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Despite its effectiveness, bisphosphonate use for osteoporosis is low. We assessed bisphosphonate information on the internet and found the most commonly listed benefits/risks were bone density loss, gastrointestinal issues, and jaw necrosis, that risk quantification was rare, and information quality varied. Findings underscore the importance of clinical communication about bisphosphonates. INTRODUCTION: The US Preventative Services Task Force recommends osteoporosis screening and treatment with bisphosphonates in high-risk populations. However, bisphosphonate use among individuals with osteoporosis remains low. The content and quality of information from outside sources may influence individuals' bisphosphonate decisions. Therefore, we sought to assess the content and quality of osteoporosis treatment information available to the public by conducting an internet search and coding available bisphosphonate information. METHODS: Eleven search terms about osteoporosis and bisphosphonates were entered into four search engines. Two raters assessed websites for information about bisphosphonates, whether and how benefits and side effects were described and quantified, contraindications, and dosing instructions. Coders also assessed website interface and slant/balance of information. RESULTS: One thousand four hundred seventy-three websites were identified. Two hundred twenty-seven websites met inclusion criteria and were coded. The most common bisphosphonate benefit described was prevention of bone density loss (77.1% of websites). The most common side effects described were gastrointestinal problems (66.1%) and jaw osteonecrosis (58.6%). Most websites did not quantify bisphosphonate benefits (78.0%) or side effects (82.4%). Complementary/integrative health websites (p < .001) and pharmaceutical litigation websites (p < .001) were more often slanted against taking bisphosphonates, compared to all websites coded. General medical knowledge websites were more balanced than other websites (p = .023). CONCLUSIONS: The quality of bisphosphonate information on the internet varies substantially. Providers counseling patients about osteoporosis treatment should inquire about patients' baseline bisphosphonate knowledge. Providers can complement accurate information and address potential bisphosphonate misconceptions.
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Difosfonatos/uso terapéutico , Comunicación en Salud/normas , Internet , Osteoporosis/tratamiento farmacológico , Indicadores de Calidad de la Atención de Salud , Densidad Ósea , Conservadores de la Densidad Ósea/efectos adversos , Conservadores de la Densidad Ósea/uso terapéutico , Difosfonatos/efectos adversos , Educación en Salud/normas , Humanos , Difusión de la Información , Motor de BúsquedaRESUMEN
UNLABELLED: We sought to evaluate the effects of antiretroviral therapy on skeletal metabolism in Chinese individuals with human immunodeficiency virus. Patients switched to tenofovir/lamivudine + lopinavir/ritonavir after treatment failure had an increase in bone resorption marker levels by nearly 60%, which is greater than the magnitude previously described in non-Chinese populations. INTRODUCTION: Few studies have evaluated the effects of antiretroviral therapy on skeletal metabolism in Asian populations infected with human immunodeficiency virus (HIV). METHODS: We performed a secondary analysis of bone turnover markers (BTM) at baseline and 2 years in stored plasma samples collected from 2/2009 to 1/2013 as part of a multi-center trial. Two groups were compared: (1) treatment-naïve patients initiated on zidovudine (AZT)/lamivudine (3TC) plus nevirapine (NVP) and (2) patients who failed first-line therapy and were switched to tenofovir (TDF)/3TC plus lopinavir/ritonavir (LPVr). Tests included the bone resorption marker, C-terminal cross-linking telopeptide of type-1 collagen (CTX), and the bone formation marker procollagen type 1 N-terminal propeptide (P1NP). RESULTS: In the TDF/3TC + LPVr group, samples were available from 59 patients at baseline and 56 patients at 2 years. Of these, 36 patients had samples available from both time points. In the AZT/3TC + NVP group, plasma samples were analyzed from 82 participants at baseline and of those, 61 had samples at 2 years. Median change over 2 years was greater in the TDF/3TC + LPVr group for both CTX (+0.24 ng/mL, interquartile ranges (IQR) 0.10-0.43 vs. +0.09 ng/mL, IQR -0.03 to 0.18, p = 0.001) and P1NP (+25.5 ng/mL, IQR 2.4-51.3 vs. +7.11 ng/mL, IQR -4.3 to 21.6, p = 0.012). Differences remained after adjusting for potential confounders in the multivariable analysis. CONCLUSIONS: Switching to TDF/3TC + LPVr after treatment failure resulted in greater increases in BTMs than initiation with AZT/3TC + NVP in Chinese patients with HIV. Following this change, bone resorption marker levels increased by nearly 60 %, which is greater than the 25-35% increase from baseline described previously in non-Chinese populations. Further studies are warranted to elucidate these findings.
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Fármacos Anti-VIH/efectos adversos , Resorción Ósea/inducido químicamente , Infecciones por VIH/tratamiento farmacológico , VIH-1 , Lopinavir/efectos adversos , Ritonavir/efectos adversos , Tenofovir/efectos adversos , Adolescente , Adulto , Anciano , Fármacos Anti-VIH/uso terapéutico , Biomarcadores/sangre , Remodelación Ósea/efectos de los fármacos , Resorción Ósea/sangre , Colágeno Tipo I/sangre , Combinación de Medicamentos , Sustitución de Medicamentos , Quimioterapia Combinada , Femenino , Infecciones por VIH/sangre , Humanos , Lopinavir/uso terapéutico , Masculino , Persona de Mediana Edad , Péptidos/sangre , Ritonavir/uso terapéutico , Tenofovir/uso terapéutico , Adulto JovenRESUMEN
OBJECTIVE: Antirheumatic treatment is frequently not appropriately modified, according to American College of Rheumatology guidelines, in patients with active rheumatoid arthritis (RA) as defined by a Disease Activity Score in 28 joints (DAS28) score greater than 3.2. The objective of this study was to determine which factors most strongly influence patients' and rheumatologists' decisions to escalate care. METHODS: We administered a Maximum Difference Scaling survey to 106 rheumatologists and 213 patients with RA. The survey included 58 factors related to the decision to escalate care in RA. Participants answered 24 choice tasks. In each task, participants were asked to choose the most important factor from a set of 5. We used hierarchical Bayes modeling to generate the mean relative importance score (RIS) for each factor. RESULTS: For rheumatologists, the 5 most influential factors were number of swollen joints (mean ± SD RIS 5.2 ± 0.4), DAS28 score (mean ± SD RIS 5.2 ± 0.5), physician global assessment of disease activity (mean ± SD RIS 5.2 ± 0.6), worsening erosions over the last year (mean ± SD RIS 5.2 ± 0.5), and RA disease activity now compared to 3 months ago (mean ± SD RIS 5.1 ± 0.6). For patients, the 5 most important factors were current level of physical functioning (mean ± SD RIS 4.3 ± 1.1), motivation to get better (mean ± SD RIS 3.5 ± 1.4), trust in their rheumatologist (mean ± SD RIS 3.5 ± 1.6), satisfaction with current disease-modifying antirheumatic drugs (mean ± SD RIS 3.4 ± 1.4), and current number of painful joints (mean ± SD RIS 3.4 ± 1.4). CONCLUSION: Factors influencing the decision to escalate care differ between rheumatologists and patients. Better communication between patients and their physicians may improve treatment planning in RA patients with active disease.
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Antirreumáticos/uso terapéutico , Artritis Reumatoide/tratamiento farmacológico , Actitud del Personal de Salud , Conocimientos, Actitudes y Práctica en Salud , Pacientes/psicología , Médicos/psicología , Pautas de la Práctica en Medicina , Reumatología , Anciano , Artritis Reumatoide/diagnóstico , Artritis Reumatoide/psicología , Femenino , Adhesión a Directriz , Encuestas de Atención de la Salud , Humanos , Masculino , Persona de Mediana Edad , Países Bajos , Selección de Paciente , Relaciones Médico-Paciente , Guías de Práctica Clínica como Asunto , Índice de Severidad de la EnfermedadRESUMEN
When one contemplates the one-parameter family of steady inviscid shear flows discovered by J. T. Stuart in 1967, an obvious thought is that these flows resemble a row of vortices diffusing in a viscous fluid, with the parameter playing the role of a reversed time. In this paper, we ask how close this resemblance is. Accordingly, the paper begins to explore Navier-Stokes solutions having as initial condition the classical, irrotational flow due to a row of point vortices. However, since we seek explicit answers, such exploration seems possible only in two relatively easy cases: that of small time and arbitrary Reynolds number and that of small Reynolds number and arbitrary time.
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OBJECTIVES: The objective of this study was to determine whether physicians' treatment preferences are influenced by patients' age. METHODS: We mailed a survey to a random sample of rheumatologists practicing in the US. The survey included a scenario describing a hypothetical patient with rheumatoid arthritis (RA) on hydroxychloroquine, sulfasalazine and low-dose prednisolone, who presents with active disease during a follow-up appointment. The scenario was formulated in two versions that were identical except for the age of the patient. After reading the scenario, respondents were asked to rate (on a 10 cm numerical rating scale) their recommendations for each of the three options: (i) increasing the dose of prednisolone, (ii) adding a new disease-modifying anti-rheumatic drug (DMARD) and (iii) switching DMARDs. Rheumatologists who rated either adding a new DMARD or switching DMARDs higher than increasing the dose of prednisolone were classified as 'preferring aggressive treatment with DMARDs', while the others were classified as 'NOT preferring aggressive treatment with DMARDs'. RESULTS: A total of 480 rheumatologists were mailed a questionnaire; 204 responded, giving a response rate of 42.5%. Overall 163 (80%) respondents were classified as preferring aggressive treatment with DMARDs. Rheumatologists responding to this survey were more likely to prefer aggressive DMARD treatment for the young RA patient vs the older RA patient (87 vs 71%, P= 0.007). CONCLUSIONS: Our findings suggest that rheumatologists' treatment recommendations may be influenced by age. Future educational efforts should increase physician awareness of this possible bias in order to ensure equal service delivery across ages.
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Antirreumáticos/administración & dosificación , Artritis Reumatoide/tratamiento farmacológico , Actitud del Personal de Salud , Toma de Decisiones , Reumatología/estadística & datos numéricos , Adulto , Factores de Edad , Anciano de 80 o más Años , Esquema de Medicación , Utilización de Medicamentos/estadística & datos numéricos , Femenino , Encuestas de Atención de la Salud , Humanos , Masculino , Selección de Paciente , Pautas de la Práctica en Medicina/estadística & datos numéricosRESUMEN
OBJECTIVE: To elicit treatment preferences of patients with rheumatoid arthritis (RA) for disease modifying antirheumatic drugs (DMARDs) with varying risk profiles. METHODS: Patient values for 16 DMARD characteristics were ascertained using published data about side effects, effectiveness, and cost. Patient preferences were determined by Adaptive Conjoint Analysis, an interactive computer program that predicts preferences by asking patients to make trade-offs between specific treatment characteristics. Simulations were run to derive preferences for four drugs: methotrexate, gold, leflunomide, and etanercept, under different risk-benefit scenarios. Infliximab was not included because it is given with methotrexate, and we did not include preferences for combination therapy. Based on each patient's expressed preferences, and the characteristics of the treatments available at the time of the study, the option that best fitted each patient's perspective was identified. RESULTS: 120 patients (mean age 70 years) were interviewed. For the base case scenario (which assumed the maximum benefits reported in the literature, a low probability of adverse effects, and low equal monthly "co-pays" (out of pocket costs)), 95% of the respondents preferred etanercept over the other treatment options. When all four options were described as being equally effective, 88% continued to prefer etanercept owing to its safer short term adverse effect profile. Increasing etanercept's co-pay to $30.00 decreased the percentage of patients preferring this option to 80%. CONCLUSIONS: In this study, older patients with RA, when asked to consider trade-offs between specific risk and benefits, preferred etanercept over other treatment options. Preference for etanercept is explained by older patients' risk aversion for drug toxicity.
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Antirreumáticos/uso terapéutico , Artritis Reumatoide/psicología , Inmunoglobulina G/uso terapéutico , Satisfacción del Paciente , Receptores del Factor de Necrosis Tumoral/uso terapéutico , Adulto , Anciano , Anciano de 80 o más Años , Antirreumáticos/efectos adversos , Artritis Reumatoide/tratamiento farmacológico , Simulación por Computador , Etanercept , Femenino , Humanos , Inmunoglobulina G/efectos adversos , Isoxazoles/efectos adversos , Isoxazoles/uso terapéutico , Leflunamida , Masculino , Metotrexato/efectos adversos , Metotrexato/uso terapéutico , Persona de Mediana Edad , Compuestos Orgánicos de Oro , RiesgoRESUMEN
Women's treatment preferences for lupus nephritis vary widely even after adjusting for sociodemographic factors and disease severity. Attitude toward risk may partially explain interpatient variability in treatment preference. The objective of this study was to examine the association between 'risk-attitude' and patient treatment preferences in lupus nephritis. Sixty-five premenopausal women with systemic lupus erythematosus were interviewed. Patient preferences for cyclophosphamide versus azathioprine for the treatment of lupus nephritis were ascertained using an Adaptive Conjoint Analysis questionnaire. Risk-attitude was ascertained by asking patients to choose between a pair of lotteries having the same expected value but differing in spread (the difference between the worst and best outcomes). Respondents preferring the wider spread were classified as relatively more risk-seeking and those preferring the narrower spread were classified as relatively more risk-averse. Twenty-eight percent of respondents were classified as relatively more risk-seeking. Risk-seeking women were more likely to prefer cyclophosphamide for the treatment of lupus nephritis compared with risk-averse women [least square mean (+/- SD) preference for cyclophosphamide 63 +/- 3 among risk-seeking women versus 55 +/- 2 among risk-averse women (P < 0.03)]. The association between risk attitude and treatment preference persisted asthe probabilities of adverse events were varied to reflect the range of risks reported in the literature. Our results suggest that patients' relative risk-attitudes, as measured by a lottery task, are related to their treatment preferences. Differences in risk-attitude may help explain the inter-patient variability in treatment preferences.
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Actitud Frente a la Salud , Nefritis Lúpica/tratamiento farmacológico , Participación del Paciente , Adulto , Antirreumáticos/efectos adversos , Antirreumáticos/uso terapéutico , Azatioprina/efectos adversos , Azatioprina/uso terapéutico , Ciclofosfamida/efectos adversos , Ciclofosfamida/uso terapéutico , Toma de Decisiones , Femenino , Humanos , Nefritis Lúpica/psicología , Medición de Riesgo , Resultado del TratamientoRESUMEN
OBJECTIVE: To evaluate patient willingness to accept the risk of adverse effects (AEs) commonly associated with arthritis medications. METHODS: Rheumatoid arthritis patients were asked to rate their willingness to take a medication associated with 17 specific AEs using a visual analogue scale. RESULTS: We interviewed 100 patients. Eighty-one were currently using one or more disease-modifying anti-rheumatic drugs (DMARDs) and 29 had previously experienced AEs related to DMARDs. Seventy-five stated that they were doing very well or well with respect to their arthritis compared with other people their age. Thirty-five per cent of those interviewed were unwilling to accept the risk of cosmetic changes, 38% were unwilling to accept the risk of temporary discomfort and 45% were unwilling to accept the risk of major toxicity. Patients who had previously experienced AEs were more willing to accept the risk of cosmetic changes (83 vs. 58%, P=0.02), temporary discomfort (79 vs. 55%, P=0.02) and major toxicity (83 vs. 44%, P=0.001) compared with those who had not previously experienced AEs. CONCLUSIONS: Many rheumatoid arthritis patients are very concerned about potential drug toxicity. However, risk adversity appeared to be attenuated by past experience with AEs. Our results suggest that certain patients, especially those with milder disease activity, might be reluctant to accept commonly used arthritis medications if they are fully informed of their potential toxicity.
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Artritis Reumatoide/psicología , Conocimientos, Actitudes y Práctica en Salud , Aceptación de la Atención de Salud/psicología , Asunción de Riesgos , Adulto , Anciano , Anciano de 80 o más Años , Antirreumáticos/efectos adversos , Artritis Reumatoide/tratamiento farmacológico , Femenino , Humanos , Entrevistas como Asunto , Masculino , Persona de Mediana EdadRESUMEN
BACKGROUND: Incorporation of patient preferences into treatment decisions is an essential component of medical care. Conjoint analysis is an established method of eliciting consumer preferences in market research and is being increasingly used to study patient preferences for health care. OBJECTIVE: To examine the value of Adaptive Conjoint Analysis (ACA), a unique method of performing conjoint analysis, and to evaluate patient treatment preferences. RESEARCH DESIGN: Interactive computer survey. SUBJECTS: Consecutive women (n = 103) with lupus followed in three community rheumatology practices. MEASURES: ACA was used to assess patients' relative preferences for specific cytotoxic medication characteristics, and to estimate the percentage of women preferring cyclophosphamide over azathioprine for different risk-benefit scenarios. RESULTS: All participants were able to complete the conjoint task in 14 +/-5 minutes. Of the nine medication characteristics studied, efficacy and risk for infection had the greatest impact on preference (each accounting for 20% of the variation in preferences), suggesting that patients consider differences in the risk for infection equally as important as differences in the probability of renal survival. Premenopausal women wanting more children were less likely to choose cyclophosphamide compared with their counterparts (56% vs. 80%, P = 0.04). Modest changes in the probability of renal survival or risk for major toxicity lowered the percentage of women preferring cyclophosphamide by more than 20%, irrespective of their desire for more children. CONCLUSIONS: ACA is a feasible method of assessing how patients consider specific medication characteristics and predicting treatment preferences under different risk-benefit scenarios. ACA may be a valuable tool to incorporate patient preferences into medical decision-making.
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Antirreumáticos/uso terapéutico , Nefritis Lúpica/tratamiento farmacológico , Participación del Paciente , Satisfacción del Paciente/estadística & datos numéricos , Medición de Riesgo/métodos , Adulto , Antirreumáticos/efectos adversos , Azatioprina/efectos adversos , Azatioprina/uso terapéutico , Connecticut , Ciclofosfamida/efectos adversos , Ciclofosfamida/uso terapéutico , Toma de Decisiones , Femenino , Humanos , Análisis de los Mínimos Cuadrados , Persona de Mediana Edad , Modelos Teóricos , Análisis de Supervivencia , Resultado del TratamientoRESUMEN
OBJECTIVE: To examine rheumatologists' attitudes toward routine ophthalmologic screening for hydroxychloroquine (HCQ) retinopathy and to estimate the acceptability of hypothetical guidelines discouraging this practice. METHODS: We E-mailed a random sample of 300 US rheumatologists listed in the American College of Rheumatology (ACR) Directory who treat adults. We asked about current screening practice, reasons for screening, and the effect of hypothetical guidelines discouraging routine screening on future practice. Associations between adherence to guidelines and clinical variables were evaluated using multiple logistic regression. RESULTS: Of 56% who responded, almost all (94%) currently screen their patients at least once per year. Seventy-five percent stated that they would continue to screen because they are unwilling to accept any risk of visual loss among their patients; 74% would continue to screen because of legal liability; and 56% felt their patients would insist on being screened regardless of their physician's opinion. Forty-four percent stated that they would continue to screen regularly, even if the ACR published guidelines discouraging routine screening. Rheumatologists unwilling to accept any risk of retinopathy were less likely to follow guidelines discouraging screening (46 vs 77%, adjusted OR 0.2, 95% CI 0.1-0.6). Patient insistence and fear of legal liability were not significantly associated with predicted adherence to guidelines. CONCLUSION: Our survey indicates that the majority of rheumatologists currently routinely screen their patients for HCQ retinopathy, and that many would not follow ACR guidelines discouraging this practice, at least in part because they are unwilling to accept any risk of visual damage.
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Antirreumáticos/toxicidad , Actitud del Personal de Salud , Hidroxicloroquina/toxicidad , Enfermedades de la Retina/inducido químicamente , Reumatología/estadística & datos numéricos , Femenino , Humanos , Responsabilidad Legal , Masculino , Tamizaje Masivo/legislación & jurisprudencia , Tamizaje Masivo/psicología , Tamizaje Masivo/normas , Guías de Práctica Clínica como Asunto , Práctica Profesional/legislación & jurisprudencia , Práctica Profesional/normas , Práctica Profesional/estadística & datos numéricos , Reumatología/legislación & jurisprudencia , Reumatología/normas , Gestión de Riesgos , Estados Unidos , Baja Visión/inducido químicamenteRESUMEN
OBJECTIVE: To quantify preference for disclosure of information among patients with rheumatoid arthritis (RA) and to examine sex-specific correlates of information preference. METHODS: We interviewed patients with RA and assessed preference for disclosure of information using 4 questions from the previously validated "Information Preference Seeking Scale." Three questions addressed preference for disclosure of side effects and 1 question addressed preference for disclosure of therapeutic options. Associations between preference for information and patient characteristics were examined using stepwise multiple linear regression. RESULTS: One hundred RA patients (mean age 68+/-12 years; 73% female) were interviewed; 89 respondents agreed or strongly agreed with all 4 statements reflecting a preference for full disclosure, and an additional 8 respondents agreed or strongly agreed with 3 of the 4 statements. The mean score (+/- SD) for information preference was 86+/-13, on a scale from 0 to 100 where 100 reflected a strong preference for full disclosure. In bivariate analyses, female sex and current employment were associated with stronger preferences for being informed (mean score for women 88+/-11, for men 80+/-15 [P = 0.02]; for employed 92+/-11, for unemployed 84+/-13 [P = 0.04]). Multivariate sex-specific analyses demonstrated that current employment and higher education level were positively associated with preference for disclosure among women and men, respectively. CONCLUSION: The results of our survey suggest that RA patients want to be fully informed about the risks associated with medications and about alternative options. The challenge remaining for rheumatologists is how to effectively communicate the risks and benefits related to the many options that are currently available for RA patients.
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Artritis Reumatoide/psicología , Confidencialidad/psicología , Satisfacción del Paciente , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Entrevistas como Asunto , Masculino , Persona de Mediana Edad , Modelos Teóricos , Distribución por SexoRESUMEN
OBJECTIVE: New scales for the clinical assessment of patients with systemic lupus erythematosus (SLE) are valid and reliable, and quantitate disease activity. We assessed the responsiveness to change of 2 widely used standardized multi-item lupus activity measures, the revised Systemic Lupus Activity Measure (SLAM-R) and the Systemic Lupus Erythematosus Disease Activity Index (SLEDAI), and their ability to detect clinically relevant changes. METHODS: Ninety-six (96) patients with definite SLE participated in this study. The group mean age was 45.0 (13.7) years, 91% were female, and the mean disease duration was 14.9 (7.5) years. Sociodemographic information, lupus activity (SLAM-R, SLEDAI), and damage were recorded at baseline. At each of the 5 monthly followup visits, the activity measures were repeated and a transition scale asked the physician if their patient's lupus activity had changed. Five different methods were used to compare the responsiveness of the activity measures studied: 1. the effect size; 2. the standardized response mean; 3. the control standardized response mean; 4. the area under the curve of a receiver operating characteristic (ROC) curve; and 5. a new multiple response modeling approach. RESULTS: Both SLAM-R and SLEDAI are responsive. SLAM-R is consistently, although moderately, more responsive than SLEDAI. All 5 methods of evaluating responsiveness yielded a consistent ranking of disease activity measures. CONCLUSION: SLAM-R and SLEDAI are responsive measures of lupus activity. SLAM-R appears to be more responsive than SLEDAI.
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Actividades Cotidianas , Lupus Eritematoso Sistémico/diagnóstico , Índice de Severidad de la Enfermedad , Encuestas y Cuestionarios , Adulto , Progresión de la Enfermedad , Femenino , Estudios de Seguimiento , Humanos , Estudios Longitudinales , Lupus Eritematoso Sistémico/rehabilitación , Masculino , Persona de Mediana Edad , Examen Físico , Sensibilidad y EspecificidadRESUMEN
OBJECTIVE: In a previous retrospective study, we had found that shoulder radiographs were overused in the initial evaluation of patients presenting to the emergency department with shoulder pain. Our objective was to prospectively define clinical criteria that identify patients who have a low risk of radiographic findings that influence the management of the initial evaluation of shoulder pain in the emergency department. METHODS: All adult patients presenting to the emergency department of a university teaching hospital with shoulder pain were eligible to participate. Patients with deformities, penetrating wounds, referred pain, and those presenting for followup were excluded. Data were recorded prospectively using a standardized form. All radiographs were classified as therapeutically uninformative (TU) except fracture, acromioclavicular joint separation (> or =Grade 3), infection, or malignancy. A classification tree was used for analysis. RESULTS: Two hundred six patients had shoulder radiographs, of which 88% were TU. The model yielded 3 sets of low risk patients with a high percentage of TU radiographs: (1) no fall, no swelling (99% TU: 106 TU, 1 radiograph with lytic lesions in a cancer patient); (2) a fall, but no swelling, and no pain at rest (100% TU, n = 18); (3) a fall and pain at rest, but no swelling and normal range of motion (100% TU, n = 10). Not performing radiographs on these low risk patients would have decreased radiograph utilization from 52 to 18% of all shoulder patients seen. CONCLUSION: Our findings suggest that specific clinical criteria are able to identify patients who do not need radiographs as part of the initial management of shoulder pain. Prospective validation of these criteria are needed to confirm that these low risk patients can be safely evaluated without radiographs.
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Dolor de Hombro/diagnóstico por imagen , Adulto , Anciano , Urgencias Médicas , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Radiografía/estadística & datos numéricos , Factores de RiesgoRESUMEN
OBJECTIVE: To determine whether the risk profile for Raynaud's phenomenon (RP) is different between men and women. METHODS: In this cross-sectional study of 800 women and 725 men participating in the Framingham Offspring Study, the association of age, marital status, smoking, alcohol use, diabetes, hypertension, and hypercholesterolemia with prevalent RP was examined in men and women separately, after adjusting for relevant confounders. RESULTS: The prevalence of RP was 9.6% (n = 77) in women and 5.8% (n = 42) in men. In women, marital status and alcohol use were each associated with prevalent RP (for marital status adjusted odds ratio [OR] 2.3, 95% confidence interval [95% CI] 1.4-3.9; for alcohol use OR 2.2, 95% CI 1.0-5.2), whereas these factors were not associated with RP in men (marital status OR 1.4, 95% CI 0.6-3.5; alcohol use OR 1.0, 95% CI 0.2-4.4). In men, older age (OR 2.3, 95% CI 1.0-5.2) and smoking (OR 2.6, 95% CI 1.1-6.3) were associated with prevalent RP; these factors were not associated with RP in women (older age OR 0.8, 95% CI 0.4-1.6; smoking OR 0.7, 95% CI 0.4-1.1). Diabetes, hypertension, and hypercholesterolemia were not associated with RP in either sex. CONCLUSION: The results indicate that risk factors for RP differ between men and women. Age and smoking were associated with RP in men only, while the associations of marital status and alcohol use with RP were observed in women only. These findings suggest that different mechanisms influence the expression of RP in men and women.
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Enfermedad de Raynaud/etiología , Factores de Edad , Consumo de Bebidas Alcohólicas , Estudios Transversales , Femenino , Humanos , Masculino , Estado Civil , Massachusetts/epidemiología , Persona de Mediana Edad , Análisis Multivariante , Oportunidad Relativa , Prevalencia , Enfermedad de Raynaud/epidemiología , Factores de Riesgo , Distribución por Sexo , FumarRESUMEN
This study was conducted to describe the utilization of plain radiography in the initial evaluation of shoulder pain in the emergency department (ED) and assess the feasibility of developing guidelines for the selective use of shoulder radiographs by determining whether clinical variables are able to discriminate between subjects having therapeutically informative versus uninformative X-rays. The study was a chart review of all adult ED patients presenting to the Boston University Medical Center Hospital (Boston, MA) between January 1994 and January 1996 with a chief complaint that included shoulder pain. Subjects with X-rays were classified into two groups, those with therapeutically informative X-rays (ie, identified conditions requiring specific therapy) and those with therapeutically uninformative X-rays (ie, did not result in specific therapy). Recursive partitioning techniques were then used to identify clinical variables that best distinguished between therapeutically informative and uninformative radiographs. Three hundred twelve patients were included in the analysis, of whom 185 (59%) had shoulder X-rays performed. Thirty-seven (20%) radiographs were therapeutically informative, including 13 glenohumeral dislocations, 3 acromioclavicular joint separations, and 21 fractures. Deformity present on shoulder examination was the strongest discriminating variable and correctly classified 21 of 23 subjects as having informative X-rays. Of the remaining patients (n = 162), only those older than 43.5 years with a history of a precipitating fall (n = 40) had a high likelihood of having therapeutically informative X-rays. No patients without a deformity or precipitating fall (n = 90) had an informative X-ray. These data show that X-rays for the initial evaluation of shoulder pain in the ED are overutilized. This preliminary model suggests that clinical variables are able to distinguish between patients with informative versus uninformative X-rays. Prospective studies are needed to derive valid decision rules for selective use of shoulder radiographs in the ED.
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Servicio de Urgencia en Hospital/estadística & datos numéricos , Dolor de Hombro/diagnóstico por imagen , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Boston , Estudios de Factibilidad , Femenino , Hospitales Universitarios , Humanos , Masculino , Registros Médicos , Persona de Mediana Edad , Proyectos Piloto , Radiografía/estadística & datos numéricos , Estudios Retrospectivos , Dolor de Hombro/etiología , Revisión de Utilización de RecursosRESUMEN
OBJECTIVE: To examine the association of peripheral blood mononuclear cell (PBMC) derived interleukin 1beta (IL-1beta), IL-1 receptor antagonist (IL-1Ra), tumor necrosis factor alpha (TNF-alpha), and radiographic osteoarthritis (OA) in the elderly. METHODS: A total of 703 subjects (436 women, 267 men, mean age 78.5+/-4.5 yrs) had both knee and hand radiographs, and cytokines were measured during the 22nd biennial examination of the Framingham Cohort. PBMC derived IL-1beta , IL-1Ra, and TNF-alpha production was assessed using a non-cross reacting polyclonal radioimmunoassay. Knee OA was defined as a score of > 2 using a modified Kellgren and Lawrence scale. The presence of osteophytes and joint space narrowing were scored separately on a 0-3 scale, in which disease was defined a priori as a score > 0 for each feature. Sex-specific odds ratios were calculated for knee OA after adjusting for weight, history of knee injury, and use of estrogen and nonsteroidal antiinflammatory drugs. RESULT: No uniform associations were found for IL-1beta or IL-1Ra in men, or for TNF-alpha production and radiographic OA in either sex. We found possible associations for the highest levels of IL-1beta production and the presence of knee osteophytes [OR=2.0 (1.2-3.5)] and joint space narrowing [OR=1.7 (1.1-2.8)] in women. Our data suggested a possible protective effect for IL-1Ra production and hand OA in women [OR=0.6 (0.4-1.0)]. CONCLUSION: We found no consistent association of PBMC cytokine production and radiographic OA. However, women with the highest production of IL-1beta and IL-1Ra had respectively higher rates of knee OA and lower rates of hand OA than expected.
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Interleucina-1/metabolismo , Monocitos/metabolismo , Osteoartritis/metabolismo , Receptores de Interleucina-1/antagonistas & inhibidores , Sialoglicoproteínas/metabolismo , Factor de Necrosis Tumoral alfa/metabolismo , Anciano , Anciano de 80 o más Años , Estudios de Cohortes , Femenino , Mano/diagnóstico por imagen , Humanos , Proteína Antagonista del Receptor de Interleucina 1 , Masculino , Osteoartritis/diagnóstico por imagen , RadiografíaRESUMEN
BACKGROUND: Hormonal factors may play an important role in the pathophysiology of the Raynaud phenomenon. Experimental studies have shown an increased vasoconstrictor response to estrogen, a response that can be prevented by the addition of progesterone. OBJECTIVE: To measure the association between estrogen replacement therapy (alone and with progesterone) and the Raynaud phenomenon. DESIGN: Cross-sectional study. SETTING: Framingham Offspring Study. PARTICIPANTS: 497 postmenopausal women. MEASUREMENTS: Prevalence of the Raynaud phenomenon according to hormone use. Covariates measured included age, body mass index, smoking, alcohol consumption, and beta-blocker use. RESULTS: Forty-nine women were classified as having the Raynaud phenomenon (9.9%). The prevalence of this phenomenon was 8.4% among women who did not receive estrogen, 19.1% among women receiving estrogen alone, and 9.8% among women receiving estrogen plus progesterone. The adjusted odds ratio for the Raynaud phenomenon was 2.5 (95% CI, 1.2 to 5.3) for unopposed estrogen and 0.9 (CI, 0.3 to 2.6) for estrogen plus progesterone, with nonusers as the reference group. CONCLUSIONS: Unopposed estrogen therapy was associated with the Raynaud phenomenon in postmenopausal women. This association was not present in women who were receiving combined hormone therapy.
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Terapia de Reemplazo de Estrógeno , Posmenopausia , Enfermedad de Raynaud/fisiopatología , Estudios Transversales , Femenino , Humanos , Progesterona/uso terapéutico , Vasoconstricción/fisiologíaRESUMEN
To test if lupus activity and damage predict physical function and general health in lupus was the objective of this study. Ninety-six patients with lupus were seen at baseline and monthly for 4 months. Sociodemographic characteristics and lupus damage (SLICC/ACR DI), were collected at baseline while lupus activity (SLAM-R, SLEDAI), health status measures (HAQ, SF-36) and immunological tests were collected at each visit. Associations of lupus activity and damage with general health and physical function were evaluated. Baseline health status measures were greatly impaired and comparable to those of severe medical illnesses. In cross-sectional analyses, baseline activity score measured by SLAM-R, but not by SLEDAI, correlated with most subscales of SF-36. Baseline damage score SLICC/ACR DI correlated only with the HAQ and the physical function subscale of SF-36. Differences in both activity measures (SLAM-R and SLEDAI) over time correlated with change in health status measures while baseline cumulative damage (SLICC/ACR DI) correlated with the average level of physical function only. Lupus activity measures, SLAM-R and SLEDAI, although differing cross-sectionally, both reflected patients' health status performance over time and lupus damage measure, SLICC/ACR DI, performed well in assessing physical function. Lupus patients scores for health are poor and comparable to those found in severe medical illnesses.
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Actividades Cotidianas , Indicadores de Salud , Lupus Eritematoso Sistémico/psicología , Adulto , Estudios Transversales , Interpretación Estadística de Datos , Femenino , Encuestas Epidemiológicas , Humanos , Lupus Eritematoso Sistémico/diagnóstico , Masculino , Persona de Mediana Edad , Evaluación de Resultado en la Atención de Salud , Estudios Prospectivos , Calidad de Vida/psicología , Índice de Severidad de la Enfermedad , Encuestas y CuestionariosRESUMEN
OBJECTIVE: To examine the relation between serum insulin-like growth factor I (IGF-I) levels and both incident and progressive radiographic knee osteoarthritis (OA) in the Framingham Osteoarthritis Study. DESIGN: Subjects had bilateral weight-bearing, anterior-posterior knee radiographs performed in 1983-1985 and again in 1992-1993. IGF-I levels were measured from blood specimens obtained in 1988-1989 by a competitive binding radio-immunoassay (RIA) after separation with octadecasilyl-silica cartridges of serum IGF-I from binding proteins. Participants without baseline radiographic OA [Kellgren and Lawrence grades (K&L) = 0-1] were classified as having incident disease if they had K&L > or = 2 grades at follow-up. Progressive OA was defined as an increase in K&L score of > or = 1 in knees with baseline OA (K&L > or = 2). All analyses were knee-based and sex-specific. We examined IGF-I tertiles in relation to the risk of incident and progressive radiographic OA separately, adjusting for age, body mass index (BMI), and baseline K&L score, and used generalized estimating equations to adjust for the correlation between fellow knees. RESULTS: Four hundred and forty-one participants had knee radiographs and serum IGF-I levels measured. No associations were found for serum IGF-I levels and incident [women: OR = 0.9 (0.6-1.7), men OR = 1.2 (0.6-2.6)] or progressive [women OR = 0.9 (0.6-1.6), men OR = 0.9 (0.3-3.0)] radiographic knee OA in either sex. Neither did we observe any association between IGF-I and worsening of individual radiographic features of OA (i.e., osteophyte growth and joint space loss). CONCLUSION: In summary, this longitudinal study did not demonstrate any association of serum IGF-I and incident or progressive radiographic knee OA. Further studies are needed to clarify the role of IGF-I in OA.