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Objectives. To determine if subgroups of patients with tennis elbow respond differently in treatment. Methods. This study used individual patient data (n ¼383) from two randomized controlled trials that investigated a wait-and-see policy, corticosteroid injections and physiotherapy. Common outcome measures were: pain severity, global improvement, severity assessed by a blinded assessor, elbow disability and pain free grip strength. Subgroup analyses for previous history of elbow pain, baseline pain severity, duration of the current episode and employment status were performed at 6 and 52 weeks. Results. Patients’ age, previous elbow symptoms and baseline pain severity were similar between trials, but other characteristics differed between trial populations. Based on individual patient data from both trials, we found that corticosteroid injections were statistically and clinically superior at 6 weeks, but significantly worse at 52 weeks compared with both wait-and-see and physiotherapy. Subgroup effects were scarce and small. Patients with higher baseline pain score showed less benefit on pain outcomes between physiotherapy and a wait-and-see policy at 6 weeks. It also appeared that non-manual workers who had an injection were the only work subgroup to follow the general trend that injections were significantly worse than a wait-and-see policy on global improvement at 52 weeks. Conclusion. The treatment outcomes were largely similar between trials and not different between most subgroups studied. In tennis elbow, it would appear that patient characteristics play only a small role in predicting treatment outcomes, which supports the generalizability of individual trial results.

Objective. To explore the relationship between measures of self-efficacy, health locus of control, health status and direct medical expenditure among community-dwelling subjects with rheumatoid arthritis (RA) and osteoarthritis (OA). Methods. This analysis is part of a larger ongoing study of the costs and outcomes of arthritis and its treatments. Community-dwelling RA and OA respondents completed questionnaires concerning arthritis-related expenditure, health status, arthritis related self-efficacy and health locus of control. Results. Data were obtained from 70 RA respondents and 223 OA respondents. The majority of respondents were female with a mean age of 63 yr for RA respondents and 68 yr for OA respondents. Among the RA respondents, those with higher self-efficacy reported better health status and lower overall costs. Health locus of control was not consistently correlated with health status. OA respondents with higher self-efficacy reported better health status and lower costs. Health locus of control had more influence. OA respondents with higher external locus of control reported worse pain and function. A higher belief in chance as a determinant of health was correlated with more visits to general practitioners and a higher cost to both the respondent and the health system. Conclusion. Higher self-efficacy, which is amenable to change through education programmes, was associated with better health status and lower costs to the respondent and the health system in this cross-sectional study. Locus of control had less of an influence; however, the tendency was for those with higher external locus of control to have higher costs and worse health status. As the measurement of these constructs is simple and the outcome potentially affects health status, these results have implications for future intervention studies to improve quality of life and reduce the financial impact of arthritis on both the health-care system and patients.

A longitudinal study of 75 young women (median age 43 yr) with early RA was performed with psychological, clinical and functional status measured every 4 months for up to 44 months. The aim was to describe functional changes, and to estimate the association between psychosocial variables and function in the early years after diagnosis. Function was measured by the Stanford Health Assessment Questionnaire (HAQ) and improved on average by about 10% per year with most improvement occurring over the first year. Pain and psychosocial variables also improved over time. There was still a residual improvement in HAQ with time of about 4% per year not accounted for by changes in these measured variables. When examined over time, psychosocial variables were as important as disease and pain in determining function. The results suggest interventions based on the importance of maintaining social relationships could impact on function.

Fifty-three patients with rheumatoid arthritis who required immunosuppressive therapy were commenced in a randomized trial comparing azathioprine to weekly oral pulse methotrexate. After an initial 24-week period, both groups had significantly improved from baseline measures of pain and functional capacity and there were no significant differences in clinical outcomes between the two groups. Laboratory variables of disease activity showed a significant improvement in haemoglobin and ESR in the methotrexate group. Subsequently, the patients were followed for up to 3 years. After one year, more than half of the patients in both groups had discontinued therapy due to inefficacy or adverse events. Adverse effects were more frequent in the patients treated with methotrexate, but withdrawal rates were similar in both groups. From these data, the probability of a patient continuing therapy with either agent for greater than 18 months is low.

As an intermediate stage in the development of an expert system to support undergraduate teaching in rheumatology, a decision tree incorporating the diagnostic criteria to be used in the expert system was produced by a team of rheumatologists. In a controlled trial, 119 final-year medical students each diagnosed 10 rheumatology cases, drawn from a pool of 96 cases, with or without the aid of the decision tree. Students who used the decision tree correctly diagnosed the following conditions more frequently than the control group: polymyalgia rheumatica (p less than 0.05), myopathies (p less than 0.01), systemic lupus erythematosus (p less than 0.05), pyrophosphate arthropathy (p less than 0.05), seronegative spondylarthropathies (p less than 0.01), intra-articular bleeding (p less than 0.05) and traumatic synovitis (p less than 0.05). The overall diagnostic accuracy of the students who used the decision tree was 81% compared with 68% for the control group (p less than 0.001).

The benefits of patient education for those with chronic arthritis are well documented. Informed patients should practice self care more often, and may show reduced disability from their disease. An important question relates to maintenance of the knowledge and skills acquired in educational programmes. This prospective study evaluated an education programme for people with rheumatoid arthritis (RA) and osteoarthritis (OA). The intervention group participated in a comprehensively planned six session behaviourally based programme. A questionnaire was given to 100 patients and 95 matched but non-random controls before the programme, 1 month later, and at 3 and 12 months. The intervention group demonstrated improvements in knowledge, self-reported health behaviour and disability scores at 12 months, compared to the controls. No differences were reported in symptoms, compliance with therapy, pain perception, and locus of control.

By means of a questionnaire, we have determined the combination of clinical features and laboratory tests which rheumatologists, nephrologists, immunologists, and neurologists in New South Wales consider most helpful in discriminating between central nervous system (CNS) involvement due to systemic lupus erythematosus (SLE) and that due to other causes. There was a uniformity of views amongst the four specialties in terms of the likelihood that a given clinical presentation was due to active CNS lupus. The clinical presentation made little difference to the interpretation of laboratory data. CNS abnormalities (EEG, CT, and CSF), as well as the finding of serum DNA antibody of 95%, influenced decision-making, although the other serological tests had little impact. There was disagreement amongst physicians as to whether a given test abnormality (e.g. focal CT scan abnormality) supported or rejected the diagnosis of active CNS lupus. This study indicates that physicians interpret test results selectively in their assessment of patients with SLE who develop CNS symptoms.

The longitudinal determinants of disability were studied in a group of 30 patients with rheumatoid arthritis over a 3-year period. The patients were investigated on two occasions using quantitative measures of disease activity and disability as well as a series of reliable psychometric instruments. Both longitudinal and cross-sectional data analyses were performed. Psychological factors consistently predicted more of the variance of disability than disease activity. These factors were associated with the tendency to deny the emotional dilemmas caused by having a chronic illness, difficulty in accepting doctors' reassurances and clinical depression. Such psychological variables required specific attention in rehabilitation programmes.

Sixty-two patients with osteoarthrosis entered a 10-week double-blind cross-over trial of diflunisal and naproxen. Eight patients withdrew for drug-related reason, and seven for other reasons. There was no statistically significant difference in parameters of disease activity on each treatment period, but naproxen produced fewer withdrawals due to drug-related side-effects.