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Objectives: To determine whether erosive osteoarthritis shares the same pattern of joint involvement and risk profile as increasing grades of non-erosive hand osteoarthritis., Methods: Participants were from two population-based cohorts, aged ≥50 years, reporting hand symptoms in the previous month. Interphalangeal joints were assessed for erosive osteoarthritis (Verbruggen-Veys erosive or remodelled phase) and radiographic osteoarthritis (sliding cut-offs of K&L≥2, K&L≥3 and K&L=4). At the joint level, similarities in the frequency and pattern of erosive and non-erosive osteoarthritis were assessed by Spearman's rank correlation coefficients and generalised estimating equations. At the person level, individuals with erosive osteoarthritis were compared to those with non-erosive osteoarthritis using logistic regression, adjusted for age and gender (aOR), for the following exposures: family history, previous injury, overuse and metabolic factors (BMI, dyslipidaemia, hypertension, diabetes)., Results: In 1076 symptomatic participants the ranked frequency of involvement for erosive joints was comparable to joints with K&L≥3 and K&L=4 (r>0.95). Patterns of joint involvement in erosive osteoarthritis were strongest for symmetry (aOR=6.5; 95% CI 3.0 to 14.1), followed by row (2.0; 0.8 to 5.0) and ray (0.3; 0.0 to 2.5), which was similar to joints with K&L≥3 and K&L=4. Individuals with erosive osteoarthritis (n=80) had an increased risk of metabolic syndrome (2.7; 1.0 to 7.1), notably dyslipidaemia (4.7; 2.1 to 10.6) compared with non-erosive osteoarthritis classed K&L≥3 (n=193)., Conclusions: The similar frequency of radiographic joint involvement and patterning in erosive osteoarthritis and more severe non-erosive osteoarthritis is consistent with prevalent erosive osteoarthritis being a severe form of hand osteoarthritis rather than a distinct entity. Metabolic exposures, dyslipidaemia in particular, may be implicated in erosive osteoarthritis., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

The generation of nephrons during development depends on differentiation via a mesenchymal to epithelial transition (MET) of self-renewing, tissue-specific stem cells confined to a specific anatomic niche of the nephrogenic cortex. These cells may transform to generate oncogenic stem cells and drive pediatric renal cancer. Once nephron epithelia are formed the view of post-MET tissue renal growth and maintenance by adult tissue-specific epithelial stem cells becomes controversial. Recently, genetic lineage tracing that followed clonal evolution of single kidney cells showed that the need for new cells is constantly driven by fate-restricted unipotent clonal expansions in varying kidney segments arguing against a multipotent adult stem cell model. Lineage-restriction was similarly maintained in kidney organoids grown in culture. Importantly, kidney cells in which Wnt was activated were traced to give significant clonal progeny indicating a clonogenic hierarchy. In vivo nephron epithelia may be endowed with the capacity akin to that of unipotent epithelial stem/progenitor such that under specific stimuli can clonally expand/self renew by local proliferation of mature differentiated cells. Finding ways to ex vivo preserve and expand the observed in vivo kidney-forming capacity inherent to both the fetal and adult kidneys is crucial for taking renal regenerative medicine forward. Some of the strategies used to achieve this are sorting human fetal nephron stem/progenitor cells, growing adult nephrospheres or reprogramming differentiated kidney cells toward expandable renal progenitors., (Copyright © 2014. Published by Elsevier Ltd.)

In recent years, there has been an ever-increasing interest in the research of polyphenols obtained from dietary sources, and their antioxidative properties. The purpose of this study was to determine the effect of boiling buckwheat and barley groats on the antioxidant properties and dietary fiber composition. Antioxidative properties were investigated using methyl linoleate model system, by assessing the DPPH (2,2-diphenyl-1-picrylhydrazyl) radical scavenging activity and metal chelating activity. The results were compared with butylated hydroxytoluene (BHT). Raw barley and buckwheat groats extracts showed higher DPPH scavenging ability compared to boiled barley and buckwheat groats extracts. Raw barley groats extract exhibited higher antioxidant activity than boiled groats extract in the methyl linoleate emulsion. Higher chelating ability in relation to Fe (II) ions was observed for boiled groats extracts as compared to raw groats extracts. BHT showed small antiradical activity and metal chelating activity, while showing higher antioxidative activity in emulsion system. The analysis of groats extracts using HPLC method showed the presence of rutin, catechin, quercetin, gallic, p-hydroxybenzoic, p-coumaric, o-coumaric, vanillic, sinapic, and ferulic acids. Differences in the content of dietary fiber and its fractions were observed in the examined products. The highest total dietary fiber content was detected in boiled buckwheat groats, while the lowest - in boiled barley groats. The scientific achievements of this research could help consumers to choose those cereal products available on the market, such as barley and buckwheat groats, which are a rich source of antioxidative compounds and dietary fiber.

Objective: To investigate the reliability and construct validity of an atlas for grading hand osteoarthritis (OA) on photographs in a separate younger community-dwelling population than the development cohort., Methods: Participants were community-dwelling adults (ages ≥50 years) in North Staffordshire, UK with hand pain or hand problems in the last year who attended a research clinic. High-quality photographs were taken in a standardized position. A photographic atlas was used to score hand joints (second and third distal interphalangeal [DIP], second and third proximal interphalangeal [PIP], and first carpometacarpal [CMC] joints) and joint groups (DIP, PIP, and CMC joints) for OA on a 0-3 scale. Hand radiographs were graded for OA using the Kellgren/Lawrence (K/L) grading system. Clinical features (nodes, bony enlargement, and deformity) were determined by physical examination. Associations of photographic hand OA grades with radiographic OA and clinical features were determined to assess construct validity., Results: In total, 558 participants (mean age 64 years, 62% women) were included in the analyses. Reliability for scoring OA on the photographs was good (mean intrarater intraclass correlation coefficient [ICC] 0.77 and mean interrater ICC 0.71). At the joint level, photographic hand OA grade was positively associated with radiographic OA grade (Spearman's ρ = 0.19-0.57, P < 0.001) and the number of clinical features (Spearman's ρ = 0.36-0.59, P < 0.001). At the person level, individuals with higher global photographic OA scores had higher summed K/L scores and higher percentages meeting the American College of Rheumatology clinical hand OA criteria., Conclusion: This photographic scoring system was reliable and a good indicator of hand OA in a separate younger community-dwelling population than the development cohort. This method of data collection offers researchers a feasible alternative to physical examination and radiography., (© 2014 The Authors. Arthritis Care & Research is published by Wiley Periodicals, Inc. on behalf of the American College of Rheumatology.)

Background: Use of theory in implementation of complex interventions is widely recommended. A complex trial intervention, to enhance self-management support for people with osteoarthritis (OA) in primary care, needed to be implemented in the Managing Osteoarthritis in Consultations (MOSAICS) trial. One component of the trial intervention was delivery by general practitioners (GPs) of an enhanced consultation for patients with OA. The aim of our case study is to describe the systematic selection and use of theory to develop a behaviour change intervention to implement GP delivery of the enhanced consultation., Methods: The development of the behaviour change intervention was guided by four theoretical models/frameworks: i) an implementation of change model to guide overall approach, ii) the Theoretical Domains Framework (TDF) to identify relevant determinants of change, iii) a model for the selection of behaviour change techniques to address identified determinants of behaviour change, and iv) the principles of adult learning. Methods and measures to evaluate impact of the behaviour change intervention were identified., Results: The behaviour change intervention presented the GPs with a well-defined proposal for change; addressed seven of the TDF domains (e.g., knowledge, skills, motivation and goals); incorporated ten behaviour change techniques (e.g., information provision, skills rehearsal, persuasive communication); and was delivered in workshops that valued the expertise and professional values of GPs. The workshops used a mixture of interactive and didactic sessions, were facilitated by opinion leaders, and utilised 'context-bound communication skills training.' Methods and measures selected to evaluate the behaviour change intervention included: appraisal of satisfaction with workshops, GP report of intention to practise and an assessment of video-recorded consultations of GPs with patients with OA., Conclusions: A stepped approach to the development of a behaviour change intervention, with the utilisation of theoretical frameworks to identify determinants of change matched with behaviour change techniques, has enabled a systematic and theory-driven development of an intervention designed to enhance consultations by GPs for patients with OA. The success of the behaviour change intervention in practice will be evaluated in the context of the MOSAICS trial as a whole, and will inform understanding of practice level and patient outcomes in the trial.

Understanding uptake of complex interventions is an increasingly prominent area of research. The interplay of macro (such as changing health policy), meso (re-organisation of professional work) and micro (rationalisation of clinical care) factors upon uptake of complex interventions has rarely been explored. This study focuses on how English General Practitioners and practice nurses make sense of a complex intervention for the management of osteoarthritis, using the macro-meso-micro contextual approach and Normalisation Process Theory (NPT), specifically the construct of coherence. It is embedded in a cluster RCT comprising four control practices and four intervention practices. In order to study sense-making by professionals introduction and planning meetings (N = 14) between researchers and the practices were observed. Three group interviews were carried out with 10 GPs and 5 practice nurses after they had received training in the intervention. Transcripts were thematically analysed before comparison with NPT constructs. We found that: first, most GPs and all nurses distinguished the intervention from current ways of working. Second, from the introduction meeting to the completion of the training the purpose of the intervention increased in clarity. Third, GPs varied in their understanding of their remit, while the practice nurses felt that the intervention builds on their holistic care approach. Fourth, the intervention was valued by practice nurses as it strengthened their expert status. GPs saw its value as work substitution, but felt that a positive conceptualisation of OA enhanced the consultation. When introducing new interventions in healthcare settings the interaction between macro, meso and micro factors, as well as the means of engaging new clinical practices and their sense-making by clinicians needs to be considered., (Copyright © 2014 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Cartilage reconstruction is a crucial issue for tissue engineering because of high damage frequency in connection with low regenerative capacity. Microfractures and shaving are the oldest and most commonly used practices. The newest techniques are: Autologous Chondrocyte Implantation, Matrix Associated Chondrocytes Implantation and their derivatives. Dedifferentiation of chondrocytes due to low proliferation rate and phenotype loss makes isolation and in vitro culture of normal human chondrocytes very complex. Therefore, obtaining mesenchymal stem cells from various sources and differentiating them into chondrocytes is another interesting approach.

The case of a 14-year-old mongrel dog with a thyroid tumor treated by thyreoidectomy is described. The resected tumor was subjected to a detailed morphological and immunohistochemical analysis utilizing antibodies directed against thyroglobulin, calcitonin, chromogranin A, cytokeratin 19, thyroid transcription factor-1, CD31, Ki-67 and minichromosome maintenance protein 3. Expression level of the above mentioned antigens allowed to characterize the resected tumor as thyroid follicular-compact carcinoma. Common application of immunohistochemistry may increase the diagnosis precision and efficacy of thyroid tumor treatment in dogs.

The literature on patient and public involvement (PPI) in research covers a wide range of topics. However, one area of investigation that appears under developed is the sustainability and impact of PPI beyond involvement in time-limited research projects. This paper presents a case study of PPI development in one primary care research centre in England, and its approach to making this sustainable using documentary sources and material from a formal evaluation. We provide narrative accounts of the set-up, operation and main processes of PPI, and its perceived impact. PPI requires a long-term perspective with participation and trust growing over time, and both users and researchers learning what approaches work best. PPI is a complex interplay of clarity of purpose, defined roles and relationships, organised support (paid PPI staff) and a well-funded infrastructure. 'Soft systems' are equally important such as flexible and informal approaches to meetings, adapting timetables and environments to meet the needs of lay members and to create spaces for relationships to develop between researchers and lay members that are based on mutual trust and respect. This case study highlights that the right combination of ethos, flexible working practices, leadership, and secure funding goes a long way to embedding PPI beyond ad hoc involvement. This allows PPI in research to be integrated in the infrastructure and sustainable.

Objective: To define the core content for an opportunistic consultation between a health care professional (HCP) and a patient with osteoarthritis (OA) in primary care., Methods: An ideas generation round and a 2-round Delphi postal consensus study allowed participants to rank the importance of tasks for an opportunistic consultation. The study was conducted with a lay group (n = 18) and 3 groups of HCPs (n = 30 for general practitioners, n = 19 for practice nurses, and n = 37 for allied health professionals)., Results: The ideas generation round formulated 35 consultation tasks. There was a 50% response rate to the 2-round postal exercise (n = 52). Consensus was reached on 12 tasks for an opportunistic OA consultation using a >80% level of agreement across all groups. Three of these consultation tasks were defined at 100%. The 3 tasks were questions asked by the HCP about how things are going with the condition, the type and amount of pain the patient has, and whether the patient is taking regular analgesia., Conclusion: In a Delphi study to define the content of an opportunistic primary care OA consultation, 12 consultation tasks provided the content of a comprehensive consultation. Three of these tasks with 100% agreement could be adopted in any multidisciplinary consultation for OA in primary care. Inquiring about the condition, the type and amount of pain the patient has, and whether analgesia is being taken forms a core set of questions that are considered important by both lay and health professional groups in an opportunistic consultation., (Copyright © 2013 by the American College of Rheumatology.)

Background: Osteoarthritis (OA) is a common condition managed in general practice, but often not in line with published guidance. The ideal consultation for a patient presenting with possible OA is not known. The aim of the study was to develop the content of a model OA consultation for the assessment and treatment of older adults presenting in general practice with peripheral joint problems., Methods: A postal Delphi consensus exercise was undertaken with two expert groups: i) general practitioners (GPs) with expertise in OA management and ii) patients with experience of living with OA. An advisory group generated 61 possible consultation tasks for consideration in the consensus exercise. Expert groups were asked to consider which tasks should be included in the model OA consultation. The exercise was completed by 15 GPs and 14 patients. The level of agreement for inclusion in the model was set at 90%., Results: The model OA consultation included 25 tasks to be undertaken during the initial consultation between a GP and a patient presenting with peripheral joint pain. The 25 tasks provide detailed advice on how the following elements of the consultation should be addressed: i) assessment of chronic joint pain, ii) patient's ideas and concerns, iii) exclusion of red flags, iv) examination, v) provision of the diagnosis and written information, vi) promotion of exercise and weight loss, vii) initial pain management and viii) arranging a follow-up appointment. Both groups prioritised a bio-medical approach to the consultation, rather than a bio-psycho-social one, suggesting a discordance between current thinking and research evidence., Conclusions: This study has enabled the priorities of GPs and patients to be identified for a model OA consultation. The results of this consensus study will inform the development of best practice for the management of OA in primary care and the implementation of evidence-based guidelines for OA in primary care.

Human UDP-glucuronosyltransferases (UGTs) are important enzymes in metabolic elimination of endo- and xenobiotics. It was recently shown that addition of fatty acid free bovine serum albumin (BSA) significantly enhances in vitro activities of UGTs, a limiting factor in in vitro-in vivo extrapolation. Nevertheless, since only few human UGT enzymes were tested for this phenomenon, we have now performed detailed enzyme kinetic analysis on the BSA effects in six previously untested UGTs, using 2-4 suitable substrates for each enzyme. We also examined some of the previously tested UGTs, but using additional substrates and a lower BSA concentration, only 0.1%. The latter concentration allows the use of important but more lipophilic substrates, such as estradiol and 17-epiestradiol. In five newly tested UGTs, 1A7, 1A8, 1A10, 2A1, and 2B15, the addition of BSA enhanced, to a different degree, the in vitro activity by either decreasing reaction's K(m), increasing its V(max), or both. In contrast, the activities of UGT2B17, another previously untested enzyme, were almost unaffected. The results of the assays with the previously tested UGTs, 1A1, 1A6, 2B4, and 2B7, were similar to the published BSA only as far as the BSA effects on the reactions' K(m) are concerned. In the cases of V(max) values, however, our results differ significantly from the previously published ones, at least with some of the substrates. Hence, the magnitude of the BSA effects appears to be substrate dependent, especially with respect to V(max) increases. Additionally, the BSA effects may be UGT subfamily dependent since K(m) decreases were observed in members of subfamilies 1A, 2A and 2B, whereas large V(max) increases were only found in several UGT1A members. The results shed new light on the complexity of the BSA effects on the activity and enzyme kinetics of the human UGTs.

This randomized, open-label, ambulatory, controlled clinical study investigated biomarkers associated with cardiovascular risk and biomarkers of exposure to 10 selected harmful and potentially harmful constituents (HPHC) in cigarette smoke in 316 male and female Polish smokers. Subjects were randomized to continue smoking conventional cigarettes (CC; N=79) or switch to smoking the Electrically Heated Cigarette Smoking System series-K cigarette (EHCSS-K6; N=237). Biomarker assessments were performed at several time points during the study at baseline and during the 1-month investigational period. The primary biomarkers were high-sensitivity C-reactive protein and white blood cell counts. No statistically significant differences in the two primary biomarkers were found between the study groups at the end of the study. End-of-study comparisons of secondary biomarkers between study groups indicated an increase in high-density lipoprotein cholesterol, and reductions in red blood cell count, hemoglobin, and hematocrit levels in the EHCSS-K6 group. All biomarkers of exposure to cigarette smoke HPHC were decreased in the EHCSS-K6 group, despite an increase in cigarette consumption, compared to the CC group. There were no apparent differences in any of the safety assessment parameters between the groups, and the overall incidence of study-related adverse events was low., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Background: In the course of production of buckwheat groats by-products are produced, such as bran and hull, which apart from high content of dietary fiber, may also constitute valuable sources of antioxidants. The aim of these investigations was to determine the antioxidant activity of extracts from by-products produced during processing of buckwheat for groats., Material and Method: Analyses were conducted on bran and hull of buckwheat cv. Kora. Extraction was run using acetone, methanol and water at room temperature for 24 h. The level of phenolics was determined spectrophotometrically with the Folin-Ciocalteau reagent, using (+) catechin as a standard. Antioxidant activity of extracts was analysed in relation to linoleic acid, running incubation for 19 h, by scavenging of stable radicals of DPPH (2,2-diphenyl-1-picrylhydrazyl) and on the basis of metal chelating ability. Recorded results were compared with the activity of BHT (butylated hydroxytoluene)., Results: The highest content of polyphenols was found in the methanol extract of hull (168.5 mg/g d.m.), which was also characterised by the best antiradical properties. The lowest content of total phenols was found for water extracts of bran after grinding and final bran, at 20.3 mg/g d.m. and 10.2 mg/g d.m. In the emulsion system the highest activity was found for methanol extracts of hull and bran after grinding (Wo = 0.89), as well as the extract of final bran (Wo = 0.85). A higher chelating ability in relation to Fe (II) ions was observed for bran extracts (after grinding - 76.1%, final bran - 62.2%) than for hull extracts (26%)., Conclusions: Extracts obtained from by-products of buckwheat were characterised by high antioxidant activity in the applied model systems.

We evaluated whether patients with self-reported whiplash differed in perceived pain, functional limitation and prognosis from patients with other painful neck complaints. Data from three Dutch trials and an English trial were used all evaluating conservative treatment in neck pain patients in primary care. All patients had non-specific neck pain. Information on any trauma or injury came from self-report at baseline. We compared frequencies of baseline variables and outcome at short-term and long term for whiplash and non-trauma neck pain patients separately. The total study population consisted of 804 neck pain patients. Of these patients 133 reported (16.5%) that an injury was the cause of their neck pain. In all trials there were 17-18% more male patients in the whiplash group. At follow-up pain decreased between 12 and 28%, function 10%, and 25-50% of patients recovered in all trials. Post-treatment improvements in pain, function and recovery were comparable between whiplash and non-trauma patients. We also found no different prognostic factors between whiplash and non-trauma patients. Overall we found in a population with mild to moderate pain no clinically relevant differences between patients with self-reported whiplash and patients with other painful neck complaints. The findings suggest that whiplash patients with mild to moderate pain should not be considered a specific subgroup of patients with non-specific neck pain., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

Objectives: The aim of this study was to investigate: (i) the frequency and patterns of radiographic OA (ROA) in the thumb joints; and (ii) associations between thumb ROA and the clinical characteristics of thumb OA in older adults with hand pain or problems., Methods: Participants were 592 community-dwelling older adults with hand pain or hand problems who attended a research clinic. Hand X-rays were taken and 32 joints were scored for the presence of ROA. The occurrence and pattern of ROA in the hand were examined. Univariable and multivariable associations of thumb pain and clinical assessments (nodes, deformity, enlargement, thenar muscle wasting, grind test, Kapandji index, Finkelstein's test and thumb extension) with ROA were investigated., Results: The first CMC and thumb IP joints were the hand joints most frequently affected with ROA. The thumb (thumb IP, first MCP, first CMC, trapezioscaphoid) was the most commonly affected joint group (n = 412). Isolated thumb ROA occurred more frequently than in any other isolated joint group. Multivariable analyses showed that older age, thumb pain, thenar muscle wasting and presence of nodes, deformity or enlargement best determined the presence of thumb ROA., Conclusion: The first CMC and thumb IP joints were frequently affected with ROA. Prevalence estimates of ROA would be underestimated if these were not scored. One-third of the individuals with thumb ROA did not have involvement of the first CMC joint. The presence of thumb ROA was strongly associated with a combination of older age, thumb pain and clinical features of OA.

Objective: To examine cerebrovascular reactivity in patients after subarachnoid haemorrhage (SAH) during long-term follow-up, using Acetazolamide test and transcranial Doppler (TCD) monitoring of blood flow velocities (BFVs), to compare of CO(2) reactivity between patients after SAH treated with three different methods: surgical (clipping), endovasculary (coiling) and conservative., Methods: The study was performed in a group of 24 patients treated for SAH. Cerebrovascular reactivity (CVR) has been evaluated after intravenous administration of 1000 mg of Acetazolamide. Studied patients were divided into three groups: group I (n = 10) treated with clipping, group II (n = 8) treated with coiling and group III (n = 6)--patients with negative angiography treated conservatively., Results: Results of this study have shown that: (1) BFVs were normal in cerebral arteries and did not differ between right and left head sides, (2) CVR was normal in all studied patients, (3) method of aneurysm treatment as well as its localization had no influence on BFV and CVR, and (4) occurrence of vasospasm in early days after SAH did not result in permanent disturbances of CO(2) arterial reactivity., Conclusion: BFV values in cerebral arteries were in normal range and did not differ on the left and right head sides. CVR was normal in all examinated patients. A method of the ruptured aneurysm treatment and its localization had no influence on CBFV and CRV. Vasospasm in early period after SAH did not provoke a persistent impairment of CO(2) reactivity.

In psychological health treatment studies it has been shown that differences between therapists account for some of the non-specific effect of treatment but this phenomenon has not so far systematically been investigated in musculoskeletal disorders. In this study we evaluated and compared the size and potential influence of the 'practitioner effect' (or 'therapist effect') in three randomised treatment trials of low back pain and neck pain patients in primary care. We calculated the proportion of variance in outcomes attributable to differences across practitioners, i.e. the practitioner-variance partition coefficient (p-vpc). As measures of outcome, we focused on self-reported disability as the primary outcome, but we also investigated assessed psychological outcomes. The p-vpc for the disability measures ranged from 2.6% to 7.1% across trials and time points (post treatment and follow up). Estimates differed between treatment subgroups within trials; being highest in treatment subgroups assigned to psychosocial-based interventions. A 'practitioner effect' does exist and is more pronounced in treatments involving greater psychosocial emphasis. This has implications for both practice and research in this clinical area. It highlights the importance of patient-practitioner interactions, and the need to address practitioner effects in designing and analysing outcome studies in low back pain and neck pain in primary care., (Copyright © 2010 European Federation of International Association for the Study of Pain Chapters. Published by Elsevier Ltd. All rights reserved.)

Background: To identify clinical questions and assessments regarded by health care practitioners as important when assessing undifferentiated hand pain or problems in adults aged 50 years and over presenting to primary care., Methods: A purposively selected panel of 26 UK-based Health Care Practitioners comprising occupational therapists, physiotherapists, rheumatologists and general practitioners, were invited to take part in a consensus study involving three postal rounds of a Delphi questionnaire with accompanying case scenarios. Participants were asked to generate questions and assessments (round 1), rate their importance (round 2), and vote on which items were most important (round 3)., Results: Sixteen Health Care Practitioners agreed to participate with 11 completing all three rounds. The first round of the Delphi study generated 156 questions and 143 assessments. After three rounds agreement was reached on the importance of 25 questions and 19 assessments. Questions were weighted towards current symptoms, but also included the history of previous hand problems, self-reported hand function, co-morbidity and general health. Observation and palpation of features predominated in the choice of assessment, but specific tests, grip strength, evaluation of sensation and hand function were also included., Conclusions: A pool of clinical questions and assessments were generated by Health Care Practitioners, and those considered most important for assessing older adults presenting with undifferentiated hand pain and hand problems in primary care were identified. Further evaluation is required to establish the reliability and feasibility of using these questions and assessments in primary care. In particular, the relative contribution of these questions and assessments in evaluating the nature and severity of hand problems, assisting diagnosis, indicating appropriate management, and predicting future course requires further investigation.

Objective: Patterns of radiographic osteoarthritis (ROA) of the hand are often examined by row, with the four joints of the thumb studied inconsistently. The objectives of this study were to determine relationships of ROA at different hand joints, use the findings to define radiographic sub-groups and investigate their associations with pain and function., Methods: Sixteen joints in each hand were scored for the presence of ROA in a community-dwelling cohort of adults, 50-years-and-over, with self-reported hand pain or problems. Principal components analysis (PCA) with varimax rotation was used to study patterns of ROA in the hand joints and identify distinct sub-groups. Differences in pain and function between these sub-groups were assessed using Australian/Canadian Osteoarthritis Index (AUSCAN), Grip Ability Test (GAT) and grip and pinch strength., Results: PCA was undertaken on data from 592 participants and identified four components: distal interphalangeal joints (DIPs), proximal interphalangeal joints (PIPs), metacarpophalangeal joints (MCPs), thumb joints. However, the left thumb interphalangeal (IP) joint cross-loaded with the PIP and thumb groups. On this basis, participants were categorised into four radiographic sub-groups: no osteoarthritis (OA), finger only OA, thumb only OA and combined thumb and finger OA. Statistically significant differences were found between the sub-groups for AUSCAN function, and in women alone for grip and pinch strength. Participants with combined thumb and finger OA had the worst scores., Conclusion: Individual thumb joints can be clustered together as a joint group in ROA. Four radiographic sub-groups of hand OA can be distinguished. Pain and functional difficulties were highest in participants with both thumb and finger OA.

The generation of a functioning Drosophila eye requires the coordinated differentiation of multiple cell types and the morphogenesis of eye-specific structures. Here we show that D-Pax2 plays a significant role in lens development through regulation of the Crystallin gene and because Crystallin is also expressed in D-Pax2(+) cells in the external sensory organs. Loss of D-Pax2 function leads to loss of Crystallin expression in both eyes and bristles. A 2.3 kilobase (kb) upstream region of the Crystallin gene can drive GFP expression in the eye and is dependent on D-Pax2. In addition, D-Pax2 binds to an evolutionarily conserved site in this region that, by itself, is sufficient to drive GFP expression in the eye. However, mutation of this site does not greatly affect the regulatory region's function. The data indicate that D-Pax2 acts to promote lens development by controlling the production of the major protein component of the lens. Whether this control is direct or indirect remains unresolved.

Objective: To develop a package of physiotherapy treatment for a randomized controlled trial in primary care for shoulder pain and audit its use within the trial., Methods: A survey of current physiotherapy approaches to the management of shoulder pain was conducted. The most frequently reported treatments were proposed as a package of care for a physiotherapy intervention in a trial of shoulder pain. The package was refined by a subgroup of 13 physiotherapists. For patients receiving the physiotherapy intervention in the main trial (n = 98), the frequency of use of modalities over the treatment period was calculated by percentages of modality usage per number of patient contacts. Treatment details were recorded by the physiotherapist at each patient visit., Results: The physiotherapy intervention included passive movements/mobilizations, active movement/mobilizations, a home exercise programme, education and advice, and ultrasound. The most frequently used modality at the assessment visit was the standardized education and advice leaflet for shoulder pain (85%) followed by the home exercise programme (79%), which was reinforced throughout the trial treatment course. The most frequently used modalities over the treatment period were ultrasound (42%), active mobilizations (41%) and passive mobilizations (41%). The mean number of trial treatment visits was 6.2 (SD: 2.1; range 1-8). Additional trial treatments (1-8) were delivered to 12 patients. Eighty-five patients were given only one therapeutic diagnosis, and 13 were given two. The most common diagnoses were tendonitis (32%) and capsulitis (25%). Pain was the major problem in 78% of patients, 15% had stiffness and 7% of patients reported both pain and stiffness., Conclusions: Physiotherapists complied well with the trial protocol. Few treatments were used in isolation. This report demonstrates how physiotherapists can agree and deliver a standardized package of treatment, which reflects current practice, as part of a randomized controlled trial., (2009 John Wiley & Sons, Ltd.)

Objective: To determine the impact of the onset of hand problems on global physical functioning in community-dwelling older adults., Methods: Three-year follow-up postal survey of a population sample of older adults (50 yrs and over) previously recruited to the North Staffordshire Osteoarthritis Project. Questionnaires at baseline and 3-yr collected data on joint pain in the past 12 months in the hands and lower limbs, and physical functioning [SF-36 subscale (PF-10)]. Onset of hand problems at 3 yrs was determined in two subgroups: (i) those free from hand problems and lower limb pain at baseline (n = 762) and (ii) those free from hand problems but with lower limb pain at baseline (n = 754). Changes in PF-10 scores from baseline to 3 yrs were examined in these two subgroups., Results: Onset of hand problems was similar in the two subgroups (20.6 and 24.3% in those without and with baseline lower limb pain, respectively). Females had a higher onset than males but age had little influence. Significantly greater mean change in PF-10 scores was seen in those who reported hand problem onset compared with persons who remained free of hand problems; 8.47 vs 4.62 and 4.78 vs 1.08 in those without and with baseline lower limb pain, respectively., Conclusions: The development of hand problems has a detrimental effect on global physical functioning even in the absence of concurrent lower limb problems. The assessment and effective treatment of hand problems could prove to be important components of maintaining function in the older adult with joint pain and OA.

Objective: In a cohort of primary care patients with chronic neck pain, to determine whether specific neck stabilization exercises, in addition to general neck advice and exercise, provide better clinical outcome at 6 weeks than general neck advice and exercise alone., Methods: This was a multicenter randomized controlled trial in 4 physical therapy departments. Seventy-four participants (mean age 51.3 yrs) were randomized to specific neck stabilization exercises with a general neck advice and exercise program (n = 37) or a general neck advice and exercise program alone (n = 37). They attended a 1-hour clinical examination, followed by a maximum of 4 treatment sessions. Assessments were undertaken at baseline, 6 weeks, and 6 months. The primary outcome was the Neck Pain and Disability Scale (NPDS). Analysis was by intention to treat., Results: Seventy-one (96%) participants received their allocated intervention. There was 91% followup at 6 weeks and 92% followup at 6 months. The mean (SD) 6-week improvement (reduction) in NPDS score was 10.6 (20.2) for the specific exercise program and 9.3 (15.7) for the general exercise program. There were no significant between-group differences in the NPDS at either 6 weeks or 6 months. For secondary outcomes, participants in the specific exercise group were less likely to be taking pain medication at 6-week followup (p = 0.02). There were no other significant between-group differences., Conclusion: Adding specific neck stabilization exercises to a general neck advice and exercise program did not provide better clinical outcome overall in the physical therapy treatment of chronic neck pain.

Objectives: To develop evidence-based recommendations for the diagnosis of hand osteoarthritis (OA)., Methods: The multidisciplinary guideline development group, representing 15 European countries, generated 10 key propositions regarding diagnosis using a Delphi consensus approach. For each recommendation, research evidence was searched for systematically. Whenever possible, the sensitivity, specificity and likelihood ratio (LR) were calculated; relative risk and odds ratios were estimated for risk factors for hand OA. Quality of evidence was categorised using the European League Against Rheumatism (EULAR) hierarchy, and strength of recommendation was assessed by the EULAR visual analogue scale., Results: Diagnostic topics included clinical manifestations, radiographic features, subgroups, differential diagnosis, laboratory tests, risk factors and comorbidities. The sensitivity, specificity and LR varied between tests depending upon the cut-off level, gold standard and controls. Overall, no single test could be used to define hand OA on its own (LR <10) but a composite of the tests greatly increased the chance of the diagnosis. The probability of a subject having hand OA was 20% when Heberden nodes alone were present, but this increased to 88% when in addition the subject was over 40 years old, had a family history of nodes and had joint space narrowing in any finger joint., Conclusion: Ten key recommendations for diagnosis of hand OA were developed using research evidence and expert consensus. Diagnosis of hand OA should be based on assessment of a composite of features.

Objective: The hypothalamic-pituitary-adrenal axis is an important part of the body's natural response to acute illness. Adrenal insufficiency has the potential to lead to hemodynamic instability and electrolyte imbalances, limit the body's ability to respond to stress, and worsen overall clinical outcome. In this case series, we describe 16 patients evaluated for acute adrenal insufficiency after aneurysmal subarachnoid hemorrhage., Clinical Presentation: Over a 2-year period, the medical records of 16 patients admitted to the adult neurosurgery service for aneurysmal subarachnoid hemorrhage who were nonresponsive to vasopressor therapy and received cosyntropin for the evaluation of adrenal insufficiency within 14 days of their event were reviewed., Intervention: The median baseline cortisol in this population was 22.5 microg/dL, with a poststimulation cortisol level of 31 microg/dL. Of the population surveyed, a total of 11 patients met the preestablished criteria for adrenal insufficiency, 3 with baseline cortisol levels of less than 15 microg/dL and 11 with poststimulation concentration changes of less than 9 microg/dL. Baseline serum cortisol concentrations were significantly correlated with hospital stay (P = 0.045), intensive care unit stay (P = 0.005), and ventilator days (P = 0.006)., Conclusion: To date, this is the only investigation evaluating the incidence of acute relative adrenal insufficiency in this population. In our cohort, 69% of the patients met the preestablished criteria for relative adrenal insufficiency. The impact of low-dose corticosteroid therapy in this population also needs review, as it could have significant implications for the management of cerebral vasospasm.

This chapter summarizes current evidence from recently published systematic reviews of land- and water-based exercise therapies for musculoskeletal conditions. The aim is to present an overview of the evidence and highlight gaps where more research is still needed. This is not a systematic review, but a systematic search of the literature and a summary of results of the best, most recent systematic reviews evaluating interventions for musculoskeletal conditions. There have been two previous summaries of systematic reviews of evidence for exercise therapies in musculoskeletal conditions. We have updated these searches, and additionally considered the evidence for the clinical effectiveness of exercise in fibromyalgia and chronic widespread pain and of hydrotherapy and water-based exercise treatments on pain and disability.

Reactions of Ti(OiPr)4 or Zr(OEt)4 with 4 equivalents of 2,3-dihydro-2,2-dimethyl-7-benzofuranol (ddbfoH) in toluene gave neutral complexes that in the solid state are dimers of [Ti(micro-ddbfo)2(ddbfo)6] and [Zr(ddbfo)3(EtOH)(micro-EtO)]2 composition. The former could also be conveniently synthesized in a direct reaction of TiCl4 with ddbfoH. This air-stable aryloxo compound was found to initiate living ring-opening polymerization of lactides affording polyesters with narrow molecular weight distribution. It also catalyzed addition of terminal acetylenes to aryl aldehydes.

Surgery timing after aneurysmal subarachnoid hemorrhage (SAH) may influence the risk of vasospasm after early surgical procedure and is correlated with SAH extensiveness. A group consisting of 127 patients with aneurysmal SAH was studied. The changes of mean flow velocity (MFV) were measured in middle cerebral artery (MCA) and in anterior cerebral artery (ACA) by transcranial Doppler sonography (TCD) in three groups of patients divided according to the surgery timing (on the first, second and third day after SAH). Changes of MFV values in MCA and in ACA were similar in all groups. MFV values in the group of patients operated on the third day were the lowest and the pathologic values lasted for the shortest time. In patients with massive SAH (Fisher IV group) and mild SAH (Fisher II group), the lowest MFV values were observed, if patients were operated within 24 hours after SAH. In patients without SAH (Fisher I group), the MFV values were the lowest, if they were operated on the third day after SAH. In patients with severe SAH (Fisher III group), the lowest risk of vasospasm was observed, if they were operated on the second day after SAH; however, the highest risk was found in patients operated on the first day after SAH. Our study suggests: (1) in patients with severe SAH operated on the second day, the lowest risk of vasospasm was observed, and the highest risk of vasospasm was observed if those were operated on the first day; (2) the highest risk of vasospasm was observed in patients operated within 24 hours with mild and massive SAH and in patients without SAH operated on the third day after SAH.

Objective: Currently there is no agreed "gold standard" definition of radiographic hand osteoarthritis (RHOA) for use in epidemiological studies. We therefore undertook a systematic search and narrative review of community-based epidemiological studies of hand osteoarthritis (OA) to identify (1) grading systems used, (2) definitions of radiographic OA for individual joints and (3) definitions of overall RHOA., Methods: The following electronic databases were searched: Medline, Embase, Science Citation Index and Ageline (inception to Dec 2006). The search strategy combined terms for "hand" and specific joint sites, OA and radiography. Inclusion and exclusion criteria were applied. Data were extracted from each paper covering: hand joints studied, grading system used, definitions applied for OA at individual joints and overall RHOA., Results: Titles and abstracts of 829 publications were reviewed and the full texts of 399 papers were obtained. One hundred fifty-two met the inclusion criteria and 24 additional papers identified from screening references. Kellgren and Lawrence (K&L) was the most frequently applied grading system used in 80% (n=141) of studies. In 71 studies defining OA at the individual joint level 69 (97%) used a definition of K&L grade > or = 2. Only 53 publications defined overall RHOA, using 21 different definitions based on five grading systems., Conclusion: The K&L scheme remains the most frequently used grading system. There is a consistency in defining OA in a single hand joint as K&L grade > or = 2. However, there are substantial variations in the definitions of overall RHOA in epidemiological studies.

Rationale: The effective integration of research evidence into everyday clinical practice continues to be an important challenge., Aims: The group aimed to answer locally relevant clinical question and produce recommendations for practice based on the best available evidence., Methods: Through a new initiative, a multidisciplinary group with a specific interest in musculoskeletal disease has been established in order to help address this problem. The group consists of clinical and academic professionals including physiotherapists, occupational therapists, nurses, clinical researchers and information technology librarians representing the health economy., Results: Results from the group's activities are shared locally through presentations and clinical algorithms and nationally through conference presentations and the National Electronic Library for Health., Conclusion: As well as clinical recommendations, other benefits of the group have been improved networking, enhanced continual professional development and identifying areas in need of further research.

Background: Pain in the hand affects an estimated 12-21% of the population, and at older ages the hand is one of the most common sites of pain and osteoarthritis. The association between symptomatic hand osteoarthritis and disability in everyday life has not been studied in detail, although there is evidence that older people with hand problems suffer significant pain and disability. Despite the high prevalence of hand problems and the limitations they cause in older adults, little attention has been paid to the hand by health planners and policy makers. We plan to conduct a prospective, population-based, observational cohort study designed in parallel with our previously reported cohort study of knee pain, to describe the course of musculoskeletal hand problems in older adults and investigate the relative merits of different approaches to classification and defining prognosis., Methods/design: All adults aged 50 years and over registered with two general practices in North Staffordshire will be invited to take part in a two-stage postal survey. Respondents to the survey who indicate that they have experienced hand pain or problems within the previous 12 months will be invited to attend a research clinic for a detailed assessment. This will consist of clinical interview, hand assessment, screening test of lower limb function, digital photography, plain x-rays, anthropometric measurement and brief self-complete questionnaire. All consenting clinic attenders will be followed up by (i) general practice medical record review, (ii) repeat postal questionnaire at 18-months, and (iii) repeat postal questionnaire at 3 years., Discussion: This paper describes the protocol for the Clinical Assessment Study of the Hand (CAS-HA), a prospective, population-based, observational cohort study of community-dwelling older adults with hand pain and hand problems based in North Staffordshire.

Objectives: Hand problems are common in older people, but their impact on everyday life is not clear. The aim of this study was to investigate the impact of hand problems in community-dwelling older adults and how this varies with age and gender., Methods: Analysis was performed in 7878 subjects who responded to a baseline questionnaire. Participants defined as having hand problems were sent a second questionnaire, which included questions about hand pain and disability. Severe disability was defined as a score of 4 or more points on a validated hand and finger function scale. Estimates of 1-month period prevalence of hand pain and severe disability were calculated for the total responder population, by age and gender., Results: 2113 persons with hand problems completed Stage 2 (78.6% response). One-year period prevalence of hand problems was 47% and estimated 1-month period prevalence of hand pain was 30.8%. These figures varied little with age. Severe hand-related disability affected 12.3% (95% confidence interval 11.3-13.3%) of this sample, was significantly more common in females than males, and increased in prevalence to the oldest age-groups., Conclusions: Musculoskeletal hand problems are common in the population aged over 50 yrs. Most are painful, and have a significant impact on everyday life. Women and the very old appear especially vulnerable to the effect of hand problems on their daily activities.

Objective: Illness perceptions may influence health outcomes, including pain. The objective of the study was to investigate the illness perceptions associated with health and behaviour in a population of older adults with musculoskeletal hand problems., Methods: A two-stage cross-sectional postal survey was sent to individuals aged 50 yrs and over, registered with three general practices in North Staffordshire. Stage 1, a Health Survey questionnaire, was sent to 11,230 individuals and enquired about general health status, including anxiety and depression. Individuals reporting hand problems at Stage 1 were sent Stage 2, a detailed hand questionnaire. The hand questionnaire included: the Arthritis Impact Measurement Scales 2 (AIMS2) (hand and finger function, pain and medication scales), and questions on self-reported diagnoses and general practitioner (GP) consultation. Perceptions were measured by the Illness Perceptions Questionnaire-Revised (IPQ-R), and an item on perceived frustration with their hand problems. Of the 7878 responders to the Health Survey questionnaire 3749 (47.6%) reported 'hand problems' and 2695 (71.9%) gave permission to be re-contacted. The hand questionnaire was completed by 2113 (adjusted response rate 78.6%)., Results: A belief that their hand problem had a profound impact on life, caused a range of symptoms and made them frustrated were the perceptions most strongly and consistently associated with health and behaviour. There was little difference between individuals who did and those who did not report their hand problem to be osteoarthritis with respect to perceptions or between perceptions associated with health and behaviour., Conclusions: The results suggest that older people who consider their musculoskeletal hand problem to have negative effects on their life will be more likely to encounter difficulties that may lead them to consult, take medication or both. Understanding the illness perceptions of these individuals may identify opportunities for intervention.

Objective: To compare the effectiveness of manual therapy and ultrasound (US) with manual therapy and placebo ultrasound (placebo US) in the treatment of new episodes of unilateral shoulder pain referred for physiotherapy., Methods: In a multicentre, double blind, placebo-controlled randomized trial, participants were recruited with a clinical diagnosis of unilateral shoulder pain from nine primary care physiotherapy departments in Birmingham, UK. Recruitment took place from January 1999 to September 2001. Participants were 18 yrs old and above. Participants all received advice and home exercises and were randomized to additionally receive manual therapy plus US or manual therapy plus placebo US. The primary outcome measure was the Shoulder Disability Questionnaire (SDQ-UK). Outcomes were assessed at baseline, 2 weeks, 6 weeks and 6 months. Analysis was by intention to treat., Results: A total of 221 participants (mean age 56 yrs) were recruited. 113 participants were randomized to US and 108 to placebo US. There was 76% follow up at 6 weeks and 71% at 6 months. The mean (95% CI) reduction in SDQ scores at 6 weeks was 17 points (13-26) for US and 13 points (9-17) for placebo US (P = 0.06). There were no statistically significant differences at the 5% level in mean changes between groups at any of the time points., Conclusions: The addition of US was not superior to placebo US when used as part of a package of physiotherapy in the short-term management of shoulder pain. This has important implications for physiotherapy practice.

The emphasis of UK Government policy on primary-care-based services has led to more physiotherapists working in the community. The aims of the present study were to identify the perceived professional, educational and personal needs of community physiotherapists, and to determine good practice in meeting these needs. A survey of physiotherapists working in 15 National Health Service community trusts in the West Midlands was carried out in September 2000. The survey questionnaire was developed through focus groups and mailed to a random sample of 200 community physiotherapists. The response rate was 67%, and the median age group of the respondents was 21-30 years. The participants worked mainly in 'urban but not inner city' areas, most commonly in domiciliary (31%, n = 38) and general practitioner surgery/health centre (26%, n = 32) locations. Fifty-one per cent (n = 66) of respondents had no specific learning objectives for continuing professional development (CPD); those with such objectives were more positive as to their helpfulness than those without them (Mann-Whitney U-test z = 2.519, P = 0.012). Fifty-three per cent (n = 68) also often/very often found it problematic getting cover for their caseloads so that they could take part in CPD activities. Access to library resources and use of computers were problems, as were confidence in appraising literature and opportunities to discuss research evidence with colleagues. Fifty-nine per cent (n = 77) of respondents indicated that they often/very often felt stressed by the size of their caseloads. Colleague support included mentorship, peer review, journal clubs, clinical interest groups and multidisciplinary in-service training; respondents with experience of these resources expressed more positive attitudes to them than those without (Mann-Whitney U-test z = 2.871, P < 0.0005 for each). Forty-two per cent (n = 54) indicated that there were problems with safety issues. This study has identified needs that will have an impact on the ability of community physiotherapists to meet the demands of clinical governance. National Health Service management at all levels has a responsibility to facilitate the education, training and support of community physiotherapists.

Objectives: To develop evidence based recommendations for the management of hand osteoarthritis (OA)., Methods: The multidisciplinary guideline development group comprised 16 rheumatologists, one physiatrist, one orthopaedic surgeon, two allied health professionals, and one evidence based medicine expert, representing 15 different European countries. Each participant contributed up to 10 propositions describing key clinical points for management of hand OA. Final recommendations were agreed using a Delphi consensus approach. A systematic search of Medline, Embase, CINAHL, Science Citation Index, AMED, Cochrane Library, HTA, and NICE reports was used to identify the best available research evidence to support each proposition. Where possible, the effect size and number needed to treat were calculated for efficacy. Relative risk or odds ratio was estimated for safety, and incremental cost effectiveness ratio was used for cost effectiveness. The strength of recommendation was provided according to research evidence, clinical expertise, and perceived patient preference., Results: Eleven key propositions involving 17 treatment modalities were generated through three Delphi rounds. Treatment topics included general considerations (for example, clinical features, risk factors, comorbidities), non-pharmacological (for example, education plus exercise, local heat, and splint), pharmacological (for example, paracetamol, NSAIDs, NSAIDs plus gastroprotective agents, COX-2 inhibitors, systemic slow acting disease modifying drugs, intra-articular corticosteroids), and surgery. Of 17 treatment modalities, only six were supported by research evidence (education plus exercise, NSAIDs, COX-2 inhibitors, topical NSAIDs, topical capsaicin, and chondroitin sulphate). Others were supported either by evidence extrapolated from studies of OA affecting other joint sites or by expert opinion. Strength of recommendation varied according to level of evidence, benefits and harms/costs of the treatment, and clinical expertise., Conclusion: Eleven key recommendations for treatment of hand OA were developed using a combination of research based evidence and expert consensus. The evidence was evaluated and the strength of recommendation was provided.

Background: Selective non-participation at baseline (due to non-response and non-consent) and loss to follow-up are important concerns for longitudinal observational research. We investigated these matters in the context of baseline recruitment and retention at 18 months of participants for a prospective observational cohort study of knee pain and knee osteoarthritis in the general population., Methods: Participants were recruited to the Knee Clinical Assessment Study-CAS(K)--by a multi-stage process involving response to two postal questionnaires, consent to further contact and medical record review (optional), and attendance at a research clinic. Follow-up at 18-months was by postal questionnaire. The characteristics of responders/consenters were described for each stage in the recruitment process to identify patterns of selective non-participation and loss to follow-up. The external validity of findings from the clinic attenders was tested by comparing the distribution of WOMAC scores and the association between physical function and obesity with the same parameters measured directly in the target population as whole., Results: 3106 adults aged 50 years and over reporting knee pain in the previous 12 months were identified from the first baseline questionnaire. Of these, 819 consented to further contact, responded to the second questionnaire, and attended the research clinics. 776 were successfully followed up at 18 months. There was evidence of selective non-participation during recruitment (aged 80 years and over, lower socioeconomic group, currently in employment, experiencing anxiety or depression, brief episode of knee pain within the previous year). This did not cause significant bias in either the distribution of WOMAC scores or the association between physical function and obesity., Conclusion: Despite recruiting a minority of the target population to the research clinics and some evidence of selective non-participation, this appears not to have resulted in significant bias of cross-sectional estimates. The main effect of non-participation in the current cohort is likely to be a loss of precision in stratum-specific estimates e.g. in those aged 80 years and over. The subgroup of individuals who attended the research clinics and who make up the CAS(K) cohort can be used to accurately estimate parameters in the reference population as a whole. The potential for selection bias, however, remains an important consideration in each subsequent analysis.

Objective: Local steroid injections and community-based physiotherapy have been shown to be of similar benefit for treating shoulder pain presenting to primary care. This paper presents a cost consequences analysis of a prospective economic evaluation, conducted alongside a randomized clinical trial (RCT) of corticosteroid injections versus physiotherapy for new episodes of unilateral shoulder pain, to determine the economic implications of injection versus physiotherapy., Methods: A pragmatic RCT with 207 patients randomized to either physiotherapy (n = 103) or local steroid injection (n = 104) was conducted. The resource inputs required were identified for each treatment arm in terms of capital, staff and consumables. These were measured for the period up to 6 months post-randomization. Outcome measures included shoulder disability, shoulder pain, global assessment of health change and the EQ5D, all at 6 months. A sensitivity analysis was performed around the general practitioner minor surgical fee., Results: Analysis is presented on the 199 patients for which the general practice record review (101 physiotherapy, 98 injection) was available. The total mean costs, per patient, were 71.28 pound sterling for the injection group and 114.60 pound sterling for the physiotherapy group. The difference in average total cost per patient was 43.32 pound sterling (95% bootstrap confidence interval: 16.21 pound sterling, 68.03 pound sterling ). This is a statistically significant difference in cost. Outcome was similar in both groups across all measures following intervention. Smaller mean differences in cost were observed between the treatment groups in the sensitivity analysis, but the difference remained in favour of injection over physiotherapy., Conclusions: This study has shown, given similar clinical outcomes across the treatment groups, that corticosteroid injections were the cost-effective option for patients presenting with new episodes of unilateral shoulder pain in primary care.

Unlabelled: The number of patients requiring kidney replacement therapy is systematically increasing world wide. At the end of 2000 there were 8424 treated with dialysis in Poland. Ultrasound examinations allow assessment of dialysis fistula morphology and function., Objective: Assessment of blood flow parameters in hemodialysis fistulas. Assessment of correlation between the analysed parameters. Optimization of number of parameters needed to characterise blood flow in dialysis fistulas., Material and Methods: Doppler ultrasound examinations were performed in 86 patients with hemodialysis fistulas. Various blood flow parameters were analysed., Results: In analysed group a following values of analysed parameters were recorded: brachial artery cross sectional area was within the range 0.28-0.78 cm2; radial artery 0.05 - 0.39 cm2. The resistance and pulsatility index (RI and PI) of brachial artery were 0.32-1.00 and 0.39-3.56 respectively. Mean blood flow through brachial artery was 1082.3 ml/min and 946 ml/min through dialysis fistulas., Conclusions: Almost full correlation was found between volume of blood flowing through dialysis fistula and brachial artery, brachial and radial arteries and between PI and RI. The volume of blood flowing through brachial artery depends mostly on brachial artery cross section area and mean blood flow velocity. In patients with dialysis fistulas located on the arm or forearm blood flow measurements may be performed within the brachial artery.

Objective: To investigate predictors of long term prognosis in patients treated for shoulder pain in primary care., Methods: Data were taken from two pragmatic randomised clinical trials investigating the effectiveness of conservative treatments for shoulder pain presenting to primary care. Shoulder pain severity, disability, and perceived recovery measured in the long term (UK, 18 months; Netherlands, 12 months) were considered as outcome measures. Prognostic indicators measured before randomisation were determined by linear regression (pain severity and disability) and logistic regression (perceived recovery)., Results: 316 adults with a new episode of shoulder pain were recruited (UK, n = 207; Netherlands, n = 109). In multivariate analysis, greater shoulder disability at follow up was associated with higher baseline disability score, concomitant neck pain, and a gradual onset and longer duration of shoulder symptoms. Pain scores at follow up were higher in women and in those with longer baseline duration of symptoms and higher baseline pain or disability scores. Being female, reporting gradual onset of symptoms, and a higher baseline disability score each independently reduced the likelihood of perceived recovery., Conclusions: The results suggest that there is no long term difference in outcome between patients with shoulder pain treated with different clinical interventions in different clinical settings, or having different clinical diagnoses. Baseline clinical characteristics of this consulting population, rather than the randomised treatments which they received, were the most powerful predictors of outcome. Whether this highlights the need for earlier intervention or reflects different natural histories of shoulder pain is a topic for further research.

Objective: In order to develop a hand assessment questionnaire for a population survey, a systematic review was undertaken of measures of hand disability. The purpose of this review was to identify valid measures to evaluate hand osteoarthritis (HOA) in the general population and primary care and to perform a quality appraisal of them., Method: Measurement tools were identified from an online search of databases (Medline, CINAHL and Institute for Scientific Information (ISI), 1990-2002) restricted to English language and adult population. Search terms combined "osteoarthritis" and "arthritis" with "hand" and ["function" or "disability" or "outcome"]. Instruments used in the evaluation of HOA were identified following application of strict eligibility criteria. The use of these tools in HOA was rated by pairs of independent reviewers according to criteria developed by the Medical Outcomes Trust., Results: The initial search yielded a list of articles which were not mutually exclusive (ISI, 127; Medline, 64; CINAHL, 61). Full journal articles were ordered from relevant abstracts (ISI, 28; Medline, 3; CINAHL, 5). Further hand searching of articles produced an additional 34 references. A total of 61 references were identified, 18 measurement tools, 5 of which met the inclusion criteria [Algofunctional Index (FIHOA), Arthritis Impact Measurement Scale 2 (AIMS2), Stanford Health Assessment Questionnaire (HAQ), Australian/Canadian Osteoarthritis Hand Index (AUSCAN), Cochin]. Overall, the AIMS2 and AUSCAN were more highly rated than the FIHOA, Cochin and HAQ., Conclusions: The aim of this review was not to recommend any one instrument over another but to provide an overall summary of the robustness of commonly used measures. The choice of instrument will depend on many factors, and will differ from project to project depending on the question asked.

A case of a 54-year-old man occupationally exposed to lead with diagnosed obstructive sleep apnea, hypertension and implanted artificial pacemaker due to atrioventricular dissociation of the third degree and pauses in sinus rhythm is presented.

Objective: To assess the repeatability and validity of the electromagnetic 3-dimensional tracking system, Fastrak, in measuring cervical spine and shoulder movement in patients with ankylosing spondylitis (AS)., Methods: Fifty patients with AS had their cervical spine and shoulder movements measured on up to 3 occasions with the Fastrak. Patients also completed disease-specific and generic patient assessed health instruments, and their spinal mobility was assessed by tape measure methods. Repeatability over 2 weeks was assessed using intraclass correlation coefficients (ICC). Fastrak measurements were compared between patients with different self-ratings of AS related health. Comparisons between the Fastrak measurements and patient assessed health instruments and tape measurements were made using Spearman correlations and multilevel modeling., Results: Patients with AS tended to be limited in both cervical spine and shoulder movements. ICC were all > 0.80 (except shoulder extension, 0.75), indicating substantial reliability. Fastrak was able to differentiate between patients with a high self-rating of AS related health and those with a poorer rating. Cervical spine flexion and shoulder flexion and abduction were most strongly related to the patient assessed health instruments, although the shoulder movements had limited relationships with the tape measurements of spinal mobility., Conclusion: The Fastrak appears to be reliable and valid in an AS population. Shoulder movements tended to have a stronger relationship with the patient assessed health instruments than cervical spine movements. Shoulder movement may be more related to everyday function measured by these instruments, which indicates the importance of this joint in assessment of AS.

Objective: To evaluate the measurement properties of an evidence-based selection of measures of spinal mobility in patients with ankylosing spondylitis (AS)., Methods: Measurements of spinal mobility were taken by trained observers within a UK rheumatology centre. Inter-observer reliability was assessed. Intra-observer reliability was assessed in patients reporting no change in AS-specific health at 2 weeks. Validity was assessed and scores were correlated with responses to health transition questions. Responsiveness was evaluated for patients reporting change in health at 6 months., Results: Reliability estimates support the use of all measures in individual evaluation (intraclass correlation>0.90). Correlations between measures of spinal mobility were in the hypothesized direction; the largest was between the modified Schober index (15 cm) (MSI) and the other measures. As hypothesized, small to moderate levels of correlation were found between mobility measures and patient-assessed health status. There was no significant linear relationship between mobility measures and self-reported health transition. Fingertip-to-floor distance following trunk forward flexion (FFD) was the most responsive mobility measure but was not as responsive as two AS-specific patient-assessed instruments, the Ankylosing Spondylitis Quality of Life Questionnaire (ASQoL) and the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI). The MSI and cervical rotation (Crot) also had evidence of responsiveness. Low levels of responsiveness were found for the remaining measures., Conclusion: All mobility measures had adequate levels of reliability and validity. The MSI had a strong relationship with all mobility measures, and the FFD and Crot were the most responsive to self-perceived changes in health at 6 months. The MSI, FFD and Crot are recommended for clinical practice and research.

Background: Knee pain affects an estimated 25% of the adult population aged 50 years and over. Osteoarthritis is the most common diagnosis made in older adults consulting with knee pain in primary care. However, the relationship between this diagnosis and both the current disease-based definition of osteoarthritis and the regional pain syndrome of knee pain and disability is unclear. Expert consensus, based on current evidence, views the disease and the syndrome as distinct entities but the clinical usefulness of these two approaches to classifying knee pain in older adults has not been established. We plan to conduct a prospective, population-based, observational cohort study to investigate the relative merits of disease-based and regional pain syndrome-based approaches to classification and prognosis of knee pain in older adults., Methods: All patients aged 50 years and over registered with three general practices in North Staffordshire will be invited to take part in a two-stage postal survey. Respondents to this survey phase who indicate that they have experienced knee pain within the previous 12 months will be invited to attend a research clinic for a detailed assessment. This will consist of clinical interview, physical examination, digital photography, plain x-rays, anthropometric measurement and a brief self-complete questionnaire. All consenting clinic attenders will be followed up by (i) general practice medical record review, (ii) repeat postal questionnaire at 18-months.

Background: In randomised clinical trials (RCTs), outcome may be influenced by the opinions of the participants about the efficacy of treatments., Aim: To examine how initial treatment preferences of participants in a shoulder pain trial affected functional outcome and future treatment preferences., Design of Study: Observational cohort study nested within a multicentre, pragmatic RCT of steroid injection versus physiotherapy for unilateral shoulder pain., Setting: Nine general practices in north Staffordshire., Method: Two hundred and seven adults were randomised in the trial. Disability scores and preferences of the participants for the trial treatments were elicited at two points: prior to randomisation and 6 months post-randomisation. A good functional outcome was defined as at least a halving in the disability score at the 6 months follow-up point., Results: Pre-randomisation preferences were: 40% for injection and 20% for physiotherapy, and 40% gave no preference. A good outcome was achieved in a higher percentage of participants who gave a pre-randomisation treatment preference compared with those who did not (62% compared with 48% percentage difference = 14%; 95% confidence interval [CI] = -1 to 27%) with similar percentages in each preferred treatment group. However, receiving the preferred treatment did not confer any additional benefit in those who expressed a preference (receiving preferred treatment = 56%; not receiving preferred treatment = 69%). At 6 months post-randomisation, participants with a good, as opposed to poor, outcome were more likely to report as their preferred treatment the one to which they had been randomised, irrespective of pre-randomisation preference and whether the preferred treatment was received., Conclusion: This analysis suggests that preferences prior to treatment can affect outcome, but that treatment outcome is a stronger influence on post-treatment preferences. We present some empirical evidence to support the statement that treatment preferences can have important effects on the results of RCTs.

Background: The clinical syndrome of joint pain and stiffness in older people is the commonest cause of disability and health care consultation in this age group. Yet there have been few prospective studies of its course over time and its impact on personal and social life. We plan a cohort study in the general population aged 50 years and over to determine the course and prognosis of hand, hip, knee and foot pain, and the impact of these syndromes on participation levels and health care use., Methods: All patients aged 50 years and over registered with 3 local general practices are to be recruited to a population-based cohort study through the use of a two-stage mailing process. Participants will initially complete a "Health Survey" questionnaire. This will collect information on several areas of life including socio-demographics, general health, physical function, participation, and bodily pain. Those who state that they have experienced any hand problem or any pain in their hands, hips, knees, or feet in the previous 12 months, and also give permission to be re-contacted, will be mailed a "Regional Pains Survey" questionnaire which collects detailed information on the four selected body regions (hand, hips, knees, feet). Follow-up data for the three-year period subsequent to cohort recruitment will be collected through two sources: i) general practice medical records and ii) repeat mailed survey.

Three cases with single and one with multiple hepatic abscesses were performed. Clinical signs, like fever, enlargement and tenderness of the liver, leukocytosis and occasionally jaundice are not symptomatic. Abdominal ultrasound and CT scans are the most useful diagnostic tests, providing accurate information regarding the presence, size, number and location of abscesses within the liver. Treatment includes antibiotics and metronidazole and also suction catheter drainage inserted percutaneously under ultrasound or CT guide. Solitary abscesses are drained efficiently but this method is not technically feasible with multiple abscesses.