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Biomedical subjects

R Buchbinder

Publications and source records attributed to R Buchbinder.

At least 55 records · Page 3Linked to original sources
PubMed1996

Management of the early and late presentations of rheumatoid arthritis: a survey of Ontario primary care physicians.

OBJECTIVE: To examine primary care physicians' management of rheumatoid arthritis, ascertain the determinants of management and compare management with that recommended by a current practice panel. DESIGN: Mail survey (self-administered questionnaire). SETTING: Ontario. PARTICIPANTS: A stratified computer-generated random sample of 798 members of the College of Family Physicians of Canada. OUTCOME MEASURES: Proportions of respondents who chose various items in the management of two hypothetical patients, one with early rheumatoid arthritis and one with late rheumatoid arthritis. Scores for investigations, interventions and referrals for each scenario were generated by summing the recommended items chosen by respondents and then dividing by the total number of items recommended in that category. The scores were examined for their association with physician and practice characteristics and physician attitudes. RESULTS: The response rate was 68.3% (529/775 eligible physicians). Recommended investigations were chosen by more than two thirds of the respondents for both scenarios. Referrals to physiotherapy, occupational therapy and rheumatology, all recommended by the panel, were chosen by 206 (38.9%), 72 (13.6%) and 309 (58.4%) physicians respectively for early rheumatoid arthritis. These proportions were significantly higher for late rheumatoid arthritis (p < 0.01). In multiple regression analysis, for early rheumatoid arthritis, internship or residency training in rheumatology was associated with higher investigation and intervention scores, for late rheumatoid arthritis, older physicians had higher intervention scores and female physicians had higher referral scores. CONCLUSIONS: Primary care physicians' investigation of rheumatoid arthritis was in accord with panel recommendations. However, rates of referral to rheumatologists and other health care professionals were very low, especially for the early presentation of rheumatoid arthritis. More exposure to rheumatology and to the role of physiotherapy, occupational therapy and social work during primary care training is strongly recommended.

Adult↗
PubMed1996

Lack of concordance between the ICD-9 classification of soft tissue disorders of the neck and upper limb and chart review diagnosis: one steel mill's experience.

The aim of this study is to determine the validity of the ICD-9 for diagnostic classification of soft tissue disorders of the neck and upper limb, using routinely collected data at a large steel company. The documentation in the clinical chart served as the gold standard. First, the overall accuracy of identifying these disorders from the ICD-9 was examined. Second, we examined whether the codes themselves, on an individual basis, accurately reflected the underlying problems as documented in the medical records. There were 1,267 new cases identified in 1991 by inclusion of all potentially applicable ICD-9 codes. Only 805 (63.5%) fulfilled the definition of a soft tissue disorder of the neck or upper limb as determined by chart review. A more restrictive strategy that only included cases coded by those ICD-9 codes that specifically pertain to these disorders yielded a higher proportion of true cases 458/480 cases (95.4%), but failed to identify the other 347 cases. The anatomical site of the problem could not be identified from the codes describing 651/1,267 cases (51.4%). There was poor agreement between the diagnostic labels recorded in the medical records and the ICD-9 codes, suggesting that many of the terms are being used interchangeably. Our results suggest that conclusions about these disorders drawn from analysis of administrative data which rely upon the ICD-9 for diagnostic classification must be interpreted cautiously. For these soft tissue disorders, researchers will need to develop strategies which would improve upon and supplement the ICD-9.

Adult↗
PubMed1996

Classification systems of soft tissue disorders of the neck and upper limb: do they satisfy methodological guidelines?

A critical appraisal of existing classifications of soft tissue disorders of the neck and upper limb was performed utilizing methodological criteria including appropriateness for purpose, validity, reliability, feasibility, and generalizability. Five classifications were assessed independently by three raters using standardized forms. For those criteria that can be assessed by inspection of the classification itself, none of the classification systems appeared acceptable for reasons such as failure to be comprehensive, overlap of categories, and lack of demonstration that the criteria for inclusion into the categories are valid and reliable. No judgement could be passed about those criteria that require formal testing, such as reliability and construct validity, because of the absence of data. The overall interrater reliability of the critical appraisal was high, with an intraclass correlation coefficient of 0.82. The validity of studies that have relied upon existing classifications of soft tissue disorders of the neck and upper limb to group the entities under study is questioned in light of the findings of this study. Future work should be directed toward improving existing classification systems and/or developing new ones that fulfil basic measurement criteria.

Arm↗
PubMed1996

Determinants of physician confidence in the primary care management of musculoskeletal disorders.

OBJECTIVE: To examine the determinants of confidence in managing musculoskeletal (MSK) disorders among primary care physicians. METHOD: A self-administered questionnaire was mailed to a stratified (by urban/rural location) random sample of 798 Ontario primary care physicians who were members of the College of Family Physicians of Canada. Two mailings and a reminder postcard were used to increase response. As the main outcome measure, confidence was measured on a 10 point Likert-type scale. RESULTS: The overall response rate was 68.3%. Most respondents were practising in a full time group setting; their average age was 40.3 years. Respondents were significantly more confident in performing a comprehensive cardiovascular examination than a MSK examination. Highest levels of confidence were observed for using nonsteroidal antiinflammatory drugs and managing common MSK disorders. Lower scores were reported for doing a joint injection/aspiration. Rural physicians were more confident than urban physicians in doing a joint injection/aspiration and monitoring patients who were taking disease modifying agents. Previous continuing medical education (CME) was significantly (p < 0.01) related to all confidence outcomes using multiple regression analysis. For many outcomes, men reported higher confidence scores than women after adjustment for various demographic characteristics. CONCLUSION: CME may be the most important and modifiable variable to improve physician management of MSK disorders.

Adult↗
PubMed1995

Critical appraisal of continuing medical education in the rheumatic diseases for primary care physicians.

OBJECTIVE: To critically appraise evidence of the effectiveness of continuing medical education (CME) in rheumatic diseases for primary care physicians. METHODS: Three physicians independently applied preset criteria to evaluated CME interventions published between January 1966 and August 1993. RESULT: Eight of 166 articles identified were critically appraised, 7 of which had positive results. Marked heterogeneity in educational interventions, evaluative methods, and outcomes was noted. CONCLUSION: Despite generally positive results, weak methodology precludes drawing firm conclusions about the effectiveness of CME in rheumatic diseases.

Education, Medical, Continuing↗
PubMed1995

Which outcome measures should be used in rheumatoid arthritis clinical trials? Clinical and quality-of-life measures' responsiveness to treatment in a randomized controlled trial.

OBJECTIVE: To determine the discriminant validity of the core set of outcome measures proposed by the American College of Rheumatology (ACR) and the Outcome Measures in Clinical Trials (OMERACT) conference committee to be used in clinical trials of rheumatoid arthritis (RA). METHODS: Utilizing data from a multicenter randomized double-blind clinical trial of low-dose cyclosporine and placebo in RA, we estimated the relative efficiency (RE) of measures to detect a treatment effect (relative to tender joint count, which was assigned a value of 1). Four pain measures (10-cm visual analog scale [VAS], 5-point categorical scale, Health Assessment Questionnaire [HAQ] pain index, Arthritis Impact Measurement Scales [AIMS] pain score) and 3 quality-of-life measures (Problem Elicitation Technique [PET], HAQ, AIMS) were compared. RESULTS: Physician and patient global measures were the most responsive instruments, although neither was statistically superior to tender joint count. Swollen joint count, grip strength, pain measured on a 10-cm VAS, and functional status as measured by the PET and HAQ were all of intermediate responsiveness. Morning stiffness, 5-point pain scale, and erythrocyte sedimentation rate were the least responsive instruments. CONCLUSION: This study provides further evidence to support the core set of outcome measures proposed by the ACR and OMERACT:

Adolescent↗
PubMed1993

Methotrexate therapy in rheumatoid arthritis: a life table review of 587 patients treated in community practice.

To determine whether methotrexate (MTX) maintains its effectiveness in rheumatoid arthritis (RA) in the setting of community based private rheumatology practice we used life table analysis to review the combined experience of a group of these practices. Of 587 patients with RA who started to take MTX, total termination rate at 70 months was 24.4% with most terminations prompted by drug toxicity. Older age (greater than 65 years) was associated with higher rates of toxicity. Treatment termination rates varied substantially between rheumatologists. We conclude that MTX therapy for RA is well tolerated and maintains effectiveness for at least 70 months.

Adult↗
PubMed1992

Efficacy of cyclosporin A in rheumatoid arthritis: long-term follow-up data and the effect on quality of life.

Cyclosporin A is a potent immunomodulator which was used initially in organ transplantation. It has subsequently been used in the management of various autoimmune conditions. This paper is concerned with experience to date with cyclosporin A in the treatment of rheumatoid arthritis. It considers the major clinical trials, long-term experience, and the impact of cyclosporin A on quality of life.

Arthritis, Rheumatoid↗
PubMed1992

Management of suspected giant cell arteritis: a decision analysis.

We used decision analysis to compare 4 strategies for managing suspected giant cell arteritis (GCA): treat no patients, treat all patients, perform temporal artery biopsy and only treat positive cases, or biopsy and treat all cases irrespective of the result. The "treat no patients" strategy is preferred only if the likelihood of disease is less than 2%. The "biopsy and treat positive cases" strategy predominates for intermediate likelihood of disease (50%) and is insensitive to altering the probability of any key variables. The "biopsy but treat irrespective of the result" strategy becomes preferred at likelihood of disease of 81%. However, this result was sensitive to alteration of the key variables. Empirical therapy without biopsy would only be preferred if the likelihood of disease exceeded 90% and the disutility one attaches to treating under uncertainty is low at high probability of disease. Management of suspected GCA should be guided by the results of temporal artery biopsy in the majority of cases. At high likelihood of disease, temporal artery biopsy may be of value independent of its usefulness in determining management strategy. Further research should be directed towards improving the accuracy of diagnosis, defining the risk of iatrogenic complications and estimating utilities for the outcomes.

Adrenal Cortex Hormones↗
PubMed1990

Takayasu's arteritis.

The cause of Takayasu's arteritis is still obscure. However, certain aspects of the disease have been greatly clarified over the past decade. The disease is worldwide in distribution, with no ethnic group being totally free from risk of the condition. The inflammatory and stenotic phases of the disease frequently coexist, and it is important that the condition be diagnosed before it has progressed to the phase of extensive, severe vascular occlusion. Corticosteroid therapy is effective in ameliorating both the more inflammatory aspects of the condition (fever, arthritis, myocarditis) and the hemodynamic problems of vascular stenoses, in some cases allowing return of previously absent pulses. The role of adjunctive cytotoxic therapy is less certain, although there is probably a place for it in cases characterized by corticosteroid resistance or severe consequences of hypercortisolism. Vascular reconstruction is safe and effective once the inflammatory phase of the disease has remitted or been controlled with drug therapy. Prognosis is related to specific disease complications associated with longer duration of disease. Therefore, treatment intervention may modify the natural history of the disease over the long term.

Adult↗
PubMed1988

Neuropsychiatric manifestations of systemic lupus erythematosus.

Forty-six episodes of major neuropsychiatric manifestations of systemic lupus erythematosus occurring in 35 patients over a ten-year period were reviewed. The frequency of central nervous system SLF was lower than that reported from overseas referral centres. Glucocorticosteroid treatment did not precipitate psychiatric problems in this group. Whilst neuropsychiatric recovery was the rule, such features indicated a subgroup of SLE with high short-term mortality.

Adolescent↗
PubMed1985

Effects of shoes and foot orthotics on VO2 and selected frontal plane knee kinematics.

The objective of this study was to investigate the effects of shoes and foot orthotics on running economy and selected frontal plane knee kinematics during the support phase of running. Twenty-one male runners who had been fitted with orthotics served as subjects. Subjects participated in three submaximal runs on a treadmill under the following conditions: barefoot, shoes, and shoes plus orthotics. A run consisted of 1 min at 161 m . min-1, 2 min at 180 m . min-1, and 4 min at 201 m . min-1. VO2 was calculated for the last 3 min of each test. Frontal plane motion was filmed during the sixth min of each submaximal run, and linear and angular displacement of the knee were then calculated from film data. Results from the mechanical aspect of this study indicate that there were no significant differences among the means for linear displacement of the knee. Angular displacement of the knee during barefoot running was significantly (P less than 0.05) less than shoe and shoe-plus-orthotic conditions. There was no difference, however, between shoes and shoes plus orthotics. The economy results revealed that the aerobic cost of running increased as the amount of mass added to the foot increased. In absolute terms (1 . min-1), running in shoes plus orthotics was significantly (P less than 0.05) more costly than running barefoot. It appears that if orthotics do, in fact, improve running economy by improving running mechanics, the amount of improvement is negated by the additional cost of running associated with the mass of the orthotics.

Energy Metabolism↗
PubMed1976

Recorded and reported sleep in chronic primary insomnia.

Sleep polygraph and questionnaire data of 18 chronic primary insomniacs were compared with those of 18 age- and sex-matched controls. The insomniacs had significantly longer sleep latencies, less total sleep, less sleep efficiency, more terminal wake time, and less delta sleep. There were significant discrepancies between the insomniacs' and controls' subjective assessments of their sleep and the sleep-polygraph data, but in opposite directions. The insomniacs' recorded sleep also showed more night-to-night variability than that of the controls. However, the controls, in contrast to the insomniacs, reported sleeping worse in the laboratory than at home. Significant differences between insomnia subtypes validly reflected the insomniacs' subjective complaints and were generally in accord with expectations based on them.

Adult↗