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Rhodes A, Gray J, Harvey N, Davies JH, Oreffo ROC, Reading I, Clarke NMP, Aarvold A. Osteonecrosis following treatment for childhood acute lymphoblastic leukaemia: The Southampton Children's Hospital experience. J Child Orthop 2017; 11:440-447. [PMID: 29263756 PMCID: PMC5725770 DOI: 10.1302/1863-2548.11.170142] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
PURPOSE To determine the prevalence of osteonecrosis (ON) in children following treatment of acute lymphoblastic leukaemia (ALL), characterise these cases and review treatment methods. METHODS All children diagnosed and treated for ALL between 01 January 2003 and 31 December 2013 at our centre were retrospectively reviewed. Logistic regression was used to investigate risk factors for ON occurrence. RESULTS Of 235 children treated for ALL, 48/235 (20.4%) children suffered musculoskeletal symptoms necessitating radiological investigation. A total of 13 (5.5%) had MRI-diagnosed ON, with a median diagnosis time of 12 months (interquartile range 10 to 14) following initiation of chemotherapy.ON affected 40 joints in 13 children. The most commonly involved joints were hips (14 joints in eight patients) and knees (12 joints in seven patients).Older age at ALL diagnosis was associated with significantly increased risk of development of ON per year (odds ratio 1.35, 95% confidence interval 1.17 to 1.57, p < 0.001).Eight children underwent at least one surgical intervention. Joint arthroplasty was undertaken in nine joints of four children at a mean age of 18.3 years. All patients who underwent hip arthroplasty had previously received core decompression, with a mean time of 27.8 months (18 to 33) between treatments. CONCLUSIONS ON is a significant complication of ALL treatment. Our results suggest risk stratification for development of ON by age, and targeted monitoring of high-risk joints is possible. ON treatment is varied with little evidence base.
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Affiliation(s)
- A. Rhodes
- University of Southampton, Tremona Road, Southampton, UK and Southampton Children’s Hospital, Tremona Road, Southampton, UK,Correspondence should be sent to A. Rhodes, Trauma & Orthopaedics, Southampton General Hospital, Southampton, SO16 6YD, United Kingdom. E-mail:
| | - J. Gray
- University of Southampton, Tremona Road, Southampton, UK and Southampton Children’s Hospital, Tremona Road, Southampton, UK
| | - N. Harvey
- MRC Lifecourse Epidemiology Unit, University of Southampton, Tremona Road, Southampton, UK and NIHR Southampton Biomedical Research Centre, Tremona Road, Southampton, UK
| | - J. H. Davies
- University of Southampton, Tremona Road, Southampton, UK and Southampton Children’s Hospital, Tremona Road, Southampton, UK
| | - R. O. C. Oreffo
- University of Southampton, Tremona Road, Southampton, UK and Bone and Joint Research Group, Centre for Human Development, Stem Cells and Regeneration, Faculty of Medicine, University of Southampton, Tremona Road, Southampton, UK
| | - I. Reading
- University of Southampton, Tremona Road, Southampton, UK and NIHR Southampton Biomedical Research Centre, Tremona Road, Southampton, UK
| | | | - A. Aarvold
- University of Southampton, Tremona Road, Southampton, UK and Southampton Children’s Hospital, Tremona Road, Southampton, UK
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Dennison EM, Dhanwal DK, Shaheen SO, Azagra R, Reading I, Jameson KA, Sayer AA, Cooper C. Is lung function associated with bone mineral density? Results from the Hertfordshire Cohort Study. Arch Osteoporos 2013; 8:115. [PMID: 23322029 PMCID: PMC3622903 DOI: 10.1007/s11657-012-0115-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2012] [Accepted: 11/14/2012] [Indexed: 02/03/2023]
Abstract
UNLABELLED Given limited information available regarding associations between lung function and bone mineral density among healthy subjects, we undertook these analyses in the Hertfordshire Cohort Study. Forced expiratory volume in 1 s (FEV(1)), forced vital capacity (FVC) and FEV(1)/FVC were not associated with bone mineral density at any site; associations with bone mineral content were removed by adjustment for body size. PURPOSE There is limited information available regarding the association between lung function and bone mineral density among healthy elderly subjects. We addressed this issue in the Hertfordshire Cohort Study. METHODS From the above cohort, 985 subjects (496 men and 489 women) aged 60-72 years were recruited. All subjects underwent bone density measurements using dual energy X-ray absorptiometry and lung function tests using standardised spirometry. Chronic obstructive pulmonary disease (COPD) was defined as a FEV(1)/FVC ratio <lower limit of normal, calculated using separate equations for men and women. RESULTS Measures of lung function (FEV(1), FVC and FEV(1)/FVC) were not associated with bone mineral density at the lumbar spine, femoral neck and total hip in men or women; associations with bone mineral content and bone area were removed by adjustment for body size and lifestyle confounders. In this cohort, there were no associations observed between COPD and any measure of bone mass. CONCLUSIONS There was no association between lung function and bone mass in this community dwelling cohort after adjustment for body size and other confounders.
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Affiliation(s)
- EM Dennison
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Southampton SO16 6YD, UK
,Victoria University, PO Box 600, Wellington 6140, New Zealand
| | - DK Dhanwal
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Southampton SO16 6YD, UK
| | - SO Shaheen
- Centre for Primary Care and Public Health, Barts and the London School of Medicine and Dentistry, London E1 2AT, UK
| | - R Azagra
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Southampton SO16 6YD, UK
,EAP Badia del Valles ICS), IDIAP Jordi Gol, Universitat Autònoma de Barcelona, Ps Vall d’ Hebron 119, 08135 Barcelona, Spain
| | - I Reading
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Southampton SO16 6YD, UK
| | - KA Jameson
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Southampton SO16 6YD, UK
| | - AA Sayer
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Southampton SO16 6YD, UK
| | - C Cooper
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Southampton SO16 6YD, UK
,Botnar Research Centre, Institute of Musculoskeletal Sciences, University of Oxford, Oxford OX3 7LD, UK
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Bullock MD, Bruce A, Sreekumar R, Curtis N, Cheung T, Reading I, Primrose JN, Ottensmeier C, Packham GK, Thomas G, Mirnezami AH. FOXO3 expression during colorectal cancer progression: biomarker potential reflects a tumour suppressor role. Br J Cancer 2013; 109:387-94. [PMID: 23828518 PMCID: PMC3721407 DOI: 10.1038/bjc.2013.355] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2013] [Revised: 03/17/2013] [Accepted: 03/22/2013] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND In previous studies, the Forkhead/winged-helix-box-class-O3 (FOXO3) transcription factor has displayed both tumour suppressive and metastasis-promoting properties.To clarify its role in human colorectal cancer (CRC) progression, we examined in vivo FOXO3 expression at key points of the metastatic cascade. METHODS Formalin-fixed paraffin-embedded resection specimens from normal colon, adenomas, primary CRC specimens of different pathological stage and CRC specimens with matched liver metastases were used to generate three separate custom-designed tissue microarray (TMA) representations of metastatic progression. Triplicate cores, immunostained for FOXO3 were scored semiquantitatively by two investigators. RESULTS The FOXO3 expression is significantly reduced in CRC specimens compared with normal tissue, and progressive FOXO3 downregulation is associated with advancing pathological stage. In addition, recurrent stage I/II primary tumours show a significantly lower FOXO3 expression compared with stage-matched non-recurrent tumours. When stratified according to high and low FOXO3 expression, mean disease-free survival in the low-expressing group was 28 months (95% CI 15.8-50.6) compared with 64 months (95% CI 52.9-75.4) in the high-expressing group. CONCLUSION We have demonstrated an association between low FOXO3 expression and CRC progression in vivo using purpose-designed TMAs. Forkhead/winged-helix-box-class-O3 may represent a novel biomarker of nodal and distant disease spread with clinical utility in CRC.
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Affiliation(s)
- M D Bullock
- Cancer Research UK Centre, University of Southampton, Somers Cancer Sciences Building, Southampton General Hospital, University Hospital Southampton, Tremona Road, Southampton, UK.
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Amer S, Raffi F, Asfour V, Varma R, Polson A, Menon P, Mol F, van Mello NM, Ankum WM, Mol BW, van der Veen F, Hajenius PJ, van Wely M, Cheong Y, Reading I, Sadek K, Ledger WL, Li TC. Session 47: Reproductive surgery. Hum Reprod 2013. [DOI: 10.1093/humrep/det180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Cushnaghan J, Bennett J, Reading I, Croft P, Byng P, Cox K, Dieppe P, Coggon D, Cooper C. Long-term outcome following total knee arthroplasty: a controlled longitudinal study. Ann Rheum Dis 2008; 68:642-7. [PMID: 18664545 DOI: 10.1136/ard.2008.093229] [Citation(s) in RCA: 76] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Objectives:To assess long-term outcome and predictors of prognosis following total knee arthroplasty (TKA) for osteoarthritis.Methods:We followed-up 325 patients from 3 English health districts approximately 6 years after TKA, along with 363 controls selected from the general population. Baseline data, collected by interview and examination, included age, sex, comorbidity, body mass index (BMI), functional status and preoperative radiographic severity of osteoarthritis. Functional status at follow-up was assessed by postal questionnaire. Predictors of change in physical function were analysed by linear regression.Results:Between baseline and follow-up, patients reported an improvement of 6 points in median Short Form 36 Health Survey (SF-36) physical function score, whereas in controls there was a deterioration of 14 points (p<0.001). Median SF-36 vitality score declined by 10 points in patients and 5 points in controls (p = 0.005), while their median SF-36 mental health scores improved by 12 and 13 points, respectively (p = 0.2). The improvement in physical function was smaller in patients who were obese than in patients who were non-obese, but compared favourably with a substantial decline in the physical function of obese controls. Better baseline physical function and older age predicted worse changes in physical function in patients and controls. Improvement in physical function tended to be greater in patients with more severe radiological disease of the knee, and was less in those who reported pain at other joint sites at baseline.Conclusions:Improvements in physical function following TKA for osteoarthritis are sustained beyond 5 years. The benefits are apparent in patients who are obese as well as non-obese, and there seems no justification for withholding TKA from obese patients solely on the grounds of their body mass index.
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Affiliation(s)
- J Cushnaghan
- MRC Epidemiology Resource Centre, Southampton General Hospital, Southampton, UK
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Abstract
OBJECTIVE Statistics from Labour Force Surveys are widely quoted as evidence for the scale of occupational illness in Europe. However, occupational attribution depends on whether participants believe their health problem is caused or aggravated by work, and personal beliefs may be unreliable. The authors assessed the potential for error for work-associated arm pain. METHODS A questionnaire was mailed [corrected] to working-aged adults, randomly chosen from five British general practices. They were asked about: occupational activities; mental health; self-rated health; arm pain; and beliefs about its causation. Those in work (n = 1769) were asked about activities likely to cause arm pain, from which the authors derived a variable for exposure to any "arm-straining" occupational activity. The authors estimated the relative risk (RR) from arm-straining activity, using a modified Cox model, and derived the population attributable fraction (PAF). They compared the proportion of arm pain cases reporting their symptom as caused or made worse by work with the calculated PAF, overall and for subsets defined by demographic and other characteristics. RESULTS Arm pain in the past year was more common in the 1143 subjects who reported exposure to arm-straining occupational activity (RR 1.2, 95% CI 1.1 to 1.5). In the study sample as a whole, 53.9% of 817 cases reported their arm pain as work-associated, whereas the PAF for arm-straining occupational activity was only 13.9%. The ratio of cases reported as work-related to the calculated attributable number was substantially higher below 50 years (5.4) than at older ages (3.0) and higher in those with worse self-rated and mental health. CONCLUSIONS Counting people with arm pain which they believe to be work-related can overestimate the number of cases attributable to work substantially. This casts doubt on the validity of a major source of information used by European governments to evaluate their occupational health strategies.
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Affiliation(s)
- K T Palmer
- MRC Epidemiology Resource Centre, Southampton General Hospital, Southampton SO16 6YD, UK.
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Mehlum IS, Kristensen P, Wergeland E, Kjuus H, Bonzin M, Palmer KT, Inskip HM, Coggon D, Madan I, Reading I, Palmer KT, Coggon DC, Lucas M, Wellman HM, Leamon TB, Tuyet BTT, Nguyen BD, Kriebel DK, Wegman DH, Mattioli S, De Fazio R, Buiatti E, Truffelli D, Zanardi F, Miglietta B, Curti S, Baldasseroni A, Tassinari G, Violante FS. Musculoskeletal and injuries 3. Occup Environ Med 2007. [DOI: 10.1136/oem.64.12.e40] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Koehoorn M, Xu F, Village J, Trask C, Teschke K, Leclerc A, Gourmelen J, Chastang JF, Lanoe JL, Lipscomb HJ, Kucera K, Epling CA, Dement JM, Palmer KT, Calnan M, Reading I, Coggon D, Venema A, De Vroome EMM, Videman T, Levalahti E, Battie MC. Musculoskeletal and injury 1. Occup Environ Med 2007. [DOI: 10.1136/oem.64.12.e17] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Palmer KT, Reading I, Linaker C, Calnan M, Coggon D. Population-based cohort study of incident and persistent arm pain: role of mental health, self-rated health and health beliefs. Pain 2007; 136:30-7. [PMID: 17689865 PMCID: PMC3284249 DOI: 10.1016/j.pain.2007.06.011] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2006] [Revised: 06/11/2007] [Accepted: 06/11/2007] [Indexed: 11/18/2022]
Abstract
To investigate whether somatising tendency, low mood and poor self-rated health (SRH) predict incident arm pain, and whether these factors and beliefs about causation and prognosis predict symptom persistence, we conducted an 18-month postal follow-up in 1798 working-aged subjects, sampled from the registers of five British general practices. At baseline questions were asked about pain in the arm (lasting >or=1day in the prior 12months), mental health (Short-Form 36 (SF-36MH)), somatising tendency (the Brief Symptom Inventory (BSI)), SRH, and beliefs about causation and prognosis. At follow-up we asked about arm pain in the last four weeks, and whether it had been present on >or=14days. Associations with incidence and persistence were explored using logistic regression. The 1256 participants (70% response) comprised 613 free of, and 643 with, arm pain initially. Among the former, 21% reported new pain at follow-up, while 53% of the latter reported symptom persistence. The odds of both incident and persistent arm pain were significantly raised (1.7- to 4-fold) in the least vs. most favourable bands of SF-36MH, BSI and SRH. Even stronger associations were found for arm pain on >or=14days. Persistent pain was significantly more common among those who attributed their pain to work or stress, and in those who expected symptoms still to be a problem in 12months. Thus, SRH and mental health indices were strong predictors of incident and persistent arm pain in adults from the community, while persistence was also predicted by beliefs about causation and prognosis.
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Affiliation(s)
- K T Palmer
- MRC Epidemiology Resource Centre, Community Clinical Sciences, University of Southampton, Southampton General Hospital, Southampton, England SO16 6YD, UK.
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Ye S, Patodi N, Walker-Bone K, Reading I, Cooper C, Dennison E. Variation in the matrix metalloproteinase-3, -7, -12 and -13 genes is associated with functional status in rheumatoid arthritis. Int J Immunogenet 2007; 34:81-5. [PMID: 17373931 DOI: 10.1111/j.1744-313x.2007.00664.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
As matrix metalloproteinases (MMPs) play an important role in rheumatoid arthritis, we investigated whether variation in MMP genes was associated with functional disability in rheumatoid arthritis patients. A cohort of patients with seropositive rheumatoid arthritis were recruited and genotyped for the MMP1-1607 1G > 2G, MMP3-1612 5A > 6A, MMP7-153C > T, MMP7-181G > A, MMP12-82A > G and MMP13-77A > G polymorphisms. Genotypes were then analysed in relation to functional disability assessed by Steinbrocker index and Health Assessment Questionnaire (HAQ) score. We detected an association between the MMP13-77 A > G polymorphism and Steinbrocker index, with patients of the A/A genotype having higher score than patients of the A/G or G/G genotype (P = 0.005), and the association remained significant after adjusting for age, sex, erythrocyte sedimentation rate, presence of erosive disease, Ritchie score, prednisolone therapy and years of diagnosis (P = 0.003). We also observed a relationship of Steinbrocker index with the MMP3-1612 5A > 6A, MMP7-181 A > G and MMP12-82A > G polymorphisms (P = 0.082, P = 0.037 and P = 0.045). No association was detected between the MMP1-1607 1G > 2G and MMP7-153C > T polymorphisms and either Steinbrocker index or HAQ score. These results suggest that MMP3, MMP7, MMP12 and MMP13 genotypes may play a role in determining functional status of rheumatoid arthritis.
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Affiliation(s)
- S Ye
- Human Genetics Division, School of Medicine, University of Southampton, Southampton General Hospital, Southampton, UK.
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Palmer KT, Reading I, Calnan M, Linaker C, Coggon D. Does knee pain in the community behave like a regional pain syndrome? Prospective cohort study of incidence and persistence. Ann Rheum Dis 2006; 66:1190-4. [PMID: 17114191 PMCID: PMC1955134 DOI: 10.1136/ard.2006.061481] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To investigate whether knee pain in the community behaves like a regional pain syndrome, determined by its association with mental health, self-rated health (SRH) and beliefs about prognosis. METHODS An 18-month postal follow-up was conducted in 1798 working-aged subjects, sampled from the community. At baseline questions were asked about pain in the knee lasting > or =1 day in the previous 12 months, mental health (Short-Form 36), somatising tendency (elements of the Brief Symptom Inventory), SRH and concern about 12-month prognosis. At follow-up we asked about knee pain during the last 4 weeks, and whether it had been present for > or =14 days or prescription-treated. Associations with incidence and persistence were explored using logistic regression. RESULTS The 1256 participants (70% response) comprised 468 with knee pain at baseline and 788 without. Among the former, 49% had persistent knee pain at follow-up, while among the latter, 15% reported new symptoms. Incident prescription-treated knee pain was strongly associated with all of the mental health variables and with SRH. The odds of knee pain persisting were significantly raised in the least versus most favourable bands of somatising tendency and SRH, and persistence was also significantly more common among those who at baseline were concerned that they would still have a problem in 12 months. CONCLUSIONS Our observations support the hypothesis that knee pain in the community shares risk factors in common with other non-specific regional pain syndromes.
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Affiliation(s)
- K T Palmer
- MRC Epidemiology Resource Centre, Community Clinical Sciences, University of Southampton, Southampton General Hospital, Southampton, England SO16 6YD, UK.
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Arden NK, Price C, Reading I, Stubbing J, Hazelgrove J, Dunne C, Michel M, Rogers P, Cooper C. A multicentre randomized controlled trial of epidural corticosteroid injections for sciatica: the WEST study. Rheumatology (Oxford) 2005; 44:1399-406. [PMID: 16030082 DOI: 10.1093/rheumatology/kei028] [Citation(s) in RCA: 125] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To determine the effectiveness and predictors of response to lumbar epidural corticosteroid injections (ESI) in patients with sciatica. We performed a 12-month, multicentre, double-blind, randomized, placebo-controlled, parallel-group trial in four secondary pain-care clinics in the Wessex Region. METHODS Two hundred and twenty-eight patients with a clinical diagnosis of unilateral sciatica of 1-18 months' duration were randomized to either three lumbar ESIs of triamcinolone acetonide or interligamentous saline injections at intervals of 3 weeks. The main outcome measure was the Oswestry low back pain disability questionnaire (ODQ). RESULTS At 3 weeks, the ESI group demonstrated a transient benefit over the placebo group (patients achieving a 75% improvement in ODQ, 12.5 vs 3.7%; number needed to treat, 11.4). No benefit was demonstrated from 6 to 52 weeks. ESIs did not improve physical function, hasten return to work or reduce the need for surgery. There was no benefit of repeated ESIs over single injection. No clinical predictors of response were found. At the end of the study the majority of patients still had significant pain and disability regardless of intervention. CONCLUSIONS In this pragmatic study, ESIs offered transient benefit in symptoms at 3 weeks in patients with sciatica, but no sustained benefits in terms of pain, function or need for surgery. Sciatica is a chronic condition requiring a multidisciplinary approach. To fully investigate the value of ESIs, they need to be evaluated as part of a multidisciplinary approach.
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Affiliation(s)
- N K Arden
- Medical Research Council Epidemiology Resource Centre, University of Southampton, Southampton General Hospital, Southampton SO16 6YD, UK.
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Edwards CJ, Arden NK, Fisher D, Saperia JC, Reading I, Van Staa TP, Cooper C. The changing use of disease-modifying anti-rheumatic drugs in individuals with rheumatoid arthritis from the United Kingdom General Practice Research Database. Rheumatology (Oxford) 2005; 44:1394-8. [PMID: 16030083 DOI: 10.1093/rheumatology/kei024] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES To describe the use of disease-modifying anti-rheumatic drugs (DMARDs) in the treatment of rheumatoid arthritis (RA) and changing trends in their use. METHODS We used the General Practice Research Database (GPRD) to describe DMARD use by patients with RA identified using ICD-9 codes. The GPRD is a UK national database containing records of more than 7 million individuals from 683 general practices. Subjects were studied between 1987 and 2002. The prevalence and duration of individual DMARD use and changing trends in DMARD use were investigated. RESULTS Thirty-four thousand three hundred and sixty-four patients with RA were identified. Only 17,115 (50%) individuals were prescribed at least one DMARD during the study period. The most commonly prescribed DMARD over the study period was sulphasalazine (46.3%) and then methotrexate (31.4%). Use of methotrexate has increased 17-fold (1.8% of all DMARD prescriptions in 1988 to 30% in 2002) whereas use of gold has fallen (13.2% to 2.3%). Analysis of DMARD persistence using Kaplan-Meier survival curves showed the methotrexate use persisted significantly longer than other DMARDs with an estimated median of 8.1 yr. Prednisolone was used in up to 50% of RA patients in any one year and has remained fairly constant throughout the study period. CONCLUSIONS Large numbers of individuals with a clinical diagnosis of RA identified from a large primary care database are not receiving DMARDs. This work suggests that many individuals with RA have not been treated appropriately and this may have major long-term consequences on joint damage and general health.
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Affiliation(s)
- C J Edwards
- MRC Epidemiology Resource Centre, University of Southampton, Southampton General Hospital, Southampton SO16 6YD, UK.
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Abstract
BACKGROUND Hospital based studies of occupational risk factors for knee disorders are complicated by the possibility of selective referral to hospital of people whose work is made difficult by their symptoms. AIMS To explore the extent of such bias and to assess the association of meniscal injury with occupational activities. METHODS A questionnaire was mailed to a community sample of 2806 men aged 20-59 years in southern England. This asked about lifetime occupational and sporting activities, and any history of knee symptoms lasting 24 hours or longer. Rates of hospital referral were compared in symptomatic men according to their occupational activities. In a nested case-control investigation, the occupational activities of 67 men who reported meniscectomy were compared with those of 335 controls. RESULTS Among 1404 men who responded to the questionnaire, the lifetime prevalence of knee symptoms was 54%, and in 70% of cases the symptoms had started suddenly, usually while playing sport. Symptomatic men whose work entailed kneeling or squatting were more likely to be referred to an orthopaedic surgeon than the average (28% and 31% versus 24%), especially if they experienced locking of the knee (69% and 73% versus 43%). In the nested case-control study, meniscectomy was associated with playing soccer and work that involved regular kneeling or squatting. CONCLUSIONS Results suggest that hospital referral for knee symptoms is influenced to some extent by patients' occupational activities. Playing soccer is confirmed as a strong risk factor for knee cartilage injury.
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Affiliation(s)
- P Baker
- MRC Environmental Epidemiology Unit, University of Southampton, Southampton General Hospital, Southampton, UK
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Mitchell S, Reading I, Walker-Bone K, Palmer K, Cooper C, Coggon D. Pain tolerance in upper limb disorders: findings from a community survey. Occup Environ Med 2003; 60:217-21. [PMID: 12598671 PMCID: PMC1740489 DOI: 10.1136/oem.60.3.217] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
AIMS To test the hypothesis that non-specific upper limb pain arises from altered pain perception with reduced tolerance of sensory stimuli. METHODS Subjects undergoing clinical examination as part of a community based survey of upper limb disorders were invited to return for an assessment of pain tolerance. A standardised algorithm was used to classify the 94 participants according to whether they had specific upper limb disorders (n = 22), non-specific arm pain (n = 15), or no arm pain (n = 57). Pain tolerance was assessed at three anatomical sites in each arm in response to electrocutaneous stimulation with alternating currents up to a maximum of 10 mA at three frequencies (5, 250, and 2,000 Hz). A proportional odds model was used to compare pain tolerance thresholds according to sex, age, and diagnosis. RESULTS Women were less tolerant of pain than men (OR 0.13) and tolerance also declined with age (OR for one year increase in age 0.97). After allowance for sex and age, there was no indication that pain tolerance was lower in subjects with non-specific arm pain than in those with specific upper limb disorders or those who had no arm pain. CONCLUSIONS The study hypothesis was not supported. However, before the hypothesis is dismissed, it should be tested further in patients with more severe and disabling arm pain.
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Affiliation(s)
- S Mitchell
- MRC Environmental Epidemiology Unit, University of Southampton, UK
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Mehta G, Roach HI, Langley-Evans S, Taylor P, Reading I, Oreffo ROC, Aihie-Sayer A, Clarke NMP, Cooper C. Intrauterine exposure to a maternal low protein diet reduces adult bone mass and alters growth plate morphology in rats. Calcif Tissue Int 2002; 71:493-8. [PMID: 12202956 DOI: 10.1007/s00223-001-2104-9] [Citation(s) in RCA: 81] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2001] [Accepted: 02/15/2002] [Indexed: 11/25/2022]
Abstract
Epidemiological studies suggest that poor growth during fetal life and infancy is associated with decreased bone mass in adulthood. However, theses observations have not, to date, been corroborated in animal models. To address this issue we evaluated the influence of maternal protein restriction on bone mass and growth plate morphology among the adult offspring, using a rat model. Maternal protein restriction resulted in a reduction in bone area and BMC, but not BMD, among the offspring in late adulthood. The widened epiphyseal growth plate in the protein-restricted offspring is compatible with the programming of cartilage and bone growth by maternal nutrition in early life.
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Affiliation(s)
- G Mehta
- The University Department of Orthopaedic Surgery, University of Southampton, Southampton General Hospital, Tremona Road, Southampton SO16 6YD, UK
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Walker-Bone K, Byng P, Linaker C, Reading I, Coggon D, Palmer KT, Cooper C. Reliability of the Southampton examination schedule for the diagnosis of upper limb disorders in the general population. Ann Rheum Dis 2002; 61:1103-6. [PMID: 12429544 PMCID: PMC1753973 DOI: 10.1136/ard.61.12.1103] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND Epidemiological research in the field of soft tissue neck and upper limb disorders has been hampered by the lack of an agreed system of diagnostic classification. In 1997, a United Kingdom workshop agreed consensus definitions for nine of these conditions. From these criteria, an examination schedule was developed and validated in a hospital setting. OBJECTIVE To investigate the reliability of this schedule in the general population. METHODS Ninety seven adults of working age reporting recent neck or upper limb symptoms were invited to attend for clinical examination consisting of inspection and palpation of the upper limbs, measurement of active and passive ranges of motion, and clinical provocation tests. A doctor and a trained research nurse examined each patient separately, in random order and blinded to each other's findings. RESULTS Between observer repeatability of the schedule was generally good, with a median kappa coefficient of 0.66 (range 0.21 to 0.93) for each of the specific diagnoses considered. CONCLUSION As expected, the repeatability of tests is poorer in the general population than in the hospital clinic, but the Southampton examination schedule is sufficiently reproducible for epidemiological research in the general population.
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Affiliation(s)
- K Walker-Bone
- MRC Environmental Epidemiology Unit, University of Southampton, UK
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Coggon D, Reading I, Croft P, McLaren M, Barrett D, Cooper C. Knee osteoarthritis and obesity. Int J Obes (Lond) 2001; 25:622-7. [PMID: 11360143 DOI: 10.1038/sj.ijo.0801585] [Citation(s) in RCA: 284] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2000] [Revised: 08/29/2000] [Accepted: 11/14/2000] [Indexed: 11/08/2022]
Abstract
OBJECTIVES To assess the risk of knee osteoarthritis (OA) attributable to obesity, and the interactions between obesity and other established causes of the disorder. METHODS We performed a population-based case-control study in three health districts of England (Southampton, Portsmouth and North Staffordshire). A total of 525 men and women aged 45 y and over, consecutively listed for surgical treatment of primary knee OA, were compared with 525 controls matched by age, sex and family practitioner. RESULTS Relative to a body mass index (BMI) of 24.0-24.9 kg/m(2), the risk of knee OA increased progressively from 0.1 (95% CI 0.0-0.5) for a BMI<20 kg/m(2) to 13.6 (95% CI 5.1-36.2) for a BMI of 36 kg/m(2) or higher. If all overweight and obese people reduced their weight by 5 kg or until their BMI was within the recommended normal range, 24% of surgical cases of knee OA (95% CI 19-27%) might be avoided. As a risk factor for knee OA obesity interacted more than additively with each of Heberden's nodes, earlier knee injury and meniscectomy. In comparison with subjects of normal weight, without Heberden's nodes, and with no history of knee injury, people with a combination of obesity, definite Heberden's nodes and previous knee injury had a relative risk of 78 (95% CI 17-354). CONCLUSIONS Our findings give strong support to public health initiatives aimed at reducing the burden of knee OA by controlling obesity. People undergoing meniscectomy or with a history of knee injury might be a focus for targeted advice.
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Affiliation(s)
- D Coggon
- MRC Environmental Epidemiology Unit, University of Southampton, Southampton General Hospital, Southampton, UK
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Palmer K, Walker-Bone K, Linaker C, Reading I, Kellingray S, Coggon D, Cooper C. The Southampton examination schedule for the diagnosis of musculoskeletal disorders of the upper limb. Ann Rheum Dis 2000; 59:5-11. [PMID: 10627419 PMCID: PMC1752977 DOI: 10.1136/ard.59.1.5] [Citation(s) in RCA: 100] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVES Following a consensus statement from a multidisciplinary UK workshop, a structured examination schedule was developed for the diagnosis and classification of musculoskeletal disorders of the upper limb. The aim of this study was to test the repeatability and the validity of the newly developed schedule in a hospital setting. METHOD 43 consecutive referrals to a soft tissue rheumatism clinic (group 1) and 45 subjects with one of a list of specific upper limb disorders (including shoulder capsulitis, rotator cuff tendinitis, lateral epicondylitis and tenosynovitis) (group 2), were recruited from hospital rheumatology and orthopaedic outpatient clinics. All 88 subjects were examined by a research nurse (blinded to diagnosis), and everyone from group 1 was independently examined by a rheumatologist. Between observer agreement was assessed among subjects from group 1 by calculating Cohen's kappa for dichotomous physical signs, and mean differences with limits of agreement for measured ranges of joint movement. To assess the validity of the examination, a pre-defined algorithm was applied to the nurse's examination findings in patients from both groups, and the sensitivity and specificity of the derived diagnoses were determined in comparison with the clinic's independent diagnosis as the reference standard. RESULTS The between observer repeatability of physical signs varied from good to excellent, with kappa coefficients of 0.66 to 1.00 for most categorical observations, and mean absolute differences of 1.4 degrees -11.9 degrees for measurements of shoulder movement. The sensitivity of the schedule in comparison with the reference standard varied between diagnoses from 58%-100%, while the specificities ranged from 84%-100%. The nurse and the clinic physician generally agreed in their diagnoses, but in the presence of shoulder capsulitis the nurse usually also diagnosed shoulder tendinitis, whereas the clinic physician did not. CONCLUSION The new examination protocol is repeatable and gives acceptable diagnostic accuracy in a hospital setting. Examination can feasibly be delegated to a trained nurse, and the protocol has the benefit of face and construct validity as well as consensus backing. Its performance in the community, where disease is less clear cut, merits separate evaluation, and further refinement is needed to discriminate between discrete pathologies at the shoulder.
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Affiliation(s)
- K Palmer
- The MRC Environmental Epidemiology Unit, University of Southampton, Southampton General Hospital, Southampton SO16 6YD
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