Search PubMed⌕ Search

Biomedical subjects

J M Esdaile

Publications and source records attributed to J M Esdaile.

At least 73 records · Page 4Linked to original sources
PubMed1995

Diagnostic associations with hypermobility in rheumatology patients.

Although we have considerable knowledge of the demographic characteristics of hypermobile individuals in population studies, we have little understanding of the implications of hypermobility. In this rheumatology clinic-based study we assessed the prevalence, diagnostic associations and clinical features of hypermobility in consecutive newly referred patients. Hypermobility was identified in 50 of 378 patients (13.2%). The most common clinical diagnosis in the hypermobile patients, compared with controls (those without hypermobility), was soft tissue rheumatism observed in 67% vs 25% (P<0.001). Fibromyalgia syndrome was the common specific rheumatological diagnosis in 30% vs 8% (P<0.001) and inflammatory arthritis the least common diagnosis in 4% vs 32% (P<0.001) of hypermobile versus non-hypermobile patients, respectively. Hypermobile patients complained of previous pain, including widespread or multiple localized sites of pain and spinal pain. Although clinic-based studies may not accurately reflect disease patterns as seen in the population, these results suggest an association between hypermobility and soft tissue rheumatic complaints and should be useful to the clinical rheumatologist.

Adolescent↗
PubMed1995

Prognostic factors in systemic necrotizing vasculitis of the polyarteritis nodosa group--a review of 45 cases.

OBJECTIVE: To evaluate the prognostic importance for mortality of age, fever, hypertension, and involvement of renal, cardiac, neural, pulmonary, gastrointestinal and cutaneous systems as well as elevated transaminases, thrombocytosis, leukocytosis, anemia, smoking status, comorbid diseases and disease severity, in 45 patients with systemic necrotizing vasculitis (SNV) identified by histological, radiological, and clinical criteria. METHODS: Kaplan-Meier nonparametric survival functions and Cox proportional hazards regression models were used. RESULTS: Twenty-four deaths were observed during the 5 year mean followup period. Five year survival was 58%. Comorbidity and severity of involvement were not predictive of mortality. Multivariable survival analysis showed that cardiac or renal involvement was associated with a relative risk of dying of 2.91 (95% CI: 1.25, 6.77). Elevated serum transaminase demonstrated a trend to having a protective effect [relative risk of 0.14 (95% CI: 0.02, 1.07)]. No other variable was an independent predictor of fatality. No cohort effect could be documented following the introduction of cytotoxic drugs in the treatment of SNV. CONCLUSION: SNV remains associated with a high mortality due largely to renal or cardiac involvement.

Adult↗
PubMed1995

Absence of an association of rheumatoid arthritis and diffuse idiopathic skeletal hyperostosis: a case-control study.

OBJECTIVE: To compare the frequency of diffuse idiopathic skeletal hyperostosis (DISH), based on an evaluation of chest radiographs, in 2 populations of patients: those with and without rheumatoid arthritis (RA). METHODS: Cases of RA were obtained from the Wichita Arthritis Center databank and controls from a private cardiology practice. Patients with RA and controls had to be older than 50 years and have a chest radiograph available. All radiographs were read, in haphazard order, by a single reader who classified them as definitely DISH, probably DISH (these 2 categories were considered as having DISH), uncertain, probably not DISH, and definitely not DISH (these 3 groups defined the absence of DISH). Logistic regression was used to investigate the probability of DISH while controlling for age and sex. Analyses were conducted to take into account the sensitivity and specificity of chest radiographs for the diagnosis of DISH. RESULTS: Among 748 radiographs (357 RA and 391 controls), 29 were diagnosed as DISH (21 controls and 8 RA). The mean age for the RA group was 66.2 yrs (SD = 11.9 and 108 (30.2%) were men. Control subjects had a mean age of 69.6 yrs (SD = 11.4 and 139 (35.4%) were men. The DISH patients, compared with those without DISH, were more likely to be male (p = 0.004) and older (p < 0.001). After accounting for age and sex, the relative risk of DISH in RA versus the controls was 0.40 (95% confidence interval: 0.20 to 1.01). After taking into account the sensitivity and specificity in this population, the adjusted prevalence of DISH for the RA group was 1% (95% confidence interval: 0.1 to 3.7) and 3.1% (95% confidence interval: 0.2 to 7.9) for the control group. CONCLUSION: We confirmed the increase in frequency of DISH with increasing age and male sex, but failed to support an increased association of DISH with RA.

Age Factors↗
PubMed1994

The time-dependence of long-term prediction in lupus nephritis.

OBJECTIVE: To assess the clinical, laboratory, and renal biopsy predictors of long-term outcome in lupus nephritis and to investigate the time-dependence of these predictors. METHODS: Eighty-seven lupus nephritis patients were studied retrospectively for the outcomes renal failure and fatality due to renal involvement. In addition to a conventional Cox model analysis, a new generalized time-dependent analytic approach was developed and used to assess the time-dependence of a predictor variable's importance. RESULTS: The mean followup time was 11.9 years. Renal failure (n = 19) was significantly predicted by measures of renal function (abnormal serum creatinine levels, proteinuria, duration of prior renal disease) and immunologic activity (elevated DNA binding, hypocomplementemia, and thrombocytopenia), by overall lupus disease activity measures (le Riche index, Lupus Activity Criteria Count), and by the activity index, the tubulointerstitial index, and the amount of subepithelial deposits on renal biopsy. In general, the laboratory predictors were significantly better prognostic markers in the early years after biopsy, the disease activity measures were best in the later years, and the biopsy variables were significant predictors over the entire observation period. In contrast to the renal failure outcome, the best predictors for death not directly related to lupus nephritis (n = 17) were the extent of comorbid diseases (principally vascular diseases), older age, and the chronicity index. All three predicted well over the extended observation period. CONCLUSION: The major predictor variables for renal outcomes and nonrenal outcomes are distinct. The time-dependence of the predictive ability of some variables may be important in managing individual patients. The new generalized time-dependent analytic technique may have widespread application in studies to identify prognostic factors for established disease or risk factors for the development of disease.

Adolescent↗
PubMed1994

Renal biopsy specimens from patients with rheumatoid arthritis and apparently normal renal function after therapy with cyclosporine. Canadian Multicentre Rheumatology Group.

Renal biopsies were performed in 14 patients with severe rheumatoid arthritis who had no evidence of compromised renal function after completion of treatment with low-dose cyclosporine (< or = 5 mg/kg/d). Mean serum creatinine at the time of biopsy was 0.84 mg/dL (range, 0.59 to 1.23 mg/dL). In the 13 patients who had received 6 months of cyclosporine therapy, mild glomerular expansion was noted in two biopsy specimens, obsolescent glomeruli (range, 5% to 20%) in five, and glomerular amyloid deposits in one. Five biopsy specimens had mild and three had mild to moderate interstitial fibrosis. Moderate interstitial fibrosis with a striped pattern was attributed to cyclosporine in the 14th patient. The results of a second biopsy performed in one patient after a further 18 months of therapy were unchanged. Although the renal biopsy changes were minimal in 13 patients and pathologic features characteristic of cyclosporine nephropathy were absent from all but one biopsy, a greater frequency of adverse effects due to cyclosporine could not be excluded. In the absence of clinical data, long-term cyclosporine therapy must be administered with caution to patients with rheumatoid arthritis, who commonly have underlying renal damage, and the value of renal biopsies in predicting and preventing end-stage renal failure remains to be determined.

Adult↗
PubMed1994

Management of occupational back pain: the Sherbrooke model. Results of a pilot and feasibility study.

OBJECTIVES: The aim was to combat occurrence of chronic occupational back pain. METHODS: A multidisciplinary model to manage back pain that includes both clinical and ergonomic approaches has been developed. Early detection, early clinical and ergonomic evaluations, and early active treatment make up the cornerstone of management. Detection of cases starts after four weeks of absence from work. An ergonomic intervention is implemented at six weeks. A medical specialist is involved at eight weeks. If return to work is not possible after 12 weeks, a functional recovery therapy followed by a therapeutic return to work is implemented. A multidisciplinary team decides if return to original or modified work is possible or if vocational rehabilitation is necessary. This model has been implemented by the investigators in the Sherbrooke (Quebec, Canada) area, and is presently being evaluated through a randomised trial in 31 industrial settlements (about 20,000 workers). A cluster randomisation of industries and workers will allow separate testing of ergonomic and clinical interventions. RESULTS: One year after implementation, 31 of 35 of the eligible industrial sites participated in the study and 79 of 88 of the eligible workers affected by recent back pain had agreed to participate. Ergonomic and clinical interventions have been implemented as planned. Only three workers dropped out. Hence this global clinical and ergonomic management programme has been shown to be feasible in a general population. CONCLUSION: A global management programme of back pain joining ergonomic and clinical intervention with a multidisciplinary approach has not been tested yet. Linking these two strategies in a same multidisciplinary team represents a systemic approach to this multifactorial ailment. During the first year of this trial we did not find any conflict between these two interventions from the employer's or worker's point of view.

Adult↗
PubMed1994

Decreasing costs and improving outcomes in systemic lupus erythematosus: using regression trees to develop health policy.

OBJECTIVE: To characterize patients with systemic lupus erythematosus (SLE) who are expected to experience the highest direct and indirect monetary costs and greatest diminished productivity so that we may intervene to reduce costs and improve outcomes. METHODS: We assessed demographics and health status in January, 1990 and costs incurred in the last 6 months of 1990 in January, 1991 in 151 patients with SLE enrolled in the Montreal General Hospital Lupus Registry. We used regression trees to separate low from high cost patients. RESULTS: Patients with poor physical or poor psychological functioning incur the highest direct costs (3-fold and 1.6-fold the group mean, respectively); those with the poorest psychological functioning incur the highest indirect costs (2-fold the group average); and those with the most intense pain experience the greatest impairment in productivity (3-fold the group average). CONCLUSION: Targeting patients with poor physical and psychological functioning and substantial pain with appropriate interventions may improve their outcomes and reduce disease costs. Targeting patients expected to have low costs with preventative interventions may delay worse outcomes and reduce future costs.

Adult↗
PubMed1994

The benefit of early treatment with immunosuppressive agents in lupus nephritis.

OBJECTIVE: In a cohort of 87 patients with lupus nephritis, delay between the detection of the onset of renal disease and renal biopsy was a significant predictor at the time of a first renal biopsy for subsequent renal insufficiency (relative risk - 4.9; 95% confidence interval = 1.7 to 14.5; p < 0.001) and death due to lupus renal involvement (relative risk = 6.7; 95% confidence interval = 2.1 to 21.2; p < 0.001). We evaluated the role of lead time bias, 2 variants of prognostic selection bias (length biased sampling), and the benefit of early treatment as explanations for this effect. METHODS AND RESULTS: Evaluation using the time of renal onset rather than the time of renal biopsy for the analysis suggested that lead time bias was unlikely to be an explanation for the effect of duration on renal insufficiency or death due to renal involvement. Identical values of age, serum creatinine and 24 hour urinary protein excretion at renal onset for those with a long duration versus short duration prior to biopsy, suggested that differences in prognostic selection were unlikely to explain the observed results. A 2nd type of prognostic selection bias arising from the failure to include patients who did not undergo a renal biopsy was further assessed by statistical simulation. The results of this approach indicated that prognostic selection bias was not solely responsible for the significant associations. Because treatment with high dose prednisone and immunosuppressive drugs was not instituted until a renal biopsy had been performed, delay in instituting these therapies remained a possible explanation for the increased frequency of renal insufficiency and death due to renal involvement observed in those with longer delays before renal biopsy. In addition, there was significant deterioration in serum creatinine (median change 0.6 mg/dl) and 24 hour urinary protein excretion (median change 2.5 gm) over the period from renal onset to renal biopsy, and significantly higher scores for the activity, chronicity and tubulointerstitial indices on renal biopsy in those in whom therapy was delayed. CONCLUSION: Prompt therapy with prednisone and immunosuppressive agents in lupus nephritis has a beneficial effect on longterm prognosis.

Adult↗
PubMed1994

Response to treatment as a predictor of longterm outcome in patients with lupus nephritis.

OBJECTIVE: To evaluate response to therapy over one year as a predictor of several longterm outcomes in lupus nephritis. METHODS: Response to treatment was evaluated by comparing serum creatinine and 24 h urine protein excretion at initial renal biopsy to those obtained after one year of treatment. Response at one year was evaluated as a predictor of renal failure, death due to lupus nephritis, and total lupus mortality, using survival analysis. RESULTS: Eighty-five patients with lupus nephritis diagnosed between 1967 and 1983 and followed through 1990 were studied. Change in proteinuria was a powerful predictor of renal failure (p = 0.001) death due to lupus nephritis (p < 0.001) and overall lupus mortality (p = 0.001). In contrast to a recent study of patients selected for severe lupus nephritis, serum creatinine was not found to be of prognostic significance. CONCLUSION: Response of proteinuria to treatment over one year is a useful predictor of longterm outcomes in lupus nephritis.

Adolescent↗
PubMed1994

The impact of disease activity, treatment and disease severity on short-term costs of systemic lupus erythematosus.

OBJECTIVE: To assess the impact of disease activity, current treatment, and global disease severity (or damage) on short-term direct and indirect costs of systemic lupus erythematosus (SLE). METHODS: 150 patients were evaluated twice, one year apart. Disease activity was assessed by the SLE disease activity index, and ordinal scales were used to evaluate treatment (prednisone = 0, 1 to 20 mg/day, > 20 mg/day, and use of immunosuppressive agents) and global disease severity [renal severity = 0 to 3, central nervous system (CNS) severity = 0 to 2, hematologic severity = 0 to 1]. Costs were assessed with the economic portion of the Health Assessment Questionnaire adapted for Canada. RESULTS: Global disease severity was significantly correlated with both direct (p = 0.0001) and indirect (p = 0.02) costs, and current treatment with indirect costs (p = 0.002). The renal and CNS subscales of the global severity measure predicted direct costs (p < 0.01) and the CNS subscale predicted indirect costs (p = 0.002). Stepwise multivariable models selected the global severity index (p = 0.004) as a predictor of direct costs, and either the treatment index (p = 0.02) or the global severity index (p = 0.02) as a predictor of indirect costs. CONCLUSION: The global disease severity index, particularly the subscales involving the renal and CNS organ systems, and the treatment index are predictors of the short-term costs of SLE.

Absenteeism↗
PubMed1994

Predictive factors for post-poliomyelitis syndrome.

Post-poliomyelitis syndrome (PPS) is generally defined as a clinical syndrome of new weakness, fatigue, and pain in individuals who have previously recovered from acute paralytic poliomyelitis. The purpose of this study was to identify, through a case-control study design, factors that predict subsequent PPS in patients with prior paralytic poliomyelitis. Among patients attending a university-affiliated hospital post-polio clinic, "cases" were patients with new weakness and fatigue, and "controls" were patients without these complaints. A chart review of 353 patients identified 127 cases and 39 controls. Logistic regression modeling was used to calculate adjusted and unadjusted odds ratios. In univariate analyses, significant risk factors for PPS were a greater age at time of presentation to clinic (p = 0.01), a longer time since acute polio (p = 0.01), and more weakness at acute polio (p = 0.02). Other significant associated, but not necessarily causal factors were a recent weight gain (p = 0.005), muscle pain (p = 0.01) particularly that associated with exercise (p = 0.005), and joint pain (p = 0.04). Multivariate analyses revealed that a model containing age at presentation to clinic, severity of weakness at acute polio, muscle pain with exercise, recent weight gain, and joint pain best distinguished cases from controls. Age at acute polio, degree of recovery after polio, weakness at best point after polio, physical activity, and sex were not contributing factors. These findings suggest that the degree of initial motor unit involvement as measured by weakness at acute polio, and possibly the aging process and overuse are important in predicting PPS.

Adult↗
PubMed1993

Low-dose methotrexate with leucovorin (folinic acid) in the management of rheumatoid arthritis. Results of a multicenter randomized, double-blind, placebo-controlled trial.

OBJECTIVE: To determine whether the side effects of methotrexate can be decreased by the concurrent use of leucovorin, without affecting the efficacy of the methotrexate. METHODS: We conducted a multicenter randomized, double-blind, placebo-controlled trial of leucovorin administration, 2.5-5.0 mg orally, to be given 24 hours after the single, weekly, oral dose of methotrexate. Every 3 weeks for 52 weeks, patients were evaluated for rheumatic disease activity and side effects. Dosage adjustments for both methotrexate and leucovorin were made as needed, according to a defined protocol. The primary outcome evaluated was the frequency of study withdrawals because of side effects and/or inefficacy. Secondary outcomes evaluated included the frequency of side effects and the relative efficacy of methotrexate in the leucovorin and placebo treatment groups. RESULTS: Ninety-two evaluable patients were analyzed (44 took leucovorin and 48 placebo). Twenty-two patients withdrew early because of side effects unresponsive to our protocol, and 1 because of inefficacy; 17 had been taking placebo and 6 had been taking leucovorin (35% versus 14%, P < 0.02). The number of visits during which side effects were reported was reduced by almost 50% in the leucovorin treatment group (P < 0.001). There were significant reductions in the frequencies of all common side effects. At 52 weeks, disease activity was similar in both patient groups. CONCLUSION: The methotrexate-leucovorin protocol used significantly reduces common side effects of methotrexate therapy without significantly altering efficacy.

Adolescent↗
PubMed1993

A Canadian study of the total medical costs for patients with systemic lupus erythematosus and the predictors of costs.

OBJECTIVE: We conducted a cost identification analysis on 164 consecutive patients with systemic lupus erythematosus (SLE) who entered the Montreal General Hospital Lupus Registry between January 1977 and January 1990, compared their costs to the population of Quebec, and determined the predictors of cost. METHODS: In January 1990 and 1991, participants completed questionnaires on health services utilization and on employment history over the preceding 6 months, as well as on functional, psychological, and social well-being. The societal burden of SLE was determined in terms of direct costs (all resources consumed in patient care) and indirect costs (wages lost due to lack of work force participation because of morbidity). RESULTS: The mean total annual cost for 1989, as assessed in January 1990 and expressed in 1990 Canadian dollars, was $13,094. Although only 44% of the patients were fully employed, indirect costs were responsible for 54% of this total ($7,071). Ambulatory costs, primarily diagnostic procedures, medications, and visits to health care professionals, comprised 55% of direct costs ($3,331). The results of the 1990 cost determination were similar. On average, hospitalizations among SLE patients were 4 times more frequent than among the general population of Quebec (matched for age and sex), and the number of ambulatory visits to physicians was double that for the average resident of Quebec. Higher 1989 values of creatinine and a poorer level of physical functioning were the best predictors of higher 1990 direct costs (R2 = 0.29). A poorer SLE well-being score, a combination of education and employment status, and a weaker level of social support were the best predictors of higher indirect costs (R2 = 0.29). CONCLUSION: The direct and indirect costs for patients with SLE are substantial, and their respective predictors are distinct. Direct costs arise from organic complications which induce functional disability. Predictors of indirect costs are potentially amenable to psychological or social interventions and may be more easily modified than the determinants of direct costs, thereby improving patient outcome while simultaneously reducing disease costs.

Adolescent↗
PubMed1993

Randomized discontinuation trials: utility and efficiency.

The randomized discontinuation trial (RDT) is a two-phase trial. In phase I all patients are openly treated with the medication being evaluated. In phase II, those who have responded are randomly assigned to continue the same treatment or switch to placebo. Usually, non-compliers and "adverse reactors" identified in phase I are excluded from phase II. To investigate the value of this design, we reviewed the advantages and limitations of discontinuation studies, and compared the RDT design to the classic randomized clinical trial design in terms of clinical utility and efficiency (sample size). A computer model was used to study the efficiency of the two designs under a broad range of assumptions. The RDT design is particularly useful in studying the effect of long-term, non-curative therapies, especially when the clinically important effect is relatively small, and the use of placebo should be minimized for ethical or feasibility reasons. However, its use is limited if the objective of an investigation is to estimate the magnitude of absolute treatment effects and toxic effects in the source population, or to evaluate a potentially curative treatment. Our results indicate that selecting responders prior to randomization has a very strong effect on the relative efficiency of the trial. Further improvement may be achieved by excluding non-compliers and adverse reactors. Under the assumptions tested in our model, the sample size required in phase II of an RDT was only 20-50% of that in a classic trial.

Computer Simulation↗