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Biomedical subjects

P Dieppe

Publications and source records attributed to P Dieppe.

At least 19 recordsLinked to original sources
PubMed2006

Indications for total hip replacement: comparison of assessments of orthopaedic surgeons and referring physicians.

OBJECTIVES: To analyse differences of opinions on indications for primary total hip replacements (THRs) within and between groups of orthopaedic surgeons and the physicians who refer patients to them. METHODS: 22 orthopaedic centres in 12 European countries took part, resulting in a postal survey of 304 orthopaedic surgeons and 314 referring physicians. Each participant was asked to state what importance different domains (pain, functional impairment, physical examination and radiographs) have on their decision to recommend THR and to select the most appropriate level of severity of each symptom or sign for recommending THR. In addition, the participants were asked to prioritise other personal or environmental factors that affect their decision to undertake a THR. RESULTS: Rest pain, pain with activity and functional limitations were the most important criteria for THR, although range of motion and radiographic changes were of least importance. Both similarities and differences were observed within and between groups of surgeons and referring physicians in the overall approach to indications and the most appropriate level of severity of disease for recommending THR. Most surgeons agreed on severity levels in only 4 of 11 items and most referring physicians in only one. Between the groups, major differences occurred with regard to the importance of activities of daily living and the appropriate level of symptoms for THR. In general, compared with surgeons, referring physicians reported that the disease needed to be more advanced to warrant surgery. CONCLUSION: Currently, no consensus exists on objective indication criteria for THR. The observed differences between the gatekeepers (referring physicians) and surgeons can lead to variations and perhaps inequities in the provision of care.

Arthroplasty, Replacement, Hip↗
PubMed2005

Prevalence and risk factors for joint pain among men and women in the West of Scotland Twenty-07 study.

OBJECTIVE: To examine the association between three modifiable risk factors (obesity, smoking, and alcohol consumption) and reported joint pain. METHODS: Cross sectional data were collected on 858 people aged 58 years living in the West of Scotland and on the same individuals four years later, aged 62 years. RESULTS: There was a positive relation between obesity and reported pain in the hips, knees, ankles, and feet. The strongest relation was with knee pain (odds ratio = 2.42 (95% confidence interval, 1.65 to 3.56)). There were no strong consistent associations between smoking habits and pain in any joint after adjusting for sex, alcohol consumption, body mass index, social class, and occupational exposures. Similarly, alcohol was not consistently related to pain in any joint in the fully adjusted models. CONCLUSIONS: Obesity had consistent and readily explained associations with lower limb joint pain. The data suggest that smoking behaviour and alcohol consumption are not consistently associated with joint pain across the body.

Arthralgia↗
PubMed2005

Differences in the views of orthopaedic surgeons and referring practitioners on the determinants of outcome after total hip replacement.

In order to assess current opinions on the long-term outcome after primary total hip replacement, we performed a multicentre, cross-sectional survey in 22 centres from 12 European countries. Different patient characteristics were categorised into 'decreases chances', 'does not affect chances', and 'increases chances' of a favourable long-term outcome, by 304 orthopaedic surgeons and 314 referring practitioners. The latter were less likely to associate age older than 80 years and obesity with a favourable outcome than orthopaedic surgeons (p < 0.001 and p = 0.006, respectively) and more likely to associate age younger than 50 years with a favourable outcome (p = 0.006). Comorbidity, rheumatoid arthritis, and poor bone quality were thought to be associated with a decreased chance of a favourable outcome. We found important differences in the opinions regarding long-term outcome after total hip replacement within and between referring practitioners and orthopaedic surgeons. These are likely to affect access to and the provision of total hip replacement.

Adult↗
PubMed2005

The causes and effects of socio-demographic exclusions from clinical trials.

OBJECTIVES: To investigate the exclusion from trials of women, older people and minority ethnic groups, focusing on two drug exemplars, statins and non-steroidal anti-inflammatory drugs (NSAIDs). DATA SOURCES: Medical and ethical databases. Workshops with stakeholders. REVIEW METHODS: Literature was reviewed on exclusions in healthcare research and three workshops were held with stakeholders. Twenty-seven randomised controlled trials (RCTs) of statins use for secondary prevention of coronary heart disease (CHD) and 25 NSAIDs trials for pain in osteoarthritis (OA) were analysed. Using a Scottish cohort with record-linkage, profiling was carried out for 3188 people needing secondary prevention for CHD (1993-1996), ascertaining the independent effects of statins, and 131,410 people dispensed NSAIDs (1989-1996), examining adverse effects. Routine data sources were accessed to profile the need for secondary prevention of CHD in England and usage was estimated by consulting published surveys. The Somerset and Avon Survey of Health (SASH) 1996-97 and published data were accessed for information on potential need and usage of NSAIDs in OA. For both drugs, the socio-demographic profiles of trial samples, the population in potential need and those on treatment were compared. An evidence synthesis was produced to clarify the effects of statins on women and older people and the relationship of absolute effectiveness outcomes with underlying risk levels of disease events was modelled, examining the likely effects of trial exclusions. RESULTS: The average age of statins trial participants was 58.5 years; only 16.3% were women. Statins reduced cardiovascular disease (CVD) incidence by about 25% in both men and women. Older people up to 75 years of age also benefited. Meta-analysis and two landmark trials confirmed these results. The average age of NSAIDs trial participants was 61.9 years and women were well represented (68.5%). Gastrointestinal (GI) adverse events were commonly reported, but renal side-effects were not. Outcomes were seldom reported according to socio-demographic group. For both drugs, USA trials were more inclusive than UK/European trials. Ethnicity was not well reported for either drug. Some 23% of the cohort were treated with statins. Users were younger than non-statins users (but no more likely to be male) and had superior outcomes. High current exposure to NSAIDs elevated the risk of GI side-effects by about 50% versus no current exposure and renal impairment risk by nearly 140%. Side-effect risk increased with age; being female diminished risk. Approximately 537,000 incident cases of CVD would qualify for statins use in England each year. Women constitute 45% of this population with need, two-thirds of whom are aged 65 years or over. Need varies by ethnic group. No sex bias in prescribing statins was detected, but use was commoner in younger people. For NSAIDs, 6.3% of adults aged 35+ years reported hip and/or knee pain associated with OA; 3.9% of adults used prescribed analgesics for this and they were more likely to be women and to be >65 years old. For statins, women formed almost half of the 'with need' and 'on treatment' populations, but were markedly under-represented in trials. Those aged 65+ years formed nearly two-thirds of the 'with need' population, but only one-fifth of trial samples, and were less likely to be treated than younger subjects. For NSAIDs, women formed similar proportions. Associations of side-effects with socio-demographic factors was revealed in cohort data but not in trials. CONCLUSIONS: The issue of exclusion from trials of women, older people and ethnic minorities has been relatively neglected in the UK research community, and there is confusion about diversity issues. Under-representation occurs, but in drug trials at least this may not always affect the external validity of relative effect estimates. However, measures of absolute effectiveness, absolute harm and cost-effectiveness are associated with underlying risk levels in different socio-demographic groups. Under-representation will therefore bias absolute effect estimates. The following areas are suggested for future research: multi-disciplinary assessment of realistic options for trialists to address the issue of exclusions; clarification of the use of ethnic categories in health research and of the implications of the different dimensions of ageing and sex/gender; identification of barriers and facilitators to the involvement of different population groups in research, further investigation of the susceptibility of older men to NSAID adverse events, and the development of a 'register of registries and databases' and exploration of how linked health information systems in the UK could be improved.

Adult↗
PubMed2004

Evaluation of the symptomatic and structural efficacy of a new hyaluronic acid compound, NRD101, in comparison with diacerein and placebo in a 1 year randomised controlled study in symptomatic knee osteoarthritis.

OBJECTIVE: To evaluate long term efficacy of three iterative courses of three weekly intra-articular (IA) injections of NRD101 in the treatment of symptomatic knee osteoarthritis (OA). PATIENTS AND METHODS: A 1 year prospective, multicentre, randomised, double blind, placebo controlled study of 301 patients aged >50 years with painful and radiological medial knee OA. Patients were randomly assigned into three groups receiving: (1) three courses of three IA injections of hyaluronic acid (HA) + oral placebo; (2) IA injections of saline solution + diacerein 100 mg/day; (3) IA injections of saline solution + oral placebo. Demographic data and symptomatic criteria-pain, Lequesne's index, patient's global assessment of disease activity, percentage of painful days-were obtained during the study; primary structural criterion was JSW. Efficacy criteria were changes in pain VAS, joint space narrowing (JSN), and percentage of progressors (JSN >0.5 mm). An intention to treat analysis was used for symptomatic variables, and completer analysis for structural variables. RESULTS: Baseline characteristics were similar between the three groups. Mean (SD) improvement in pain VAS was clinically relevant (-33.9 (27.3), n = 301), but with no difference between the groups (p = 0.96). JSW deteriorated (-0.09 (0.55) mm, n = 277, p = 0.01), but with no difference between the groups (p = 0.82). Percentages of progressors were 17.7, 18.9, and 20.3% (p = 0.90), in groups 1, 2, and 3, respectively. CONCLUSION: A weak but statistically significant structural deterioration occurred over 1 year, together with clinically relevant symptomatic improvement in patients receiving oral drug and iterative IA injections. Symptomatic and/or structural effects for both this new HA compound and diacerein were not demonstrated.

Aged↗
PubMed2004

Trends in hip and knee joint replacement: socioeconomic inequalities and projections of need.

OBJECTIVES: To examine trends in primary and revision joint (hip and knee) replacement in England between 1991 and 2000. METHODS: Analysis of hospital episodes statistics between 1 April 1991 and 30 March 2001 for total hip replacement (THR) and total knee replacement (TKR). Descriptive statistics and regression modelling were used to summarise patients' demographic and clinical characteristics and to explore variations in joint surgery rates by age, sex, and deprivation. RESULTS: Between 1991 and 2000, the incidence of primary THR increased by 18%, while the incidence of revision THR more than doubled. The incidence of primary TKR doubled, with revision TKR increasing by 300%. Over the 10 year period, the proportion of THR episodes that involved revision operations rose from 8% to 20%. Substantial variations in operation rates by socioeconomic status were seen, with the most deprived fifth of the population experiencing significantly lower rates. Projections estimate that primary THR numbers could rise by up to 22% by the year 2010, with primary TKR numbers rising by up to 63%. CONCLUSIONS: Provision of joint replacement surgery in English NHS hospitals has increased substantially over the past decade. Revision operations in particular have increased markedly. The growth in primary operations has mostly occurred among those aged 60 years and over; rates among young people have changed very little. There is a significant deprivation based gradient in rates. If current trends continue there would be almost 47 000 primary hip and 54 000 primary knee operations annually by 2010.

Adult↗
PubMed2003

Population requirement for primary knee replacement surgery: a cross-sectional study.

OBJECTIVES: To determine the population requirement for total knee replacement (TKR) in England. METHODS: Population-based study using an age/sex-stratified random sample of 28 080 individuals aged 35 yr and over. Incident disease was estimated from prevalence by statistical modelling. The New Zealand priority criteria for major joint replacement were used for case selection. RESULTS: Patients with knee disease were less likely than those with equally severe hip disease to have been referred to a specialist, to have consulted an orthopaedic surgeon or to be on a waiting list for joint replacement. The estimated annual requirement of TKRs in England, based on New Zealand Scores alone, was 55,800 (95% CI 40 700-70,900), contrasting sharply with an annual provision of 29,300 actually observed. However, in contrast to previously reported hip replacement data, when patient willingness to undergo surgery was considered, this estimate decreased considerably. CONCLUSIONS: There appears to be an underprovision of TKR in England. This may be due in part to differences in perception of disease severity and likely response to surgery between patients and general practitioners on one hand, and rheumatologists and orthopaedic surgeons on the other.

Adult↗
PubMed2003

EULAR Recommendations 2003: an evidence based approach to the management of knee osteoarthritis: Report of a Task Force of the Standing Committee for International Clinical Studies Including Therapeutic Trials (ESCISIT).

OBJECTIVES: To update the EULAR recommendations for management of knee osteoarthritis (OA) by an evidence based medicine and expert opinion approach. METHODS: The literature search and guidelines were restricted to treatments for knee OA pertaining to clinical and/or radiological OA of any compartment of the knee. Papers for combined treatment of knee and other types of OA were excluded. Medline and Embase were searched using a combination of subject headings and key words. Searches for those treatments previously investigated were conducted for January 1999 to February 2002 and for those treatments not previously investigated for 1966 to February 2002. The level of evidence found for each treatment was documented. Quality scores were determined for each paper, an effect size comparing the treatment with placebo was calculated, where possible, and a toxicity profile was determined for each treatment modality. RESULTS: 497 new publications were identified by the search. Of these, 103 were intervention trials and included in the overall analysis, and 33 treatment modalities were identified. Previously identified publications which were not exclusively knee OA in the initial analysis were rejected. In total, 545 publications were included. Based on the results of the literature search and expert opinion, 10 recommendations for the treatment of knee OA were devised using a five stage Delphi technique. Based on expert opinion, a further set of 10 items was identified by a five stage Delphi technique as important for future research. CONCLUSION: The updated recommendations support some of the previous propositions published in 2000 but also include modified statements and new propositions. Although a large number of treatment options for knee OA exist, the evidence based format of the EULAR Recommendations continues to identify key clinical questions that currently are unanswered.

Adrenal Cortex Hormones↗
PubMed2002

The value of synovial fluid assays in the diagnosis of joint disease: a literature survey.

OBJECTIVE: To carry out a critical appraisal of the literature in an attempt to assess the current value of synovial fluid (SF) analysis in the diagnosis of joint disease. METHODS: A literature search was undertaken using the Medline, Biomed, Bids, Pubmed, and Embase electronic databases using the keywords: synovial fluid (SF) analysis, SF crystals, joint sepsis, acute arthritis, and SF cell counts, cytology, biomarkers, and microbiology. RESULTS: Publications fell into three main categories. Firstly, reports assessing the value of the three traditional assays (microbiology, white blood cell counts, and microscopy for pathogenic crystals). For these quality control evidence was found to be sparse, and tests for sensitivity, specificity, and reliability showed worrying variations. These poor standards in SF analysis may be due to lack of inclusion of some tests within routine pathology services. Secondly, claims for the usefulness of "new" assays (cytology and biochemical markers). For cytology, the supporting evidence was mainly anecdotal and there were no reports on specificity, sensitivity, and reliability. Interpretation difficulties are a major hindrance to the clinical use of biochemical assays, which remain primarily research tools. Finally, work on the diagnostic value of SF analysis in general. The appraisal confirmed that SF analysis remains of major diagnostic value in acute arthritis, where septic arthritis or crystal arthropathy is suspected, and in intercritical gout. CONCLUSIONS: Given the importance of SF tests, rationalisation of their use, together with improved quality control, should be immediate priorities. Further investigation is recommended into the contribution of SF inspection and white cell counts to diagnosis, as well as of the specificity and sensitivity of SF microbiological assays, crystal identification, and cytology.

Acute Disease↗