The importance of cultural tailoring of communicators and media outlets in an influenza vaccination awareness campaign: a digital randomized trial.

The COVID-19 pandemic has exposed the vulnerability of ethnic minorities again. Health inequity within ethnic minorities has been explained by factors such as higher prevalence of underlying disease, restricted access to care, and lower vaccination rates. In this study, we investigated the effect of cultural tailoring of communicators and media outlets, respectively, on vaccine willingness in an influenza vaccination campaign in the Netherlands. A total of 1226 participants were recruited from two culturally non-tailored media outlets (Dutch newspaper and Facebook), and one media outlet tailored to a large community in the Netherlands with Indian ancestry. The participants from all three media outlets were randomly exposed to a vaccination awareness video delivered by a physician with an Indian or Dutch background, followed by an online survey. Cultural tailoring compared to cultural non-tailoring of communicators showed no difference in improvement of vaccine willingness (13.9% vs. 20.7% increment, respectively, p = 0.083). However, the media outlet tailored to the community with Indian ancestry, resulted in a higher improvement of vaccine willingness compared to non-tailored media outlets (46.7% vs. 14.7% increment, respectively, p < 0.001, unadjusted OR = 5.096). These results suggest that cultural tailoring of media outlets may be critical to effectively reach out to ethnic minorities to help optimize vaccination rates and improve general health.

Rewetting does not return drained fen peatlands to their old selves.

Peatlands have been drained for land use for a long time and on a large scale, turning them from carbon and nutrient sinks into respective sources, diminishing water regulation capacity, causing surface height loss and destroying biodiversity. Over the last decades, drained peatlands have been rewetted for biodiversity restoration and, as it strongly decreases greenhouse gas emissions, also for climate protection. We quantify restoration success by comparing 320 rewetted fen peatland sites to 243 near-natural peatland sites of similar origin across temperate Europe, all set into perspective by 10k additional European fen vegetation plots. Results imply that rewetting of drained fen peatlands induces the establishment of tall, graminoid wetland plants (helophytisation) and long-lasting differences to pre-drainage biodiversity (vegetation), ecosystem functioning (geochemistry, hydrology), and land cover characteristics (spectral temporal metrics). The Paris Agreement entails the rewetting of 500,000 km2 of drained peatlands worldwide until 2050-2070. A better understanding of the resulting locally novel ecosystems is required to improve planning and implementation of peatland rewetting and subsequent management.

Survival, comorbidities and joint damage 11 years after the COBRA combination therapy trial in early rheumatoid arthritis.

BACKGROUND: COBRA (for 'COmbinatie therapie Bij Rheumatoide Artritis') combination therapy is effective for the treatment of rheumatoid arthritis (RA), but long-term safety is unknown. This study evaluates survival, comorbidities and joint damage in the original COBRA trial cohort. METHODS: In the COBRA trial, 155 patients with early RA were treated with sulfasalazine (SSZ) monotherapy (SSZ group) or a combination of step-down prednisolone, methotrexate (MTX) and SSZ (COBRA group). The current 11-year follow-up study of the COBRA trial invited all original patients and performed protocollised scrutiny of clinical records, questionnaires, physical examination, laboratory and imaging tests. RESULTS: In all, 152 out of 155 patients yielded at least partial data. After a mean of 11 years follow-up, 18 (12%) patients had died, 6 COBRA patients and 12 SSZ patients, HR 0.57 (95% CI 0.21 to 1.52). Treatment for hypertension was significantly more prevalent in the COBRA group (p=0.02) with similar trends for diabetes and cataract. Conversely, hypercholesterolaemia, cancer and infection showed a trend in favour of COBRA. Other comorbidities such as cardiovascular disease and fractures appeared in similar frequency. Radiographic findings suggest as a minimum sustained benefit for COBRA therapy, that is, difference in joint damage but similar subsequent progression rates after 5 years. Imputation to compensate for selective dropout suggests increasing benefit for COBRA, that is, difference in yearly progression rates similar to that seen in the first 5 years of follow-up. CONCLUSIONS: After 11 years, initial COBRA combination therapy resulted in numerically lower mortality and similar prevalence of comorbidity compared with initial SSZ monotherapy. In addition, lower progression of joint damage suggests long-term disease modification.

Communicating the effectiveness and ineffectiveness of government policies and their impact on public support: a systematic review with meta-analysis.

Low public support for government interventions in health, environment and other policy domains can be a barrier to implementation. Communicating evidence of policy effectiveness has been used to influence attitudes towards policies, with mixed results. This review provides the first systematic synthesis of such studies. Eligible studies were randomized controlled experiments that included an intervention group that provided evidence of a policy's effectiveness or ineffectiveness at achieving a salient outcome, and measured policy support. From 6498 abstracts examined, there were 45 effect sizes from 36 eligible studies. In total, 35 (N = 30 858) communicated evidence of effectiveness, and 10 (N = 5078) communicated evidence of ineffectiveness. Random effects meta-analysis revealed that communicating evidence of a policy's effectiveness increased support for the policy (SMD = 0.11, 95% CI [0.07, 0.15], p < 0.0001), equivalent to support increasing from 50% to 54% (95% CI [53%, 56%]). Communicating evidence of ineffectiveness decreased policy support (SMD = -0.14, 95% CI [-0.22, -0.06], p < 0.001), equivalent to support decreasing from 50% to 44% (95% CI [41%, 47%]). These findings suggest that public support for policies in a range of domains is sensitive to evidence of their effectiveness, as well as their ineffectiveness.

A review of instruments to assess illness representations in patients with rheumatic diseases.

OBJECTIVE: Critical appraisal of instruments to assess illness representations in rheumatology. METHODS: A first search (MEDLINE, EMBASE, PsycINFO) identified articles describing development of instruments assessing illness representations. A second search identified articles applying them in rheumatology. Appraisal was performed using checklists. RESULTS: Five instruments were identified: the Illness Perception Questionnaire (IPQ), the Revised Illness Perception Questionnaire (IPQ-R), the Illness Cognition Questionnaire (ICQ), the Implicit Models of Illness Questionnaire (IMIQ) and the Meaning of Illness Questionnaire (MIQ). The number of items varied from 18 to 70. Internal consistency was good. Construct validity was moderate to good for all instruments, but was not tested for the IMIQ. Predictive validity was assessed for the ICQ and IPQ and was low to moderate. Sensitivity to change was tested for ICQ and was good. Applications in rheumatology are increasing. Significant relationships with different outcomes and additional evidence for predictive validity were found. CONCLUSIONS: Five instruments that assess illness representations can be used in rheumatology. The number of subscales and items vary. The ICQ and IPQ are most extensively validated and have been most frequently applied in rheumatology. Illness representations have relevant associations with self-report and objective outcomes. They should be considered when exploring health in rheumatology.

Ankylosing spondylitis and the risk of fracture: results from a large primary care-based nested case-control study.

BACKGROUND AND AIMS: Ankylosing spondylitis (AS) is associated with bone loss in the vertebrae and an increased prevalence of vertebral fractures, but literature about the magnitude of the risk of fracturing is limited. One retrospective cohort study provided evidence of an increased risk of clinical vertebral fractures but not of non-vertebral fractures. This study further explores the risk of clinical vertebral and non-vertebral fractures in a large population database. METHODS: In a primary care-based nested case-control study, 231,778 patients with fracture and 231,778 age- and sex-matched controls were recruited. A history of AS was assessed from the medical records. Odds ratios (OR) and 95% confidence intervals (CI) were calculated after adjustment for medication, other illnesses, smoking and body mass index when known. RESULTS: AS was diagnosed in 758 subjects. The prevalence of AS was 0.18% in patients with fracture and 0.15% in controls. Patients with AS had an increased risk of clinical vertebral fracture (OR 3.26; 95% CI 1.51 to 7.02). The risk of fractures of the forearm and hip was not significantly increased (OR 1.21; 95% CI 0.87 to 1.69 and OR 0.77; 95% CI 0.43 to 1.37, respectively). The risk of any clinical fracture was increased in patients with AS with a history of inflammatory bowel disease (OR 2.79; 95% CI 1.10 to 7.08), whereas it was decreased in patients with AS taking non-steroidal anti-inflammatory drugs (OR 0.65; 95% CI 0.50 to 0.84). The risk was not associated with recent back pain, psoriasis, joint replacement therapy and use of sulfasalazine. CONCLUSIONS: Patients with AS have an increased risk of clinical vertebral fracture but not of non-vertebral fractures, while the risk of any clinical fracture is increased in patients with concomitant inflammatory bowel disease. The mechanism by which non-steroidal anti-inflammatory drugs reduce the risk of any clinical fracture warrants further research.

Development of an ASAS-endorsed disease activity score (ASDAS) in patients with ankylosing spondylitis.

OBJECTIVES: To develop a new index for disease activity in ankylosing spondylitis (ASDAS) that is truthful, discriminative and feasible, and includes domains/items that are considered relevant by patients and doctors. METHODS: Eleven candidate variables covering six domains of disease activity, selected by ASAS experts in a Delphi exercise, were tested in a three-step approach, similar to the methodology used for the disease activity score in rheumatoid arthritis. Data on 708 patients included in ISSAS (International Study on Starting tumour necrosis factor blocking agents in Ankylosing Spondylitis) were used. Cross validation was carried out in the OASIS cohort (Outcome in Ankylosing Spondylitis International Study). RESULTS: Principal component analysis disclosed three factors with eigenvalues >0.75: patient assessments, peripheral joint assessments and acute phase reactants. Discriminant function analysis resulted in a correct classification in approximately 72% of the cases (prior probability approximately 50%). Regression analysis resulted in an index with five variables (total back pain, patient global assessment, duration of morning stiffness, C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR)). Three additional candidate indices were designed using similar methodology while omitting either ESR or CRP or patient global assessment. All four scores correlated with the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI; r = 0.67-0.80), patient (0.58-0.75) and physician's global assessment (0.41-0.48) of disease activity. All four candidate ASDAS indices performed better than BASDAI or single-item variables in discriminating between high and low disease activity state, according to doctors as well as patients in the OASIS cohort. CONCLUSION: The first steps in the development of a new assessment tool of disease activity in AS derived four candidate indices with good face and construct validity, and high discriminant capacity.

New criteria for inflammatory back pain in patients with chronic back pain: a real patient exercise by experts from the Assessment of SpondyloArthritis international Society (ASAS).

OBJECTIVE: Inflammatory back pain (IBP) is an important clinical symptom in patients with axial spondyloarthritis (SpA), and relevant for classification and diagnosis. In the present report, a new approach for the development of IBP classification criteria is discussed. METHODS: Rheumatologists (n = 13) who are experts in SpA took part in a 2-day international workshop to investigate 20 patients with back pain and possible SpA. Each expert documented the presence/absence of clinical parameters typical for IBP, and judged whether IBP was considered present or absent based on the received information. This expert judgement was used as the dependent variable in a logistic regression analysis in order to identify those individual IBP parameters that contributed best to a diagnosis of IBP. The new set of IBP criteria was validated in a separate cohort of patients (n = 648). RESULTS: Five parameters best explained IBP according to the experts. These were: (1) improvement with exercise (odds ratio (OR) 23.1); (2) pain at night (OR 20.4); (3) insidious onset (OR 12.7); (4) age at onset <40 years (OR 9.9); and (5) no improvement with rest (OR 7.7). If at least four out of these five parameters were fulfilled, the criteria had a sensitivity of 77.0% and specificity of 91.7% in the patients participating in the workshop, and 79.6% and 72.4%, respectively, in the validation cohort. CONCLUSION: This new approach with real patients defines a set of IBP definition criteria using overall expert judgement on IBP as the gold standard. The IBP experts' criteria are robust, easy to apply and have good face validity.

The development of Assessment of SpondyloArthritis international Society classification criteria for axial spondyloarthritis (part I): classification of paper patients by expert opinion including uncertainty appraisal.

OBJECTIVE: Non-radiographic axial spondyloarthritis (SpA) is characterised by a lack of definitive radiographic sacroiliitis and is considered an early stage of ankylosing spondylitis. The objective of this study was to develop candidate classification criteria for axial SpA that include patients with but also without radiographic sacroiliitis. METHODS: Seventy-one patients with possible axial SpA, most of whom were lacking definite radiographic sacroiliitis, were reviewed as "paper patients" by 20 experts from the Assessment of SpondyloArthritis international Society (ASAS). Unequivocally classifiable patients were identified based on the aggregate expert opinion in conjunction with the expert-reported level of certainty of their judgement. Draft criteria for axial SpA were formulated and tested using classifiable patients. RESULTS: Active sacroiliitis on magnetic resonance imaging (MRI) (odds ratio 45, 95% CI 5.3 to 383; p<0.001) was strongly associated with the classification of axial SpA. The knowledge of MRI findings led to a change in the classification of 21.1% of patients. According to the first set of candidate criteria (sensitivity 97.1%; specificity 94.7%) a patient with chronic back pain is classified as axial SpA in the presence of sacroiliitis by MRI or x rays in conjunction with one SpA feature or, if sacroilitiis is absent, in the presence of at least three SpA features. In a second set of candidate criteria, inflammatory back pain is obligatory in the clinical arm (sensitivity 86.1%; specificity 94.7%). CONCLUSION: The ASAS group has developed candidate criteria for the classification of axial SpA that include patients without radiographic sacroiliitis. The candidate criteria need to be validated in an independent international study.

Association of markers of bone- and cartilage-degradation with radiological changes at baseline and after 2 years follow-up in patients with ankylosing spondylitis.

OBJECTIVE: There is a lack of knowledge on factors that reliably can predict radiological changes in patients with AS. We have investigated whether urinary C-terminal cross-linking telopeptide of type I (CTX-I) and type II (CTX-II) collagen, as specific biochemical markers of bone and cartilage degradation, respectively, are associated with radiological damage and progression, and with BMD in patients with AS. METHODS: Eighty-three patients with AS [mean (s.d.) age: 50.4 (12) yrs, 65% male, mean (s.d.) disease duration after diagnosis: 16.7 (10) yrs] who participate in an ongoing cohort study of patients with AS [Outcome in AS International Study (OASIS) cohort] were assessed for urinary CTX-I and -II. Results of both biochemical markers were compared with baseline scores for radiological damage (modified modified Stoke Ankylosing Spondylitis Spine Score, primarily reflecting syndesmophyte-formation and -growth), and with scores for radiological progression after 2 yrs follow-up. Markers were also associated with disease activity parameters and BMD. RESULTS: Mean duration of complaints was 28.6 yrs. At that time, 54% of patients had signs of radiological damage, and 35% of them showed radiological progression after 2 yrs. Baseline radiological damage (rho = 0.24; P

From Near-Neutral to Strongly Stratified: Adequately Modelling the Clear-Sky Nocturnal Boundary Layer at Cabauw.

The performance of an atmospheric single-column model (SCM) is studied systematically for stably-stratified conditions. To this end, 11 years (2005-2015) of daily SCM simulations were compared to observations from the Cabauw observatory, The Netherlands. Each individual clear-sky night was classified in terms of the ambient geostrophic wind speed with a [Formula: see text] bin-width. Nights with overcast conditions were filtered out by selecting only those nights with an average net radiation of less than [Formula: see text]. A similar procedure was applied to the observational dataset. A comparison of observed and modelled ensemble-averaged profiles of wind speed and potential temperature and time series of turbulent fluxes showed that the model represents the dynamics of the nocturnal boundary layer (NBL) at Cabauw very well for a broad range of mechanical forcing conditions. No obvious difference in model performance was found between near-neutral and strongly-stratified conditions. Furthermore, observed NBL regime transitions are represented in a natural way. The reference model version performs much better than a model version that applies excessive vertical mixing as is done in several (global) operational models. Model sensitivity runs showed that for weak-wind conditions the inversion strength depends much more on details of the land-atmosphere coupling than on the turbulent mixing. The presented results indicate that in principle the physical parametrizations of large-scale atmospheric models are sufficiently equipped for modelling stably-stratified conditions for a wide range of forcing conditions.

Experts' beliefs on physiotherapy for patients with ankylosing spondylitis and assessment of their knowledge on published evidence in the field. Results of a questionnaire among international ASAS members.

AIM: The aim of this study was to assess both the opinion of an international group of experts about the place and importance of physiotherapy in the management of ankylosing spondylitis (AS) as well as the awareness of the responders about scientific evidence on efficacy and cost-effectiveness of physiotherapy in AS. METHODS: An e-mail questionnaire ''Experts' Beliefs on Physiotherapy for Patients with Ankylosing Spondylitis'' has been sent to all 71 international ASsessment of Ankylosing Spondylitis (ASAS) members. Completion of the twenty-eight-item questionnaire was done through the ASAS website (www.ASAS-group.org). RESULTS: The number of responders was 53 (response rate 73%). Altogether 94% of the responders regard themselves as experts in the field of clinical care for AS patients. There is almost unanimous (86-92%) consensus on the efficacy of physiotherapy (widely defined, i.e. as physical therapy-including exercises, application of physical modalities and spa-therapy) for patients with axial and peripheral joint manifestations of AS. Physiotherapy is considered to be indicated for both early AS (less than 2 years after diagnosis) (88%) and AS of longer duration (2 to 10 years) (94%), implying that this non-pharmaceutical intervention should be made available for or should be prescribed to AS patients. Also daily exercises at home are considered indicated for both early (less than 2 years after diagnosis) AS (90%) and AS of longer duration of disease (90%). High-level evidence (Cochrane reviews or publications of one or more randomized controlled clinical trials) favoring efficacy of physiotherapy was considered available by 33% of the participants, whereas 43% replied ''no'' and 24% did not know. Finally, excluding the costs of the intervention, 39% of the participants reported that Spa-therapy might reduce health care costs as usage of NSAIDs, physician visits and ability to work or sick leave, whereas 26% said ''no'' and 35% did not know. CONCLUSIONS: The international ASAS experts hold a favorable opinion on the efficacy of physiotherapy in AS, including group exercises and spa therapy, almost irrespective of disease duration and type of articular involvement (axial/peripheral). Awareness of published evidence on physiotherapy in AS is unsatisfactory.

Health and Utilities in Patients With Gout Under the Care of a Rheumatologist.

OBJECTIVE: To compare limitations in health between Dutch patients with gout and the general population and to determine factors influencing societal and patient values for health as assessed with different utility approaches. METHODS: A cross-sectional study was done among 110 patients with gout under the care of a rheumatologist, with patients completing the EuroQol 5-domain instrument (EQ-5D), the EQ-5D visual analog scale (EQ-5D VAS), and the Short Form 6-dimensions health survey (SF-6D). Scores on EQ-5D domains were compared with age- and sex-matched general population data. Agreement between utility measures was assessed using the intraclass correlation coefficient (ICC). Mixture modeling was used to assess factors associated with the different approaches to assess utility. RESULTS: Compared to the general population, gout patients reported more limitations in mobility (66% versus 12%), self-care (24% versus 8%), daily activities (49% versus 24%), and pain (76% versus 45%), but equal anxiety/depressive symptoms (18% versus 19%). For patients with gout, utilities were reduced: the mean, median, and interquartile range, respectively, were 0.74, 0.81, and 0.69-0.84 for EQ-5D, 0.69, 0.67, and 0.59-0.81 for SF-6D, and 66, 70, and 57-77 for EQ-5D VAS. ICC agreement between each pair of utilities was only moderate (0.52-0.59). Only minor differences were seen in the type of variables associated with each utility approach, with worse Health Assessment Questionnaire scores, cardiovascular disease (CVD), gout concern, and gout pain consistently associated with lower utility. The strength of contribution of these variables, however, differed among the 3 approaches. CONCLUSION: Patients with gout experience substantially impaired health compared to the general population. Although absolute values of utility varied between instruments and perspectives, functional disability, CVD, and higher gout impact contributed to utility independently of which instrument was used.

Patient utilities in chronic musculoskeletal pain: how useful is the standard gamble method?

The main goal of current pain management approaches is to increase the patients' quality of life by improving pain coping skills and by reducing the levels of disability in daily life, often despite persistent pain. Direct measurement of quality of life is of crucial importance in economic evaluation research, in which not only is the estimation of financial costs and benefits included, but so is the evaluation of costs and benefits in terms of changes in health states. The purpose of this study is to compare the psychometric qualities of two instruments for assessing patients' utilities, the rating scale (RS) and the standard gamble (SG). Such instruments are designed for their application in economic evaluation research, but have seldomly been used in chronic pain trials. Both methods provide a single measure between 0 and 1. The relationship between these utility measures and descriptive and domain-specific quality of life measures was examined in 133 fibromyalgia patients and 148 patients with chronic non-specific low back pain. Mean utility score at baseline was 0.43 with the RS and 0.78 for the SG. The correlation between both methods was found to be poor (r = 0.21). Both measures appeared to be fairly stable in a 2-week test-retest period (intra class correlation coefficient (ICC) = 0.74 and 0.77). Scores on the description of patient's own health on six domains, global assessment of change and domain specific measures correlated moderately with the RS scores and low with the SG. Multiple regression analyses demonstrated that 32% of the variance in RS values and only 13% of the variance in SG utilities could be explained by domain-specific measures. These results suggest an acceptable construct validity for the RS but insufficient construct validity for the SG. Valuations of ones own health appear only partially to be related to the assessment of the pain-specific measures and measures of distress. It can be concluded that the RS and domain-specific measures assess partly different, but nevertheless complementary aspects of health-related quality of life. It is therefore recommended to include in economic evaluation studies both domain-specific measures and valuation measures. Finally, in chronic musculoskeletal pain patients, RS scores were found to be more responsive in detecting significant changes in preferences than SG scores. For use in patients with chronic musculoskeletal pain, the RS is preferred to the SG for establishing accurate decisions about the impact of new interventions on their health outcomes.

Corticosteroid effects on sodium and calcium currents in acutely dissociated rat CA1 hippocampal neurons.

Consequences of corticosteroid receptor activation on voltage-dependent Na+ conductances were studied in acutely dissociated CA1 hippocampal neurons. This preparation was selected because of the compact electrotonic properties of dissociated neurons, allowing reliable voltage-clamp of the large and fast Na+ currents. The Na+ currents were studied in (i) neurons of adrenalectomized animals (no steroid receptors occupied), (ii) neurons from tissue of adrenalectomized rats treated in vitro with corticosterone and the glucocorticoid receptor antagonist RU38486 (selectively occupying the mineralocorticoid receptor), (iii) corticosterone-treated neurons of adrenalectomized animals (occupying both the mineralocorticoid and glucocorticoid receptors) and (iv) neurons of sham-operated animals. Activation and steady-state inactivation properties of the Na+ current recorded in neurons of adrenalectomized animals were slightly shifted (3-5 mV) to hyperpolarized potentials as compared to the Na+ currents from neurons of the other experimental groups. Furthermore, the removal from inactivation of the Na+ current in the group of neurons of adrenalectomized animals was relatively slow. Although small, these effects could influence neuronal properties like action potential generation and accommodation. Under the present experimental conditions, no apparent differences were seen between cells with predominant mineralocorticoid receptor activation and cells where both mineralocorticoid and glucocorticoid receptors were occupied. In contrast to Na+ currents, voltage-dependent Ca2+ currents displayed no steroid-dependent shifts in voltage-dependent properties. However, Ca2+ current amplitudes were increased by approximately 160% in CA1 neurons of adrenalectomized animals as compared to Ca2+ currents from neurons of the other experimental groups. We conclude that corticosteroid receptor activation affects various properties of voltage-dependent Na+ and Ca2+ conductances in CA1 neurons, indicating that the steroid receptors are involved in the modulation of neuronal excitability in these cells.

Blood lymphocytes from ankylosing spondylitis patients fail to induce disease-specific cytotoxic T lymphocytes.

The intriguing observation made by Geczy et al. (1) showing the possibility of generating specific ankylosing spondylitis--cytotoxic T lymphocytes by presenting HLA-B27+AS+ cells as antigen-specific stimulator cells prompted us (by using Geczy's approach) to identify cytotoxic T lymphocytes specific for this apparent B27+AS+ target structure. Peripheral blood mononuclear cells (PBMC) of 21 healthy B27+ individuals were stimulated in primary and in short-term cultures with PBMC of an HLA-identical sibling suffering from definite AS (n = 12). In addition, PBMC in vitro modified by "Geczy bacterial products" from two healthy B27+ individuals were used to stimulate B27+ AS- lymphocytes (either autologous or from a healthy HLA-identical sibling). Effector cells raised in primary AS- versus AS+ and AS- versus "modified B27" mixed lymphocyte culture combinations showed no proliferative nor cytotoxic activity at all. The scarcely observed cytotoxic reactivity of restimulated mixed lymphocyte culture was not restricted to AS+B27+ cells. These results demonstrate that PBMC from ankylosing spondylitis patients fail to induce disease-specific cytotoxic T lymphocytes and suggest that an ankylosing spondylitis--related "modified B27" structure does not exist, at least in the patient material tested.

A wider spectrum of spondyloarthropathies.

As in other diseases of undetermined etiology, the diagnosis of ankylosing spondylitis (AS) and related spondyloarthropathies (SpA) is based on clinical and roentgenographic features. The current criteria for diagnosis of some of these diseases are too restricted, and do not recognize the existence of a much wider disease spectrum. For example, radiographically detected sacroiliitis is extremely frequent in AS, but may not be an obligate manifestation, especially in early or atypical forms of the disease. Arthritis involving the axial skeleton, including the sacroiliac joints, can be present in some patients without evidence of erosive disease roentgenographically. The disease spectrum of Reiter's syndrome has also been broadened considerably, and "incomplete" forms of Reiter's syndrome are observed much more commonly than the classical triad of arthritis, conjunctivitis, and urethritis. The term "B27-associated reactive arthritis" has been used in recent years to refer to SpA following enteric or urogenital infections, and the disease spectrum includes the clinical picture of typical Reiter's syndrome. The clinical spectrum of psoriatic SpA has been better clarified. Some of the less well defined B27-associated clinical syndromes include seronegative oligoarthritis, polyarthritis, or dactylitis ("sausagelike" toes) of the lower extremities, and heel pain caused by calcaneal (and tarsal) periostitis. These and other undifferentiated SpA have been ignored in previous epidemiological studies because of the inadequacy of the existing classification criteria. The European Spondylarthropathy Study Group (ESSG) has completed a study aimed at developing preliminary classification criteria for the whole group of SpA patients, with the specific intention of encompassing patients with undifferentiated SpA.

Diagnostic tools in Lyme borreliosis: clinical history compared with serology.

The occurrence of a history of clinical Lyme borreliosis and the prevalence of positive antibodies to Borrelia burgdorferi were studied in 431 Dutch hunters. The majority of the hunters (336 or 78%) did not report any complaints and had no positive IgG antibodies to B. burgdorferi. Sixty-five hunters (15.1%) had no clinical manifestations but did not have positive antibodies to B. burgdorferi. Only 1.9% of the population studied had had past symptoms of definite or probable Lyme borreliosis. Likelihood ratios were high (21.3) for the recognition of erythema migrans, but much lower for tick bites (3.6) or positive IgG Lyme serology (3.5). Clinical history turned out to be a more powerful diagnostic tool than Lyme serology.

The cost diary: a method to measure direct and indirect costs in cost-effectiveness research.

From a societal perspective long-term clinical trials or follow-up studies should preferably not only include an evaluation of the health effect for the patient, but also an economic evaluation. In order to yield comprehensive medical and nonmedical resource use data, we at least partly depend on respondents' recall for collecting these costing data. A patient cost diary was developed in order to estimate total resource use, expenses, and lost production due to illness and treatment. We applied the cost diary in two randomized clinical trials evaluating the cost-effectiveness of behavioral rehabilitation in 205 fibromyalgia and chronic low back pain patients. The use of the diary was evaluated, studying the feasibility, the influence of the period of data collection on the results, and some aspects of validity. Eighty-five percent of the patients completed at least one diary and in total 68% of the diaries were returned. Although the results for the three alternative periods of data collection (keeping the diary 1 week every month, 2 weeks every 2 months, or a full year) were not significantly different, they were only moderately correlated. Finally, self-reported specialist care contacts were generally in agreement with data from an insurance company. However, for physiotherapy contacts there were differences between the self-reported and insurance data. This study shows how the cost diary might be used successfully in cost-effectiveness studies.

Ankylosing spondylitis. Clinical features.

The clinical spectrum of ankylosing spondylitis (AS) is wider than just symptomatic sacroiliitis. The disease may be atypical or may occur as forme fruste. Atypical cases are encompassed in classification criteria for the whole family of spondyloarthropathies. AS may result primarily from additive genetic variability. Nonsteroidal anti-inflammatory drugs and physical exercise remain the cornerstone in the treatment of AS. Core sets for the assessment of the disease now exist for different treatment settings.