Association of mycophenolate and azathioprine use with cognitive function in systemic lupus.

OBJECTIVES: Cognitive dysfunction (CD) is a common manifestation of SLE that can have detrimental consequences for those affected. To date, no treatments have been approved for SLE-CD. This study aims to assess the association of azathioprine (AZA) and mycophenolate (MMF) use with SLE-CD, given that these medications have demonstrated neuroprotective qualities in prior studies. METHODS: Consecutive adult SLE patients presenting to a single healthcare center were considered for participation. The ACR neuropsychological battery for SLE was administered to consenting patients at 0, 6 and 12 months. Scores were compared with age- and sex-matched controls. Primary outcome was CD, defined as a z-score ≤-1.5 in two or more cognitive domains. Mixed-effects logistic regression models were constructed to estimate the odds of CD with respect to AZA and MMF use. RESULTS: A total of 300 participants representing 676 patient visits completed the study; 114 (38%) met criteria for CD at baseline. The cumulative AZA dose (g/kg) was associated with reduced odds of CD [odds ratio (OR) 0.76 (95% CI 0.58, 0.98), P = 0.04]. Years of AZA treatment was also associated with reduced odds of CD [OR 0.72 (95% CI 0.54, 0.97), P = 0.03]. MMF use was not associated with CD. CONCLUSION: AZA use was associated with significantly lower odds of SLE-CD, while MMF use was not. Additional studies are warranted to further investigate the relationship of AZA and SLE-CD.

A Sensibility Assessment of the Job Demands and Accommodation Planning Tool (JDAPT): A Tool to Help Workers with an Episodic Disability Plan Workplace Support.

Purpose Sensibility refers to a tool's comprehensiveness, understandability, relevance, feasibility, and length. It is used in the early development phase to begin assessing a new tool or intervention. This study examined the sensibility of the job demands and accommodation planning tool (JDAPT). The JDAPT identifies job demands related to physical, cognitive, interpersonal, and working conditions to better target strategies for workplace supports and accommodations aimed at assisting individuals with chronic health conditions. Methods Workers with a chronic health condition and workplace representatives were recruited from health charities, workplaces, and newsletters using convenience sampling. Cognitive interviews assessed the JDAPT's sensibility. A 70% endorsement rate was the minimum level of acceptability for sensibility concepts. A short screening tool also was administered, and answers compared to the complete JDAPT. Results Participants were 46 workers and 23 organizational representatives (n = 69). Endorsements highly exceeded the 70% cut-off for understandability, relevance, and length. Congruence between screening questions and the complete JDAPT suggested both workers and organizational representatives overlooked job demands when completing the screener. Participants provided additional examples and three new items to improve comprehensiveness. The JDAPT was rated highly relevant and useful, although not always easy to complete for someone with an episodic condition. Conclusions This study highlights the need for tools that facilitate accommodations for workers with episodic disabilities and provides early evidence for the sensibility of the JDAPT.

Disclosure, Privacy and Workplace Accommodation of Episodic Disabilities: Organizational Perspectives on Disability Communication-Support Processes to Sustain Employment.

Purpose Employers increasingly are asked to accommodate workers living with physical and mental health conditions that cause episodic disability, where periods of wellness are punctuated by intermittent and often unpredictable activity limitations (e.g., depression, anxiety, arthritis, colitis). Episodic disabilities may be challenging for workplaces which must comply with legislation protecting the privacy of health information while believing they would benefit from personal health details to meet a worker's accommodation needs. This research aimed to understand organizational perspectives on disability communication-support processes. Methods Twenty-seven participants from diverse employment sectors and who had responsibilities for supporting workers living with episodic disabilities (e.g., supervisors, disability managers, union representatives, occupational health representatives, labour lawyers) were interviewed. Five participants also had lived experience of a physical or mental health episodic disability. Participants were recruited through organizational associations, community networks and advertising. Semi-structured interviews and qualitative content analysis framed data collection and analyses, and mapped communication-support processes. Results Seven themes underpinned communication-support process: (1) similarities and differences among physical and mental health episodic disabilities; (2) cultures of workplace support, including contrasting medical and biopsychosocial perspectives; (3) misgivings about others and their role in communication-support processes; (4) that subjective perceptions matter; (5) the inherent complexity of the response process; (6) challenges arising when a worker denies a disability; and (7) casting disability as a performance problem. Conclusions This study identifies a conceptual framework and areas where workplace disability support processes could be enhanced to improve inclusion and the sustainability of employment among workers living with episodic disabilities.

PROM-ED: Development and Testing of a Patient-Reported Outcome Measure for Emergency Department Patients Who Are Discharged Home.

STUDY OBJECTIVE: Common outcomes of care valued by emergency department (ED) patients who are not hospitalized have been characterized, but no measurement instrument has been developed to date. We developed and validated a patient-reported outcome measure for use with adult ED patients who are discharged home (PROM-ED). METHODS: In previous research, 4 main outcomes of importance to ED patients were defined: symptom relief, understanding, reassurance, and having a plan. We developed a bank of potential questions (phase 1) that were first tested for suitability through cognitive debriefing with patients (phase 2). Revised questions were then tested quantitatively with a large panel of participants who had recently received ED care (phase 3). Informed by these results, a panel of experts used a modified Delphi process to make decisions on item reduction. The resulting instrument (PROM-ED 1.0) was then evaluated for its measurement properties (structural validity, hypothesis testing, and reliability). RESULTS: Sixty-seven questions divided among 4 scales (1 for each outcome domain) were assembled. In accordance with cognitive debriefing with 8 patients (phase 2), 15 questions were modified and 13 removed. Testing of these questions with 444 participants (phase 3) identified problematic floor or ceiling effects (n=10), excessive correlations between items (n=11), and low item-total correlations (n=7). The expert panel (22 participants, phase 4) made decisions using this information on the exclusion of items, resulting in 22 questions across 4 scales that together constitute the PROM-ED 1.0. Testing provided good evidence of validity and test-retest reliability (n=200). CONCLUSION: The PROM-ED enables the measurement of patient-centered outcomes of importance to patients receiving care in the ED who are not hospitalized. These data could have important applications in research and care improvement.

Factors associated with screening positive for high falls risk in fragility fracture patients: a cross-sectional study.

BACKGROUND: We sought to report the prevalence of fragility fracture patients who were screened at high falls risk using a large provincial database, and to determine the characteristics associated with being screened at high falls risk. METHODS: The study population included fragility fracture patients 50+ years of age who were screened at 35 hospital fracture clinics in Ontario over a 3.5 year period. The outcome was based on two screening questions measuring the risk of falling, both adapted from the STEADI (Stopping Elderly Accidents, Deaths & Injuries) tool. Multivariable associations of sociodemographic, fracture-related, and health-related characteristics were evaluated using logistic regression. RESULTS: Of the sample, 9735 (44.5%) patients were classified as being at high falls risk, and 12,089 (55.3%) were not. In the multivariable logistic regression, being 80+ years of age (vs. 50-64 years of age), non-community dwelling (vs. living with spouse, family member, roommate), having a mental/physical impairment (vs. none), and taking multiple medications, were all strongly associated with being screened at high falls risk. CONCLUSIONS: Living in a non-community dwelling and taking 4+ medications were the variables most strongly associated with being screened at high falls risk. These are potentially modifiable characteristics that should be considered when assessing falls risk in fragility fracture patients, and particularly when designing interventions for preventing subsequent falls. Ongoing work to address the higher risk of falls in the fragility fracture population is warranted.

Systematic Review of Measurement Property Evidence for 8 Financial Management Instruments in Populations With Acquired Cognitive Impairment.

OBJECTIVES: To critically appraise the measurement property evidence (ie, psychometric) for 8 observation-based financial management assessment instruments. DATA SOURCES: Seven databases were searched in May 2015. STUDY SELECTION: Two reviewers used an independent decision-agreement process to select studies of measurement property evidence relevant to populations with adulthood acquired cognitive impairment, appraise the quality of the evidence, and extract data. Twenty-one articles were selected. DATA EXTRACTION: This review used the COnsensus-based Standards for the selection of health Measurement Instruments review guidelines and 4-point tool to appraise evidence. After appraising the methodologic quality, the adequacy of results and volume of evidence per instrument were synthesized. Measurement property evidence with high risk of bias was excluded from the synthesis. DATA SYNTHESIS: The volume of measurement property evidence per instrument is low; most instruments had 1 to 3 included studies. Many included studies had poor methodologic quality per measurement property evidence area examined. Six of the 8 instruments reviewed had supporting construct validity/hypothesis-testing evidence of fair methodologic quality. There is a dearth of acceptable quality content validity, reliability, and responsiveness evidence for all 8 instruments. CONCLUSIONS: Rehabilitation practitioners assess financial management functions in adults with acquired cognitive impairments. However, there is limited published evidence to support using any of the reviewed instruments. Practitioners should exercise caution when interpreting the results of these instruments. This review highlights the importance of appraising the quality of measurement property evidence before examining the adequacy of the results and synthesizing the evidence.

Patients' Perspectives on Outcomes of Care After Discharge From the Emergency Department: A Qualitative Study.

STUDY OBJECTIVE: Much effort has been expended to understand what care experiences patients value in the emergency department (ED), yet little is known about which outcomes patients value after ED care. Our goal is to define outcomes of ED care that are valued by patients discharged from the ED, with the goal of informing the development of a patient-reported outcome measure for ED care. METHODS: We conducted qualitative semistructured interviews with patients recruited during their care at 1 of 2 EDs and interviewed in either English or French 1 to 9 days after their visit. Patients who were hospitalized were excluded. Interviews focused on perceived outcomes of care since the ED visit and expectations of care before the ED visit. We identified themes with standard descriptive content analysis techniques and a modified version of the constant comparative method, drawing on grounded theory methods. RESULTS: We interviewed 46 patients in English (n=38) or French (n=8). Participants with diverse reasons for seeking care appeared to value common outcomes from ED care that centered around 4 themes: understanding the cause and expected trajectory of their symptoms; reassurance; symptom relief; and having a plan to manage their symptoms, resolve their issue, or pursue further medical care. These themes were also reflected in the expectations participants recalled having when they decided to seek care in the ED. CONCLUSION: The 4 outcomes defined constitute areas for improvement and will inform the development of an ED patient-reported outcome questionnaire. Consideration should be given to measuring patient-reported outcomes separately from patient experience.

A user's survey of the clinical application and content validity of the DASH (Disabilities of the Arm, Shoulder and Hand) outcome measure.

STUDY DESIGN: Survey. PURPOSE OF THE STUDY: To elicit feedback on the clinical use and content validity of the Disabilities of the Arm, Shoulder and Hand (DASH) outcome measure from frontline users of the instrument. METHODS: A cross-sectional survey was administered to registered DASH users and inquired about how the DASH was being used and to identify the informational value of items of the DASH (content validity). RESULTS: About 172 completed the survey. One or both of the DASH and/or QuickDASH were consistently (89.5%) being used. About 90% were using it in adults (21-65 years), and at least 70% were using it across the entire extremity, and to a lesser extent, 10% reported using it in isolated neck injuries. Most respondents (66.9%-75.8%) were using the DASH in musculoskeletal (MSK) disorders, with some applying it for other more unique or non-MSK conditions (2.5%-16.6%). All but 1 of the 30 DASH items had at least 10% endorsement as being informative, and 4 items were identified as being problematic by greater than 20%. CONCLUSIONS: The DASH is being used as intended (whole extremity and MSK conditions), and in addition, it is being used in different body regions and diverse conditions. LEVEL OF EVIDENCE: Not applicable (descriptive survey).

Does the Upper-Limb Work Instability Scale Predict Transitions Out of Work Among Injured Workers?

OBJECTIVE: To investigate the predictive ability of the Upper-Limb Work Instability Scale (UL-WIS) for transitioning out of work among injured workers with chronic, work-related upper extremity disorders (WRUEDs). DESIGN: Secondary analysis of a 12-month cohort study with data collection at baseline and 3-, 6-, and 12-month follow-up. Survey questionnaires were used to collect data on an array of sociodemographic, health-related, and work-related variables. SETTING: Upper extremity specialty clinics. PARTICIPANTS: Injured workers (N=356) with WRUEDs who were working at the time of initial clinic attendance. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Transitioning out of work. RESULTS: Multivariable logistic regression that considered 9 potential confounders revealed baseline UL-WIS (range, 0-17) to be a statistically significant predictor of a subsequent transition out of work (adjusted odds ratio, 1.18; 95% confidence interval [CI], 1.07-1.31; P=.001). An assessment of predictive values across the UL-WIS score range identified cut-scores of <6 (negative predictive value, .81; 95% CI, .62-.94) and >15 (positive predictive value, .80; 95% CI, .52-.96), differentiating the scale into 3 bands representing low, moderate, and high risk of exiting work. CONCLUSIONS: The UL-WIS was shown to be an independent predictor of poor work sustainability among injured workers with chronic WRUEDs; however, when applied as a standalone tool in clinical settings, some limits to its predictive accuracy should also be recognized.

A Test-Retest Reliability Study of the Whiplash Disability Questionnaire in Patients With Acute Whiplash-Associated Disorders.

OBJECTIVE: The purpose of this study was to determine the test-retest reliability and the Minimal Detectable Change (MDC) of the Whiplash Disability Questionnaire (WDQ) in individuals with acute whiplash-associated disorders (WADs). METHODS: We performed a test-retest reliability study. We included insurance claimants from Ontario who were at least 18 years of age, within 21 days of their motor vehicle collision and diagnosed as having acute WAD grades I to III. The WDQ, a 13-item questionnaire scored from 0 (no disability) to 130 (complete disability), was administered to all participants at baseline and by telephone 3 days later. We computed the intraclass correlation coefficient (model 2,1) and the MDC with 95% confidence intervals (CIs; MDC95). RESULTS: The mean (SD) age of the 66 participants was 41.6 (12.7) years and 71.2% were female. Twenty-nine percent had WAD I and 71.2% had WAD II. Time since injury ranged from 0 to 19 days. The mean (SD) baseline WDQ score was 49.3 (28.8) and 46.5 (29.8) 3 days later. The intraclass correlation coefficient for the WDQ total score was 0.89 (95% CI, 0.85-0.92) in the entire sample and 0.83 (95% CI, 0.69-0.93) for the 15 participants reporting no change in neck pain. The MDC95 of the WDQ was 21.4 (SD = 14.9) for participants reporting no change. CONCLUSION: The WDQ was reliable in individuals with acute WAD. There is 95% confidence that a change of approximately one-sixth of the total score is beyond the daily variation of a stable condition. This level of measurement error must be taken into consideration when interpreting change in WDQ scores.

Work factors are associated with workplace activity limitations in systemic lupus erythematosus.

OBJECTIVE: The objective of this study was to examine the extent of workplace activity limitations among persons with lupus and to identify factors associated with activity limitations among those employed. METHODS: We conducted a cross-sectional study using a mailed survey and clinical data of persons with lupus who attended a large lupus outpatient clinic. Data were collected on demographics, health, work factors and psychosocial measures. The workplace activity limitations scale (WALS) was used to measure difficulty related to different activities at work. Multivariable analysis examined the association of health, work context, psychosocial and demographic variables with workplace activity limitations. RESULTS: We received 362 responses from 604 (60%) mailed surveys. Among those not employed, 52% reported not working because of lupus. A range of physical and mental tasks were reported as difficult. Each of the physical, cognitive and energy work activities was cited as difficult by more than one-third of participants. Among employed participants, 40% had medium to high WALS difficulty scores. In the multivariable analysis, factors significantly associated with workplace activity limitations were older age, greater disease activity, fatigue, poorer health status measured by the 36-item Short Form Health Survey, lower job control, greater job strain and working more than 40 h/week. CONCLUSION: People with lupus experience limitations and difficulty at work. Determinants of workplace activity limitations are mainly those related to workplace and health factors.

Striking a balance: work-health-personal life conflict in women and men with arthritis and its association with work outcomes.

PURPOSE: To examine men and women's perceptions of inter-role balance/imbalance in work, arthritis, and personal roles and its association with demographic, health and employment factors, including job stress, career satisfaction, job disruptions, absenteeism and perceived productivity losses. METHODS: Participants were employed, aged ≥40 years and diagnosed with osteoarthritis or inflammatory arthritis. They were recruited through community advertising and rheumatology clinics in two Canadian provinces. Respondents completed a 35-45 min telephone interview and a 20-min self-administered questionnaire assessing role perceptions [(arthritis negatively impacts work (A → W); work/personal life negatively impact arthritis (W/P → A); work as a positive role (W +))], demographic, health and work context information. Analyses included exploratory factor analysis and multivariate regressions. RESULTS: Findings revealed similarities between men (n = 104) and women (n = 248) in health, work and role perceptions, although women reported more benefits of working with arthritis (W+) than men. Some gender differences were found in factors associated with inter-role perceptions highlighting the importance of children, fatigue, unpredictable work hours, job control, and workplace activity limitations. Role perceptions were associated with work outcomes but only one perception, W/P → A, interacted with gender. Among men, greater perceptions that work and personal demands interfered with managing arthritis were associated with more job disruptions. CONCLUSIONS: This study revealed negative and positive inter-role perceptions related to working with a chronic illness and associations with work outcomes. It highlights potentially modifiable factors that could assess risk and inform interventions to improve role balance and working experiences.

Increasing uptake through collaboration in the development of core outcome sets: Lessons learned at OMERACT 2023.

OBJECTIVE: This manuscript highlights the importance of enhancing the uptake of Core Outcome Sets (COS) by building partnerships with Collaborators and addressing their needs in COS development. METHODS AND SETTING: This session was structured as a simulation, resembling a format akin to a classic television game show. The moderator posed a series of questions to eight different Collaborator groups who briefly described the importance of COS within their areas of interest. Previous studies examining the uptake of individual core outcomes revealed disparities in uptake rates. The Identified barriers to the uptake of COS include the lack of recommendations for validated instruments for each domain, insufficient involvement of patients and key Collaborator groups in COS development, and a lack of awareness regarding the existence of COS. CONCLUSIONS: This analysis underscores the need for COS development approaches that prioritize the inclusion of patients and diverse Collaborator groups at every stage. While current studies on COS uptake are limited, future research should explore the broader implementation of COS across diverse disease categories and delve into the factors that hinder or facilitate their uptake such as, the importance of COS developers extending their work to recommending domains with well validated instruments. Embracing patient leadership and multifaceted engagement is essential for advancing the relevance and impact of COS in clinical research.

Defining domains: developing consensus-based definitions for foundational domains in OMERACT core outcome sets.

OBJECTIVE: To develop a set of detailed definitions for foundational domains commonly used in OMERACT (Outcome Measures in Rheumatology) core domain sets. METHODS: We identified candidate domain definitions from prior OMERACT publications and websites and publications of major organizations involved in outcomes research for six domains commonly used in OMERACT Core Domain Sets: pain intensity, pain interference, physical function, fatigue, patient global assessment, and health-related quality of life. We conducted a two-round survey of OMERACT working groups, patient research partners, and then the OMERACT Technical Advisory Group to establish their preferred domain definitions. Results were presented at the OMERACT 2023 Methodology Workshop, where participants discussed their relevant lived experience and identified potential sources of variability giving the needed detail in our domain definitions. RESULTS: One-hundred four people responded to both rounds of the survey, and a preferred definition was established for each of the domains except for patient global assessment for which no agreement was reached. Seventy-five participants at the OMERACT 2023 Methodology Workshop provided lived experience examples, which were used to contextualise domain definition reports for each of the five domains. CONCLUSION: Using a consensus-based approach, we have created a detailed definition for five of the foundational domains in OMERACT core domain sets; patient global assessment requires further research. These definitions, although not mandatory for working groups to use, may facilitate the initial domain-match assessment step of instrument selection, and reduce the time and resources required by future OMERACT groups when developing core outcome sets.

Measurement properties of the QuickDASH (disabilities of the arm, shoulder and hand) outcome measure and cross-cultural adaptations of the QuickDASH: a systematic review.

PURPOSE: To identify and synthesize evidence for the measurement properties of the QuickDASH, a shortened version of the 30-item DASH (Disabilities of the Arm, Shoulder and Hand) instrument. METHODS: This systematic review used a best evidence synthesis approach to critically appraise the measurement properties [using COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN)] of the QuickDASH and cross-cultural adaptations. A standard search strategy was conducted between 2005 (year of first publication of QuickDASH) and March 2011 in MEDLINE, EMBASE and CINAHL. RESULTS: The search identified 14 studies to include in the best evidence synthesis of the QuickDASH. A further 11 studies were identified on eight cross-cultural adaptation versions. CONCLUSIONS: Many measurement properties of the QuickDASH have been evaluated in multiple studies and across most of the measurement properties. The best evidence synthesis of the QuickDASH English version suggests that this tool is performing well with strong positive evidence for reliability and validity (hypothesis testing), and moderate positive evidence for structural validity testing. Strong negative evidence was found for responsiveness due to lower correlations with global estimates of change. Information about the measurement properties of the cross-cultural adaptation versions is still lacking, or the available information is of poor overall methodological quality.

Confirmatory factor analysis of the Work Limitations Questionnaire (WLQ-25) in Workers' Compensation Claimants with chronic upper-limb disorders.

PURPOSE: To examine the factorial validity of the Work Limitations Questionnaire (WLQ-25) among workers' compensation claimants with chronic upper-limb disorders. METHODS: Attendees of the WSIB Shoulder and Elbow Specialty clinic in Toronto, Ontario, Canada, completed a survey that includes the WLQ-25 [4 subscales: time-management (TM), physical demands (PD), mental-interpersonal (MI), and output demands (OD)]. Confirmatory factor analyses (n = 2262) were conducted to evaluate and compare alternative 4- and 5-factor WLQ-25 structures [MI subscale intact vs. separated into mental demands (MD) and interpersonal demands (IP) subscales]. Model fit indices, saliency of factor loadings, and convergent/divergent validity of latent factors (r = 0.4 - 0.85 expected) were concurrently assessed. RESULTS: The 4-factor WLQ-25 showed acceptable model fit after allowing the residuals of a pair of PD items to correlate (CFI = 0.924, TLI = 0.915, RMSEA = 0.057, SRMR = 0.054); however, significantly lower-than-expected correlations between the PD factor and all other factors (r = -0.11 - -0.03) were also observed. Model fit for the 5-factor WLQ-25 was even more optimal (CFI = 0.934, TLI = 0.925, RMSEA = 0.053, SRMR = 0.051), with MD and IP factors correlating at r = 0.83. CONCLUSIONS: Evidence of factorial validity was demonstrated by the WLQ-25; however, users should be attentive of an instrumentation issue that could be directly related to the psychometric performance of its PD subscale.

The ability of outcome questionnaires to capture patient concerns following ankle reconstruction.

BACKGROUND: The objective of this study was to compare questions from outcome questionnaires with items generated by preoperative and postoperative ankle reconstruction patients (using the open-ended questions of self-reported Patient-Specific Index [PASI]) to determine whether existing questionnaires address patients' concerns. METHODS: Patients (n = 142) completed the PASI. Questions from 6 standardized questionnaires (American Academy of Orthopaedic Surgeons Foot and Ankle Questionnaire [AAOS], patient-reported portion of the American Orthopaedic Foot and Ankle Society Clinical Rating System Ankle-Hindfoot Scale [AOFAS], Foot Function Index [FFI], Lower Extremity Functional Scale [LEFS], Short Musculoskeletal Function Assessment [SMFA], Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC]) and PASI were matched by 3 reviewers to corresponding categories in the International Classification of Functioning, Disability and Health (ICF). Standardized questionnaires were then compared with the patient responses produced by the PASI. RESULTS: Patients identified 690 items corresponding to 45 ICF categories. Most PASI concepts fell into Activities and Participation (60.3%) and Body Functions (29.0%) components, including the categories "walking" (19.1%), "pain" (16.5%), and "recreation and leisure" (15.4%); 237 items were identified in questionnaires and linked to 39 ICF categories. Core issues in questionnaires ("pain," "walking," "stairs") were important concerns for patients, but other key patient concerns ("swelling," "recreation and leisure," "sports") were seldom included in questionnaires. CONCLUSION: No single questionnaire captured all patient concerns, and standardized questionnaires differed largely in content. This analysis may help guide development of a more comprehensive instrument for evaluating outcomes following ankle reconstruction. CLINICAL RELEVANCE: When choosing an outcome questionnaire, clinicians and researchers should consider the targeted outcome because no one questionnaire captures the full patient experience.

Bone mineral density testing after fragility fracture: Informative test results likely.

OBJECTIVE: To determine the proportion of patients with fragility fractures who can be expected to have low bone mineral density (BMD) at the time of fracture and to assist FPs in deciding whether to refer patients for BMD testing. DATA SOURCES: MEDLINE, EMBASE, and CINAHL were searched from the earliest available dates through September 2009. STUDY SELECTION: English-language articles reporting BMD test results of patients with fragility fractures who were managed in an orthopedic environment (eg, fracture clinic, emergency management by orthopedic surgeons, inpatients) were eligible for review. While the orthopedic environment has been identified as an ideal point for case finding, FPs are often responsible for investigation and treatment. Factors that potentially influenced BMD test results (eg, selection of fracture types, exclusion criteria) were identified. Studies with 2 or more selection factors of potential influence were flagged, and rates of low BMD were calculated including and excluding these studies. SYNTHESIS: The distribution of the proportion of persons with low BMD was summarized across studies using descriptive statistics. We calculated lower boundaries on this distribution, using standard statistical thresholds, to determine a lower threshold of the expected rate of low BMD. CONCLUSION: Family physicians evaluating patients with fragility fractures can expect that at least two-thirds of patients with fragility fractures who are older than 50 years of age will have low BMD (T score ≤ -1.0). With this a priori expectation, FPs might more readily conduct a fracture risk assessment and pursue warranted fracture risk reduction strategies following fragility fracture.

Assessing the Utility of the Montreal Cognitive Assessment in Screening for Cognitive Impairment in Patients With Systemic Lupus Erythematosus.

OBJECTIVE: Screening for cognitive impairment (CI) in systemic lupus erythematosus (SLE) relies on the American College of Rheumatology (ACR) neuropsychological battery (NB). By studying the concurrent criterion validity, our goal was to assess the Montreal Cognitive Assessment (MoCA) as a screening tool for CI compared to the ACR-NB and to evaluate the added value of the MoCA to the Automated Neuropsychological Assessment Metrics (ANAM). METHODS: A total of 285 adult SLE patients were administered the ACR-NB, MoCA, and ANAM. For the ACR-NB, patients were classified as having CI if there was a Z score of ≤-1.5 in ≥2 domains. The area under the curve (AUC) and sensitivities/specificities were determined. A discriminant function analysis was applied to assess the ability of the MoCA to differentiate between CI, undetermined CI, and non-CI patients. RESULTS: CI was not accurately identified by the MoCA compared to the ACR-NB (AUC of 0.66). Sensitivity and specificity were poor at 50% and 69%, respectively, for the cutoff of 26, and 80% and 45%, respectively, for the cutoff of 28. The MoCA had a low ability to identify CI status. The addition of the MoCA to the ANAM led to improvement on the AUC by only 2.5%. CONCLUSION: The MoCA does not have adequate concurrent criterion validity to accurately identify CI in patients with SLE. The low specificity of the MoCA may lead to overdiagnosis and concern among patients. Adding the MoCA to the ANAM does not substantially improve the accuracy of the ANAM. These results do not support using the MoCA as a screening tool for CI in patients with SLE.

Tension at the borders: perceptions of role overload, conflict, strain and facilitation in work, family and health roles among employed individuals with arthritis.

OBJECTIVE: To examine inter-relationships among arthritis (A), work (W) and personal life (P) roles and their reciprocal influences, especially experiences of role balance/imbalance among individuals with inflammatory arthritis (IA) and OA. METHODS: Eight focus groups were conducted with 24 women and 16 men (aged 29-72 years). A purposive sample was recruited from community advertising. Eligibility included current employment or having been employed within the previous year. Participants were asked about ways arthritis, work and personal life roles intersected and their impact. A standardized questionnaire collected demographic, symptom and employment data for descriptive purposes. RESULTS: Participants noted that having arthritis affected their identity and intersected with work and personal roles, creating role overload, role conflict, role strain and role facilitation. Role overload highlighted that arthritis both affected and was impacted by work and personal life (A → W; A → P; W → A; P → A). Role conflict focused on A → W and A → P difficulties, whereas role facilitation emphasized the positive impact of work and personal life roles on arthritis (W → A; P → A). Role strain was pervasive and arose from numerous sources. Personal strategies (e.g. positive framing) and contextual factors (e.g. support) were important in contributing to or ameliorating role balance/imbalance. CONCLUSIONS: By comprehensively examining multiple types of role balance/imbalance and the context within which it occurs, this study identifies gaps in patient-oriented measurement of the impact of arthritis and areas of need in the development of arthritis intervention.