Assessment of two screening tools to identify psoriatic arthritis in patients with psoriasis.

BACKGROUND: Many patients with psoriasis have undiagnosed psoriatic arthritis. Low specificity is found with many PsA screening tools. A new instrument, the CONTEST questionnaire, was developed utilizing the most discriminative items from existing instruments. OBJECTIVE: The aim of this study was to compare the CONTEST and PEST screening tools. METHODS: People attending secondary care clinics with psoriasis, but not PsA, completed the questionnaires, were assessed for function and quality of life, and had a physical examination. Patients thought to have PsA were compared to those without. The performance of CONTEST and PEST was compared using area under the receiver operating curve (AUC), and sensitivity and specificity at the previously published cut-offs. RESULTS: A total of 451 dermatology patients were approached, 35% were reviewed and 27 (17%, 95% CI 12.3-21.7) had unidentified psoriatic arthritis. The sensitivity and specificity (95% CI) of PEST were 0.60 (0.42-0.78)/0.76 (0.69-0.83) and for CONTEST 0.53 (0.34-0.72)/0.71 (0.63-0.79). The confidence limits for the AUC overlapped (AUC for PEST 0.72 (0.61-0.84), for CONTEST 0.66 (0.54-0.77). CONCLUSIONS: PEST and CONTEST questionnaires performed equally well, with no superiority of the new CONTEST tool.

A feasibility study of educational tools for osteomalacia.

Many people in the UK, particularly people of South Asian origin, are advised to supplement their vitamin D intake, yet most do not. This suggests an unmet educational need. The osteomalacia mind map was developed to meet this need. The mind map contains culturally sensitive images, translated into Urdu and made interactive on a DVD. This study explores the feasibility of a randomised controlled study to measure the effect of education on improving vitamin D knowledge and adherence. This was a pilot and feasibility study. Cluster randomisation was used to avoid inter person contamination. Two South Asian women's groups were recruited to receive information about osteomalacia either by interactive DVD or an Arthritis Research UK leaflet. Knowledge and compliance were tested before and after the educational interventions via a knowledge questionnaire and the measurement of vitamin D and parathormone levels. The groups were found to be mismatched for knowledge, educational attainment and language at baseline. There were also organisational difficulties and possible confounding due to different tutors and translators. The DVD group had high knowledge at baseline which did not improve. The leaflet group had low knowledge at baseline that did improve. The DVD group had lower parathormone which did not change. The leaflet group had an increase in vitamin D but parathormone remained high. Performing a randomised study with this population utilising an educational intervention was difficult to execute. If cluster randomisation is used, extreme care must be taken to match the groups at baseline.

Comparison of screening questionnaires to identify psoriatic arthritis in a primary-care population: a cross-sectional study.

BACKGROUND: Many questionnaires are available for assessment of psoriatic arthritis (PsA), but there is little evidence comparing them. OBJECTIVES: To test the proposed CONTEST questionnaire, which was developed to identify patients with psoriasis who have undiagnosed PsA, and compare it with the validated Psoriasis Epidemiology Screening Tool (PEST) questionnaire in a primary-care setting. METHODS: A random sample of adult patients with psoriasis and no diagnosis of arthritis was identified from five general practice surgeries in Yorkshire, U.K. Consenting patients completed both questionnaires and were assessed by a dermatologist and rheumatologist. Diagnosis of PsA was made by the assessing rheumatologist. Receiver operator characteristic (ROC) curve analysis examined the sensitivity and specificity of potential cut points. RESULTS: In total 932 packs were sent to recruit 191 (20·5%) participants. Of these, 169 (88·5%) were confirmed to have current or previous psoriasis. Using physician diagnosis 17 (10·1%) were found to have previously undiagnosed PsA, while 90 (53·3%) had another musculoskeletal complaint and 62 (36·7%) had no musculoskeletal problems. Using ROC curve analysis, all of the questionnaires showed a significant ability to identify PsA. The area under the curve (AUC) for the CONTEST questionnaires was slightly higher than that of PEST (0·69 and 0·70 vs. 0·65), but there was no significant difference identified. Examining the sensitivities and specificities for the different cut points suggested that a PEST score ≥ 2 would perform better in this dataset, and the optimal scores for CONTEST and CONTEST plus joint manikin were 3 and 4, respectively. CONCLUSIONS: The accuracy of the questionnaires to identify PsA appeared similar, with a slightly higher AUC for the CONTEST questionnaires. The optimal cut points in this study appeared lower than in previous studies.

Comparison of three screening tools to detect psoriatic arthritis in patients with psoriasis (CONTEST study).

BACKGROUND: Multiple questionnaires to screen for psoriatic arthritis (PsA) have been developed but the optimal screening questionnaire is unknown. OBJECTIVES: To compare three PsA screening questionnaires in a head-to-head study using CASPAR (the Classification Criteria for Psoriatic Arthritis) as the gold standard. METHODS: This study recruited from 10 U.K. secondary care dermatology clinics. Patients with a diagnosis of psoriasis, not previously diagnosed with PsA, were given all three questionnaires. All patients who were positive on any questionnaire were invited for a rheumatological assessment. Receiver operating characteristic (ROC) curves were used to compare the sensitivity, specificity and area under the curve of the three questionnaires according to CASPAR criteria. RESULTS: In total, 938 patients with psoriasis were invited to participate and 657 (70%) patients returned the questionnaires. One or more questionnaires were positive in 314 patients (48%) and 195 (62%) of these patients attended for assessment. Of these, 47 patients (24%) were diagnosed with PsA according to the CASPAR criteria. The proportion of patients with PsA increased with the number of positive questionnaires (one questionnaire, 19·1%; two, 34·0%; three, 46·8%). Sensitivities and specificities for the three questionnaires, and areas under the ROC curve were, respectively: Psoriatic Arthritis Screening Evaluation (PASE), 74·5%, 38·5%, 0·594; Psoriasis Epidemiology Screening Tool (PEST), 76·6%, 37·2%, 0·610; Toronto Psoriatic Arthritis Screen (ToPAS), 76·6%, 29·7%, 0·554. The majority of patients with a false positive response had degenerative or osteoarthritis. CONCLUSION: Although the PEST and ToPAS questionnaires performed slightly better than the PASE questionnaire at identifying PsA, there is little difference between these instruments. These screening tools identify many cases of musculoskeletal disease other than PsA.

The prevalence of psoriatic arthritis in people with psoriasis.

OBJECTIVE: To determine the prevalence of psoriatic arthritis (PsA) using the ClASsification criteria for Psoriatic ARthritis (CASPAR) for classification. METHODS: People with psoriasis were identified from the computerized morbidity indices of 2 large UK general practices, total population 22,500. Questionnaires were mailed to all 633 patients thus identified. Of the respondents, a 50% sample was assessed clinically and a proportion had blood samples and radiographs taken. Patients labeled as having psoriasis were also cross-referenced with a local secondary care morbidity index for PsA and rheumatoid arthritis. Figures for the prevalence of PsA were estimated from these data. RESULTS: One hundred sixty-eight questionnaires were returned (response rate 27%) and 93 people (55% of questionnaire respondents) were examined. Of these 93 people, 12 (4 of whom were cross-referenced to the hospital database) were thought to have PsA clinically, all fulfilling the CASPAR criteria for PsA. Six of the 93 examined patients did not have psoriasis or a family history of psoriasis and had no historical features or clinical signs of psoriasis on interview and examination. Extrapolating from the data of those people actually examined, the estimated (corrected) prevalence was 13.8% (95% confidence interval 7.1-24.1%). CONCLUSION: The estimated prevalence of PsA in this population, using the CASPAR criteria, was 13.8%. Misclassification of psoriasis and arthritis, and response bias, indicate that this is probably an overestimate.

Evaluation of an existing screening tool for psoriatic arthritis in people with psoriasis and the development of a new instrument: the Psoriasis Epidemiology Screening Tool (PEST) questionnaire.

OBJECTIVE: To evaluate an existing tool (the Swedish modification of the Psoriasis Assessment Questionnaire) and to develop a new instrument to screen for psoriatic arthritis in people with psoriasis. DESIGN: The starting point was a community-based survey of people with psoriasis using questionnaires developed from the literature. Selected respondents were examined and additional known cases of psoriatic arthritis were included in the analysis. The new instrument was developed using univariate statistics and a logistic regression model, comparing people with and without psoriatic arthritis. The instruments were compared using receiver operating curve (ROC) curve analysis. RESULTS: 168 questionnaires were returned (response rate 27%) and 93 people attended for examination (55% of questionnaire respondents). Of these 93, twelve were newly diagnosed with psoriatic arthritis during this study. These 12 were supplemented by 21 people with known psoriatic arthritis. Just 5 questions were found to be significant predictors of psoriatic arthritis in this population. Figures for sensitivity and specificity were 0.92 and 0.78 respectively, an improvement on the Alenius tool (sensitivity and specificity, 0.63 and 0.72 respectively). CONCLUSIONS: A new screening tool for identifying people with psoriatic arthritis has been developed. Five simple questions demonstrated good sensitivity and specificity in this population but further validation is required.

Provision of foot health services in rheumatology in the UK.

OBJECTIVES: To determine the provision of foot health services in rheumatology for the UK and Northern Ireland. METHODS: Two hundred and sixteen rheumatology departments were surveyed by postal questionnaire. Questions covered the contribution of various disciplines to rheumatology out-patient clinics, and opinions on existing and potential services, with emphasis on foot health provision. Inter-regional variations were explored for eight UK regions. RESULTS: Valid responses were received from 170 respondents (78.7% response rate). More than 80% of out-patient departments reported having rheumatology nurse specialists included in the staff mix but fewer than half used other allied health professionals, such as podiatrists. One quarter of the departments had access to a podiatrist and in 18% there was a foot health service dedicated to rheumatology. Awareness of guidelines for referral or of standards of foot care provision was very low (6%). There was high satisfaction with the adequacy of provision of footwear and insoles (81-87%) but low satisfaction with the adequacy of basic foot care (48-52%). Regional variation was extremely high for the provision of basic foot care (0-73%), the non-English regions reporting poorer provision of service. CONCLUSIONS: Regional variation in the adequacy of foot health services was high and the non-English regions especially are failing to meet the foot health needs of rheumatology patients. Multidisciplinary care is generally well developed despite the composition of teams being highly variable. Fewer than half of rheumatologists reported that basic foot care needs were being met, although adequacy of provision of more advanced foot services is perceived to be better. The absence of nationally agreed standards and poor awareness of local standards may be detrimental to care in this patient group.

A tool for assessing 'readiness' in emergency obstetric care: the room-by-room 'walk-through'.

This article presents a tool that can be used to assess the readiness of a health facility to provide emergency obstetric care. The 'walk-through' tool is a checklist that follows the physical path that a woman and her caregivers might follow. The items on the checklist are critical to an enabling environment in which skilled providers can save lives. The article explains how the tool can be used and by whom, and it describes several experiences in the field.

Investigation of interaction between N-acetyltransferase 2 and heterocyclic amines as potential risk factors for colorectal cancer.

Fast N-acetyltransferase 2 (NAT2) acetylators may be at increased risk of colorectal cancer through the activation of carcinogenic heterocyclic amines (HA), which are produced by meat cooked at high temperatures and are found in cigarette smoke. A study of 500 incident colorectal cancer cases and population controls, matched for age, sex and general practitioner, was conducted in the UK to investigate this hypothesis. Usual meat intake and lifetime smoking habits were estimated using a detailed questionnaire administered by interview. Subjects also indicated how well cooked they ate their meat. Subjects were classified as fast or slow NAT2 acetylators on the basis of NAT2 genotype. Complete genotype data were available on 433 matched pairs. The risk of colorectal cancer showed a steady increase with meat intake, rising to an odds ratio of 1.51 [95% confidence interval (1.03, 2.23)] for the highest versus the lowest quartile, after adjustment for total energy intake, and this was even more pronounced for red meat [odds ratio 1.97 (1.30, 2.98)]. However, this effect was not influenced by the preference for well-done meat. Smoking was also associated with an increased risk [odds ratio 1.47 (1.10, 1.98) for ever- versus never-smokers]. In both cases and controls approximately 40% of subjects were classified as fast acetylators, and the risks associated with (red) meat intake and smoking did not vary with NAT2 status. This study provides no support for the hypothesis that fast NAT2 acetylators are at increased risk of colorectal cancer, even if exposed to high levels of HA from well-cooked meat or smoking.

Mental health, health, and education staff working together in schools.

The movement to develop expanded school mental health programs is still in its early stages. For child and adolescent psychiatrists to become involved and effective means negotiating a culture that is novel for many schools and forming and maintaining relationships with diverse staff in mental health, health, and education.

A prospective follow-up study of low back pain in the community.

STUDY DESIGN: Opportunistic prospective follow-up study. OBJECTIVE: To describe the natural history of low back pain in the community and to model the factors predictive of recovered versus persistent low back pain. SUMMARY OF BACKGROUND DATA: A two-phase questionnaire was mailed to adults in the Bradford Metropolitan Health District in 1994. Valid respondents were surveyed again in 1997. Analysis is based on the combined results of these two surveys. METHODS: Unifactorial and multifactorial statistics were analyzed based on 1455 adults, with and without low back pain. RESULTS: One third of respondents reported no lifetime low back pain. Average lifetime prevalence was 59% and average annual prevalence 41%. Of those who reported lifetime low back pain, 42% reported persistent annual low back pain, 18% reported a first episode in 1997, resulting in a 4% population incidence rate, and 40% reported intermittent low back pain. The likelihood of having had low back pain increased significantly with age. Those who reported a new case of low back pain in 1997 were significantly more likely to be 25-34 years of age, and these persons were most likely to report acute low back pain with very little disability. Those with persistent low back pain were significantly more likely to report chronic low back pain with some disability. Logistic regression modeling was unable to predict recovered versus persistent low back pain, given the person, pain, and treatment factors available. CONCLUSIONS: Results showed that low back pain is a mutable problem with acute episodes blending into longer periods resulting in more disability as time progresses. A wide range of demographic, pain, consultation, and treatment factors were not predictive of low back pain recovery.

The occurrence of ocular and visual dysfunctions in an acquired brain-injured patient sample.

BACKGROUND: Acquired brain injury (ABI) is a general term referring to brain injury occurring secondary to trauma, stroke, or post-surgical complications. This paper reports on the occurrence of various ocular and visual conditions in an ABI patient sample. METHODS: The subjects for this study were 62 brain-injured adults who resided in two extended care facilities in the New York area. Subjects ranged from 19 to 70 years of age. The standard protocol for the visual evaluation incorporated a patient interview; cover test; refraction; and assessment of visual acuity, ocular motility, accommodation, binocularity, visual fields, color vision, contrast sensitivity, pupils, and anterior and posterior segments. RESULTS: Results were reported as a ratio comparing the occurrence of a condition in our ABI sample relative to that in a reference normal population (where normative data are available) and as a comparison to other published data on ABI samples. An increased occurrence of exo deviations, oculomotor dysfunctions, and vertical deviations was evident. An elevated occurrence of dry eye, blepharitis, optic nerve pathologies, and visual field deficits was also manifest. CONCLUSION: Our patient sample demonstrates that certain ocular and visual conditions occur more frequently among ABI patients in comparison to a random, adult population.

Toward collaboration in the growing education-mental health interface.

Expanded school mental health (ESMH) programs involve the provision of comprehensive mental health services for youth in schools, including assessment, intervention, prevention, and consultation. Related to increased awareness of the benefits of these programs, and growing disenchantment with traditional forms of mental health service delivery for children, ESMH programs are growing rapidly in the United States. Coinciding with the growth of these programs is a developing interface between and among education and mental health professionals in schools. In this interface, there is an increasing need for real collaboration; however, associated with differences in professional training, language, and expectations, and related to "turf," such collaboration is often an elusive prospect. In this article, we review historical trends that provide background to the growing education-mental health interface in schools. We discuss tensions that arise between staff of various disciplines when ESMH programs are developed, and provide recommendations on strategies to develop truly collaborative approaches to the provision of comprehensive mental health services in schools.

Community survey of factors associated with consultation for low back pain.

OBJECTIVE: To investigate the psychosocial factors associated with consultation for low back pain. DESIGN: Two phase cross sectional postal survey. SETTING: Bradford Metropolitan Health District. SUBJECTS: 1813 adults responding to the phase 1 questionnaire. 540 of the 782 with an episode of low back pain in the past 12 months completed the second questionnaire. MAIN OUTCOME MEASURES: Six psychosocial constructs. RESULTS: 406 (52%) of the respondents reporting back pain in the past 12 months had not consulted a health professional. Logistic regression showed that consultation was associated with externalised beliefs regarding pain management (odds ratio 3.6; 95% confidence interval 2.1 to 6.0). Duration of pain affected the factors associated with consultation. Consultation for episodes lasting less than two weeks (n=290) was associated with greater than median pain (3.0; 1.7 to 5.5), consultation for episodes over two weeks (n=243) was associated with increased disability (3.7; 1.5 to 9.0), and consultation for episodes over three months (n=143) with increased depression (3.9; 1.3 to 11.8). CONCLUSIONS: The results support a role for psychosocial factors in consultation for low back pain and suggest that the reasons for consultation vary with duration of pain. Duration of the episode may be a useful guide to management of non-specific low back pain.

The influence of prior stroke on the prosthetic rehabilitation of lower limb amputees.

Concurrent stroke is believed to have an adverse influence on the process and outcome of prosthetic rehabilitation, but there is limited published evidence for this. The aim of this study was to establish a clearer picture in order to assist decision making for both patients and professionals. Demographic and clinical data were collected from all lower limb amputees referred from North and West Yorkshire for prosthetic rehabilitation. Additional data were collected from all new lower limb amputees in three of the referring health districts, irrespective of prosthetic referral. Patients with prior stroke were less likely to be referred for prosthetic rehabilitation. Improved mobility and independence were seen following prosthetic rehabilitation irrespective of prior stroke. The group with prior stroke compared well with the non-stroke group in terms of walking aid usage, but a smaller proportion of the stroke group were able to walk 30 m without stopping and there were trends for smaller gains in independence in the stroke group. Nevertheless, this study demonstrates that prosthetic rehabilitation can be successful in a selected amputee population with prior stroke. In those who continue prosthetic use for one year, outcome is similar to that in patients without stroke.

MR differential diagnosis of normal-pressure hydrocephalus and Alzheimer disease: significance of perihippocampal fissures.

PURPOSE: In the older patient with dilated ventricles, it is often difficult to differentiate normal pressure hydrocephalus (NPH) from cerebral atrophy caused by Alzheimer disease (AD). This study was undertaken to see if dilatation of the perihippocampal fissures (PHFs) could be used as a distinguishing characteristic of these two disorders. METHODS: MR images of 17 patients with AD were compared with those from an equal number of patients with NPH who improved after ventriculoperitoneal shunting. The PHFs, lateral ventricles, third ventricle, and temporal horns were graded subjectively. Objective, computer-aided volumetric measurements of the PHFs and lateral ventricles were obtained. The preshunt images of the NPH patients were evaluated. RESULTS: Significant differences between the two groups were found for the PHFs and lateral ventricles by both the subjective and objective methods, with a high degree of correlation between the two methods. CONCLUSION: The degree of dilatation of PHFs appears to be a sensitive and specific marker for differentiating AD from NPH by both subjective and objective means, with a very small overlap between the two groups. This observation may have relevance in day-to-day practice.

Optimizing the roles of school mental health professionals.

Each mental health discipline offers unique contributions to the development and operation of school-based mental health programs. The collaboration of professionals from different disciplines with each other, as well as with health and educational staff, is essential for service delivery in school settings. Conversely, interprofessional conflicts and turf issues can impede the development of effective school-based mental health programs. The authors, who represent counseling, nursing, psychiatry, psychology, and social work, discuss the roles and competencies of each profession in providing school-based mental health services. Training requirements within each discipline that relate to school mental health are described. Barriers to effective interdisciplinary collaboration, and methods of overcoming them, are delineated.