Search PubMed⌕ Search

Biomedical subjects

J M Esdaile

Publications and source records attributed to J M Esdaile.

At least 37 records · Page 2Linked to original sources
PubMed1999

Rheumatic diseases in North America's indigenous peoples.

OBJECTIVES: There are at least 3 million North American Indians and Eskimos in North America. The epidemiology of rheumatic diseases in Native North Americans differs from that described for the remainder of the North American population. An enhanced understanding of rheumatic diseases in these indigenous people may provide valuable clues to the cause of these disorders and improve rheumatologic care. METHODS: The world literature was searched for all reports of rheumatic diseases in North American Indians and Eskimos. The reports were reviewed and the findings summarized by disease process. RESULTS: Many Native American groups have high prevalence rates of rheumatoid arthritis (RA), systemic lupus erythematosus, connective tissue diseases, and spondyloarthropathies. There appears to be a correlation between the pattern of rheumatic diseases in Native North Americans and the patterns of migration and ancestry. In general, Amerind Indians have increased rates of RA and connective tissue disease, while Na-Dene Indians and Eskimos have high rates of spondyloarthropathies. The RA seen in Native Americans is generally severe, seropositive, with an early age of onset, and frequent extraarticular manifestations. Many Native American groups have very high frequencies of the RA shared epitope. The majority of Native American and Eskimo groups also have high frequencies of HLA-B27, and some of the world's highest prevalence rates of spondyloarthropathies are described in these groups. Although some groups show a marked tendency to develop either Reiter's syndrome or ankylosing spondylitis, psoriatic and enteropathic arthritis are rare. CONCLUSIONS: The excess rheumatic disease seen in this population is most likely genetic in origin. Because of the combination of high rates of rheumatic disease and relative genetic homogeneity, Native North Americans represent a singular opportunity to study genetic contributions to rheumatic disease. For clinicians, the index of suspicion for rheumatic diseases in North American Indians and Eskimos should be high, and the severe disease and sometimes atypical presentations kept in mind.

Humans↗
PubMed1999

The relationship between health status, social support and satisfaction with medical care among patients with systemic lupus erythematosus.

OBJECTIVE: To examine the effect of physical and mental health status and social support on patient satisfaction with health care in patients with systemic lupus erythematosus (SLE). STUDY DESIGN: Using a cross-sectional design, 220 SLE patients were recruited from rheumatology departments in two hospitals in the Montreal (Canada) area. Data comprised physician-rated indices of health status and patient-completed questionnaires. MEASURES: Independent variables included demographics, disease duration, physician-rated indices of disease activity (SLAM-R) and disease damage (SLICC/ACR), patient self-reported health status (SF-36), and perceived social support (ISEL). Patient satisfaction with medical care (PSQ-IV) was the dependent variable. ANALYSES: Univariate analyses were performed to describe the sample and examine univariate associations between the independent variables and patient satisfaction with medical care. A hierarchical multiple linear regression analysis was computed to determine the relative importance of physician-rated indices of health status, self-reported physical and mental health status and social support on patient satisfaction after controlling for demographic variables. RESULTS: A multivariate hierarchical regression computed to predict patient satisfaction included the following variables in the equation: age, education, income (step 1), disease duration, SLAM-R, SLICC/ACR (step 2), mental and physical health status (step 3), and perceived social support (step 4). Less education (P< 0.01), better self-reported mental (P< 0.05) and physical health status (P< 0.005) and higher perceived social support (P< 0.005) were significant predictors of patient satisfaction (R2 = 0.15, P< 0.0001). CONCLUSION: The findings suggest that self-reported physical and mental health status and social support are more important than clinical status variables in understanding patient satisfaction with medical care.

Adult↗
PubMed1999

Discontinuation of antimalarial drugs in systemic lupus erythematosus.

OBJECTIVE: To assess the reasons for and timing of discontinuation of antimalarial drugs, principally hydroxychloroquine (HCQ), in systemic lupus erythematosus (SLE). METHODS: A lupus database was reviewed to identify antimalarial use from inception to April 1996. Reasons for drug discontinuation were assessed by medical record review. RESULTS: Of 224 patients with SLE, 156 (70%) had received antimalarials. The 156 users received 203 courses of antimalarials, of which 197 (97%) were for HCQ. The average duration of use was 6.9 years/patient. Antimalarials were discontinued at least once in 62 patients. When only the first course of use was considered, 67, 50, and 38% of patients continued to receive antimalarials at 5, 10, and 15 years, respectively (for all courses, the rates were 82, 66, and 52%, respectively). Reasons for discontinuation were disease remission in 26 (42%), side effects in 18 (29%), noncompliance in 9 (15%), lack of efficacy in 5 (8%), and miscellaneous causes such as pregnancy/surgery in 4 (6%). When all courses were considered, 20 subjects were withdrawn for side effects, including gastrointestinal in 11; headache and dizziness, and nonretinal eye problem in 2 each; and hearing loss and rash in one each. Two developed HCQ myopathy (1.9 cases/1000 patient-years of HCQ therapy; 95% CI 0.2, 7.0). One developed HCQ retinopathy after 6 years at a dose of 6.5 mg/kg/day (0.95 cases/1000 patient-years of HCQ; 95% CI 0.0, 5.5). Among patients who had received HCQ for at least 6 years, 1.3% developed retinopathy (95% CI 0.03, 7.0%). CONCLUSION: HCQ is well tolerated in SLE. However, ophthalmologic testing remains essential, as retinopathy does occur, albeit rarely.

Adult↗
PubMed1999

Predicting the short term direct medical costs incurred by patients with rheumatoid arthritis.

OBJECTIVE: With increasing interest in revising the mechanisms of health care funding, the ability to anticipate patients' medical expenditures as well as to identify potentially modifiable predictors would be informative for health care providers, payers, and policy makers. METHODS: Eight hundred fifty-eight patients with rheumatoid arthritis from 2 Canadian centers reported semi-annually on their health services utilization and health status for up to 12 years. Annual direct costs were calculated using 1994 Canadian prices. Regression models for the variation in total direct costs and the individual resource components (i.e., physicians, tests, medications, acute and non-acute hospital care) were estimated using previous values of age, sex, disease duration, education, methotrexate availability, employment status, global well being, pain, duration of morning stiffness, and functional disability as predictor variables. The models were developed using all available data except the last 2 observations (i.e., data collected on the last 2 self-report questionnaires) from each patient, which were reserved for model validation. The predictive abilities of the models were assessed by comparing the most recent costs with those predicted by the model using values of the predictor variables from the previous time period. Further, to assess whether the models conferred any advantage over cost estimates based only on previous costs, most recent observed costs were also compared with costs observed in the preceding time period. RESULTS: Self-reported indices of either global well being, pain, or functional disability predicted total direct costs as well as the costs of the 5 individual resource components. Being younger, female, disabled from the work force, having shorter disease duration, and receiving more formal education also predicted higher costs in at least on health resource category. However, being older predicted higher acute and non-acute care hospital costs. Regression models incorporating longitudinal data did not perform better than average costs in the preceding time period in predicting future short term costs. CONCLUSION: Global well being, pain, functional disability, and previous costs are the most important predictors of short term direct medical costs. Although we have demonstrated that regression models do not perform better than previous costs in predicting future short term costs, previous costs are a much less informative predictor than health status variables. Variables such as functional disability and pain identify potentially modifiable disease features and suggest interventions that may improve patient well being and reduce costs.

Aged↗
PubMed1999

An international perspective on the well being and health care costs for patients with systemic lupus erythematosus. Tri-Nation Study Group.

OBJECTIVE: To compare health care expenditure and health status for patients with systemic lupus erythematosus (SLE) between nations with distinct mechanisms for funding and delivering health care services. METHODS: Seven hundred eight patients with SLE from 2 centers in each of 3 countries (Canada 229, United States 268, United Kingdom 211) underwent physician assessment of disease activity and damage and reported on physical and psychosocial well being, satisfaction, social support, and health resource utilization. To compare overall utilization, constant prices (1997 Canadian dollars) were applied across countries for each service, enabling diverse resources to be collapsed into a single expression. RESULTS: After adjusting for important patient covariates, Canadian, compared to American and British patients, reported significantly superior health status in 3 of 8 Medical Outcome Survey Short Form-36 (SF-36) subscales, the SF-36 physical component summary score, and the visual analog scale of general health status. There was no consistent trend in patient satisfaction. Overall annual resource utilization did not vary significantly, with mean annual per patient expenditures (adjusted for demographics, disease duration, activity, damage, social support, health status, patient satisfaction, and age and sex adjusted country-specific SF-36 general population norms) totalling $4853, $5285, and $4760 for Canada, US, and the UK, respectively. However, within each resource category, differences were observed. Canadians saw more specialists than the British, the British more generalists. Canadians and Americans were more frequent users of the emergency room; Americans of laboratory/imaging procedures. Canadians had higher hospital costs than Americans. CONCLUSION: After adjustment, Canadian patients reported better well being than their counterparts. Despite considerable differences in the mechanisms of health care funding and service mixture, overall resource utilization did not vary significantly between the countries, although there was a trend towards more intense use of inpatient services in Canada and outpatient services in the United States.

Adult↗
PubMed1998

Psychosocial contributors to mental and physical health in patients with systemic lupus erythematosus.

OBJECTIVE: To delineate psychosocial and systemic lupus erythematosus (SLE)-related medical factors that contribute to the mental and physical health of SLE patients. METHODS: In a cross-sectional study, 44 women completed standardized instruments assessing daily hassles, social support, psychologic distress, and quality of life and underwent a physician examination to assess disease activity and disease damage. Four multiple linear regression analyses were computed to identify factors associated with the following outcomes: patient-perceived psychologic distress and global physical health and physician-assessed disease activity and damage. Variables entered into the regression analyses were: hassles severity, types of social support, SLE disease activity and damage, age, disease duration, education, ethnicity, and global psychologic distress (for the outcomes of self-perceived global physical health and disease activity and damage). RESULTS: The best model explaining global psychologic distress included hassles severity and self-esteem social support. The best model explaining patients' perceptions of their global physical health included hassles severity and tangible social support. Psychologic distress accounted for a significant proportion of variance in both disease activity and damage. CONCLUSION: High stress (assessed by hassles severity), poor social support, and psychologic distress--potentially modifiable variables--are associated with the mental and physical health of SLE patients.

Adult↗
PubMed1998

Comprehensive radiographic evaluation of diffuse idiopathic skeletal hyperostosis: development and interrater reliability of a scoring system.

OBJECTIVE: To develop a scoring system for radiographic findings in diffuse idiopathic skeletal hyperostosis (DISH) and to test interrater reliability. MATERIALS AND METHODS: Fifty-five DISH patients and 35 spondylosis patients underwent two views (anteroposterior and lateral) of the cervical, thoracic, and lumbar spine, lateral views of both ankles, knees, and elbows, and anteroposterior views of the pelvis and shoulders. Two raters reviewed and scored the x-rays. Interrater reliability was assessed with the alpha statistic (alpha) for categorical variables and with the intraclass correlation coefficient (ICC) for continuous variables. RESULTS: The agreement was similar for the three spinal segments (alpha = 0.44 to 0.71). The lower extremity agreement ranged from 0.28 to 0.76, with higher agreement at the knee (alpha > or = 0.46) and the ankle (alpha > or = 0.56) than at the pelvis (ICC < or = 0.58). The agreement at the shoulders and elbows ranged from 0.50 to 0.75. The agreement between the readers was higher with summary measurements than with single (site-by-site) measurements: for each spinal segment, the ICC was 0.83 or greater; for the lower extremity, the ICC = 0.79; and for the upper extremity, the ICC = 0.68. CONCLUSION: We have described a comprehensive scoring system to assess the spinal and peripheral involvement of DISH.

Aged↗
PubMed1998

Current role of renal biopsy in patients with SLE.

All aspects of the role of renal biopsy in systemic lupus erythematosus may not be defined and accepted, but there is increasing agreement as to the information that can be obtained from biopsy. Awareness of the importance of clinical (non-biopsy) predictors has permitted a clearer understanding of the ability of renal biopsy to confirm and to add information to a determination of prognosis based on clinical data. New techniques for scoring the patterns of injury detectable on renal biopsy have provided important insights into prognosis, pathogenesis and treatment of lupus nephritis. Watchful waiting is often an unwise course for the management of lupus nephritis. Thus, renal biopsy is increasingly seen as an important tool in the timely determination of prognosis.

Biopsy↗
PubMed1998

The association of soft-tissue rheumatism and hypermobility.

Soft-tissue rheumatism (STR--tendinitis, bursitis, fasciitis and fibromyalgia) accounts for up to 25% of referrals to rheumatologists. The estimated prevalence of generalized hypermobility in the adult population is 5-15%. There have previously been suggestions that hypermobile individuals may be predisposed to soft-tissue trauma and subsequent musculoskeletal pain. This study was designed to examine the mobility status and physical activity level in consecutive rheumatology clinic attendees with a primary diagnosis of STR. Of 82 patients up to age 70 yr with STR, 29 (35%) met criteria for generalized hypermobility. Hypermobile compared to non-hypermobile individuals reported significantly more previous episodes of STR (90% vs 51%, P < 0.01), and more recurrent episodes of STR at a single site (69% vs 38%, P < 0.001). Although we were unable to show any difference in the time spent carrying out physical activity between the two groups, the hypermobile patients were performing significantly more repetitive activities. When specific anatomical sites of STR were analysed, small joints (elbows, hands and feet) currently affected with STR were more likely to show localized hypermobility than if those joints were asymptomatic. These findings suggest that hypermobility may be a factor in the development of STR. Repetitive activity may be a contributing factor towards STR in some hypermobile individuals.

Adolescent↗
PubMed1998

A long-term study of hydroxychloroquine withdrawal on exacerbations in systemic lupus erythematosus. The Canadian Hydroxychloroquine Study Group.

The ability of antimalarials to moderate severe disease activity in systemic lupus erythematosus (SLE) is plausible but undemonstrated. We evaluated the long-term effectiveness of maintaining treatment with hydroxychloroquine sulphate (HCQ) to prevent major flares in quiescent SLE. Forty-seven patients with quiescent SLE who had been randomized to take HCQ (n = 25) or placebo (n = 22) as part of a 24-week withdrawal trial were evaluated for an additional 3 years. The primary outcome was time to a major flare of SLE which resulted in either the institution of or an increase in the current dosage of prednisone of 10 mg/day or more, or institution of therapy with immunosuppressive agents. Secondary outcomes included the specific subtype of these major flares (glomerulonephritis, vasculitis or other) and hospitalization for an exacerbation of SLE. An intent-to-treat analysis was conducted. Over the 42 months of study, 11 of 22 (50%) patients randomized initially to placebo, and seven of 25 (28%) patients randomized to continue treatment experienced a major flare. The relative risk of major flare for those randomized to continue HCQ compared with controls was 0.43 (95% CI: 0.17, 1.12). The relative risks for subtypes of flares were 0.26 (95% CI: 0.03, 2.54) for nephritis, 0.51 (95% CI: 0.09, 3.08) for vasculitis and 0.65 (95% CI: 0.17, 2.41) for flares characterized by other symptoms. The relative risk of hospitalization for major flare for patients randomized to continue hydroxychloroquine was 0.58 (95% CI: 0.13, 2.60). While the results are not statistically significant, they are compatible with the clinical belief that HCQ has a long-term protective effect against major disease flares in SLE and suggest that on average, HCQ use reduces major flares by 57% (95% CI: 83% reduction to 12% increase).

Adult↗
PubMed1998

Occupational role performance in persons with back pain.

PURPOSE: Back pain is a major cause of work disability but there is little data on the impact of back pain among persons who are working. The purpose of this study was to develop a measure of occupational role performance for individuals with back pain and to examine its relationship with sociodemographic and work-related factors. METHOD: Item analysis and reduction resulted in a short, eight-item Occupational Role Questionnaire (ORQ) consisting of two scales, a productivity scale and a satisfaction with work scale. The scales had good internal consistency and correlated as expected with the Roland and Morris Disability Scale. RESULTS: In a multivariate logistic model, significant negative effects on work satisfaction were observed for age 30-39 years relative to age 50+, having a job that required lifting, and the level of disability. CONCLUSION: The ORQ may have applications in studying the consequences of back pain and other chronic conditions in the workplace.

Adult↗
PubMed1997

A population-based, randomized clinical trial on back pain management.

STUDY DESIGN: Population-based randomized clinical trial. OBJECTIVES: To develop and test a model of management of subacute back pain, to prevent prolonged disability. SUMMARY OF BACKGROUND DATA: The present management of back pain seems inadequate, and development of innovative models has been urged. METHODS: A model for the treatment of subacute work-related back pain has been developed and evaluated in a population-based randomized clinical trial. Workers (n = 130) from eligible workplaces in the Sherbrooke area (N = 31), who had been absent from work for more than 4 weeks for back pain, were randomized, based on their workplace, in one of four treatment groups: usual care, clinical intervention, occupational intervention, and full intervention (a combination of the last two). The duration of absence from regular work and from any work was evaluated using survival analysis. Functional status and pain were compared at study entry and after 1 year of follow-up. RESULTS: The full intervention group returned to regular work 2.41 times faster than the usual care intervention group (95% confidence interval 1.19-4.89; P < 0.01). The specific effect of the occupational intervention accounted for the most important part of this result, with a rate ratio of return to regular work of 1.91 (95% confidence interval = 1.18-3.10; P < 0.01). Pain and disability scales demonstrated either a statistically significant reduction or a trend toward reduction in the three intervention groups, compared with the trend in the usual care intervention group. CONCLUSIONS: Close association of occupational intervention with clinical care is of primary importance in impeding progression toward chronicity of low back pain.

Adolescent↗
PubMed1997

Reliability of tuberculin skin test measurement.

BACKGROUND: Important management decisions depend on results of the tuberculin skin test. However, the test is subject to several potential errors, and its reliability has not been adequately studied. OBJECTIVE: To ascertain the reliability of tuberculin skin testing. DESIGN: Cross-sectional study. SETTING: University hospital. PARTICIPANTS: 96 persons who received a tuberculin skin test. MEASUREMENTS: Ballpoint-pen and palpation measures of induration. RESULTS: Global intra- and interobserver reliability coefficients of the ballpoint-pen technique were high. Five percent of the time, however, a second measurement by the same observer could be at least 2.7 mm less to 3.0 mm more than the first measurement and the measurement from the second observer could be at least 3.4 mm less to 3.7 mm more than the measurement from the first observer. This could lead to the reclassification of a positive test result as negative or vice versa. The area of imprecision was 38% less broad for the ballpoint-pen technique than for the palpation technique. CONCLUSION: Reading of tuberculin skin tests may frequently result in misclassifications when measurements are close to the cutoff point that separates negative from positive results.

Cross-Sectional Studies↗
PubMed1997

The overdiagnosis of fibromyalgia syndrome.

PURPOSE: As fibromyalgia syndrome (FM) has gained greater acceptance and awareness in both the medical and the lay community, the possibility of overdiagnosis exists. Diffuse body pain in a woman is likely to suggest this diagnosis. We report the diagnosis of FM in 11 female patients whose primary cause for musculoskeletal symptoms was spondyloarthritis rather than only FM. PATIENTS AND METHODS: Of a total of 321 new rheumatology referrals in a 1-year period, 35 (11%) were diagnosed with FM. A further 11 (3%) were referred with either a previous diagnosis of FM or a presumed diagnosis of FM in whom the musculoskeletal syndrome could be attributed to previously unrecognized spondyloarthropathy. RESULTS: The 11 female patients had mostly experienced musculoskeletal symptoms for prolonged periods of time ranging from 1 to 40 years. Symptoms included prominent spinal pain involving at least 2 locations in the spine (n = 10), night pain that disturbed sleep (n = 10), and prolonged morning stiffness (n = 9). A previous history of enthesopathy, or history in the patient or first-degree relative of one of the seronegative associated diseases, such as psoriasis or ulcerative colitis, occurred in nine patients. Most patients had already undergone extensive investigations by various specialists in musculoskeletal medicine, but spondyloarthritis had only infrequently been considered a diagnostic possibility. CONCLUSION: Spondyloarthropathy in women may present subtly and have considerable overlap in symptomalogy with FM. A diagnosis of spondyloarthropathy should be considered in women with an ill-defined pain syndrome with prominent spinal pain and associated enthesopathy, or history or family history of seronegative-associated disease. It is possible that a primary diagnosis of FM is being made too freely, without consideration of other diagnoses, in the setting of ill-defined musculoskeletal pain.

Adult↗
PubMed1997

A controlled study of diffuse idiopathic skeletal hyperostosis. Clinical features and functional status.

Diffuse idiopathic skeletal hyperostosis (DISH) is a common but little-studied disorder in the elderly that is infrequently recognized by physicians. Its prevalence in adults over 40 years of age is estimated at 3.8% for men and 2.6% for women. The present case-control study evaluated the history of pain and stiffness, radicular pain and enthesitis, physical findings on the musculoskeletal examination, and level of physical and psychologic disability in 130 persons: 56 patients with DISH, 43 control patients with spondylosis of the lumbar spine, and 31 healthy control patients. DISH patients were more likely to report a past history of upper extremity pain, medial epicondylitis of the elbow, enthesitis of the patella or heel, or dysphagia than spondylosis patients. They had more extremity and spinal stiffness and pain than healthy controls. DISH patients weighed more at a young age and their body mass index was greater at the time of the clinical evaluation than either spondylosis or healthy control patients. On musculoskeletal examination, DISH patients had a greater reduction in neck rotation and thoracic movements than either spondylosis patients or healthy controls, and had a greater reduction in lumbar movement than healthy controls. DISH patients had similar levels of spinal disability and physical disability overall, as measured by standardized indices, as spondylosis patients. No differences were found among the 3 groups of patients for the laboratory tests evaluated. DISH is clearly a distinct disorder with signs and symptoms that distinguish it from other causes of spinal complaint and from healthy individuals. It has the potential to cause major disability. Future studies need to address the natural history of DISH, pursue pathogenic mechanisms, and evaluate treatment modalities.

Activities of Daily Living↗