Development and validation of a bi-lingual interactive tool to educate people about osteomalacia.

Osteomalacia is a condition where bone mineralisation is impaired by lack of vitamin D. It more commonly affects darker skinned individuals in the UK, especially if they wear occlusive clothing. Lifestyle changes and Vitamin D supplementation are recommended for those people most at risk through these factors, but such advice is not commonly followed. This indicates an educational need for information on osteomalacia and its treatment. Using a previously developed Mind-Map on osteomalacia, a layered and interactive" PowerPoint" style presentation was developed, using hyperlinks. The "basic" layer was translated into Urdu and validated by Urdu speaking professionals. The translation was accurate and meaningful and the tool was well received by representatives of the community. The tool was used to educate a group of 10 community leaders from the Urdu community in Stourbridge, UK. Knowledge about osteomalacia was tested in these people, before and after the education, and increased from an average of 14 to 25 points (p < 0.05). Qualitative feedback gained was very positive. Conclusion: An interactive educational tool for Osteomalacia was developed and translated into Urdu. Use of the tool resulted in increased knowledge about osteomalacia.

Patient involvement in outcome measures for psoriatic arthritis.

Psoriatic arthritis (PsA) is a heterogeneous inflammatory arthritis with a varied clinical phenotype. There has been considerable international collaboration over recent years to develop and prioritise appropriate disease domains and outcome measures to capture all aspects of this complex disease. It has been recognised that patient-reported measures and physician assessments are complementary and, when used together, allow an improved reflection of disease burden. Taking this concept one step further, the experience in rheumatoid arthritis has demonstrated benefits of incorporating the patient perspective in the development of outcome measures. We report a systematic review demonstrating (1) that there has been little incorporation of the patient perspective in the development of outcome measures and domains in PsA, (2) the proceedings from the preliminary patient involvement in outcome measures for PsA (PIOMPSA) meetings, and (3) a proposed roadmap for improving patient involvement.

Management of radicular pain in rheumatic disease: insight for the physician.

Rheumatologists are still relatively unaware of the causes, presentation, diagnosis and management of radicular pain. This is against a background of increasing evidence of the presence and importance of radicular problems in patients with rheumatological disorders. When they coexist in patients, differentiating between nociceptive and neuropathic pain is clinically important because these components require different pain management strategies. Consequently, it is essential that rheumatologists become skilled in identifying as well as managing both forms of pain. This review will serve to further increase awareness among rheumatologists of this important issue as well as discuss the practical aspects of managing these conditions. The evaluation of patients requires very careful history taking and full thorough neurological examination. Diagnostic testing is suggested mainly to confirm the diagnosis and aetiology in patients with persistent symptoms despite conservative treatment. Neuroimaging is recommended for patients with acute radicular pain with progressive neurological deficits or those with high suspicion of neoplasm or epidural abscess. If neuroimaging does not confirm diagnosis, electrophysiology studies may be helpful. The management of this condition is multifaceted and involves physicians and allied healthcare professionals as well as the patients who should be encouraged to participate in self-management programmes. Nociceptive and neuropathic pain often coexists in patients with rheumatic disease. There are challenges to making the diagnosis of radicular pain in these patients. The diagnosis is primarily clinical but pathophysiological issues, diversity in symptoms, the multiple mechanisms of action and difficulties in communication between patients and their doctors as well as variable response to therapy pose challenges to the effective management of these patients. Despite these difficulties and challenges, it is essential that rheumatologists familiarize themselves with the management of radicular pain in rheumatic diseases. The evaluation of patients requires very careful history taking, aided by the use of an appropriate screening tool and full, thorough neurological examination. In addition, investigations such as the use of imaging or electrophysiology studies when required may help to differentiate between the pain phenotypes.

A survey of the images used on the Arthritis Research UK (ARUK) Osteomalacia Mind-Map in relation to cultural background.

OBJECTIVE: To explore the appropriateness of the images in the Arthritis Research UK Mind-Map for Osteomalacia with people for whom it was intended (Bengali; Gujarati; Hindi; Punjabi and Urdu). METHODS: Participants were identified in a convenient sample from contacts within their communities. They were asked to comment on the images for meaning, suitability and offence to people from their culture. A total of 56 people were surveyed. RESULTS: Appropriateness responses were either generic: Images of bone metabolism were confusing [31/56]; muscle weakness "looked like knee pain" [16/56]; a bending and cracking bone "looked like a dog's bone" [22/56] and that the bone pain man "looked like he had toothache" [21/56]; or culture-specific the depiction of food and the Burqa as below. Only 3 images caused any offence, phrased as "may offend someone". The Burqa was described as stereotyping. CONCLUSION: The images on the current Osteomalacia Mind-Map are largely appropriate and have little capacity to offend. Some may be improved upon in terms of conveying meaning. One set of images can suit all of the cultures. PRACTICE IMPLICATIONS: Images can cross cultural barriers. The revised Mind-Map should be more useful in conveying meaning to a wider selection of patients.

Effect of the early use of the anti-tumor necrosis factor adalimumab on the prevention of job loss in patients with early rheumatoid arthritis.

OBJECTIVE: To compare work disability and job loss in early rheumatoid arthritis (RA) patients receiving adalimumab plus methotrexate (adalimumab + MTX) versus MTX alone. METHODS: In this multicenter, randomized, controlled trial, patients with RA for <2 years who had never taken MTX and who self-reported work impairment were randomized to adalimumab + MTX or placebo + MTX for 56 weeks. Primary outcome was job loss of any cause and/or imminent job loss at or after week 16. Secondary outcomes included disease activity, function (Health Assessment Questionnaire [HAQ] score), and RA quality of life (RAQoL) questionnaire score. Work was evaluated with work diaries and the RA Work Instability Scale. RESULTS: Although job loss during the 56-week study was significantly lower with adalimumab + MTX (14 of 75 patients) compared with MTX alone (29 of 73 patients; P=0.005), the primary end point was not met (12 of 75 versus 20 of 73 patients; P=0.092), likely owing to early drop out in the MTX group. There were significant improvements in American College of Rheumatology 20% response criteria, 28-joint Disease Activity Score, DeltaHAQ, DeltaRAQoL, and working time lost in the adalimumab + MTX group. Twenty-four serious adverse events were reported in 17 participants, with no differences between groups. CONCLUSION: Adalimumab + MTX reduced job loss and improved productivity in early RA when compared with MTX alone, which supports the early use of anti-tumor necrosis factor therapy and suggests its cost efficacy.

Initiative for quality in psoriasis and psoriatic arthritis.

Psoriasis is a common and severe skin disease. Up to 30% of psoriasis patients develop psoriatic arthritis (PsA), another severe disease that contributes significantly to the burden of psoriatic disease in patients. The treatment of patients with both psoriasis and PsA is particularly challenging, because different strategies are often followed, and considerable resources are needed for these chronic inflammatory diseases. Of note, psoriasis patients tend to be undertreated. Efforts to improve the management of psoriasis and PsA are urgently needed, to incorporate improvement of patient outcomes by promotion of best practice from both the medical and the pharmacoeconomic perspective. These are the goals of the Quality Movement in the USA and of quality management in general. The need for evidence-based guidance on safety, efficacy, overall outcome, and cost-effectiveness is being addressed by numerous initiatives striving to generate practice guidelines, control costs, and optimize cost-effectiveness of treatments. The 2007 Group for Research and Assessment of Psoriasis and Psoriatic Arthritis's (GRAPPA) Initiative for Quality aims to secure and improve management of psoriasis and PsA, elaborating on these evidence-based guidelines by defining major domains of quality and creating a checklist that identifies physicians who can administer state-of-the-art medical services to patients who need their services.

Consensus on a core set of domains for psoriatic arthritis.

A psoriatic arthritis (PsA) module was convened at OMERACT 8 in order to achieve consensus on the core domains that should be included in randomized controlled trials and longitudinal observational cohorts of subjects with PsA. Following a plenary session at which current status of measures used to assess PsA were reviewed, and discussion at breakout groups, the group achieved consensus on 6 core domains: peripheral joint activity, skin activity, pain, patient global assessment, physical function, and health-related quality of life. In addition the following domains were considered important but not mandatory: spinal disease, dactylitis, enthesitis, fatigue, nail disease, radiography, physician global assessment, and acute-phase reactants. A research agenda was proposed to include development and validation of instruments for the domains where none existed, and in particular further research was recommended for the following areas: magnetic resonance imaging and ultrasound of joints, enthesitis, skin and synovial tissue analysis, and "participation."