Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA): updated treatment recommendations for psoriatic arthritis 2021.

Since the second version of the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) treatment recommendations were published in 2015, therapeutic options for psoriatic arthritis (PsA) have advanced considerably. This work reviews the literature since the previous recommendations (data published 2013-2020, including conference presentations between 2017 and 2020) and reports high-quality, evidence-based, domain-focused recommendations for medication selection in PsA developed by GRAPPA clinicians and patient research partners. The overarching principles for the management of adults with PsA were updated by consensus. Principles considering biosimilars and tapering of therapy were added, and the research agenda was revised. Literature searches covered treatments for the key domains of PsA: peripheral arthritis, axial disease, enthesitis, dactylitis, and skin and nail psoriasis; additional searches were performed for PsA-related conditions (uveitis and inflammatory bowel disease) and comorbidities. Individual subcommittees used a GRADE-informed approach, taking into account the quality of evidence for therapies, to generate recommendations for each of these domains, which were incorporated into an overall schema. Choice of therapy for an individual should ideally address all disease domains active in that patient, supporting shared decision-making. As safety issues often affect potential therapeutic choices, additional consideration was given to relevant comorbidities. These GRAPPA treatment recommendations provide up-to-date, evidence-based guidance on PsA management for clinicians and people with PsA.

Does a modified STarT Back Tool predict outcome with a broader group of musculoskeletal patients than back pain? A secondary analysis of cohort data.

OBJECTIVES: The STarT Back Tool has good predictive performance for non-specific low back pain in primary care. We therefore aimed to investigate whether a modified STarT Back Tool predicted outcome with a broader group of musculoskeletal patients, and assessed the consequences of using existing risk-group cut-points across different pain regions. SETTING: Secondary analysis of prospective data from 2 cohorts: (1) outpatient musculoskeletal physiotherapy services (PhysioDirect trial n=1887) and (2) musculoskeletal primary-secondary care interface services (SAMBA study n=1082). PARTICIPANTS: Patients with back, neck, upper limb, lower limb or multisite pain with a completed modified STarT Back Tool (baseline) and 6-month physical health outcome (Short Form 36 (SF-36)). OUTCOMES: Area under the receiving operator curve (AUCs) tested discriminative abilities of the tool's baseline score for identifying poor 6-month outcome (SF-36 lower tertile Physical Component Score). Risk-group cut-points were tested using sensitivity and specificity for identifying poor outcome using (1) Youden's J statistic and (2) a clinically determined rule that specificity should not fall below 0.7 (false-positive rate <30%). RESULTS: In PhysioDirect and SAMBA, poor 6-month physical health was 18.5% and 28.2%, respectively. Modified STarT Back Tool score AUCs for predicting outcome in back pain were 0.72 and 0.79, neck 0.82 and 0.88, upper limb 0.79 and 0.86, lower limb 0.77 and 0.83, and multisite pain 0.83 and 0.82 in PhysioDirect and SAMBA, respectively. Differences between pain region AUCs were non-significant. Optimal cut-points to discriminate low-risk and medium-risk/high-risk groups depended on pain region and clinical services. CONCLUSIONS: A modified STarT Back Tool similarly predicts 6-month physical health outcome across 5 musculoskeletal pain regions. However, the use of consistent risk-group cut-points was not possible and resulted in poor sensitivity (too many with long-term disability being missed) or specificity (too many with good outcome inaccurately classified as 'at risk') for some pain regions. The draft tool is now being refined and validated within a new programme of research for a broader musculoskeletal population. TRIAL REGISTRATION NUMBER: ISRCTN55666618; Post results.

What predicts change in pulmonary function and quality of life in asthma or COPD?

Information about predictors of decline in pulmonary function (forced expiratory volume in 1 second [FEV1]) or health-related quality of life (HRQoL) in patients with asthma or (chronic obstructive pulmonary disease [COPD]) might help to determine those who need additional care. A 2-year prospective cohort study was conducted among 380 asthma and 120 COPD patients. In both asthma and COPD patients, a 2-year change in FEV1 was only weakly associated with a 2-year change in HRQoL (r = .0.19 and 0.24, respectively). In both groups, older age, living in an urban environment, and a lower peak expiratory flow rate (PEFR) at baseline were associated with a decline in FEV1. Additional predictors of FEV1 decline were greater body weight, less chronic cough or sputum production, and less respiratory symptoms in asthma patients and current smoking in COPD patients. A decline in HRQoL was associated with older age, non-compliance with medication, more dyspnea, and a lower PEFR in asthma patients and with male gender, lower education, lower body weight, more dyspnea, and more respiratory symptoms in COPD patients. Our results show that FEV1 and HRQoL appear to represent different disease aspects influenced by different predictors.

The test of Lasègue: systematic review of the accuracy in diagnosing herniated discs.

STUDY DESIGN: A systematic review of the literature including statistical meta-analysis. OBJECTIVES: To evaluate published methods of the test of Lasègue or straight leg raising test and the cross straight leg raising test by using a recently developed criteria list and to summarize and explore reasons for variation in diagnostic accuracy. SUMMARY OF BACKGROUND DATA: Little evidence exists on the diagnostic accuracy of the widely used straight leg raising test and the cross straight leg raising test in diagnosing herniated discs in patients with low back pain. METHODS: MEDLINE and EMBASE searches up to 1997 showed 17 diagnostic publications evaluating the straight leg raising test with surgery as reference standard. Quality of methods was assessed with a specific checklist. Eleven studies were selected for statistical pooling. Sources of variation and heterogeneity were studied by meta-regression of the diagnostic odds ratio. RESULTS: All studies were surgical case-series at nonprimary care level. Verification-bias was obvious in one study. Pooled sensitivity for straight leg raising test was 0. 91 (95% CI 0.82-0.94), pooled specificity 0.26 (95% CI 0.16-0.38). Pooled diagnostic odds ratio was 3.74 (95% CI 1.2-11.4). Discriminative power was lower in recent studies, in studies with only inclusion of primary hernias, and with blind assessment of both the index-test (straight leg raising test) and the reference (surgery). For the cross straight leg raising test pooled sensitivity was 0.29 (95% CI 0.24-0.34), pooled specificity was 0.88 (95% CI 0.86-0.90), and the pooled diagnostic odds ratio 4.39 (95% CI 0.74-25.9). CONCLUSIONS: The diagnostic accuracy of the straight leg raising test is limited by its low specificity. Discriminative power decreased with a more valid design, a more homogenous case-mix, and year of publication. Although the studies may reflect everyday clinical practice, they do not enable a valid evaluation of the diagnostic accuracy of both tests. Diagnostic research should evaluate the validity of the complete diagnostic process and study the evidence of the added value of the different tests used. [Key words: sensitivity, specificity, diagnosis, meta-analysis, test of Lasègue, straight leg raising test]

Energy expenditure during walking in subjects with tibial rotationplasty, above-knee amputation, or hip disarticulation.

The surgical treatment of osteosarcoma with a tibial rotationplasty seems to offer functional advantages in comparison with an above-knee amputation. It has not been established whether the functional advantages are accompanied by a lower rate of energy expenditure during walking. In children with a tibial rotationplasty (n = 15), an above-knee amputation (n = 6), or a hip disarticulation (n = 5), energy expenditure was measured during treadmill walking at various walking velocities. The subjects with a tibial rotationplasty were able to walk faster, but there were no differences between the groups in energy expenditure per unit time or per unit distance. Correction for confounding variables including age, sex, height, time since operation, level of activity, and support during walking in a multiple linear regression model did not reveal any significant differences in energy expenditure during walking between groups. 1992 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation.