Is the Patient Activation Measure a valid measure of osteoarthritis self-management attitudes and capabilities? Results of a Rasch analysis.

BACKGROUND: The Patient Activation Measure (PAM-13) was developed using Rasch analysis to assess knowledge, skills and confidence in the management of one's health. Previous studies report positive relationships between PAM-13 scores, self-management behaviours and longitudinal health outcomes in adults with chronic disease. There is little extant measurement property evidence for the use of PAM-13 in specific osteoarthritis (OA) populations. This study tested measurement properties of the PAM-13 in people living with hip and knee OA. METHODS: Item response frequency analysis was conducted. Rasch analysis evaluated the fit of the PAM-13 data to the Rasch model. Model-data fit was evaluated using infit and outfit statistics; person/item reliability and person separation indices were computed. Unidimensionality was evaluated using Principal Components Analysis of Rasch residuals and the data were assessed for item redundancy. Differential Item Functioning (DIF) examined bias in respondent subgroups and correlations tested relationships between PAM-13 and other patient-reported outcomes. RESULTS: Two-hundred-and-seventeen PAM-13 surveys were completed; there were no missing responses, floor or ceiling effects. Person and item reliability were acceptable (0.98 and 0.87 respectively) with good separation (person separation index 2.58). Unidimensionality was evaluated, with 49.4% of the variance explained by the first eigenvector. There was evidence of potential local response-dependence. The Rasch fit statistics were acceptable (except for item-2). There were some issues identified with targeting of the PAM-13 items to people with higher ability and the item difficulty order was different to that proposed in original cohorts. Significant DIF was identified for sex and educational level for a small number of items. PAM-13 scores were moderately correlated with depressive symptoms on the Depression Anxiety Stress Scale and Assessment of Quality of Life-6D. There were small correlations between PAM-13 and Knee injury and Osteoarthritis Outcome Score pain and activities of daily living scores. CONCLUSIONS: This study provides some evidence of adequate person and item reliability, unidimensionality, and construct validity to support the use of PAM-13 to measure patient activation in people living with hip and knee OA. Possible limitations regarding targeting, different item difficulty order, DIF and local response dependence should be investigated in future research.

Acute cholecystitis in a patient with heterotaxic anatomy and partial situs inversus.

It is well recognised that situs inversus totalis can make surgery challenging. However, partial situs inversus with heterotaxic anatomy has rarely been reported. While routine, the presence of symptomatic gallstones or cholecystitis can lead to a complex and difficult operation for such patients. We present the case of a patient with heterotaxic anatomy and partial situs inversus with acute cholecystitis.

Association between multimorbidity and undiagnosed obstructive sleep apnea severity and their impact on quality of life in men over 40 years old.

BACKGROUND: Multimorbidity is common but little is known about its relationship with obstructive sleep apnea (OSA). METHODS: Men Androgen Inflammation Lifestyle Environment and Stress Study participants underwent polysomnography. Chronic diseases (CDs) were determined by biomedical measurement (diabetes, dyslipidaemia, hypertension, obesity), or self-report (depression, asthma, cardiovascular disease, arthritis). Associations between CD count, multimorbidity, apnea-hyponea index (AHI) and OSA severity and quality-of-life (QoL; mental & physical component scores), were determined using multinomial regression analyses, after adjustment for age. RESULTS: Of the 743 men participating in the study, overall 58% had multimorbidity (2+ CDs), and 52% had OSA (11% severe). About 70% of those with multimorbidity had undiagnosed OSA. Multimorbidity was associated with AHI and undiagnosed OSA. Elevated CD count was associated with higher AHI value and increased OSA severity. CONCLUSION: We demonstrate an independent association between the presence of OSA and multimorbidity in this representative sample of community-based men. This effect was strongest in men with moderate to severe OSA and three or more CDs, and appeared to produce a greater reduction in QoL when both conditions were present together.

Association between Body Mass Index and All-Cause Mortality among Oldest Old Chinese.

OBJECTIVES: To examine the association between BMI and all-cause mortality in the oldest old (≥80 years). DESIGN: The study used a prospective cohort study design. SETTING: Chinese Longitudinal Healthy Longevity Survey (CLHLS) between 1998/99 and 2011. POPULATION: 8026 participants aged 80 years and older were followed every two to three years. MEASUREMENTS: Body weight and knee height were measured. Height was calculated based on knee height using a validated equation. Deaths were ascertained from family members during follow-up. RESULTS: The mean BMI was 19.8 (SD 4.5) kg/m2. The prevalence of underweight, overweight and obese was 37.5%, 10.2% and 4.4%, respectively. There were 5962 deaths during 29503 person-years of follow-up. Compared with normal weight, underweight was associated with a higher mortality risk (HRs: 1.20 (95%CI 1.13-1.27) but overweight (HR 0.89 (95%CI 0.81-0.99)) were associated with a lower risk. Obesity had a HR 0.91 (95%CI 0.78-1.05) for mortality. CONCLUSION: Among oldest old Chinese, underweight is associated with an increased risk of all-cause mortality but overweight is associated with a reduced risk. Interventions to reduce undernutrition should be given priority among the oldest old Chinese.

Evaluation of prediagnosis emergency department presentations in patients with active tuberculosis: the role of chest radiography, risk factors and symptoms.

INTRODUCTION: London has a high rate of tuberculosis (TB) with 2572 cases reported in 2014. Cases are more common in non-UK born, alcohol-dependent or homeless patients. The emergency department (ED) presents an opportunity for the diagnosis of TB in these patient groups. This is the first study describing the clinico-radiological characteristics of such attendances in two urban UK hospitals for pulmonary TB (PTB) and extrapulmonary TB (EPTB). METHODS: We conducted a retrospective cohort study using the London TB Register (LTBR) and hospital records to identify patients who presented to two London ED's in the 6 months prior to their ultimate TB diagnosis 2011-2012. RESULTS: 397 TB cases were identified. 39% (154/397) had presented to the ED in the 6 months prior to diagnosis. In the study population, the presence of cough, weight loss, fever and night sweats only had prevalence rates of 40%, 34%, 34% and 21%, respectively. Chest radiography was performed in 76% (117/154) of patients. For cases where a new diagnosis of TB was suspected, 73% (41/56) had an abnormal radiograph, compared with 36% (35/98) of patients where it was not. There was an abnormality on a chest radiograph in 73% (55/75) of PTB cases and also in 40% (21/52) of EPTB cases where a film was requested. CONCLUSIONS: A large proportion of patients with TB present to ED. A diagnosis was more likely in the presence of an abnormal radiograph, suggesting opportunities for earlier diagnosis if risk factors, symptoms and chest radiograph findings are combined.

Deranged liver function tests following laparoscopic cholecystectomy: What would Occam have to say?

Postoperative complications can pose a significant obstacle in the ongoing management of surgical patients. However, it is pertinent to remember that postoperative events are not always complications of the preceding operation. We present the case of a patient with calculous cholecystitis and gallbladder empyema who underwent laparoscopic cholecystectomy. Postoperatively, he continued to have right upper quadrant pain associated with abnormal liver function tests. Ultimately, the cause of his postoperative symptoms was rather prosaic and ran counter to Occam's razor, the relevance of which is discussed below.

Towards an evidence-based management of right iliac fossa pain in the over 50-year-old patient.

Introduction Right iliac fossa pain is a common presenting complaint to general surgery. The differential diagnosis is wide, particularly in the elderly. Computed tomography (CT) is often used in the 'older' population, as they have a higher prevalence of acute colonic diverticulitis and colonic neoplasia, both of which should be identified prior to surgery. There is, however, no published evidence to support this practice. Methods We retrospectively reviewed the records of all patients aged over 50 years who presented with right iliac fossa (RIF) pain to a district general hospital. We determined whether tenderness was predominantly right- or left-sided and whether systemic inflammatory response syndrome (SIRS) was present on admission. The use of imaging modalities, their results and, if performed, operative findings were recorded. Results Of 3160 patients identified, 89 met the inclusion criteria. Diagnoses included appendicitis (27%), neoplasia (15%), non-specific abdominal pain (15%) and acute colonic diverticulitis (10%). CT was performed in 82% of patients, with a sensitivity of 97% based on operative findings. Six patients underwent surgery without a scan, two of whom required a change in the planned procedure due to unexpected findings. Conclusions Unless contraindicated, CT scanning should be mandatory in patients aged over 50 years presenting with signs of peritonism in the RIF or lower abdomen.

ST2249-MRSA-III: a second major recombinant methicillin-resistant Staphylococcus aureus clone causing healthcare infection in the 1970s.

Typing of healthcare-associated methicillin-resistant Staphylococcus aureus (MRSA) from Australia in the 1970s revealed a novel clone, ST2249-MRSA-III (CC45), present from 1973 to 1979. This clone was present before the Australian epidemic caused by the recombinant clone, ST239-MRSA-III. This study aimed to characterize the genome of ST2249-MRSA-III to establish its relationship to other MRSA clones. DNA microarray analysis was conducted and a draft genome sequence of ST2249 was obtained. The recombinant structure of the ST2249 genome was revealed by comparisons to publicly available ST239 and ST45 genomes. Microarray analysis of genomic DNA of 13 ST2249 isolates showed gross similarities with the ST239 chromosome in a segment around the origin of replication and with ST45 for the remainder of the chromosome. Recombination breakpoints were precisely determined by the changing pattern of nucleotide polymorphisms in the genome sequence of ST2249 isolate SK1585 compared with ST239 and ST45. One breakpoint was identified to the right of oriC, between sites 1014 and 1065 of the gene D484_00045. Another was identified to the left of oriC, between sites 1185 and 1248 of D484_01632. These results indicate that ST2249 inherited approximately 35.3% of its chromosome from an ST239-like parent and 64.7% from an ST45-like parent. ST2249-MRSA-III resulted from a major recombination between parents that resemble ST239 and ST45. Although only limited Australian archival material is available, the oldest extant isolate of ST2249 predates the oldest Australian isolate of ST239 by 3 years. It is therefore plausible that these two recombinant clones were introduced into Australia separately.

Elective day-case laparoscopic cholecystectomy: a formal assessment of the need for outpatient follow-up.

INTRODUCTION: Elective laparoscopic cholecystectomy (LC) is performed routinely as day-case surgery. Most hospital trusts have a policy of no routine postoperative outpatient follow-up although there are no formal guidelines on this. The aim of this retrospective study was to identify the incidence of complications, the degree of symptom resolution and patient satisfaction with a view to formally appraising the need for outpatient follow-up. METHODS: Patients who underwent LC in the period between February 2011 and June 2012 were contacted retrospectively by telephone. A standardised questionnaire was used to ascertain the incidence of surgical site infection (SSI), other complications, symptom resolution and patient satisfaction. RESULTS: A total of 211 responses were collected. The rate of SSI was 7.6% (n=16), with the only specific risk factor being smoking (p=0.027). All other complications had a combined incidence of 7% (n=15). There was complete resolution of symptoms in 64% of patients. Of the 36% of patients with residual symptoms, 45% described abdominal discomfort or pain, 41% described reflux symptoms and 14% complained of diarrhoea. Patient satisfaction was very high (96%), yet 33% of patients visited their general practitioner postoperatively in relation to their surgery. CONCLUSIONS: Patients are highly satisfied with elective day-case LC. However, SSI is not uncommon, occurring in 1 in 13 patients. Although the majority of patients experience complete symptom resolution, a significant proportion do not. In our experience, routine outpatient follow-up is not required. Nevertheless, the lack of formal follow-up may prove a missed learning opportunity, potentially resulting in inappropriate patient selection for surgery.

Acute gastric necrosis after routine oesophagogastroduodenoscopy with therapeutic argon plasma coagulation.

A 56-year-old woman presented to the accident and emergency department with peritonitis 2 days after a routine oesophagogastroduodenoscopy. She was taken to theatre with the finding of gastric necrosis. Blood and peritoneal cultures grew group A haemolytic Streptococcus. Histology revealed normal vasculature, no volvulus but marked neutrophilia in the submucosa with an intact mucosa. The stomach was resected and the patient recovered in the intensive care unit but overwhelming acidosis progressed to multiorgan failure and treatment was eventually withdrawn. Acute phlegmonous gastritis has been well described in the literature but mainly before the advent of antibiotics. The most common organism is group A haemolytic Streptococcus (commonly found in throat infections) and predisposing factors include instrumentation. Should antibiotics be given at the start of an oesophagogastroduodenoscopy and should routine procedures be delayed if active upper respiratory tract infections are present?

Morbid obesity after spinal cord injury: an ailment not to be treated?

A 28-year-old man with a T12 incomplete paraplegia after a spinal cord injury (SCI) was referred for weight management in October 2011. He reported a weight gain from about 120 to 180.3 kg since his SCI. He put on a further 11.4 kg in January 2012 despite intensive dietetic treatment, including very low-caloric diet, anti obesity medication and active physiotherapy programme. He had undergone an uncomplicated laparoscopic Roux-en-Y gastric bypass successfully in March 2012. For the first 7 months after surgery, his total weight loss was 32.4 kg. He has shown functional improvement (6 min walking distance and Berg balance score). There were important improvements in body mass index; waist circumference; mid-upper arm circumference; triceps-skinfold thickness; mid-arm muscle circumference; total cholesterol; high-density lipoprotein-cholesterol; and low-density lipoprotein-cholesterol and triglycerides. This report describes the first UK morbidly obese SCI patient who has undergone gastric bypass surgery and highlights the provision of bariatric surgery as an option to consider if all nonsurgical interventions have been tried.

Untreated hypertension: prevalence and patient factors and beliefs associated with under-treatment in a population sample.

Identifying barriers to hypertension management may facilitate cardiovascular risk reduction. Therefore, our objective, was to determine the prevalence of hypertension not managed with medication ('untreated') in a representative adult sample and identify patient factors/beliefs, and aspects of the patient-general practitioner (GP) relationship associated with untreated hypertension. The North West Adelaide Health Study, a biomedical cohort study over three stages from 2000-2009, assesses hypertension (systolic > or =140 mm Hg and/or > or =90 mm Hg or current treatment with anti-hypertensive medication), chronic disease and associated risk factors and health-care experiences, including risk perception, decision-making preferences, GP/primary care provider affiliation and satisfaction with care (n=2425). The prevalence of hypertension was 32.1% (n=781) comprised of treated (19.0%, n=462) and untreated (13.1%, n=319) hypertension. Thus, 40.8% of hypertension was untreated. Among hypertensive subjects, non-treatment was significantly associated with male sex, age <45 years, workforce participation, infrequent GP visits, dissatisfaction with recent medical care, high total cholesterol, moderate-level physical activity and lower body weights. Compared with participants without hypertension (and no treatment), untreated subjects demonstrated significant (15%) 10-year Framingham general cardiovascular risk (odds ratio=6.44, 95% confidence interval=4.52-9.17). Novel screening strategies and public health messages to address beliefs and perceptions of both patients and the health system are required to identify untreated, at-risk hypertensive individuals.

Sicca Symptoms and their Association with Chronic Rhinosinusitis in a Community Sample.

OBJECTIVE: To determine associations between sicca symptoms, chronic rhinosinusitis (CRS) symptoms and asthma in a community survey. METHODS: Data was obtained from the Spring 2009 South Australian Health Omnibus Survey which sampled, via interviewer administered questionnaire, 3007 individuals aged 15 years and over whose socio-demographic distribution corresponded to South Australian population estimates. Respondents were asked a range of questions relating to the presence of persistent dry eyes or dry mouth, CRS and medically diagnosed nasal polyps and asthma. Relationships between symptoms were explored using maximum likelihood dependency tree analysis. RESULTS: THE RESPECTIVE POPULATION PREVALENCES WERE: dry mouth (5.9%), dry eyes (8.6%), nasal polyps (3.8%), CRS (13.2%) and asthma (12.0%). The overall prevalence of sicca symptoms (dry eyes or dry mouth) was 12.4%. Dependency tree analysis revealed the expected symptom clustering between (1) sicca symptoms and their association with female gender and increasing age and (2) CRS, nasal polyps and asthma (one airway hypothesis). However there was also an association between dry eyes and CRS (OR 2.5, 95% CI 1.9, 3.4), which was in fact stronger than the association between CRS and asthma (OR 1.9, 95% CI 1.4, 2.5). CONCLUSIONS: Sicca symptoms are common in the community. Our novel finding of a strong association between dry eyes and CRS suggests that further research into the relationship between airway inflammation and sicca symptoms is required. These findings may have particular relevance to Sjögren's syndrome (SS) in both its primary and secondary forms.

Long-acting beta2-agonists for poorly reversible chronic obstructive pulmonary disease.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is characterised by partially reversible airflow limitation. Many patients have little reversibility to short acting bronchodilators, but long acting bronchodilators are frequently advocated. OBJECTIVES: To determine the effectiveness of long acting beta-2 adrenoceptor agonists (LABAs) in COPD patients demonstrating poor reversibility to short-acting bronchodilators. SEARCH STRATEGY: The Cochrane Airways Group Specialised Register was searched ('all years' to 2005) along with the reference lists from identified randomised controlled trials (RCTs). SELECTION CRITERIA: All RCTs comparing inhaled LABAs (salmeterol or formoterol) with placebo in the treatment of patients with stable, poorly reversible COPD. Studies were a minimum of four weeks in duration. DATA COLLECTION AND ANALYSIS: Two authors independently performed data extraction and study quality assessment. If we required additional data, we contacted authors and pharmaceutical companies sponsoring the identified RCTs. MAIN RESULTS: Twenty-three published and unpublished studies (6061 participants) were included in the review. There was a significant change in forced expiratory volume in 1 second (FEV1) in favour of salmeterol 50 mcg twice daily (BID) of 51 mls (95% confidence intervals (CI) 32 to 70), end of study morning peak expiratory flow (PEF) 14.89 L/min (95% CI 10.86 to 18.91). Supplemental short-acting bronchodilator usage was reduced by just under one puff per day. There were significant differences in the total, activity and impact domain scores of the St George's respiratory questionnaire in favour of salmeterol 50 mcg BID. Findings from other health status measurements and symptom scores were conflicting. There was no significant difference in exercise tolerance. The number of participants experiencing exacerbations was significantly reduced with salmeterol 50 mcg treatment compared with placebo (numbers needed to treat to benefit 21). AUTHORS' CONCLUSIONS: This review shows that the treatment of patients with COPD with salmeterol 50 mcg produces modest increases in lung function. There were varying effects for other important outcomes such as health related quality of life or reduction in symptoms. However, there was a consistent reduction in exacerbations which may help people with COPD who suffer frequent deterioration of symptoms prompting healthcare utilisation. The strength of evidence for the use of salmeterol 100 mcg, formoterol 12 mcg, 18 mcg, 24 mcg was insufficient to provide clear indications for practice.

Ipratropium bromide versus long-acting beta-2 agonists for stable chronic obstructive pulmonary disease.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is a condition associated with high morbidity, mortality and cost to the community. Patients often report symptomatic improvement with long acting beta-2 agonists (LABAs) and anticholinergic bronchodilator medications, both of which are recommended in COPD guidelines. These medications have different mechanisms of action and therefore theoretically could have an additive effect when combined. As these medications are prescribed in COPD as long term therapy, it is important to assemble reliable evidence on their relative and additive effects. OBJECTIVES: To compare the relative efficacy and safety of regular long term use (at least four weeks) of ipratropium bromide and LABA in patients with stable COPD. Comparisons were made between single agents and in combination versus LABAs alone. SEARCH STRATEGY: We searched the Cochrane Airways Group Specialised Register of Trials (August 2005) and reference lists of articles. We also contacted drug companies for relevant trial data. SELECTION CRITERIA: All randomised controlled trials comparing treatment for at least four weeks with an anticholinergic agent (ipratropium bromide) alone or in combination with LABA versus LABA alone, delivered via metered dose inhaler or nebuliser, in non-asthmatic adult subjects with stable COPD. DATA COLLECTION AND ANALYSIS: Three review authors independently performed data extraction and study quality assessment. We contacted study authors and pharmaceutical companies for missing data. MAIN RESULTS: Seven studies met the inclusion criteria of the review (2652 participants). Monotherapy comparison (six studies): There was a significantly greater change in favour of salmeterol in morning PEF and FEV1. There were no significant differences in quality of life, exacerbations, or symptoms. Formoterol appeared to confer some benefits over ipratropium treatment in terms of morning peak flow. Combination comparison (three studies): There was a significant improvement in post-bronchodilator lung function, supplemental short-acting beta-agonist use and HRQL in favour of combination therapy compared with salmeterol alone. AUTHORS' CONCLUSIONS: The available data from the trials suggest that there is little difference between regular long term use of IpB alone and salmeterol if the aim is to improve COPD symptoms and exercise tolerance. However, salmeterol was more effective in improving lung function variables. In terms of post-bronchodilator lung function, combination therapy conferred modest benefits and a significant improvement in HRQL, and reduced supplemental short-acting beta-agonist requirement, although this effect was not consistent. Additional studies are needed to assess the relative effects of combining therapies, using validated subjective measurements, and should consider concordance and the convenience of people having to use different inhaler devices.

Ipratropium bromide versus short acting beta-2 agonists for stable chronic obstructive pulmonary disease.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is a condition associated with high morbidity, mortality and cost to the community. Patients often report symptomatic improvement with short-acting beta-2 agonists (SABA) and anticholinergic bronchodilator medications, and both are recommended in COPD guidelines. These medications have different mechanisms of action and therefore could have an additive effect when combined. OBJECTIVES: To compare the relative efficacy and safety of regular long term use (at least four weeks) of ipratropium bromide and short- acting beta-2 agonist therapy in patients with stable COPD. SEARCH STRATEGY: The Cochrane Airways Group Specialised Register of Trials was searched. Bibliographies were checked to identify relevant cross-references. Drug companies were contacted for relevant trial data. The searches are current to August 2005. SELECTION CRITERIA: All randomised controlled trials comparing at least 4 weeks of treatment with an anticholinergic agent (ipratropium bromide) alone or in combination with a beta-2 agonist (short acting) versus the beta-2 agonist alone, delivered via metered dose inhaler or nebuliser, in non-asthmatic adult subjects with stable COPD. DATA COLLECTION AND ANALYSIS: Data extraction and study quality assessment was performed independently by three reviewers. Authors of studies and relevant manufacturers were contacted if data were missing. MAIN RESULTS: Eleven studies (3912 participants) met the inclusion criteria of the review. Small benefits of ipratropium over a short-acting beta-2 agonist were demonstrated on lung function outcomes. There were small benefits in favour of ipratropium on quality of life (HRQL), as well as a reduction in the requirement for oral steroids. Combination therapy with ipratropium plus a short-acting beta-2 agonist conferred benefits over a short-acting beta-2 agonist alone in terms of post-bronchodilator lung function. There was no significant benefit of combination therapy in subjective improvements in HRQL, but again there was a reduction in the requirement for oral steroids. AUTHORS' CONCLUSIONS: The available data from the trials included in this review suggest that the advantage of regular long term use of ipratropium alone or in combination with a short-acting beta-2 agonist or over a beta-2 agonist alone are small, if the aim is to improve lung function, symptoms and exercise tolerance. Until further data are available, the strategy of providing a short-acting beta-2 agonist on a PRN basis, and then either continuing with the short-acting beta-2 agonist regularly or conducting an "n of 1" trial of regular beta-2 agonist or regular anticholinergic to determine the treatment that gives the best relief of symptoms (and continuing with it), would seem cost effective. This strategy does need formal evaluation. Patient preference is also important, as is the relative importance of avoiding the use of systemic corticosteroids.