searches of the MedLine (1966-1994) and Embase (Exerpta Medica) (1980-1994) databases for the keywords epicondylitis, tendinitis and elbow, injection. References given in relevant publications were further examined.

STUDY SELECTION

The criteria for selecting studies were as follows: randomized clinical trials (treatment allocation in random or alternate order); one of the treatments to include one or more corticosteroid injections (additional interventions were allowed); participants suffering from lateral epicondylitis; and publication in English, German or Dutch. Abstracts and unpublished studies were not included.

DATA SYNTHESIS

Methodological quality was assessed by means of a standardized criteria list (range 1-100 points). The extracted outcomes were the general conclusion drawn by the authors of the reports on the trials, and the success rates at the various follow-up points as (re)calculated by us. The success rates were subsequently graphically displayed and statistically pooled. Separate stratified analyses were conducted according to a predetermined analysis plan.

RESULTS

Twelve randomized clinical trials were identified. The median methodological score was 40 points, indicating an overall poor to moderate quality. The pooled analysis indicated short-term effectiveness (2-6 weeks): pooled odds ratio (OR) = 0.15 [95% confidence interval (CI) 0.10-0.23], chi 2 [degrees of freedom (df = 5) = 13.3], indicating statistical heterogeneity. At longer term follow-up, no difference could be detected. The studies of better methodological quality indicated more favourable results than those of lesser methodological quality. The most suitable corticosteroid to use as well as dosage, injection interval and injection volume could not be derived from the various trials.

CONCLUSION

The existing evidence on corticosteroid injections for the treatment of tennis elbow is not conclusive. Many trials were conducted in a secondary care setting and clearly had serious methodological flaws, and there was statistical heterogeneity among the trials. Corticosteroid injections appear to be relatively safe and seem to be effective in the short term (2-6 weeks). Although the treatment seems to be suitable for application in general practice, further trials in this setting are needed. As yet, questions regarding the optimal timing, dosage, injection technique and injection volume remain unanswered.

Systemic lupus erythematosus

Assessing patients with SLE is difficult because of the heterogeneity of the disease. The Revised 1982 ARA Classification Criteria set has been widely accepted for classifying SLE patients for inclusion in clinical studies, but it is not appropriate for making the diagnosis of SLE in an individual and is not helpful for classifying patients with early or mild disease in population based epidemiological studies. Further refinement of this criteria set to meet these objectives and to facilitate subdivision of patients with SLE into those with similar clinical, serological or genetic features poses a future challenge for the clinical epidemiologist. A number of valid and reliable indices are available for measuring clinical disease activity in SLE (Table 3). Despite their different approaches they have been shown to correlate well with each other and hence would appear to be measuring the same thing. The exact choice of instrument will be dictated by the purpose for which it is required. Although none is perfect they are useful for monitoring groups of patients in outcome studies in a research setting. Practically, disease activity indices are unlikely to be appropriate for dictating treatment decisions in individual cases: an instrument comprehensive and flexible enough for this purpose would undoubtedly be far too cumbersome for widespread use. Ultimately such fine tuning will continue to rely upon the skill and intuition of experienced physicians.

ABC of rheumatology. Systemic lupus erythematosus and lupus-like syndromes

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Lack of influence of non-inherited maternal HLA-DR alleles on susceptibility to rheumatoid arthritis

OBJECTIVE

To reproduce findings from previous reports that non-inherited maternal HLA class II antigens might contribute to rheumatoid arthritis (RA) susceptibility in the offspring.

METHODS

Families were recruited from the Arthritis and Rheumatism Council's National Repository of RA families and HLA-DRB1 alleles were examined in these individuals and their first degree relatives using DNA typing methods.

RESULTS

There was no evidence of an increase in either non-inherited maternal HLA-DR4 or the HLA-DRB1 shared epitope as a whole compared with the frequency expected using the non-inherited paternal antigens as controls.

CONCLUSIONS

The numbers of probands who were shared epitope negative were small, but we are unable to confirm in these families the findings that non-inherited maternal HLA contributes an additional susceptibility factor to rheumatoid arthritis.

Relative contributions of HLA-DQA and complement C4A loci in determining susceptibility to systemic lupus erythematosus

The objective of this study was to reassess the role of C4A null alleles in systemic lupus erythematosus (SLE) susceptibility after taking into account the association of DQA*0501 with this disease. The frequency of C4A null alleles in 82 SLE patients and 59 controls was determined using both immunofixation and a TaqI RFLP method. HLA-DQA and DQB alleles were identified by sequence-specific oligonucleotide typing. Empirical logistic analysis was used to assess the interactive effects of C4 and DQA alleles. It was found that the strongest association with SLE was for the combination of DQA*0501 and C4A*Q0 [odds ratio (OR) = 5.4, 95% confidence interval (CI) 2.5-11.7]. Both DQA*0501 (P = 0.02) and C4A*Q0 (P = 0.03) appeared to have significant individual effects on SLE susceptibility, with a significant statistical interaction between the two loci (P = 0.01). However, when anti-La antibody negative patients were examined only C4A*Q0 had a significant individual effect (P = 0.04). A significant statistical interaction between DQA*0501 and C4A*Q0 was again detected (P = 0.02). These results support the hypothesis that susceptibility to SLE is influenced by several genes with differing functions: HLA-DQA*0501 may predispose to autoantibody formation while C4A*Q0 impairs immune complex clearance.

Psychiatric disorder and cognitive impairment in SLE

Poor performance on cognitive testing is common in SLE but it is not progressive in the majority of patients and may fluctuate or resolve without specific treatment. Cognitive impairment in patients without overt CNS-SLE may result from generalised disease activity or psychiatric disorder which reduce speed, concentration and motivation. This emphasises once again the importance of recognising and treating psychiatric disorder in these patients. Although mean cognitive scores are lower in SLE patients with overt CNS involvement than those without, an individual's cognitive score is a poor predictor of the presence of CNS involvement because of considerable overlap between groups. It has been suggested that the pattern of cognitive impairment, rather than simply whether it is present or absent, may be more helpful in identifying patients with CNS involvement but this requires further investigation in prospective studies. Cognitive impairment at one point in time is not predictive of future CNS events during 1 or 2 years of follow-up. Routine cognitive testing in SLE does not therefore appear to be helpful either for identifying patients with current CNS involvement or for identifying those at future risk of this complication. In the absence of double-blind randomised controlled trials, treatment of neuropsychiatric SLE is based on clinical experience and anecdotal case reports. Aggressive immunosuppression with high-dose corticosteroids in conjunction with either azathioprine or cyclophosphamide may be indicated in patients with life-threatening CNS-SLE but, on the basis of current evidence, is not justified in those with lone subtle cognitive abnormalities.

A prospective study of psychiatric disorder and cognitive function in systemic lupus erythematosus

OBJECTIVES

To investigate change in psychiatric disorder and change in cognitive function in patients with systemic lupus erythematosus (SLE) assessed on two occasions two years apart.

METHODS

A prospective cohort study of 49 patients with SLE using standardised psychiatric and clinical research methods.

RESULTS

The point prevalence of psychiatric disorder (20% and 24%), and of cognitive impairment (23% and 18%), was similar at first and second interview for the whole group. There was, however, considerable change in individual patient's psychiatric status and cognitive function: only 1/9 patients with impairment on two or more cognitive tests at first interview was still impaired at second interview. Change in cognitive function appeared to mirror change in psychiatric status.

CONCLUSIONS

These findings suggest that the previously reported high prevalence of cognitive impairment in SLE may be explained by coexisting psychiatric disorder, rather than reflecting subclinical central nervous system (CNS) involvement.

HLA-DP does not contribute towards susceptibility to systemic lupus erythematosus

OBJECTIVES

To determine whether HLA-DP genes are involved in determining susceptibility to systemic lupus erythematosus (SLE).

METHODS

HLA-DPA1 and DPB1 genes were amplified by PCR of DNA samples from a panel of patients with SLE and normal controls. Amplified DNA was blotted on to nylon filters and probed with sequence-specific oligonucleotide (SSO) probes.

RESULTS

No DPA1 or DPB1 allele was significantly associated with SLE, or with any immunological or clinical subset of SLE. Evidence was found for only limited linkage disequilibrium between HLA-DP and HLA-DQ/DR variants, and none between HLA-DP and the TAP2 gene.

CONCLUSIONS

These data indicate that HLA-DP genes do not contribute towards determining susceptibility to SLE.

HLA-DQ, DR and complement C4 variants in systemic lupus erythematosus

We have defined HLA-DQA, DQB, DR and complement C4 variants in 92 subjects with SLE and 73 controls. Subjects with SLE showed an increased frequency of HLA-DQA*0501 (P < 0.01 corrected, odds ratio (OR) = 4.97; 95% C.I. = 2.52-9.81), DR3 (P < 0.001, OR = 3.18; 95% C.I. = 1.67-6.04) and C4A*Q0 (P < 0.05, OR = 1.91; 95% C.I. = 0.999-3.65) vs controls. These increases were particularly marked in those subjects positive for antibodies to both Ro and La. HLA-DQB*0501 (P < 0.01 corrected, OR = 0.03), DQA*0101 (P = 0.0012 uncorrected, OR = 0.23) and DR7 (P = 0.0018 uncorrected, OR = 0.28) were decreased in frequency in SLE. SLE patients with disease onset prior to age 30 yr were more likely to possess a DR3-bearing haplotype (P < 0.05 corrected) than those with onset after age 30 yr. No significant associations were found in patients with circulating antibodies to double-stranded DNA, Ro alone, U1 RNP, Sm or in those SLE patients with renal disease or vasculitis. The different associations found in different clinical and immunological subsets of SLE support the concept that SLE contains a variety of immunogenetic subgroups. Analysis of the associations between SLE and DR3, DQA*0501 and C4A*Q0 using the empirical logistic test suggests that the association of SLE with HLA-DQA*0501 is likely to be primary to the associations with both DR3 and C4A*Q0 (P < 0.001). Our results therefore raise the possibility that genes within the HLA-DQ region may have a direct effect upon susceptibility to SLE.

Antiribosomal P protein antibodies in different populations of patients with systemic lupus erythematosus

We report a significantly increased prevalence of antiribosomal P protein antibodies in Malaysian Chinese patients (38%) with SLE compared to white Caucasian (13%) and Afro-Caribbean (20%) patients. The increased prevalence was not due to a generalized increase in autoantibody production because anti-dsDNA and anti-SSA antibodies were present in comparable frequencies in the three ethnic groups while anti-Sm and anti-SSB antibodies were rarely found in the Malaysian Chinese patients.

The BILAG index: a reliable and valid instrument for measuring clinical disease activity in systemic lupus erythematosus

The British Isles Lupus Assessment Group (BILAG) index is a computerized index for measuring clinical disease activity in systemic lupus erythematosus (SLE), which was developed according to the principle of the physician's 'intention to treat'. The index allocates separate alphabetic scores to each of eight organ-based systems; a total score is not calculated. This study demonstrated good between-rater reliability for the BILAG index for each organ-based system. There was no evidence of bias between observers. The BILAG index had good overall sensitivity (87%) and specificity (99%) when compared with the 'gold standard' criterion (starting or increasing disease-modifying therapy). There were high positive predictive values overall (80%), and for each organ-based system, with the exception of the neurological system.

Anti-P antibodies are associated with psychiatric and focal cerebral disorders in patients with systemic lupus erythematosus

In a cross-sectional study, 62 patients with systemic lupus erythematosus were assessed using standardized psychiatric and psychological methods; systemic disease activity was scored using the British Isles Lupus Assessment Group and the Lupus Activity Criteria Count indices. IgG and IgM anti-P antibodies were measured by ELISA using a synthetic 22 amino acid peptide as the relevant antigen. IgG and IgM anti-P antibodies were significantly associated with neuropsychiatric disorders (psychiatric and neurological) but failed to distinguish patients with psychiatric disorders from those with neurological disorders. These antibodies were not associated with cognitive impairment or systemic disease activity.

Autoantibodies in central nervous system lupus

Central nervous system (CNS) involvement in patients with lupus remains both a diagnostic and a therapeutic challenge. The role of autoantibodies in the pathogenesis of CNS lupus and/or as markers for disease activity is reviewed. Doubt is cast on the value of measuring anti-neuronal antibodies. Those antibodies binding ribosomal-P protein antigens or certain phospholipids appear to have greater utility, although even in these cases there is no uniform agreement as to their precise role in CNS disease induction, or how well antibody levels reflect disease activity.

Soluble CD23 levels are elevated in the serum of patients with primary Sjögren's syndrome and systemic lupus erythematosus

The low affinity IgE receptor Fc epsilon RII (CD23) is important in several aspects of T and B cell function. In this study serum levels of soluble CD23 (sCD23) were measured in three groups: 26 female patients with systemic lupus erythematosus (SLE), 21 females with primary Sjögren's syndrome (pSS) and 25 normal healthy females. The concentration of sCD23 was determined using an enhanced chemiluminescent sandwich ELISA developed in this laboratory. Increased levels of sCD23 were observed in pSS and in SLE patients compared with controls (median 23.0 versus 8.6, P less than 0.0002 and 18.1 versus 8.6, P less than 0.002 respectively). While the median level of sCD23 was found to be higher in pSS than in SLE the difference was not statistically significant. Patients with SLE and pSS on glucocorticoid treatment had significantly lower levels of sCD23 than patients not on this treatment (median 28.9 versus 14.4, P less than 0.05). Amongst the control patients sCD23 was inexplicably lower in the female members relative to the males (median 8.5 versus 12.3, P less than 0.05). Although serum IgG and IgA levels were significantly elevated in pSS and SLE patients relative to controls there was no direct correlation between sCD23 and the serum levels of these immunoglobulins. We conclude that B cell hyperactivity which occurs in both pSS and SLE is associated with raised levels of sCD23.

Psychiatric disorder and cognitive impairment in systemic lupus erythematosus

OBJECTIVES

To determine the point prevalence of psychiatric disorder in patients with systemic lupus erythematosus (SLE). To investigate associations between psychiatric disorder and social stress, cognitive impairment, systemic disease activity, and corticosteroid therapy.

METHODS

A cross-sectional study of 73 consecutive patients with SLE assessed using standardized psychiatric and clinical research methods.

RESULTS

Current psychiatric disorder was present in 15 patients (20.5%) and was significantly associated with social stress, lack of social support, and impairment on 2 tests of cognitive function (Verbal Fluency Test and Benton Visual Retention Test, Part A, number of errors). There was no association with systemic disease activity or corticosteroid therapy. Cognitive impairment on 2 or more tests was found in 26% and was associated with clinical evidence of central nervous system (CNS) disease, but not systemic disease activity or corticosteroid therapy.

CONCLUSIONS

The point prevalence of psychiatric disorder in this cohort of patients with SLE was found to be similar to that observed in patients with rheumatoid arthritis. It was independently associated with social stress and 2 indicators of cognitive impairment, but not with systemic disease activity or corticosteroid therapy. Marked cognitive impairment was present in a significant percentage of patients even when there was no overt evidence of CNS involvement.