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1.  Pain trajectory groups in persons with, or at high risk of, knee osteoarthritis: findings from the Knee Clinical Assessment Study and the Osteoarthritis Initiative 
Osteoarthritis and Cartilage  2014;22(12):2041-2050.
Summary
Objective
The authors aimed to characterize distinct trajectories of knee pain in adults who had, or were at high risk of, knee osteoarthritis using data from two population-based cohorts.
Method
Latent class growth analysis was applied to measures of knee pain severity on activity obtained at 18-month intervals for up to 6 years between 2002 and 2009 from symptomatic participants aged over 50 years in the Knee Clinical Assessment Study (CAS-K) in the United Kingdom. The optimum latent class growth model from CAS-K was then tested for reproducibility in a matched sample of participants from the Osteoarthritis Initiative (OAI) in the United States.
Results
A 5-class linear model produced interpretable trajectories in CAS-K with reasonable goodness of fit and which were labelled “Mild, non-progressive” (N = 201, 35%), “Progressive” (N = 162, 28%), “Moderate” (N = 124, 22%) “Improving” (N = 68, 12%), and “Severe, non-improving” (N = 15, 3%). We were able to reproduce “Mild, non-progressive”, “Moderate”, and “Severe, non-improving” classes in the matched sample of participants from the OAI, however, absence of a “Progressive” class and instability of the “Improving” classes in the OAI was observed.
Conclusions
Our findings strengthen the grounds for moving beyond a simple stereotype of osteoarthritis as “slowly progressive”. Mild, non-progressive or improving symptom trajectories, although difficult to reproduce, can nevertheless represent a genuinely favourable prognosis for a sizeable minority.
doi:10.1016/j.joca.2014.09.026
PMCID: PMC4256061  PMID: 25305072
Knee; Pain; Latent class growth analysis; Longitudinal; Osteoarthritis; Trajectories; ABIC, sample-size adjusted Bayesian information criterion; AIC, Akaike information criterion; BIC, Bayesian information criterion; B-LRT, Bootstrap likelihood ratio test; CAS-K, knee clinical assessment study; OAI, osteoarthritis initiative; VLMR-LRT, Viong-Lo-Mendall-Rubin likelihood ratio test; WOMAC, Western Ontario & McMaster Universities Osteoarthritis Index
2.  Symptoms and radiographic osteoarthritis: not as discordant as they are made out to be? 
Objectives
Joint pain and radiographic osteoarthritis are often discordant.
Aim
To investigate this issue more closely by studying the detailed nature of pain and disability, and how this relates to radiographic osteoarthritis.
Methods
Population‐based study of 819 adults aged ⩾50 years with knee pain. The severity of knee pain, stiffness and disability was measured using a validated scale (the Western Ontario and McMaster Universities (WOMAC) Score) and pain persistence was recorded. Global severity was measured by the graded chronic pain scale. Three radiographic views of the knees were obtained—weight‐bearing posteroanterior metatarsophalangeal, supine skyline and supine lateral.
Results
745 participants with knee pain in the past 6 months were eligible (mean age 65 years, 338 men). Radiographic osteoarthritis was more common in those with a longer history and more persistent symptoms. A strong trend was found of radiographic osteoarthritis being more strongly associated with higher WOMAC scores for pain severity, stiffness and disability (adjusted odds ratio (95% confidence interval (CI)) for highest v lowest WOMAC category: 3.7 (2.0 to 6.7), 3.0 (2.0 to 4.6) and 2.8 (1.6 to 5.0), respectively). Those individual WOMAC items for pain and disability pertaining to weight‐bearing mobility were the most strongly associated with radiographic osteoarthritis. Combining pain persistence and global severity, persistent severe pain was associated with a significant increase in the occurrence of radiographic osteoarthritis (2.6 (95% CI 1.5 to 4.7)).
Conclusions
A consistent association was found between severity of pain, stiffness and physical function and the presence of radiographic osteoarthritis. This study highlights the potential contribution of underlying joint disease to the degree of pain and disability.
doi:10.1136/ard.2006.052548
PMCID: PMC1798418  PMID: 16877532
3.  Clinical classification criteria for knee osteoarthritis: performance in the general population and primary care 
Annals of the Rheumatic Diseases  2006;65(10):1363-1367.
Background
Doubts have been expressed about the performance of the American College of Rheumatology (ACR) clinical classification criteria for osteoarthritis when applied in the general population.
Objective
To investigate whether the distribution of population subgroups and underlying disease severity might explain the performance of these criteria in the population setting.
Methods
Population‐based cross‐sectional study. 819 adults aged ⩾50 years reporting knee pain in the last 12 months were clinically assessed by research therapists using standardised protocols and blinded to radiographic status. All participants underwent plain radiography of the knees, scored by a single reader blinded to clinical status. The relationship between fulfilling the ACR clinical classification criteria for knee osteoarthritis and the presence of symptomatic radiographic knee osteoarthritis was summarised for the sample as a whole and within subgroups.
Results
Radiographic osteoarthritis was present in 539 participants (68%) and symptomatic radiographic knee osteoarthritis in 259 (33%). 238 participants (30%) fulfilled the ACR clinical criteria for knee osteoarthritis. Agreement between the ACR clinical criteria and symptomatic radiographic knee osteoarthritis was low (sensitivity 41%; specificity 75%; positive predictive value 44%; negative predictive value 72%). Sensitivity and specificity did not vary markedly between population subgroups, although they were influenced by the underlying severity of radiographic osteoarthritis.
Conclusion
The ACR clinical criteria seem to reflect later signs in advanced disease. Other approaches may be needed to identify early, mild osteoarthritis in the general population and primary care.
doi:10.1136/ard.2006.051482
PMCID: PMC1798313  PMID: 16627539
4.  A comparison of two primary care trials on tennis elbow: issues of external validity 
Annals of the Rheumatic Diseases  2005;64(10):1406-1409.
Objective: To assess clinical heterogeneity across two studies with respect to study population, interventions, and outcome measures, and to evaluate the influence of these sources of heterogeneity on the results of the studies.
Methods: The individual patient data were used from two randomised controlled trials investigating the effectiveness of conservative treatments in patients with tennis elbow in primary care. Patients were allocated at random to treatment with steroid injection, wait and see policy, non-steroidal anti-inflammatory drugs, placebo tablets, or physiotherapy. Outcome measures included severity of the main complaint, inconvenience of the elbow complaints, pain during the day, elbow disability, pain-free grip strength, and global improvement. All outcomes were assessed at 1, 6, and 12 months after randomisation.
Results: The two study populations were similar with respect to age, sex, comorbid neck/shoulder complaints, and baseline scores for the severity of pain. However, significant differences were observed for employment status, duration of elbow complaints, dominant side affected, previous history of elbow complaints, and use of analgesics. Local injections differed between the two studies with respect to volume, number, and steroid preparation. However, after 1, 6, and 12 months, the treatment effects of steroid injections were very similar between the study populations.
Conclusions: Despite large differences in study population at baseline, the responses to steroid injections were remarkably similar. Also the responses to other conservative interventions and the placebo treatment were very consistent, suggesting a uniform course of a tennis elbow and a lack of influence of clinical heterogeneity.
doi:10.1136/ard.2004.029363
PMCID: PMC1755250  PMID: 15800009
5.  Substance misuse and psychiatric illness: prospective observational study using the general practice research database 
Objectives: To quantify the relation between substance misuse and psychiatric illness in the UK general practice population in terms of (a) the relative risk of developing one condition given prior exposure to the other and (b) the proportion of cases of one condition attributable to exposure to the other.
Design: Population based prospective observational study using the general practice research database (GPRD) between 1993 and 1998. The 230 GP practices represent 3.1% of the population.
Setting: England and Wales.
Participants: 1.4 million registered patients of whom 3969 had both substance misuse and psychiatric diagnoses between 1993 and 1998.
Main outcome measures: Relative risk (RR) for subsequent psychiatric illness among participants exposed to substance misuse and RR for subsequent substance misuse among participants exposed to psychiatric illness. Population attributable risk (PAR) of psychiatric illness attributable to substance misuse and of substance misuse attributable to psychiatric illness.
Results: The baseline prevalence of psychiatric illness over the study period was 15% and 0.3% for substance abuse. RR for psychiatric illness for substance misusers compared with non-substance misusers was 1.54 (95% CI 1.47 to 1.62). RR for substance misuse among psychiatric compared with non-psychiatric cases was 2.09 (95% CI 1.99 to 2.22). PAR for psychiatric illness attributable to substance misuse was 0.2%. PAR for substance misuse attributable to psychiatric illness was 14.2%.
Discussion: Only a comparatively small proportion of psychiatric illness seems possibly attributable to substance use whereas a more substantial proportion of substance use seems possibly attributable to psychiatric illness. This study does not support the hypotheses that comorbidity between substance misuse and psychiatric illness is primarily the result of substance misuse or that increasing comorbidity is largely attributable to increasing substance misuse.
doi:10.1136/jech.2004.030833
PMCID: PMC1732930  PMID: 16166357
6.  Two pragmatic trials of treatment for shoulder disorders in primary care: generalisability, course, and prognostic indicators 
Annals of the Rheumatic Diseases  2005;64(7):1056-1061.
Objective: To investigate predictors of long term prognosis in patients treated for shoulder pain in primary care.
Methods: Data were taken from two pragmatic randomised clinical trials investigating the effectiveness of conservative treatments for shoulder pain presenting to primary care. Shoulder pain severity, disability, and perceived recovery measured in the long term (UK, 18 months; Netherlands, 12 months) were considered as outcome measures. Prognostic indicators measured before randomisation were determined by linear regression (pain severity and disability) and logistic regression (perceived recovery).
Results: 316 adults with a new episode of shoulder pain were recruited (UK, n = 207; Netherlands, n = 109). In multivariate analysis, greater shoulder disability at follow up was associated with higher baseline disability score, concomitant neck pain, and a gradual onset and longer duration of shoulder symptoms. Pain scores at follow up were higher in women and in those with longer baseline duration of symptoms and higher baseline pain or disability scores. Being female, reporting gradual onset of symptoms, and a higher baseline disability score each independently reduced the likelihood of perceived recovery.
Conclusions: The results suggest that there is no long term difference in outcome between patients with shoulder pain treated with different clinical interventions in different clinical settings, or having different clinical diagnoses. Baseline clinical characteristics of this consulting population, rather than the randomised treatments which they received, were the most powerful predictors of outcome. Whether this highlights the need for earlier intervention or reflects different natural histories of shoulder pain is a topic for further research.
doi:10.1136/ard.2004.029959
PMCID: PMC1755568  PMID: 15640264
7.  Prevalence of comorbid psychiatric illness and substance misuse in primary care in England and Wales 
Study objective: To estimate the annual period prevalence of co-occurring psychiatric illness and substance misuse among patients in primary care.
Design: Analysis of the general practice research database.
Setting: England and Wales, 1993–1998.
Participants: Registered patients at 230 general practices representing 3.1% of the population. A comorbid case was defined as one with both a psychiatric diagnosis and substance misuse diagnosis (not including alcohol or tobacco) within a calendar year. A potentially chronic comorbid case was one that met this definition and, in addition, was treated in subsequent years for either a psychiatric condition or substance misuse.
Main results: The annual period prevalence of comorbidity increased from 50/100 000 patient years of exposure (PYE) to 80/100 000 PYE, an increase of 62% during the study period. Rates of comorbid psychoses, comorbid schizophrenia, and comorbid paranoia increased by 147%, 128%, and 144%. The average age of comorbid cases decreased from 38 years to 34 years. Over 80% of comorbid cases were newly diagnosed in each study year, although many are treated in subsequent years for either psychiatric illness or substance misuse.
Conclusions: This study provides data on the nature and extent of comorbidity in primary care in England and Wales. As the comorbidity rate is increasing by about 10% each year, and as comorbid cases are becoming younger, it is probable that the comorbidity rate will have increased beyond the study end point.
doi:10.1136/jech.2003.017384
PMCID: PMC1732645  PMID: 15547069
8.  A comparison of four shoulder-specific questionnaires in primary care 
Annals of the Rheumatic Diseases  2004;63(10):1293-1299.
Objectives: To compare the validity, responsiveness to change, and user friendliness of four self completed, shoulder-specific questionnaires in primary care.
Methods: A cross sectional assessment of validity and a longitudinal assessment of responsiveness to change of four shoulder questionnaires was carried out: the Dutch Shoulder Disability Questionnaire (SDQ-NL); the United Kingdom Shoulder Disability Questionnaire (SDQ-UK); and two American instruments, the Shoulder Pain and Disability Index (SPADI) and the Shoulder Rating Questionnaire (SRQ). 180 primary care consulters with new shoulder region pain each completed two of the questionnaires, as well as EuroQoL and 10 cm visual analogue scales (VAS) for overall pain and difficulty due to the shoulder problem. Each participant was assessed by a standardised clinical schedule. Postal follow up at 6 weeks included baseline measures and self rated assessment of global change of the shoulder problem (seven point Likert scale).
Results: Strongest correlations were found for SDQ-UK with EuroQoL 5 score, and for SPADI and SRQ with shoulder pain and difficulty VAS. All shoulder questionnaires correlated poorly with active movement at the painful shoulder. SPADI and SRQ performed better on ROC analysis than SDQ-NL and SDQ-UK (areas under the curve of 0.87, 0.85, 0.77, and 0.77, respectively). However, SRQ scores changed significantly over time in stable subjects.
Conclusions: Cross sectional comparison of the four shoulder questionnaires showed they had similar overall validity and patient acceptability. SPADI and SRQ were most responsive to change. Additionally, SPADI was the quickest to complete and scores did not change significantly in stable subjects.
doi:10.1136/ard.2003.012088
PMCID: PMC1754749  PMID: 15361390
9.  Clinical comorbidity in patients with osteoarthritis: a case-control study of general practice consulters in England and Wales 
Annals of the Rheumatic Diseases  2004;63(4):408-414.
Objectives: To determine patterns of clinical comorbidity in general practice consulters with OA and compare them with comorbidity in consulters without OA.
Methods: A case-control study nested in a one-year prevalence survey of consultations in 60 general practices in England and Wales. Cases were 11 375 subjects aged 50 and over who had consulted with OA during the study year. Controls were 11 780 subjects matched for age and sex who had consulted during the study year, but not for OA. Morbidity outcomes were based on a standard clinical classification system.
Results: After adjusting for age, sex, and social class, cases were significantly more likely to have high levels of comorbidity than controls (2.35; 2.16 to 2.55). Significant OA comorbid associations with other musculoskeletal conditions included arthropathies (OR 2.26; 99% CI 1.50 to 3.41), upper limb sprain (2.04; 1.38 to 3.00), synovial and tendon disorders (2.03; 1.54 to 2.68), and other joint disorders (2.00; 1.71 to 2.32). OA non-musculoskeletal associations were with obesity (2.25; 1.73 to 2.92), gastritis (1.98; 1.46 to 2.68), phlebitis (1.80; 1.28 to 2.52), diaphragmatic hernia (1.80; 1.29 to 2.51), ischaemic heart disease (1.73; 1.13 to 2.66) and intestinal diverticula (1.63; 1.20 to 2.23).
Conclusions: Comorbidity for OA was extensive, with musculoskeletal as well as non-musculoskeletal conditions. Age, sex, and social class did not explain this comorbidity but propensity to consult may be a part explanation. An important question remains as to whether comorbidity in general practice significantly adds to the disability or further impairs the health of patients with OA.
doi:10.1136/ard.2003.007526
PMCID: PMC1754944  PMID: 15020335
10.  Health status after hip or knee arthroplasty 
Annals of the Rheumatic Diseases  2003;62(8):700-701.
doi:10.1136/ard.62.8.700
PMCID: PMC1754637  PMID: 12860721
11.  How do GPs use x rays to manage chronic knee pain in the elderly? A case study 
Annals of the Rheumatic Diseases  2003;62(5):450-454.
Objectives: To determine whether clinical signs and symptoms of osteoarthritis influence general practitioners' (GPs) decisions about x raying older patients with knee pain and whether x ray reports alter their initial treatment or referral plan.
Methods: A cross sectional survey of 1000 GPs in England and Wales using "paper cases" in three questionnaires mailed at two-weekly intervals. The first questionnaire assessed GPs' management of patients with knee pain using four case scenarios, two with features of clinical knee osteoarthritis. The second questionnaire contained the same scenarios with information on x ray findings added. The third questionnaire considered management of knee pain in general.
Results: 447 GPs responded to questionnaire 1, 316 (71%) to questionnaire 2, 287 (64%) to questionnaire 3. 106 responders (25%) would have x rayed all four patients and 64 (15%) none. Choosing to carry out an x ray examination was not influenced by the presence of clinical signs and symptoms of osteoarthritis but was linked to other management choices, such as referral to orthopaedics (odds ratio (OR) 2.13; 95% confidence interval (CI) 1.62 to 2.81). The strongest predictor in questionnaire 2 of a treatment or referral was whether it had been chosen in the first survey. However, the x ray report was associated with a significant change in treatment and referrals. Where radiographic osteoarthritis was present, GPs were less likely to refer to a physiotherapist (OR 0.64; 95% CI 0.50 to 0.83) or rheumatologist (OR 0.15; 95% CI 0.08 to 0.28), and more likely to refer to an orthopaedic surgeon (OR 31.34; 95% CI 21.51 to 45.66). Questionnaire 3 showed that GPs' general views on the use of x rays correlated with the frequency of their choosing to x ray in the four individual case scenarios.
Conclusions: A GP's choice to x ray older people with knee symptoms is linked with decisions on treatment and referral even before the x ray result is known, but it does not appear to be influenced by clinical features of osteoarthritis. The presence of radiographic osteoarthritis has a marked impact on the decision to refer to secondary care. More evidence on the outcome of management without x rays is needed to help GPs in decision making.
doi:10.1136/ard.62.5.450
PMCID: PMC1754519  PMID: 12695159
12.  A pragmatic randomised controlled trial of local corticosteroid injection and physiotherapy for the treatment of new episodes of unilateral shoulder pain in primary care 
Annals of the Rheumatic Diseases  2003;62(5):394-399.
Objectives: To compare the long term effectiveness of local steroid injections administered by general practitioners with practice based physiotherapy for treating patients presenting in primary care with new episodes of unilateral shoulder pain.
Methods: Adults consulting with shoulder pain were recruited by their general practitioner. Patients were randomly allocated to receive either corticosteroid injections or community based physiotherapy. Primary outcome was self reported disability from shoulder problems at six months. Secondary outcomes included participant's global assessment of change; pain; function; "main complaint"; range of shoulder movement; co-interventions. A study nurse unaware of the treatment allocation performed baseline and follow up assessments. Analysis was by intention to treat.
Results: Over 22 months 207 participants were randomised, 103 to physiotherapy and 104 to injection. Prognostic variables were similar between the two groups at baseline. Mean (SD) improvements in disability scores at six weeks were 2.56 (5.4) for physiotherapy and 3.03 (6.3) for injection (mean difference=-0.5, 95% confidence interval (95% CI): -2.1 to 1.2) and at six months were 5.97 (5.4) for physiotherapy and 4.55 (5.9) for injection (mean difference=1.4, 95% CI -0.2 to 3.0). A "successful outcome" (a minimum 50% drop in the disability score from baseline) at six months was achieved by 59/99 (60%) in the physiotherapy group and 51/97 (53%) in the injection group (percentage difference=7%, 95% CI -6.8% to 20.4%). Co-interventions were more common in the injection group during follow up.
Conclusion: Community physiotherapy and local steroid injections were of similar effectiveness for treating new episodes of unilateral shoulder pain in primary care, but those receiving physiotherapy had fewer co-interventions.
doi:10.1136/ard.62.5.394
PMCID: PMC1754522  PMID: 12695148
13.  Syndrome of symptomatic adult acetabular dysplasia (SAAD syndrome) 
Annals of the Rheumatic Diseases  2003;62(4):356-358.
Design: Cross sectional analysis of a prospective cohort.
Setting: 35 general practices across the UK.
Subjects: 195 patients (63 male, 132 female) aged 40 years and over presenting with a new episode of hip pain
Results: The prevalence of acetabular dysplasia in this study of new presenters with hip pain was high (32%). There was no significant relationship between acetabular dysplasia and radiographic OA overall.
Conclusions: The high prevalence of acetabular dysplasia across all grades of OA severity suggests that dysplasia itself may be an important cause of hip pain ("symptomatic adult acetabular dysplasia").
doi:10.1136/ard.62.4.356
PMCID: PMC1754512  PMID: 12634238
14.  Previous consultation and self reported health status as predictors of future demand for primary care 
Design: Population based cohort study in two phases. Firstly, a baseline survey (1995/96) to identify the cohort and to obtain self reported health status using the UK census limiting long term illness (LLI) question and the Short Form-36 (SF-36) health profile. Secondly, analysis of general practice medical records for two years (1994/1995) before the survey and for two years (1997/1998) after the survey. Analysis was performed on: (a) all contacts coded by the GP, (b) the subgroup of contacts given a diagnostic morbidity code by the GP.
Setting: One general practice in North Staffordshire, UK.
Participants: 738 survey respondents who had consented to viewing of medical records including all those who reported LLI together with an age-gender matched control group of those who reported no LLI.
Main results: High frequency consulters in 1994/95 were more likely than non-consulters or average consulters in that year to be high consulters in 1997/98 (odds ratio 5.6, 95% confidence interval 3.82 to 8.25, for all contacts; 4.4 for diagnostic coded consultations). Self reported role disability and physical limitation from the SF-36 at baseline increased the probability of being a future high consulter but the effects were weaker than for previous consultation. Previous consultation within a diagnostic group was the main predictor for future consultation within that group with weaker but significant prediction by self reported health status.
Conclusions: Reliable morbidity coding in general practice provides the best available basis for predicting future demand in primary care. Self reported health status survey instruments add to this information but on their own are weaker predictors of future consultation.
doi:10.1136/jech.57.2.109
PMCID: PMC1732375  PMID: 12540685
15.  Chronic shoulder pain in the community: a syndrome of disability or distress? 
Annals of the Rheumatic Diseases  2002;61(2):128-131.
Objectives: To investigate two questions in a community based population of people with chronic shoulder pain. Firstly, does chronic pain lead to impaired psychological health over time? Secondly, how does restriction of daily activity influence pain perception and psychological health?
Methods: Two postal surveys, two years apart, were carried out to identify a group of subjects with chronic shoulder pain. The first survey was sent to a random sample of adults (n=40026) registered with a primary care practice, and included a pain manikin, demographic information, and the Hospital Anxiety and Depression scale (HAD). The second survey was sent to those subjects who reported unilateral shoulder region pain in the first survey and it included a shoulder-specific disability scale, pain severity score, and the HAD.
Results: 2606 (65.1%) people responded to the initial survey. Of these, 304 (11.7%) reported unilateral shoulder region pain at baseline. In the subsequent survey, there were 234 responders (83.3% adjusted response): 142 of these reported shoulder pain and formed our study group of "subjects with chronic shoulder pain". Within this group there was no significant change in psychological distress scores between baseline and follow up. Both the disability score and psychological distress scores correlated significantly with pain severity (disability v pain r=0.536, p<0.001; psychological distress v pain r=0.269, p=0.002). When the correlation between disability and pain severity was corrected for possible confounders, it remained significant (r=0.490, p<0.001). This was not the case for the correlation between psychological distress and pain (p>0.05). Disability was significantly correlated with psychological distress on univariate (r=0.445, p<0.001) and multivariate analysis (r=0.341, p=0.002).
Conclusion: In those with chronic shoulder pain the relation between pain and psychological health seems to be linked to disability. Psychological distress was not explained by persistent pain itself.
doi:10.1136/ard.61.2.128
PMCID: PMC1754001  PMID: 11796398
16.  Knee pain and osteoarthritis in older adults: a review of community burden and current use of primary health care 
BACKGROUND—Osteoarthritis is the single most common cause of disability in older adults, and most patients with the condition will be managed in the community and primary care.
AIM—To discuss case definition of knee osteoarthritis for primary care and to summarise the burden of the condition in the community and related use of primary health care in the United Kingdom.
DESIGN—Narrative review.
METHOD—A literature search identified studies of incidence and prevalence of knee pain, disability, and radiographic osteoarthritis in the general population, and data related to primary care consultations. Findings from UK studies were summarised with reference to European and international studies.
RESULTS—During a one year period 25% of people over 55 years have a persistent episode of knee pain, of whom about one in six in the UK and the Netherlands consult their general practitioner about it in the same time period. The prevalence of painful disabling knee osteoarthritis in people over 55 years is 10%, of whom one quarter are severely disabled.
CONCLUSION—Knee osteoarthritis sufficiently severe to consider joint replacement represents a minority of all knee pain and disability suffered by older people. Healthcare provision in primary care needs to focus on this broader group to impact on community levels of pain and disability.


doi:10.1136/ard.60.2.91
PMCID: PMC1753462  PMID: 11156538
17.  Health impact of pain in the hip region with and without radiographic evidence of osteoarthritis: a study of new attenders to primary care 
Annals of the Rheumatic Diseases  2000;59(11):857-863.
OBJECTIVES—To assess the health impact of hip pain at the time of first presentation to primary care, and the influence on this of radiographic evidence of osteoarthritis.
SUBJECTS AND METHODS—Cross sectional survey of 195 patients (63 male, 132 female), aged 40 years and over, presenting with a new episode of hip pain, recruited from 35 general practices across the UK. Health status at presentation was determined by a structured questionnaire on symptoms, healthcare use, and health related quality of life (SF-36). Pelvic radiographs were assessed blindly for hip osteoarthritis using standard scoring systems.
RESULTS—The overall impact on health was substantial. Before their first consultation, three quarters of patients needed analgesics, half used topical creams or ointments, and one in eight used a walking stick. Most of these impact measures were, however, unrelated to the degree of radiographic change, though use of a walking stick was increased in those with the most severe damage. Health status, as judged by the SF-36, was also impaired for measures of physical function and pain, but the impact on the "mental health", "general health", and "vitality" dimensions was small. There was a weak relation between the SF-36 scores and radiographic change, with many domains unrelated to the severity of radiographic damage.
CONCLUSIONS—This study is the first to show the therapeutic impact and pattern of impairment in health status resulting from hip pain at the time of first presentation to the healthcare services. Unlike many regional pain syndromes seen in primary care, such as back pain, hip pain does not impact on wider aspects of quality of life, such as general health status, mental health, or vitality. Furthermore, any impact of hip pain in this group is not markedly influenced by the degree of structural damage. Further follow up is required to determine whether such damage influences the persistence of any adverse impact.


doi:10.1136/ard.59.11.857
PMCID: PMC1753020  PMID: 11053061
18.  Social class, smoking and the severity of respiratory symptoms in the general population 
STUDY OBJECTIVE—The prevalence of respiratory symptoms has been found in some studies to vary with social class. One explanation of this link may be the effect of exposure to cigarette smoke. To investigate this, the relation between social class, smoking and respiratory symptoms was explored in a population based survey.
DESIGN—A cross sectional survey using a validated questionnaire.
SETTING—Two general practices in Staffordshire, United Kingdom.
PATIENTS—A random sample of 4237 patients aged 16 and over from two general practices in Staffordshire were mailed a questionnaire enquiring about respiratory symptoms and their severity.
MAIN RESULTS—The severity of respiratory symptoms increased with increasing exposure to cigarette smoke and was greater among manual social classes. Current smokers (odds ratio (OR) = 2.9, 95% confidence limits (CI) 2.3, 3.6), past smokers (OR = 1.5, 95% CI 1.2, 1.8) and passive smokers (OR = 1.4, 95% CI 1.0, 1.8) were more likely to report the more severe respiratory symptoms compared with non-smokers. Responders from social class V (OR = 2.4, 95% CI 1.3, 4.4) were more likely to report the more severe respiratory symptoms compared with social class I, as were responders from social classes IIIM (OR = 1.3, 95% CI 0.9, 1.9) and IV (OR = 1.4, 95% CI 0.9, 2.1). These effects were independent of each other.
CONCLUSIONS—This study has shown that social class is linked to the severity of respiratory symptoms, independently of smoking. Although the need to reduce and quit smoking in manual class households remains a crucial preventive issue, other mechanisms by which social class differences may influence symptom occurrence and severity need to be explored.


Keywords: social class; smoking; respiratory symptoms
doi:10.1136/jech.54.5.340
PMCID: PMC1731680  PMID: 10814653
19.  Factors affecting over-the-counter use of aspirin in the secondary prophylaxis of cardiovascular disease. 
The British Journal of General Practice  2001;51(473):1001-1003.
Little is known about the contribution of over-the-counter (OTC) aspirin to cardiovascular prophylaxis. To investigate this, a two-phase cross-sectional study was carried out in nine general practices in North Staffordshire. In the first phase, all patients with cardiovascular disease (CVD) were identified from computer searches using morbidity registers and drug searches. The search also identfied the subgroup receiving prescribed prophylactic aspirin. In the second phase, a questionnaire was posted to all patients with CVD who were not on prescribed aspirin to establish their current use of OTC aspirin. Overall, 69% of the CVD group used aspirin, with 26% of aspirin being OTC. OTC aspirin use was more common in those aged under 65 years, men, and the more affluent. Also, there were significant differences in OTC aspirin use between the various practices. This study shows that a considerable amount of aspirin is used OTC in those with CVD. Its use is influenced by several factors that could be addressed when considering attempts to improve the overall uptake of aspirin.
PMCID: PMC1314169  PMID: 11766849
20.  A qualitative study of patients' views on anxiety and depression. 
BACKGROUND: In the management of patients with anxiety and depression in general practice, the emphasis has been on improving detection and appropriate use of drug therapies by health professionals. Patients' own perceptions of their problems and what services they would prefer have not often been sought. AIM: To explore patient perspectives in relation to their healthcare needs in anxiety and depression. DESIGN OF STUDY: Semi-structured individual and focus group interviews. SETTING: A total of 27 patients from an urban four-partner group general practice who were identified as having anxiety and depression by a practice population questionnaire survey. METHOD: All interviews were transcribed and the major themes were summarised using grounded theory analysis. RESULTS: Patients seek many different ways of coping with their problems but view their general practice as a focal point for help. Their experiences are dominated by the struggle to control unwelcome and intrusive thoughts and to live in a hostile and threatening world. They also have distinct preferences regarding their health needs and there is universal scepticism about drug therapies. CONCLUSION: Patients describe personal and professional barriers to seeking help and have particular views on the treatment options. This perspective contrasts with the current professional emphasis on detection and drug use. This view is therefore central to informing the debate on management of neurotic disorders in primary care and on improving the care of these patients.
PMCID: PMC1314002  PMID: 11360702
22.  Association of sexual problems with social, psychological, and physical problems in men and women: a cross sectional population survey 
STUDY OBJECTIVE: To investigate the association of sexual problems with social, physical, and psychological problems. DESIGN: An anonymous postal questionnaire survey. SETTING: Four general practices in England. PARTICIPANTS: 789 men and 979 women responding to a questionnaire sent to a stratified random sample of the adult general population (n = 4000). MAIN RESULTS: Strong physical, social, and psychological associations were found with sexual problems. In men, erectile problems and premature ejaculation were associated with increasing age. Erectile problems were most strongly associated with prostate trouble, with an age adjusted odds ratio of 2.6 (95% confidence intervals 1.4, 4.7), but hypertension and diabetes were also associated. Premature ejaculation was predominantly associated with anxiety (age adjusted odds ratio 3.1 (95% confidence intervals 1.7, 5.6)). In women, the predominant association with arousal, orgasmic, and enjoyment problems was martial difficulties, all with odds ratios greater than five. All female sexual problems were associated with anxiety and depression. Vaginal dryness was found to increase with age, whereas dyspareunia decreased with age. CONCLUSIONS: This study indicates that sexual problems cluster with self reported physical problems in men, and with psychological and social problems in women. This has potentially important consequences for the planning of treatment for sexual problems, and implies that effective therapy could have a broad impact on health in the adult population.
 
PMCID: PMC1756846  PMID: 10396490
23.  Atrial fibrillation: a comparison of methods to identify cases in general practice. 
The importance of atrial fibrillation as a treatable risk factor for stroke is well established. Less is known about how to find previously unidentified cases within the community so that antithrombotic treatment can be offered to a wider group of at-risk patients. The aim of our study was to examine ways to improve the efficiency of practice-based screening for atrial fibrillation, including issues of time and financial cost. We used different combinations of pulse palpation and interpretation of 12-lead and bipolar electrocardiographs as carried out by practice nurses. The best strategy for the detection of atrial fibrillation in a practice population would appear to be to screen all eligible subjects by nurse pulse palpation, followed by 12-lead electrocardiograph readings in those who have a pulse suggestive of atrial fibrillation. The electrocardiograph interpretation can be undertaken effectively by a trained nurse.
PMCID: PMC1313802  PMID: 11050790
24.  Psychosocial risks for low back pain: are these related to work? 
Annals of the Rheumatic Diseases  1998;57(8):500-502.
OBJECTIVES—To examine whether psychosocial risks for low back pain, reported in previous studies, are specific to the working population or are more widely relevant.
METHODS—A large population-based survey identified subjects free of low back pain, and obtained information on the degree of satisfaction with work (or not working) and the adequacy of income for their family's needs. New episodes of consulting and non-consulting low back pain were identified prospectively over 12 months. The psychosocial risks for developing a new low back pain episode are examined in employed and non-employed groups separately.
RESULTS—Dissatisfaction with work status doubled the risk of reporting a new low back pain episode in both the employed (odds ratio 2.0, 95% confidence intervals 1.2, 3.3) and non-employed (OR 2.0, 1.2, 3.1). Those perceiving their income as inadequate were at a threefold risk of consulting for this symptom regardless of their employment status (employed: OR 3.6, 1.8, 7.2; non-employed: OR 3.6, 1.4, 9.0).
CONCLUSION—Psychosocial factors pose similar risks for a new low back pain episode in workers and the non-employed. This suggests that such influences may not be related solely to work but be a function of general aspects of life. The economic and individual impact of psychosocial interventions in the workplace, therefore, are likely to be limited unless account is taken of the influence of broader non-work related aspects.

 Keywords: low back pain; risk factors; psychosocial; workplace
PMCID: PMC1752724  PMID: 9797557
25.  Admissible evidence 
Annals of the Rheumatic Diseases  1998;57(7):387-389.
PMCID: PMC1752674  PMID: 9797562

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