Associations of low formal education level and poor health status: behavioral, in addition to demographic and medical, explanations?
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Demography↗
Biomedical subjects
T Pincus
Publications and source records attributed to T Pincus.
Rheumatoid arthritis: a medical emergency?
Rheumatoid arthritis (RA), previously considered to be a benign controllable disease with a good prognosis in the majority of patients, is now known to be a severe, progressive disease in terms of radiographic damage, severe functional deterioration, progressive work disability and premature mortality. The traditional approach to RA therapy (from less toxic to more toxic drugs) is inadequate and the risk of drug toxicity is generally overestimated while that of severe disease is underestimated. Consequently, aggressive treatment could be considered in an attempt to reverse the inflammation prior to long-term end-organ damage, rather than in response to such damage. As patients with RA may progress to an anticipated 5-year survival similar to that in patients with cardiovascular or neoplastic disease, RA should be viewed as an urgent medical problem--a "medical emergency"--in order to control the long-term consequences of the disease process.
Arthritis, Rheumatoid↗
Progression of childhood linear scleroderma to fatal systemic sclerosis.
An 8-year-old girl presented with linear scleroderma, no evidence of systemic disease, and a negative antinuclear antibody (ANA) test. Over the next 12 months, she functioned normally. However, over the subsequent 5 months, she developed dyspnea, progressive pulmonary hypertension, a positive ANA test, and died 17 months after presentation. At autopsy, diffuse pulmonary interstitial fibrosis, small pulmonary arterial fibroplasia, tricuspid and mitral valve subendocardial fibrosis, and distal esophageal fibrosis were seen. Contrary to suggestions in the rheumatology literature, childhood linear scleroderma, even when ANA negative at presentation, may progress to fatal systemic sclerosis.
Antibodies, Antinuclear↗
How many types of patients meet classification criteria for rheumatoid arthritis?
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Arthritis, Rheumatoid↗
Depression scales in rheumatoid arthritis: criterion contamination in interpretation of patient responses.
Self-report depression scales include items concerning somatic symptoms, such as fatigue, pain, and inability to work, which may be symptoms of depression in individuals who do not have a chronic disease. However, in patients with somatic diseases such as rheumatoid arthritis, these symptoms may reflect disease rather than depression. Interpretation of responses to these items in patients with chronic disease as indicating depression is known as "criterion contamination". Criterion contamination has been described in responses of patients with rheumatoid arthritis on many widely-used depression scales, including the Minnesota Multiphasic Personality Inventory (MMPI), the Beck Depression Inventory, and the Center for Epidemiologic Studies Depression Index (CES-D). Evidence for criterion contamination in responses of patients with rheumatoid arthritis on these depression scales is summarized in this essay.
Arthritis, Rheumatoid↗
Limitations of randomized clinical trials to recognize possible advantages of combination therapies in rheumatic diseases.
Potential advantages of combination second-line drug therapy in rheumatoid arthritis (RA) may not be detectable in standard randomized controlled clinical trials, despite excellent design and performance. This results from intrinsic limitations of usual clinical studies, such as a short time frame, patient selection, and insufficient numbers of patients. Examples of selected clinical protocols in rheumatic diseases that illustrate these problems are presented. In systemic lupus erythematosus, many well-designed and -performed trials comparing combinations of cytotoxic drugs and corticosteroids with corticosteroids alone were inconclusive. However, combination therapy was superior in three types of studies: a 15-year clinical trial, a pooled analysis of multiple trials, and longitudinal databases of unselected patients. In RA, a 48-week study indicated no differences in results of treatment with auranofin, methotrexate, and the combination of these two drugs. In contrast, a clinical database from 15 rheumatology practices indicates that methotrexate was continued for 5 years by more than 50% of patients, compared with fewer than 10% for auranofin. A subset from the clinical database of courses of second-line drugs over 1 year (rather than 5 years), for only the initial course of a second-line drug (rather than any course), was examined. Using these selected data, which mimic the conditions of the clinical trial, no significant differences were seen in continuation of methotrexate versus auranofin. This observation suggests that intrinsic limitations, including patient selection, insufficient patient numbers, and a short time frame, may render it difficult (or impossible) to document the efficacy of combination therapy in RA using standard randomized controlled clinical trials.
Arthritis, Rheumatoid↗
Self-referential selective memory in pain patients.
The effect of self-reference on recall bias for pain stimuli was compared in chronic pain patients and controls. It was hypothesized that self-referential encoding would result in better recall of pain stimuli in chronic pain patients. In contrast, it was predicted that a non-pain control group would display no recall bias for pain-associated stimuli, regardless of the encoding reference. Subjects were tested in two conditions. The first condition (self-referential) involved encoding a list of words constructed from sensory pain, affective and neutral words. Elaboration at the encoding stage was achieved by asking subjects to imagine themselves in situations involving these words. Subjects were also asked to rate the likelihood of these situations occurring on a scale of 1 to 5 (from 1 = 'will not happen' to 5 = 'certain to happen'). The second condition (other-person reference) repeated this task in reference to another person with a matched list of words. A 2 x 2 x 3 factorial analysis of variance based on group x reference (self and other) x word type (sensory, affective and neutral) was carried out on recall scores, with the likelihood ratings as a covariate. Results reveal a significant three-way interaction. The analysis indicated that, while pain patients show an increase in recall of sensory words and a decrease in recall of neutral words when these are encoded in reference to themselves, control subjects show no difference in recall of these word types regardless of the encoding condition. The results support the notion that pain patients selectively recall more pain-associated words in comparison with other word types. However, this effect is only true for stimuli encoded in reference to themselves. It is proposed that this processing bias may contribute to the maintenance of a sense of helplessness and exacerbate the emotional impact of the pain experience.
Adult↗
Patients' experience of surgical accidents.
OBJECTIVE: To examine the psychological impact of surgical accidents and assess the adequacy of explanations given to the patients involved. DESIGN: Postal questionnaire survey. SETTING: Subjects were selected from files held Action for Victims of Medical Accidents. PATIENTS: 154 surgical patients who had been injured by their treatment, who considered that their treatment had fallen below acceptable standards. MAIN MEASURES: Adequacy of explanations given to patients and responses to standard questionnaires assessing pain, distress, psychiatric morbidity, and psychosocial adjustment (general health questionnaire, impact of events scale, McGill pain questionnaire, and psychosocial adjustment to illness scale). RESULTS: 101 patients completed the questionnaires (69 women, 32 men; mean age 44 (median 41.5) years. Mean scores on the questionnaires indicated that these injured patients were more distressed than people who had suffered serious accidents or bereavements; their levels of pain were comparable, over a year after surgery, to untreated postoperative pain; and their psychosocial adjustment was considerably worse than in patients with serious illnesses. They were extremely unsatisfied with the explanations given about their accident, which they perceived as lacking in information, unclear, inaccurate, and given unsympathetically. Poor explanations were associated with higher levels of disturbing memories and poorer adjustment. CONCLUSIONS: Surgical accidents have a major adverse psychological impact on patients, and poor communication after the accident may increase patients' distress. IMPLICATIONS: Communication skills in dealing with such patients should be improved to ensure the clear and comprehensive explanations that they need. Many patients will also require psychological treatment to help their recovery.
Accidents↗
Variability in individual responses of 532 patients with rheumatoid arthritis to first-line and second-line drugs.
Variability in individual responses to drugs used to treat rheumatoid arthritis was studied in 532 patients under care in seven U.S. rheumatology private practices. Among 15 nonsteroidal anti-inflammatory drugs (NSAIDs), estimated continuation of 1,775 courses was 48% at 12 months and 20% at 60 months. Acetylated salicylates, other than plain aspirin, were continued significantly longer than other NSAIDs. Among second-line drugs, estimated continuation of 50% of courses was 10 months for oral gold, 20 months for hydroxychloroquine, 21 months for penicillamine, 25 months for parenteral gold, 27 months for azathioprine, and more than 60 months for methotrexate and prednisone, the only drugs continued by more than 50% of patients 60 months after initiation.
Anti-Inflammatory Agents, Non-Steroidal↗
A pragmatic approach to cost-effective use of laboratory tests and imaging procedures in patients with musculoskeletal symptoms.
In this article, serologic tests and other procedures widely used to establish diagnoses of patients with rheumatic diseases are discussed. Musculoskeletal conditions are among the most common seen by physicians, and the current practice of including extensive laboratory tests and imaging procedures is not only ineffective but frequently results in misdiagnosis and inappropriate treatment. The approach outlined should provide treatment that is not only cost-effective but is directed to relief of symptoms and preservation of function, which are the primary goals of the patient and physician in the management of musculoskeletal problems. The costs in diagnosis of most patients with musculoskeletal pain often are considerably greater than the costs of treatment, which might be a reasonable consideration if expensive diagnostic studies would provide meaningful specificity regarding treatment. Many results, however, are misleading, for example, phenomena seen in at least 1% of the population, such as elevated ESR, rheumatoid factor titer, ANA, elevated uric acid, and Lyme Borreliosis titer, may be seen in individuals whose primary problem is fibromyalgia. In view of the fact that treatment is generally based on clinical observations, a considerable reduction in diagnostic studies might considerably reduce costs of patient care, without adversely affecting results and outcomes.
Clinical Laboratory Techniques↗
What is the natural history of rheumatoid arthritis?
Analyses of the natural history of RA, recognizing that all patients receive therapies, indicate the following: 1. Classification criteria for RA identify individuals with (at least) three different types of pathogenetic processes and long-term outcomes; most patients seen in clinical settings have progressive disease. 2. Results of therapies documented to be efficacious in clinical trials are not applicable to the long-term course of RA, in part due to patient selection and the short-time frame of observation in clinical trials; most therapies for RA are not effective in most patients over long periods. 3. Over periods of 10 years or longer, most patients with RA experience radiographic progression and severe functional declines, and work disability is seen in 60% of patients after 10 years of disease. 4. Mortality rates are increased in patients with RA, although RA is generally not listed on death certificates. 5. Individual patients with RA who are at risk for early mortality may be identified through clinical markers, including many involved joints, comorbid cardiovascular disease, and poor functional status according to questionnaires and physical measures. 6. Patient behaviors and lifestyles identified through formal educational level as a marker appear of great importance in the prevalence, morbidity, and mortality of RA.
Arthritis, Rheumatoid↗
Limitations to standard randomized controlled clinical trials to evaluate combination therapies in rheumatic diseases.
Randomized controlled clinical trials provide the cornerstone of modern research concerning medical therapies. However, important limitations intrinsic to clinical trials may restrict the generalizability of results to usual clinical practice. Limitations which appear particularly prominent in studies of combination therapies in inflammatory rheumatic diseases include: a) appropriate attention to group data which does not address variability of individual patient responses to specific agents; b) exclusion criteria to enter the clinical trial; c) small numbers with insufficient statistical power to identify clinically important trends; d) a time frame too short to recognize clinically meaningful differences between treatment regimens which may emerge over long periods. These limitations present problems in interpretation of studies in polymyositis, systemic lupus erythematosus, and rheumatoid arthritis. Strategies to improve accurate assessment of therapies include meta-analyses, clinical trials over at least five years, and long-term databases concerning consecutive patients seen in usual care.
Arthritis, Rheumatoid↗
The 'side effects' of rheumatoid arthritis: joint destruction, disability and early mortality.
Most patients with RA experience disease progression over periods longer than 5 years, characterized by radiographic joint destruction, declines in functional capacity to perform activities of daily living, frequent work disability, high levels of co-morbidities, and death earlier than expected. These long-term consequences of RA may be viewed as 'side effects' of disease, which must be balanced against possible side effects of drugs in planning treatments of patients with RA. Aggressive approaches, which may include acceptance of mild and even moderate side effects of drugs, may be appropriate in efforts to prevent 'side effects' of RA.
Anti-Inflammatory Agents↗
The American College of Rheumatology 1991 revised criteria for the classification of global functional status in rheumatoid arthritis.
OBJECTIVE: To develop and validate revised criteria for global functional status in rheumatoid arthritis (RA). METHODS: Revised criteria were formulated and tested for criterion and discriminant validity in 325 patients with RA. RESULTS: The revised criteria developed are as follows: class I = able to perform usual activities of daily living (self-care, vocational, and avocational); class II = able to perform usual self-care and vocational activities, but limited in avocational activities; class III = able to perform usual self-care activities but limited in vocational and avocational activities; class IV = limited in ability to perform usual self-care, vocational, and avocational activities. Usual self-care activities include dressing, feeding, bathing, grooming, and toileting; vocational and avocational activities are both patient-desired and age-, and sex-specific. The distribution properties of this classification schema were superior to those of the original Steinbrocker criteria. Mean Health Assessment Questionnaire scores were significantly (P less than 0.0001) different between, and increased across, the 4 classes. CONCLUSION: Although there are limitations inherent in the use of global ordinal scales, the American College of Rheumatology revised criteria will be useful in describing the functional consequences of RA. A more detailed quantitative measure of physical disability should be used, however, for optimal monitoring of patients' clinical status in office practice and clinical research.
Activities of Daily Living↗
The paradox of effective therapies but poor long-term outcomes in rheumatoid arthritis.
Treatment of rheumatoid arthritis (RA) presents a paradox: Many effective therapies are extensively documented in numerous clinical trials, but all long-term studies from clinical settings indicate that most patients with RA have progressive disease. This paradox may be explained in part on the basis of four observations: (1) Results of therapies for RA have been evaluated primarily according to clinical trials over short periods rather than according to long-term clinical observations over many years; (2) increased mortality rates in RA have not been widely recognized because RA is not included on death certificates of more than half of the patients who die with this disease; (3) mortality in RA generally has been attributed to causes unrelated to RA or to drug toxicity, but higher mortality in specific patients is predicted primarily by more severe clinical status; and (4) published reports indicating an optimistic prognosis in RA have been based on epidemiological studies rather than on patients in clinical settings. In epidemiological studies of large populations, 75% of individuals who meet the 1958 American Rheumatism Association (ARA) criteria for RA have no evidence of disease 3 to 5 years later; in contrast, in clinical settings more than 90% of patients with RA have evidence of disease 3 to 5 years later, generally with progression.
Arthritis, Rheumatoid↗
Identification of work disability in rheumatoid arthritis: physical, radiographic and laboratory variables do not add explanatory power to demographic and functional variables.
Work disability, a common problem in rheumatoid arthritis (RA), is known to be associated with demographic variables such as occupation, age, and formal education, as well as with disease duration. However, physical, radiographic and laboratory variables, which are included in the traditional "medical model" of work disability and collected routinely in the application process, have not been studied for their capacity to explain whether patients are working or receiving work disability payments. A cross-sectional database which included an extensively characterized group of patients with RA was examined to determine possible associations of demographic, functional, physical, radiographic and laboratory variables with work disability status. All these variables differed in patients who were receiving work disability payments and those who were working full time, but in multivariate analyses, work or disability status was best identified by demographic and functional variables. Physical, radiographic, and laboratory data did not add significantly to explanation of work disability status beyond the demographic and functional variables and disease duration, despite the fact that receipt of disability payments was used as the criterion for work disability status.
Activities of Daily Living↗
Educational attainment and osteoarthritis: differential associations with radiographic changes and symptom reporting.
Educational attainment has been negatively associated with the prevalence, morbidity and mortality of many diseases. With knee osteoarthritis as an example, we used NHANES I data to examine whether the cross-sectional association between formal education and disease is due to known risk factors, and also whether educational attainment is more strongly associated with self-reported symptoms or with radiographic change. We found univariate associations between osteoarthritis and low levels of education. For radiographic knee osteoarthritis in women, and in both sexes combined, this relationship was explained by controlling for known risk factors, which included age, knee injury, race, obesity, and occupation. However, even after adjusting for these major risk factors and the presence of radiographic changes, reporting of knee pain and arthritis at any site remained significantly associated with low educational attainment, especially for those with less than or equal to 8 years of education.
Adult↗
The case for early intervention in rheumatoid arthritis.
A case for early intervention in rheumatoid arthritis is presented on the basis of the following observations: (1) established rheumatoid arthritis of 5 years duration or more is a progressive disease in most patients; (2) most patients with rheumatoid arthritis already have evidence of permanent radiographic damage within the first 2 years of disease; (3) the morbidity and mortality of rheumatoid arthritis are predicted by baseline data indicating more severe clinical status, rather than drug toxicity or causes 'unrelated' to rheumatoid arthritis; (4) currently used therapies, even those documented to be effective in randomized controlled trials, are not effective in most patients over periods of 2 years or longer. It is not known whether earlier intervention will result in better outcomes. However, these phenomena suggest a need for studies to evaluate early aggressive intervention in rheumatoid arthritis.
Antimalarials↗