Motivational interviewing-based training enhances clinicians' skills and knowledge in psoriasis: findings from the Pso Well® study.

BACKGROUND: Psoriasis is a common long-term, immune-mediated skin condition associated with behavioural factors (e.g. smoking, excess alcohol, obesity), which increase the risk of psoriasis onset, flares and comorbidities. Motivational interviewing (MI) is an evidence-based approach to health-related behaviour change that has been used successfully for patients with long-term conditions. This study assessed change in clinicians' MI skills and psoriasis knowledge following Psoriasis and Wellbeing (Pso Well® ) training. OBJECTIVES: To investigate whether the Pso Well training intervention improves clinicians' MI skills and knowledge about psoriasis-related comorbidities and risk factors; and to explore the acceptability and feasibility of the Pso Well training content, delivery and evaluation. METHODS: Clinicians attended the 1-day training programme focused on MI skills development in the context of psoriasis. MI skills were assessed pre- and post-training using the Behaviour Change Counselling Index. Knowledge about psoriasis-related comorbidity and risk factors was assessed with a novel 22-point measure developed for the study. Interviews with clinicians were analysed qualitatively to identify perceptions about the feasibility and acceptability of the training. RESULTS: Sixty-one clinicians completed the training (35 dermatology nurses, 23 dermatologists and three primary-care clinicians). Clinicians' MI skills (P < 0·001) and knowledge (P < 0·001) increased significantly post-training. Clinicians found the training valuable and relevant to psoriasis management. CONCLUSIONS: Attendance at the Pso Well training resulted in improvements in clinicians' knowledge and skills to manage psoriasis holistically. Clinicians deemed the training itself and the assessment procedures used both feasible and acceptable. Future research should investigate how this training may influence patient outcomes.

Primary care-based screening for cardiovascular risk factors in patients with psoriasis.

BACKGROUND: Studies assessing cardiovascular disease (CVD) risk factors in patients with psoriasis have been limited by selection bias, inappropriate controls or a reliance on data collected for clinical reasons. OBJECTIVES: To investigate whether screening for CVD risk factors in patients with psoriasis in primary care augments the known prevalence of CVD risk factors in a cross-sectional study. METHODS: Patients listed as having psoriasis in primary care were recruited, screened and risk assessed by QRISK2. RESULTS: In total, 287 patients attended (mean age 53 years, 57% women, 94% white British, 22% severe disease, 33% self-reported psoriatic arthritis). The proportion with known and screen-detected (previously unknown) risk factors was as follows: hypertension 35% known and 13% screen-detected; hypercholesterolaemia 32% and 37%; diabetes 6·6% and 3·1% and chronic kidney disease 1·1% and 4·5%. At least one screen-detected risk factor was found in 48% and two or more risk factors were found in 21% of patients. One in three patients (37%) not previously known to be at high risk were found to have a high (> 10%) 10-year CVD risk. Among the participants receiving treatment for known CVD risk factors, nearly half had suboptimal levels for blood pressure (46%) and cholesterol (46%). CONCLUSIONS: Cardiovascular risk factor screening of primary care-based adults with psoriasis identified a high proportion of patients (i) at high CVD risk, (ii) with screen-detected risk factors and (iii) with suboptimally managed known risk factors. These findings need to be considered alongside reports that detected limited responses of clinicians to identified risk factors before universal CVD screening can be recommended.

Multiple somatic symptoms predict impaired health status in functional somatic syndromes.

BACKGROUND: The relationship between functional somatic syndromes and multiple somatic symptoms is unclear. PURPOSE: We assessed whether the number of somatic symptoms is a predictor of health status in three functional somatic syndromes (FSS). METHODS: In a population-based study of 990 UK adults we assessed chronic widespread pain (CWP), chronic fatigue (CF) and irritable bowel syndrome (IBS) by questionnaire and medical record data. We assessed health status (Short Form 12 and EQ-5D), number of somatic symptoms (Somatic Symptom Inventory) and anxiety/depression (Hospital Anxiety and Depression Scale) both at baseline and at follow-up 1 year later. RESULTS: The proportion of people with an FSS who also have multiple somatic symptoms (52-55 %) was similar in the three functional syndromes. The presence of multiple somatic symptoms was associated with more impaired health status both at baseline and at follow-up. This finding was not explained by severity of FSS. In the absence of multiple somatic symptoms, the health status of the FSS was fair or good. In multiple regression analysis, the number of somatic symptoms, the presence of a functional syndrome (CWP or CF) and anxiety/depression were predictors of EQ-5D thermometer at follow-up after adjustment for confounders. CONCLUSIONS: Multiple somatic symptoms in people with an FSS are associated with impaired health status and this cannot be explained by more severe functional syndrome or the presence of anxiety and depression.

A geometrical model of vertical translation and alar ligament tension in atlanto-axial rotation.

INTRODUCTION: While allowing the greatest range of axial rotation of the entire spine with 40° to each side, gradual restraint at the extremes of motion by the alar ligaments is of vital importance. In order for the ligaments to facilitate a gradual transition from the neutral to the elastic zone, a complex interaction of axial rotation and vertical translation via the biconvex articular surfaces is essential. The aim of this investigation is to establish a geometrical model of the intricate interaction of the alar ligaments and vertical translatory motion of C1/C2 in axial rotation. METHODS: Bilateral alar ligaments including the odontoid process and condylar bony entheses were removed from six adult cadavers aged 65-89 years within 48 h of death. All specimens were judged to be free of abnormalities with the exception of non-specific degenerative changes. Dimensions of the odontoid process and alar ligaments were measured. Graphical multiplanar reconstruction of atlanto-axial rotation was done in the transverse and frontal planes for the neutral position and for rotation to 40° with vertical translation of 3 mm. The necessary fibre elongation of the alar ligaments in the setting with and without vertical translation of the atlas was calculated. RESULTS: The mean diameter of the odontoid process in the sagittal plane was 10.6 mm (SD 1.1). The longest fibre length was measured from the posterior border of the odontoid enthesis to the posterior border of the condylar enthesis with an average of 13.2 mm (SD 2.5) and the shortest between the lateral (anterior) border odontoid enthesis and the anterior condylar enthesis with an average of 8.2 mm (SD 2.2). In graphical multiplanar reconstruction of atlanto-axial rotation to 40° without vertical translation of C1/C2, theoretical alar fibre elongation reaches 27.1% for the longest fibres, which is incompatible with the collagenous structure of the alar ligaments. Allowing 3 mm caudal translation of C1 on C2 at 40° rotation, as facilitated by the biconvex atlanto-axial joints, reduces alar fibre elongation to 23.3%. CONCLUSION: The biconvex configuration of the atlanto-axial joints is an integral feature of the functionality of upper cervical spine as it allows gradual vertical translation of the atlas against the axis during axial rotation, with gradual tensing of the alar ligaments. Vertical translation on its own, however, does not explain the tolerance of the alar ligaments towards the maximum of 40° of rotation and is most likely synergistic with the effects of the coupled motion of occipitocervical extension during rotation.

Correction to: Diagnostic efficacy of cone beam computed tomography in paediatric dentistry: a systematic review.

In the original publication of the article the fifth author's name "A. Littlewood" was submitted as "A. Littewood" which was left unnoticed in the later stages. The correct name is as published in this erratum.

Diagnostic efficacy of cone beam computed tomography in paediatric dentistry: a systematic review.

PURPOSE: To determine in which clinical situations it is indicated or contra-indicated to prescribe cone beam computed tomography (CBCT) for paediatric patients. METHODS: Systematic review of in vivo paediatric research studies of diagnostic efficacy using CBCT, with supplementary searches for guideline documents on CBCT and for systematic reviews permitting inclusion of ex vivo and adult studies. RESULTS: After screening, 190 publications were included, mostly case studies. No systematic reviews were found of in vivo paediatric research. Fourteen studies of diagnostic efficacy were identified. The supplementary searches found 18 guideline documents relevant to the review and 26 systematic reviews. The diagnostic efficacy evidence on CBCT was diverse and often of limited quality. There was ex vivo evidence for diagnostic accuracy being greater using CBCT than radiographs for root fractures. The multiplanar capabilities of CBCT are advantageous when localising dental structures for surgical planning. Patient movement during scanning is more common in children which could reduce diagnostic efficacy. CONCLUSIONS: No strong recommendations on CBCT are possible, except that it should not be used as a primary diagnostic tool for caries. Guidelines on use of CBCT in the paediatric age group should be developed cautiously, taking into account the greater radiation risk and the higher economic costs compared with radiography. CBCT should only be used when adequate conventional radiographic examination has not answered the question for which imaging was required. Clinical research in paediatric patients is required at the higher levels of diagnostic efficacy of CBCT.

A prospective study of screening for musculoskeletal pathology in the child with a limp or pseudoparalysis using erythrocyte sedimentation rate, C-reactive protein and MRI.

PURPOSE: To determine if the detection of musculoskeletal pathology in children with a limp or acute limb disuse can be optimized by screening with blood tests for raised inflammatory markers, followed by MRI. METHODS: This was a prospective observational study. Entry criteria were children (0 to 16 years of age) presenting to our emergency department with a non-traumatic limp or pseudoparalysis of a limb, and no abnormality on plain radiographs. Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) blood tests were performed. Children with ESR > 10 mm/hr or CRP > 10 mg/L underwent a MRI scan. When the location of the pathology causing the limp was clinically unclear, screening images (Cor t1 and Short Tau Inversion Recovery) of both lower limbs from pelvis to ankles ('legogram') was undertaken. Data was gathered prospectively from 100 consecutive children meeting the study criteria. RESULTS: In all, 75% of children had a positive finding on their MRI. A total of 64% of cases had an infective cause for their symptoms (osteomyelitis, septic arthritis, pyomyositis, fasciitis, cellulitis or discitis). A further 11% had positive findings on MRI from non-infective causes (juvenile idiopathic arthritis, cancer or undisplaced fracture). The remaining 25% had either a normal scan or effusion due to transient synovitis. ESR was a more sensitive marker than CRP in infection, since ESR was raised in 97%, but CRP in only 70%. CONCLUSION: In our opinion MRI imaging of all children with a limp and either raised ESR or CRP is a sensitive method to minimize the chance of missing important pathology in this group, and is an effective use of MRI resources. We advocate the use of both blood tests in conjunction. LEVEL OF EVIDENCE: Level II.

Detecting the earliest radiological signs of bisphosphonate-related osteonecrosis.

Introduction Oral bisphosphonates are the most commonly prescribed anti-resorptive drugs used in the treatment of osteoporosis, but osteonecrosis of the jaw is a serious complication. The early diagnosis of this destructive side effect is crucial in preventing excessive bone loss, pain and infection.Objective To aid dental practitioners in the early identification of bisphosphonate-related osteonecrosis of the jaw.Method A scoping review was carried out.Data sources We searched MEDLINE via OVID, EMBASE via OVID, Dentistry and Oral Sciences Source (DOSS), Proquest Dissertation and Theses Search, to identify references that described clinical and radiological findings in medication-related osteonecrosis of the jaw (MRONJ).Data selection Nineteen references mentioned the earliest radiological changes in MRONJ with a description of the observations and were included in the analysis.Data synthesis The radiographic signs included osteosclerosis/lysis, widening of the periodontal ligament and thickening of the lamina dura and cortex. To assess the quality of original data on which recommendations had been made, these 19 studies were subjected to a quality appraisal.Conclusion Using bone exposure as a criterion for diagnosis of MRONJ, leads to delayed diagnosis and a poor response to treatment. In those patients at risk of bone exposure with MRONJ, insufficient information is present in the literature to allow the general dental practitioner to reliably identify the radiographic features indicating imminent bone exposure. A well-designed prospective study is needed.

Human small cell lung cancer cell lines expressing the proopiomelanocortin gene have aberrant glucocorticoid receptor function.

Some human small cell lung carcinomas (SCLC) secrete proopiomelanocortin (POMC) derived peptides, but in contrast to the pituitary, glucocorticoids fail to inhibit this hormone production. We have previously described an in vitro model using human SCLC cell lines that express POMC and are resistant to glucocorticoids. We have now identified the glucocorticoid receptor (GR) in the SCLC cell line COR L24 using a whole cell ligand binding assay (Kd = 5.7 nM; Bmax = 11 fmol/million cells), while another cell line, DMS 79, lacked significant glucocorticoid binding. To analyze GR function both positive (GMCO) and negative (TRE)3-tkCAT), glucocorticoid-regulated reporter gene constructs were transfected into COR L24 cells. In the SCLC cell line, neither hydrocortisone nor dexamethasone (500-2,000 nM) significantly induced chloramphenicol acetyltransferase expression from GMCO; in addition, they did not suppress chloramphenicol acetyltransferase expression from (TRE)3-tkCAT. Similar results were obtained with two other POMC-expressing SCLC cell lines. Expression of wild type GR in COR L24 cells restored glucocorticoid signaling, with marked induction of GMCO reporter gene expression by dexamethasone (9,100 +/- 910%; n = 3), and an estimated EC50 of 10 nM. This failure of the GR explains the resistance of the POMC gene to glucocorticoid inhibition and may have implications for cell growth in SCLC.

Common and unique associated factors for medically unexplained chronic widespread pain and chronic fatigue.

OBJECTIVE: Chronic widespread pain and chronic fatigue share common associated factors but these associations may be explained by the presence of concurrent depression and anxiety. METHODS: We mailed questionnaires to a randomly selected sample of people in the UK to identify participants with chronic widespread pain (ACR 1990 definition) and those with chronic fatigue. The questionnaire assessed sociodemographic factors, health status, healthcare use, childhood factors, adult attachment, and psychological stress including anxiety and depression. To identify persons with unexplained chronic widespread pain or unexplained chronic fatigue; we examined participant's medical records to exclude medical illness that might cause these symptoms. RESULTS: Of 1443 participants (58.0% response rate) medical records of 990 were examined. 9.4% (N=93) had unexplained chronic widespread pain and 12.6% (N=125) had unexplained chronic fatigue. Marital status, childhood psychological abuse, recent threatening experiences and other somatic symptoms were commonly associated with both widespread pain and fatigue. No common effect was found for few years of education and current medical illnesses (more strongly associated with chronic widespread pain) or recent illness in a close relative, neuroticism, depression and anxiety scores (more strongly associated with chronic fatigue). Putative associated factors with a common effect were associated with unexplained chronic widespread pain or unexplained chronic fatigue only when there was concurrent anxiety and/or depression. DISCUSSION: This study suggests that the associated factors for chronic widespread pain and chronic fatigue need to be studied in conjunction with concurrent depression/anxiety. Clinicians should be aware of the importance of concurrent anxiety or depression.

Human osteoblastlike cells do not respond to interleukin-6.

Interleukin 6 (IL-6) exerts well-established effects on cells of the immune system as well as on various other cell types. It has been implicated in the control of connective tissue cells in such conditions as rheumatoid arthritis and osteoporosis. We have investigated the effects of recombinant human interleukin-6 (rhIL-6) on human osteoblastlike cells derived from explants of trabecular bone. ROS 17/2.8 cells were used as an additional osteoblastlike cell model system. We were unable to identify any effects of rhIL-6 (5-5000 pg/ml) on the proliferation, alkaline phosphatase activity. osteocalcin production, or release of cytokines or prostaglandins by either osteoblastlike cell model system. Since we have shown previously that these cells release IL-6 in culture, we used a sheep anti-human IL-6 antibody to investigate the possibility that (1) action of added exogenous IL-6 could be masking endogenous production, and (2) endogenous IL-6 may regulate the effects of osteotropic agents on the osteoblastlike cells. Presence of the antibody exerted no detectable effects on 1,25-(OH)2D3-stimulated alkaline phosphatase or on proliferation or TNF production enhanced by IL-1. Thus IL-6 does not appear to be involved in the regulation of osteoblast activity.

Production of tumor necrosis factor by human osteoblasts is modulated by other cytokines, but not by osteotropic hormones.

Human osteoblast cultures derived as out-growths from trabecular bone released tumor necrosis factor (TNF alpha) upon stimulation of the cells with human recombinant interleukin 1 (IL1; 10(-13)-10(-11) M), human recombinant granulocyte-macrophage colony-stimulating factor (100-1000 U/ml), and bacterial lipopolysaccharide (5-500 ng/ml). The osteotropic hormones 1,25-dihydroxyvitamin D3, PTH, and calcitonin had no effect on TNF production. The TNF released by the osteoblasts was identified as TNF alpha, using a specific anti-TNF alpha monoclonal antibody to neutralize its activity. Immunohistochemical staining of the cells using the same antibody revealed that all of the cells in the cultures were capable of producing TNF alpha, including those that also expressed alkaline phosphatase activity. Immunoreactive protein could be detected in the perinuclear region when cells were cultured in the presence of monensin, suggesting accumulation of newly synthesised protein in the Golgi apparatus. These results suggest that human osteoblasts, which have been shown previously to respond to TNF alpha, can synthesize and release TNF in response to IL1 and granulocyte-macrophage colony-stimulating factor. TNF may, therefore, not only have a pathological role in conditions of chronic inflammation, but also may act as a local paracrine or autocrine regulator of osteoblast function.

The modulation of the expression of IL-6 and its receptor in human osteoblasts in vitro.

Interleukin 6 (IL-6) probably plays a central role in the acute phase response and in haemopoiesis and may be involved in the control of bone turnover. We have studied the release of IL-6 from human trabecular bone cells treated with a variety of stimuli using a specific bioassay. In serum free medium, unstimulated human osteoblast-like cells produced IL-6 in the range of 1000-2050 pg/ml/24 h. Recombinant human interleukin 1 (IL-1 alpha) (10(-13)-10(-11) M), tumor necrosis factor alpha (TNF alpha) (10(-9)-10(-7) M) and lipopolysaccharide (5-500 ng/ml) all stimulated release of IL-6 from human bone cells. Maximal levels of 17,000 pg/ml were observed using the highest concentration of IL-1. 1,25(OH)2D3 and PTH did not stimulate IL-6 release. Using a specific sheep antihuman IL-6 antibody, all IL-6 activity could be neutralized. In parallel studies, ROS 17/2.8 rat osteosarcoma cells released around 50 pg/ml of IL-6 under basal conditions which were increased to a maximum of 900 pg/ml by treatment with PTH (10(-9) M). The cytokines were less effective and 1,25(OH)2D3 again had no effect. Modulation of expression of IL-6 mRNA in human osteoblast cells was examined using a human complementary deoxyribonucleic acid probe. The mRNA was constitutively expressed, and IL-1 (10(-11) M) and TNF (10(-7) M) induced further mRNA expression within 2 h, which was sustained over 24 h. 1,25(OH)2D3 (10(-7) M), IL-6 (2000 pg/ml), and PTH (10(-9) M) exerted no effects at any time point. Dexamethasone (10(-6) M) suppressed both basal and IL-1- and TNF-induced IL-6 mRNA expression. IL-6 receptor mRNA was constitutively expressed but was not regulated by any of the above agents. It is clear that rodent and human osteoblasts differ in their production of IL-6 and its modulation. These data support the hypothesis that IL-6 is produced locally in human bone by osteoblasts under the direction of other cytokines. This could have implications in bone remodeling, haemopoiesis, and systemic responses to local injury.

Expression of mRNA for IL1 beta, IL6 and TGF beta 1 in developing human bone and cartilage.

Using in situ hybridization, we investigated the expression of mRNA for interleukin-1 beta (IL1 beta), interleukin-6 (IL6), and transforming growth factor-beta-1 (TGF beta 1) in sections of developing bone in human osteophytes. The expression was related to the cellular activity of alkaline phosphatase to aid in the identification of pre-osteoblast populations. IL1 beta mRNA was localized in active osteoblasts within distinct areas of intramembranous ossification. However, the expression was sporadic and appeared to occur at a specific stage of the osteoblast life cycle. There was no IL1 beta mRNA expression in any cell types during endochondral ossification. IL6 mRNA expression was located within pre-osteoblasts and in newly differentiated and matrix-secreting osteoblasts; expression was absent or reduced in flattened, inactive osteoblasts. Weak or no IL6 expression was observed in chondroblasts and chondrocytes, respectively. However, there was a close association between IL6 mRNA expression and the differentiation of mesenchymal cells into osteoblasts. TGF beta 1 expression was localized to osteoblasts apposed to bone or cartilage matrix; the intensity of expression correlated with matrix secretion. Chondroblasts and chondrocytes expressed lower but significant levels of TGF beta 1 mRNA; the expression was lost with the progression to calcifying cartilage. The three cytokines studied were differentially expressed both temporally and spatially, suggesting different roles for each in osteoblast and chondrocyte function.

Elevated serum interleukin-6 levels associated with active disease in systemic connective tissue disorders.

OBJECTIVE: It is well established that connective tissue diseases such as systemic lupus erythematosus (SLE) are associated with a weak or absent acute phase response, although elevated serum interleukin 6 levels have been described. In this study, we have sought to correlate serum levels of IL-6 with standard laboratory and clinical assessments of disease activity in two connective tissue diseases, namely SLE and systemic sclerosis (SSc), and, for comparative purposes, rheumatoid arthritis (RA). METHODS: Serum IL-6 levels were determined by bioassay and also, in some sera, by immunoradiometric assay. They were compared with two inflammatory parameters, serum C-reactive protein (CRP) and plasma viscosity (PV), and with appropriate clinical measurements in the various patient groups, including BILAG in SLE, the skin score in SSc, and the Ritchie index in RA. RESULTS: Serum IL-6 (SeIL-6) levels were elevated in active SLE, SSc, and RA. This was poorly correlated with the acute phase response in SLE and SSc, but there was a strong relationship of SeIL-6 to disease activity in these conditions. In SLE, the BILAG disease activity index correlated best with SeIL-6 levels while there was only a weak relationship between CRP and IL-6, and no relationship between CRP and disease activity. In SSc there was a relationship of disease activity to SeIL-6 but not between SeIL-6 and either CRP or PV. In a small RA group there was a much stronger relationship of SeIL-6 to CRP and PV, as has been previously described. CONCLUSION: The determination of SeIL-6 may be a useful indicator of disease activity in those patients groups, including SLE and SSc, in which a normal acute phase response by the liver is often lacking. The mechanism underlying this hepatic impairment requires further investigation, but is clearly not due to a failure to generate the appropriate cytokine signal. Excessive local or systemic production of IL-6 in connective tissue diseases could play an important pathogenic role in these conditions, for example through stimulating autoantibody synthesis.

The misleading appearance of silver nitrate on plain radiography.

Cauterisation with silver nitrate is commonly used to treat overgranulation. Silver nitrate has a high density and a high mass attenuation coefficient, and it is therefore highly radio-opaque. We present a case in which its topical application to an area of overgranulation was interpreted as a bony fragment by the reporting radiologist in a patient with a supracondylar humeral fracture whose radiograph after removal of K-wires showed a large radio-opaque lesion. Although not a new phenomenon, it is one not widely known, and it can lead to confusion and unnecessary further imaging.

Haemangioma of the maxilla: a case report.

A rapidly expanding central haemangioma of the left maxilla in a 7-year-old boy was treated by ligation of the left external carotid and facial arteries and of the major vessel draining the lesion. Clinical and radiographic regression of the lesion has followed this treatment. Possible alternative approaches are discussed, as are the appropriate diagnostic techniques.