[Experiential acceptance in the treatment of complex somatic symptom disorder]. / Ervaringsgerichte acceptatie bij de behandeling van complexe somatisch-symptoomstoornis.

BACKGROUND: Acceptance and Commitment Therapy (ACT) plays an important role in the treatment of patients with refractory Somatic Symptom Disorder and related disorders with complex problems and/or somatic or psychiatric comorbidity (complex SSD). AIM: To gain insight into the possible role of (experiential) acceptance in improved quality of life during and after treatment. METHOD: Observational longitudinal study in 41 patients with complex SSD treated at Altrecht Psychosomatic Medicine Eikenboom. They completed online questionnaires around the start and completion of treatment and after six months of follow-up. Assessed were experiential acceptance (AAQ-II-NL) and three aspects of quality of life (RAND-36: mental health, physical functioning, general health perception). The associations between changes in acceptance and quality of life were determined. RESULTS: Acceptance increased significantly from treatment initiation to follow-up. Mental health increased significantly between start and end of treatment, and general health perception increased significantly in the follow-up period. Physical functioning did not change. During treatment, an increase in acceptance was significantly associated with improvement in mental health and general health perception; during follow-up, an increase in acceptance was associated with an improvement in mental health. CONCLUSION: The current study demonstrates that an increase in experiential acceptance goes hand in hand with an improvement in mental health and general health perception. These results indicate the potential importance of acceptance-based treatment in patients with complex SSD. Experimental research with more frequent measurements is needed to test a temporal relationship between (first) increased acceptance and (then) improved quality of life.

High tibial osteotomy versus unicompartmental knee arthroplasty for Kellgren-Lawrence grade 3-4 knee osteoarthritis in younger patients: comparable improvements in patient-reported outcomes, adjusted for osteoarthritis grade and sex.

PURPOSE: Previous studies comparing high tibial osteotomy (HTO) with unicompartmental knee arthroplasty (UKA) have seldom accounted for differing patient characteristics between both groups. This study compared patient-reported outcomes (PROs) of HTO and UKA patients, adjusted for preoperative PROs, osteoarthritis grade and sex. METHODS: A retrospective study was performed analysing prospectively collected PROs, namely the Oxford Knee Score (OKS) and pain/satisfaction scores, collected preoperatively and at 6 months, 12 months and 24 months postoperatively. Consecutive medial opening-wedge HTOs and medial UKAs from 2016-2019, with a preoperative Kellgren-Lawrence grade ≥ 3, aged 50-60 years, were included. Linear mixed model analyses, with the OKS over time as the primary outcome, were used. RESULTS: We included 84 HTO patients (mean age 55.0 ± 3.0, 79% male, mean BMI 27.8 ± 3.4, 75% Kellgren-Lawrence grade 3) and 130 UKA patients (mean age 55.7 ± 2.8, 47% male, mean BMI 28.7 ± 4.0, 36% Kellgren-Lawrence grade 3). Response rates were ≥ 87% at all time points. Corrected for preoperative PROs, Kellgren-Lawrence grade and sex, the HTO group had a 2.5 (95% CI 1.0-4.0) points lower OKS over time than the UKA group (p = 0.001). The Numeric Rating Scale scores (NRS; 0-10) for pain at rest and during activity were higher (p < 0.01) in the HTO group. The EQ-5D-descriptive system (p < 0.01), NRS satisfaction (p < 0.01), anchor function and pain scores (p < 0.01) were lower over time in the HTO group. CONCLUSION: UKA patients had better OKS scores, pain and satisfaction scores over time than HTO patients. However, the observed differences were below their established minimal clinically important differences. Therefore, from the patients' perspective, HTO did not appear to be inferior to UKA under the indications outlined in this study. Level of evidence Level IV.

Opening- and closing-wedge high tibial osteotomy are comparable and early full weight bearing is safe with angular stable plate fixation: a meta-analysis.

PURPOSE: The purpose of this study was to establish the gold standard for surgical technique, fixation, and rehabilitation for HTO in patients with unicompartmental knee osteoarthritis. METHODS: Medline, Embase, and SPORTDiscus databases were searched up to April 2022. Included were (1) randomized controlled trials (RCTs) comparing opening-wedge HTO (owHTO) and closing-wedge HTO (cwHTO), (2) biomechanical studies and prospective patient studies comparing biomechanical and clinical results for plate fixators, and (3) RCTs comparing an early versus delayed full-weight-bearing (FWB) protocol. RESULTS: The pooled results for the surgical technique showed no significant differences between owHTO and cwHTO for most PROMs on pain, activity, and risk for conversion to TKA. The cwHTO group showed a slightly better improvement in KOOS/WOMAC pain scores (4.51; 95% CI 1.18-7.85), and a significantly lower change in posterior tibial slope (p = 0.03). The pooled results for the fixation method showed the highest force at maximum failure for the Activmotion (Newclip Technics, France), Aescula (B. Braun Korea, Korea), 2nd generation Puddu (Arthrex Inc., USA), and TomoFix plate (Depuy Synthes, Switzerland). The pooled results for the rehabilitation protocol showed no significant differences between the early full-weight-bearing (FWB) group and the delayed FWB group for functional scores, complication rates, and delayed unions. CONCLUSION: Both owHTO and cwHTO reduced pain and improved knee function. Locking plate fixation should be used for owHTO. An early FWB protocol has proven to be safe in patients with small corrections, no hinge fractures, and non-smokers. LEVEL OF EVIDENCE: Level II.

Does Consulting an Occupational Medicine Specialist Decrease Time to Return to Work Among Total Knee Arthroplasty Patients? A 12-Month Prospective Multicenter Cohort Study.

PURPOSE: The aim of this study is to investigate whether total knee arthroplasty (TKA) patients who consulted an occupational medicine specialist (OMS) within 3 months after surgery, return to work (RTW) earlier than patients who did not consult an OMS. METHODS: A multi-center prospective cohort study was performed among working TKA patients, aged 18 to 65 years and intending to RTW. Time to RTW was analyzed using Kaplan Meier and Mann Whitney U (MWU), and multiple linear regression analysis was used to adjust for effect modification and confounding. RESULTS: One hundred and eighty-two (182) patients were included with a median age of 59 years [IQR 54-62], including 95 women (52%). Patients who consulted an OMS were less often self-employed but did not differ on other patient and work-related characteristics. TKA patients who consulted an OMS returned to work later than those who did not (median 78 versus 62 days, MWU p < 0.01). The effect of consulting an OMS on time to RTW was modified by patients' expectations in linear regression analysis (p = 0.05). A median decrease in time of 24 days was found in TKA patients with preoperative high expectations not consulting an OMS (p = 0.03), not in patients with low expectations. CONCLUSIONS: Consulting an OMS within 3 months after surgery did not result in a decrease in time to RTW in TKA patients. TKA patients with high expectations did RTW earlier without consulting an OMS. Intervention studies on how OMSs can positively influence a timely RTW, incorporating patients' preoperative expectations, are needed.

18F-DCFPyL PET/CT for primary staging in 160 high-risk prostate cancer patients; metastasis detection rate, influence on clinical management and preliminary results of treatment efficacy.

PURPOSE: Prostate-specific membrane antigen (PSMA) PET/CT shows better diagnostic performance for detection of lymph node and bone metastases as compared to conventional imaging. Studies of PSMA PET/CT in primary staging comprise highly selected patient cohorts. This study evaluates 18F-DCFPyL PET/CT as first-line imaging modality for primary staging of high-risk prostate cancer. MATERIAL: From February 2018 until April 2019, all patients with high-risk prostate cancer received 18F-DCFPyL PET/CT for staging of prostate cancer. Baseline characteristics, findings at 18F-DCFPyL PET/CT, number and type of required additional diagnostic procedures, findings at additional diagnostic procedures, and effects of therapy on PSA levels for all patients treated with curative intent were collected and evaluated. RESULTS: One hundred-sixty patients were included in the study of which 90 (56%) had evidence of metastasized disease (N1, M1a, M1b and, M1c in 49%, 28%, 31%, and 3% respectively). Additional diagnostic imaging was needed in 2/160 patients (1%) because of equivocal findings on 18F-DCFPyL PET/CT. Eighty-one patients had evidence of PSMA-positive lymph node metastases, of whom 39 (48%) had no enlarged lymph nodes on CT; 18F-DCFPyL PET detected additional metastatic lymph nodes in 41/42 patients that had evidence of lymph node metastases on CT. 18F-DCFPyL PET altered patients' management in 17% of patients. CONCLUSION: 18F-DCFPyL PET/CT can be used as first-line imaging modality for therapy selection in patients with primary high-risk prostate cancer, without need for further diagnostic imaging procedures in the majority of patients.

The effect of restored medial knee anatomy in total knee arthroplasty with the flexion first balancer technique on mid-flexion laxity and functional outcome.

BACKGROUND: The Flexion First Balancer (FFB) technique for total knee arthroplasty (TKA) was developed to maintain the isometry of the medial collateral ligament (MCL) by restoring the medial anatomy of the knee. Inability to correct MCL isometry could hypothetically result in an increased mid-flexion laxity. The aim of the current study was to evaluate if the FFB technique results in improved functional outcome and less mid-flexion laxity compared to Measured Resection (MR). METHODS: A cross-sectional study was performed comparing 27 FFB patients with 28 MR patients. Groups were matched for age, gender, BMI and ASA classification. All patient received the cruciate retained type, Vanguard Complete Knee System (Biomet Orthopedics, Warsaw, IN, USA). Stress X-rays of the knee with 30 degrees of flexion were made to assess varus-valgus laxity. Furthermore, three tests were conducted to asses functional outcome: a 6 min walk test, a stair climb test and quadriceps peak force measurements. Mean follow-up was respectively 2.6 (SD 0.4) and 3.9 years (SD 0.2). RESULTS: The MR group showed a postoperative elevation in joint line in contrast to the FFB group, the mean difference between the two groups was 3 mm (p < 0.001). No differences in total laxity between the two groups was found. The FFB group showed a higher quadriceps peak force (1.67 (SD 0.55) N/BMI) in comparison with the MR group (1.38 (SD 0.48) N/BMI) (p < 0.05). All other outcome parameters were comparable between the two groups (p: n.s.). Correlation analysis showed a moderate negative correlation between joint line elevation and quadriceps peak force (r = - 0.29, p < 0.05). CONCLUSION: The FFB technique did not lead to less coronal laxity in the mid-flexion range compared to MR. Although peak quadriceps force was significantly higher for the FFB group no clinically relevant benefits could be identified for the patients with regards to functional outcome. Therefore, minor deviations in joint line seems to have no effect on functional outcome after TKA. TRIAL REGISTRATION: ISRCTN, ISRCTN85351296. Registered 23 april 2021 - Retrospectively registered, https://www.isrctn.com/ISRCTN85351296.

[Patient-tailored approach in tertiary care expert centres using individual dynamic network analysis]. / Maatwerk in hoogspecialistische ggz met individuele dynamische netwerkanalyse.

BACKGROUND: Patients with mental health disorders often have difficulty perceiving associations between multiple symptoms, such as inter-relations between somatic and psychological symptoms. This difficulty may be particularly challenging in patients with complex disorders. Individual dynamic network analysis may provide novel diagnostic and treatment possibilities because it can create a starting point for a personalized approach in complex cases in tertiary mental health care expert centres, where standard protocolized interventions were insufficiently effective. AIM: To explore the possibilities provided by dynamic network technologies in the care of patients in tertiary care expert centres. METHOD: Overview of these possibilities, with a focus on somatic symptom disorder. RESULTS: Intensive longitudinal data can be obtained using a short and personalized questionnaire that is presented via a patient's smartphone a few times per day during several weeks. These data are then converted to patient-specific dynamic symptom networks using time series analysis. These networks display how variations over time in somatic and mental symptoms and other factors (such as specific situations) mutually influence each other in daily life. They also provide information about cause-effect associations. CONCLUSION: Dynamic symptom networks provide insight into the associations between symptoms and other factors and can be used to personalize treatment goals and interventions in tertiary care expert centres. Furthermore, these networks create opportunities to examine the (patient-tailored) effects of personalized interventions.

Synovial neutrophilic gelatinase-associated lipocalin in the diagnosis of periprosthetic joint infection after total knee arthroplasty.

BACKGROUND: Periprosthetic joint infection (PJI) is one of the most serious complications following total knee arthroplasty (TKA). However, the diagnosis remains a challenge for clinicians. In 2011, the muscoskeletal infection society (MSIS) criteria provided a consensus which has been updated in 2013, but these criteria are complex and contain tests that are time-consuming. The same is applicable to the pro-Implant guidelines. Therefore, a simpler diagnostic test is desirable. OBJECTIVES: The value of neutrophil gelatinase-associated lipocalin (NGAL), leucocyte esterase (LE) levels, and the white blood cell (WBC) count in synovial fluid to diagnose PJI after TKA was evaluated. METHODS: In a retrospective cohort study, we analyzed 89 synovial fluid samples from 86 patients with suspected PJI after TKA. Thirteen and 23 of those samples were classified as PJI according to the MSIS and pro-Implant criteria, respectively. Subsequently, NGAL, LE levels, and the WBC count were determined, the former one using an immunoassay. Using either the MSIS or pro-Implant criteria as the golden standard for PJI, sensitivity and specificity of those markers were determined with ROC curves, and medians were compared with Mann-Whitney U and Pearson Chi-square tests. RESULTS: When applying the MSIS criteria, NGAL revealed 92% sensitivity and 83% specificity. WBC count showed similar sensitivity (92%) and specificity (84%), whereas sensitivity and specificity for LE were 39% and 88% respectively. When applying the pro-Implant criteria, sensitivity was 95% and specificity was 95% for NGAL. Sensitivity and specificity for WBC count were 100% and 97% and for LE 39% and 92% respectively. CONCLUSION: NGAL and WBC count in synovial fluid has high accuracy in the diagnosis of PJI after TKA and should seriously be considered as part of PJI diagnostics. Leucocyte esterase can serve as rule-in criterion peroperatively. These conclusions are independent of which criteria set was used as golden standard.

Body image in patients with somatoform disorder.

BACKGROUND: Although body-related problems are common in patients with somatoform disorder, research focusing on how patients with somatoform disorder perceive and evaluate their body is scarce. The present study compared differences in body image between patients with somatoform disorder and respondents from a general population sample. It also examined differences within the somatoform disorder group between men and women and between the diagnostic subgroups conversion disorder, pain disorder and undifferentiated somatoform disorder. METHODS: Data were obtained from 657 patients (67.5% female) with somatoform disorder (DSM-IV-TR 300.7, 300.11, 300.81, 300.82) and 761 participants (58.6% female) from the general population. The Dresden Body Image Questionnaire (DBIQ) was used to assess body image in five domains: body acceptance, vitality, physical contact, sexual fulfilment, and self-aggrandizement. Confirmatory factor analysis and analyses of variance were performed. Since differences in age and sex were found between the somatoform disorder sample and the comparison sample, analyses were done with two samples of 560 patients with somatoform disorder and 351 individuals from the comparison sample matched on proportion of men and women and age. RESULTS: Patients scored significantly lower than the comparison sample on all DBIQ domains. Men scored higher than women. Patients with conversion disorder scored significantly higher on vitality and body acceptance than patients with undifferentiated somatoform disorder and pain disorder. CONCLUSIONS: The mostly large differences in body image between patients with somatoform disorder and the comparison sample as well as differences between diagnostic subgroups underline that body image is an important feature in patients with somatoform disorder. The results indicate the usefulness of assessing body image and treating negative body image in patients with somatoform or somatic symptom disorder.

Crying Without Tears: Dimensions of Crying and Relations With Ocular Dryness and Mental Well-Being in Patients With Sjögren's Syndrome.

This study examined dimensions of crying and its relations with ocular dryness and mental well-being in patients with Sjögren's syndrome, a systemic autoimmune disease with dryness as primary symptom. Three-hundred patients with Sjögren's syndrome completed questionnaires on crying, dryness, and well-being. The crying questionnaire revealed four dimensions: "Cryability" (comprising both crying sensibility and ability to cry), Somatic consequences, Frustration, and Suppression. Compared to 100 demographically-matched control participants from the general population, patients scored low on Cryability and high on Somatic consequences and Frustration. The crying dimensions generally showed significant but weak associations with ocular dryness and mental well-being in patients. This is the first quantitative study indicating that crying problems are more common in patients with Sjögren's syndrome than in the general population. Perhaps, patients who experience problems with crying could be helped to rely on other ways of expressing emotions than crying in tear-inducing situations.

Embitterment in patients with a rheumatic disease after a disability pension examination: occurrence and potential determinants.

OBJECTIVES: Health care and vocational professionals regularly encounter patients with rheumatic diseases who are embittered after a disability pension examination. People who are embittered typically feel victimised, experience resentment and injustice, resist help, and have difficulty coping. Our objective was to examine the occurrence of embitterment in patients with rheumatic diseases after a disability pension examination and the association of embitterment with its possible determinants helplessness and illness invalidation at work. METHODS: The Illness Cognition Questionnaire (ICQ), Illness Invalidation Inventory (3*I), and Bern Embitterment Inventory were completed by patients who had 9 to 12 weeks earlier received the result of a disability pension examination. Diagnoses were fibromyalgia (n=103), rheumatoid arthritis (n=46), osteoarthritis (n=158), another rheumatic disease (n=62), and more than one rheumatic disease (n=187). Scores were compared to scores of reference groups. Hierarchical regression analyses were conducted. RESULTS: Eighteen to 27 percent of patients had high levels of embitterment with no differences between diagnostic groups (p=0.71). Helplessness (p<0.001), the two invalidation dimensions discounting and lack of understanding (p<0.001), and the combination of helplessness with these invalidation dimensions (p<0.01), were predictive of more embitterment. CONCLUSIONS: Our results suggest that, after a disability pension examination, embitterment is present in about one out of five patients with a rheumatic disease. This is problematic insofar as embitterment limits well-being, functioning, and the potential to reintegrate to work. To the extent that helplessness and invalidation at work are causal determinants of embitterment, interventions targeting these aspects may be key to reduce embitterment.

The separate impact of tight control schemes and disease activity on quality of life in patients with early rheumatoid arthritis: results from the CAMERA trials.

OBJECTIVES: To examine in patients with early rheumatoid arthritis (RA) whether quality of life (QoL), independently of disease activity, is affected by tight control treatment strategy schemes. METHODS: In the Computer Assisted Management in Early RA (CAMERA) trials, patients with early RA, disease duration <1 year, no prior use of DMARDs) had been randomised to a methotrexate (MTX)-based tight control strategy or usual care (CAMERA study) or to 10 mg/d prednisone or placebo both added from start to a MTX-based tight control strategy (CAMERA-II study). In either study, randomisation to the more intensive strategy resulted in lower disease activity. To assess QoL, the 'Influence of Rheumatic Diseases on General Health and Lifestyle' questionnaire (IRGL) was used. Baseline and 1- and/or 2-year measurements were analysed with regression analyses with the IRGL (sub)scales as outcome variables and treatment strategy and disease activity assessing 28 joints (DAS28) as independent variables, correcting for baseline values of each scale and possible confounders (gender, age, rheumatoid factor status). RESULTS: There was no clear association between either of the treatment strategies and QoL, but a decrease in DAS28 was associated with improvement in the majority of QoL (sub)scales. CONCLUSIONS: No independent effect of the specific tight control strategies schemes on QoL was found, while there was a clear disease activity related effect. Thus frequent outpatient visits or the inclusion of prednisone in a tight control strategy did not negatively influence QoL.

Fatigue in patients with systemic lupus erythematosus: the role of dehydroepiandrosterone sulphate.

Fatigue is a major problem in systemic lupus erythematosus (SLE), but the physiological substrate of this fatigue is largely unclear. To examine if low levels of dehydroepiandrosterone (DHEA) and its sulphate DHEAS play a role in SLE fatigue, we compared: 1) DHEAS levels and fatigue between 60 female patients with SLE with low disease activity (31 using, 29 not using prednisone) and 60 age-matched healthy women, and 2) fatigue between patients with SLE with low and normal DHEAS levels. Serum DHEAS levels were determined with an Advantage Chemiluminescense System. The Multidimensional Fatigue Inventory (MFI) was used to assess fatigue. Patients were more fatigued (p ≤ 0.001) than healthy women and more often had below-normal DHEAS levels (p < 0.001). Patients using prednisone with low and normal DHEAS levels reported a similar level of fatigue (p ≥ 0.39). Patients with low DHEAS levels not using prednisone reported less fatigue than those with normal DHEAS levels (p ≤ 0.03). Thus, our results indicate that low DHEAS levels in SLE are not - or even inversely - related to fatigue. After our previous finding that DHEA administration does not reduce fatigue, this result further indicates that low serum DHEA(S) levels alone do not offer an explanation for SLE fatigue.

Patient and spouse appraisals of health status in rheumatoid arthritis and fibromyalgia: discrepancies and associations with invalidation.

OBJECTIVES: The health problems of patients with rheumatoid arthritis and fibromyalgia are mostly invisible to others, which can lead to a discrepancy between patients' and spouses' appraisals of the severity of the health problems. As a consequence, some patients may feel 'invalidation' from their spouse, such as not being understood and believed. Aim of this study was to compare patients' and spouses' appraisals of the health status of patients with rheumatoid arthritis and patients with fibromyalgia, and to examine whether discrepancies in these appraisals are associated with invalidation experiences of the patient. METHODS: Eighty-four patients with rheumatoid arthritis and 95 patients with fibromyalgia filled out a health status questionnaire (MOS short-form general health survey, SF-20) and a questionnaire on invalidation by the spouse (Illness Invalidation Inventory, 3*I). The spouses appraised the patients' health status independently from the patients using a spouse version of the SF-20. RESULTS: Patients with fibromyalgia and their spouses appraised the patients' health status significantly worse than patients with rheumatoid arthritis and their spouses. The agreement between patients and spouses was generally fair with somewhat more agreement in rheumatoid arthritis than in fibromyalgia. Patient-spouse discrepancies in health status appraisals were not associated with invalidation experiences. CONCLUSIONS: The invisibility of health problems in fibromyalgia and rheumatoid arthritis is not accompanied by large patient-spouse discrepancies of health status appraisals, which suggests that invalidation by spouses is not dependent on observable evidence such as clinical signs of damage or pathology.

Serum dehydroepiandrosterone sulphate levels and laboratory and clinical parameters indicating expression of disease are not associated with fatigue, well-being and functioning in patients with primary Sjögren's syndrome.

OBJECTIVES: The aim of this study was to compare serum dehydroepiandrosterone sulphate (DHEAS) levels and clinical and laboratory parameters reflecting expression of disease between female patients with primary Sjögren's syndrome (pSS) and age-matched healthy women and to examine in pSS patients the correlation of these variables with fatigue, well-being, and functioning. METHODS: Comparisons were made between 60 female pSS patients and 60 age-matched healthy women. We assessed questionnaire scores of general fatigue, depressed mood, mental wellbeing, and physical functioning, tear production (Schirmer I test), tender point counts, serum DHEAS level, haemoglobin concentration, erythrocyte sedimentation rate, and serum immunoglobulin G. RESULTS: As compared to healthy participants, patients had more fatigue and depressed mood, reduced well-being and functioning, more dryness and pain, lower serum DHEAS levels, and more expression of disease as reflected by laboratory assessments (p≤0.001). In pSS patients, fatigue, well-being, and functioning correlated with tender point counts, but not with the extent of dryness and also not with laboratory assessments including serum DHEAS levels. CONCLUSIONS: The high prevalence of fatigue and reduced functioning in pSS patients might suggest a mediating role of generalised autoimmune processes. In the present study, clinical observations and laboratory assessments are not correlated with persistent fatigue and reduced functioning. Our results suggest that treatment of fatigue, well-being, and functioning, should target other variables than those examined in this study, preferably psychological variables or perhaps specific immunologic parameters.

Effects of dehydroepiandrosterone on fatigue and well-being in women with quiescent systemic lupus erythematosus: a randomised controlled trial.

OBJECTIVE: Dehydroepiandrosterone (DHEA) has been reported to improve fatigue and reduced well-being. Both are major problems in patients with systemic lupus erythematosus (SLE), even with quiescent disease. Low serum DHEA levels are common in SLE. The present work investigates the effects of DHEA administration on fatigue, well-being and functioning in women with inactive SLE. METHODS: In a double-blind, randomised, placebo-controlled study, 60 female patients with inactive SLE received 200 mg oral DHEA or placebo. Primary outcome measures were general fatigue, depressive mood, mental well-being and physical functioning. Assessments were made before treatment, after 3, 6 and 12 months on medication, and 6 months after cessation of treatment. RESULTS: Patients from the DHEA and placebo group improved on general fatigue (p<0.001) and mental well-being (p=0.04). There was no differential effect of DHEA. The belief that DHEA had been used was a stronger predictor for improvement of general fatigue than the actual use of DHEA (p=0.04). CONCLUSIONS: The trial does not indicate an effect of daily 200 mg oral DHEA on fatigue and well-being, and therefore DHEA treatment is not recommended in unselected female patients with quiescent SLE. Clinical Trials Registration Number NCT00391924.

Lack of understanding in fibromyalgia and rheumatoid arthritis: the Illness Invalidation Inventory (3*I).

BACKGROUND: Patients with rheumatic diseases may face 'discounting' (denying and patronising) or 'lack of understanding' because of having symptoms without external clinical signs, but instruments to assess such invalidation experiences are lacking. OBJECTIVES: To develop and evaluate the Illness Invalidation Inventory (3*I), to compare invalidation experiences of two groups of patients who differ in visual signs and laboratory findings-rheumatoid arthritis (RA) and fibromyalgia-and to examine the association of invalidation with health status. METHODS: A questionnaire (eight items with respect to five sources: spouse, family, medical professionals, work environment and social services) was constructed. It was completed by 142 patients with RA and 167 patients with fibromyalgia. RESULTS: Principal axis factoring with oblimin rotation yielded two factors with high internal consistency (α>0.70): 'discounting' (five items) and 'lack of understanding' (three items). Patients with fibromyalgia experienced significantly more discounting and lack of understanding from their family, medical professionals, colleagues and social services than did patients with RA. Both patient groups experienced more invalidation from social services, colleagues and family than from medical professionals and spouses. More discounting and lack of understanding correlated with poorer mental well-being and social functioning in both patient groups. Discounting correlated with more physical disability and pain in patients with RA. CONCLUSIONS: The 3*I is a brief, reliable instrument for assessing patients' perceptions of invalidation from different sources, which differ between patient groups and are associated with health status. Future validation research should clarify the clinical impact of invalidation on treatment adherence and outcome.

Variability of fatigue during the day in patients with primary Sjögren's syndrome, systemic lupus erythematosus, and rheumatoid arthritis.

OBJECTIVES: Fatigue is a common complaint of patients with primary Sjögren's syndrome (pSS), systemic lupus erythematosus (SLE), and rheumatoid arthritis (RA). The aim of this study was to examine and compare in patients with these diseases the course of fatigue within the first hour after awakening and during the day, and to examine sleep disturbance as a potential determinant of fatigue. METHODS: Eight repeated measurements at 5 fatigue dimensions were assessed on 2 consecutive days in the natural environment of female patients with pSS (n=29), SLE (n=23), RA (n=19), and healthy women (n=52). Sleep disturbance of the previous night was assessed. Fatigue levels and the change of fatigue after awakening and during the day were analysed with analyses of variance (adjusted for age). RESULTS: The patients showed significantly elevated levels at all fatigue dimensions as compared to healthy participants. Fatigue levels decreased in the first hour after awakening in patients with SLE and RA, but increased or did not change in patients with pSS. Fatigue progressively increased during the remainder of the day for all patient groups. Sleep disturbance correlated with overall fatigue levels, but hardly with the change of fatigue within the first hour after awakening. CONCLUSIONS: Our study confirms the presence of increased fatigue in patients with pSS, SLE, and RA. Patients with pSS failed to show a decrease in fatigue in the first hour after awakening. Future research should examine the causes of this difference in fatigue after awakening.

Flexion First Balancer: description of new technique in TKA to reproduce joint line and pre-disease mechanical alignment.

A considerable proportion of patients (19%) are dissatisfied after total knee arthroplasty (TKA). Possible factors contributing to this dissatisfaction are decreased posterior condylar offset (PCO) with subsequent joint line elevation, leading to mid-flexion instability. Secondly, the pre-disease mechanical alignment is changed into a neutral alignment. The Flexion First Balancer was developed to avoid these problems. This technique aims to maintain MCL isometry by restoring medial PCO and medial joint line to its pre-disease level. Also, to reconstruct the pre-disease mechanical alignment by adjusting the distal femoral angle. In this study we provide a detailed technical overview of the Flexion First Balancer technique.