bluuebunny/crossref_metadata_2025 huggingface dataset:
Medical-Legal Partnerships: Addressing Competency Needs Through Lawyers
Authors: Paul Edward , Fullerton Danya Fortess , Cohen Ellen , Lawton Ellen , Ryan Anne , Sandel Megan
Published: December 2009

Background

Many low- and moderate-income individuals and families have at least one unmet legal need (for example, unsafe housing conditions, lack of access to food and/or income support, lack of access to health care), which, if left unaddressed, can have harmful consequences on health. Eighty unique medical-legal partnership programs, serving over 180 clinics and hospitals nationwide, seek to combine the strengths of medical and legal professionals to address patients' legal needs before they become crises. Each partnership is adapted to serve the specific needs of its own patient base.

Intervention

This article describes innovative, residency-based medical-legal partnership educational experiences in pediatrics, internal medicine, and family medicine at 3 different sites (Boston, Massachusetts; Newark, New Jersey; and Tucson, Arizona). This article addresses how these 3 programs have been designed to meet the Accreditation Council for Graduate Medical Education's 6 competencies, along with suggested methods for evaluating the effectiveness of these programs. Training is a core component of medical-legal partnership, and most medical-legal partnerships have developed curricula for resident education in a variety of formats, including noon conferences, grand rounds, poverty simulations and day-long special sessions.

Discussion

Medical-legal partnerships combine the skill sets of medical professionals and lawyers to teach social determinants of health by training residents and attending physicians to identify and help address unmet legal needs. Medical-legal partnership doctors and lawyers treat health disparities and improve patient health and well-being by ensuring that public programs, regulations, and laws created to benefit health and improve access to health care are implemented and enforced.
Effect of Number of Clinics and Panel Size on Patient Continuity for Medical Residents
Authors: Francis Maureen D. , Zahnd Whitney E. , Varney Andrew , Scaife Steven L. , Francis Mark L.
Published: December 2009

Background

Accreditation Council for Graduate Medical Education program requirements for internal medicine residency training include a longitudinal, continuity experience with a panel of patients.

Objective

To determine whether the number of resident clinics, the resident panel size, and the supervising attending physician affect patient continuity. To determine the number of clinics and the panel size necessary to maximize patient continuity.

Design

We used linear regression modeling to assess the effect of number of attended clinics, the panel size, and the attending physician on patient continuity.

Participants

Forty medicine residents in an academic medicine clinic.

Measurements

Percent patient continuity by the usual provider of care method.

Results

Unadjusted linear regression analysis showed that patient continuity increased 2.3% ± 0.7% for each additional clinic per 9 weeks or 0.4% ± 0.1% for each additional clinic per year (P  =  .003). Conversely, patient continuity decreased 0.7% ± 0.4% for every additional 10 patients in the panel (P  =  .04). When simultaneously controlling for number of clinics, panel size, and attending physician, multivariable linear regression analysis showed that patient continuity increased 3.3% ± 0.5% for each additional clinic per 9 weeks or 0.6% ± 0.1% for each additional clinic per year (P < .001). Conversely, patient continuity decreased 2.2% ± 0.4% for every additional 10 patients in the panel (P < .001). Thus, residents who actually attend at least 1 clinic per week with a panel size less than 106 patients can achieve 50% patient continuity. Interestingly, the attending physician accounted for most of the variability in patient continuity (51%).

Conclusions

Patient continuity for residents significantly increased with increasing numbers of clinics and decreasing panel size and was significantly influenced by the attending physician.
Use of a Postpartum Hemorrhage Simulator for Instruction and Evaluation of Residents
Authors: Deering Shad H. , Chinn Michael , Hodor Jonathon , Benedetti Thomas , Mandel Lynn S. , Goff Barbara
Published: December 2009

Objective

Postpartum hemorrhage is a common and potentially life-threatening obstetric emergency. We sought to create a realistic simulation and validate a standardized grading form to evaluate competency in the management of postpartum hemorrhage.

Methods

Residents from 3 programs underwent training with a postpartum hemorrhage simulation using a standard obstetric birthing model equipped with an inflatable uterus to simulate uterine atony. All simulations were graded by staff physicians with a standardized grading sheet constructed from the current literature on the topic. Residents were expected to recognize the hemorrhage and take appropriate steps, including asking the assistant to administer medications, to correct the problem. Objective and subjective performance was measured with standardized grading sheets, and results were analyzed for reliability using Cronbach α and intraclass correlation coefficients. This project was conducted in accordance with the hospital Institutional Review Board policies at each institution.

Results

Forty residents from 3 institutions underwent simulation training. The majority were unable to correct the hemorrhage within 5 minutes and almost half also made at least 1 error, either the dose or route, in the medications they requested. Reliability was evaluated with Cronbach α and demonstrated the grading sheets were valid and had good interrater reliability.

Discussion

A simulated postpartum hemorrhage scenario can identify important deficiencies in resident knowledge and performance, with no risk to patients. The standardized grading form worked well for our purposes and was reliable in our study. Further testing is needed to evaluate whether the training improves performance in real-life hemorrhages.
Changing the Conversation From Burnout to Wellness: Physician Well-being in Residency Training Programs
Authors: Eckleberry-Hunt Jodie , Van Dyke Anne , Lick David , Tucciarone Jennifer
Published: December 2009

Background

The existing literature either does not address physician wellness or defines it as a lack of burnout. The goal of this article is to call attention to this important gap in the literature and provide ideas for how to fill it. We need a culture change, and we propose that this change begin within graduate medical education.

Methods

We describe a case example of culture change and definitions of wellness at William Beaumont Hospitals, Troy Family Medicine Residency Program, a community-based, university-affiliated program in suburban Detroit, Michigan.

Results

We developed a toolbox of practical steps to create a culture that emphasizes wellness. We present a general timeline illustrating necessary steps toward accomplishing a true cultural change.

Discussion

The time has come for academic medicine to move beyond a simple discussion of physician burnout. To do this, we must first develop a shared definition of physician wellness followed by interventional strategies to bolster it. The benefits of cultural change include providing a more positive educational environment for residents and faculty, raising awareness of burnout and its symptoms, decreasing the stigma associated with admitting burnout symptoms, enabling the development of prevention strategies, and creating a more positive, strength-based approach to understanding the toll of physician-patient relationships on physicians.
Creating a Common Patient Safety Denominator: The Interns' Course
Authors: Shekhter Ilya , Nevo Igal , Fitzpatrick Maureen , Everett-Thomas Ruth , Sanko Jill S. , Birnbach David J.
Published: December 2009

Aim

After finishing medical school, interns are in many ways unprepared for handling patient care challenges independently. Recognizing that interns may benefit from a patient safety orientation, we developed an innovative curriculum to impart competencies related to their role in preventing medical errors. In the course, which runs during the first week of the intern year, we specifically address 1) calling for help; 2) teamwork and communication; 3) hand hygiene compliance; and, 4) preventing medication and other system errors.

Methods

The course consists of a lecture, interactive workshop, and a Web-based didactic component. Small-group simulation sessions allow instructors to assess interns' baseline competence in hand hygiene and patient hand-offs. In an individual exercise, interns performed a directed physical exam on a standardized patient and their hand hygiene adherence was recorded. In a group exercise, team performance was evaluated in accepting a hand-off from another provider and managing a deteriorating patient.

Results

Of the 131 interns, 35% (41) did not wash their hands before and 95% (121) did not wash their hands after patient examination. In the team exercise, scores for 23 teams ranged from 8 to 18 out of 30. None of the participants asked for additional information prior to accepting responsibility for the patient, despite a clearly inadequate hand-off. Post-course surveys indicate that interns consider the course worthwhile: 95% (121) found it beneficial, acquired new teamwork skills, had more appreciation for patient safety, and felt better prepared for clinical duties.

Discussion

We observed serious gaps in hand-hygiene compliance and in communication during hand-offs, both significant impediments to quality patient care. Nevertheless, positive responses to the course from both the interns and the institution reflect an important step in fostering a culture of patient safety.
Grommets and Glue Guns: Standardization of a Pfannenstiel Model for Low-Fidelity Obstetrics-Gynecology Education
Authors: Best Kelly A. , Seibel Brent E. , Lyon Deborah S.
Published: December 2009

Objective

To validate standardized instructions for the creation, implementation, and performance assessment of a low-fidelity model for Pfannenstiel incision.

Study Design

The Pfannenstiel model used at the University of Florida-Jacksonville was broken down into composite steps and constructed by obstetrics-gynecology faculty from across the country. The model was then utilized at participants' home institutions and evaluated with respect to realism of the model, ability to replicate the simulation, appropriateness of the skills checklists, and perceived utility of a publication of similarly catalogued simulation modules for use in obstetrics-gynecology training programs.

Results

The model was correctly constructed by 94.7% (18 of 19) participants and 72.2% (13 of 18) completed a post construction/post simulation survey indicating a high degree of perceived educational utility, feasibility of construction, and desire for additional catalogued modules.

Conclusions

A low-fidelity simulation model was developed, successfully reproduced using inexpensive materials, and implemented across multiple training programs. This model can serve as a template for developing, standardizing and cataloging other low-fidelity simulations for use in resident education. As discussions among medical educators continue regarding further restrictions on duty hours, it is highly likely that more programs will be looking for guidance in establishing quick, inexpensive, and reliable means of developing and assessing surgical skills in their learners. Furthermore, the Accreditation Council for Graduate Medical Education (ACGME) has well-defined goals of programs developing better and more reproducible tools for all of their assessments. For programs with limited resources, preparing and disseminating reproducible, validated tools could be invaluable in complying with future ACGME mandates.
Team Behavior During Trauma Resuscitation: A Simulation-Based Performance Assessment
Authors: Hamilton Nicholas , Freeman Bradley D. , Woodhouse Julie , Ridley Clare , Murray David , Klingensmith Mary E.
Published: December 2009

Introduction

Trauma resuscitations require a coordinated response from a diverse group of health care providers. Currently, there are no widely accepted methods of assessing team effectiveness in this setting. Simulation affords a method to assess team effectiveness. The purpose of this study was to use a simulation setting to develop a specialized assessment instrument for team response in trauma resuscitation.

Methods

We developed our assessment instrument using clinical simulation. Four teams of 3 postgraduate year–2 surgical trainees in conjunction with scripted confederates were videotaped enacting 6 separate trauma resuscitation scenarios that mirrored clinical conditions encountered at our level 1 trauma center. Ten of the resulting videotaped scenarios represented a spectrum of team behavior (ineffective to effective) and were scored by 8 experienced clinicians using the Mayo High Performance Teamwork Scale.

Results

Based in part on the Mayo High Performance Teamwork Scale, we created a prototype trauma team assessment tool consisting of 7 attributes that we scored in binary fashion (present/absent). We validated this prototype by assigning a normalized ranking score to each of the 10 scenarios based on the score supplied by each rater. The presence/absence of the 7 attributes varied significantly among scenarios (52.5% to 93.8%; P < .001). Median scores differed significantly comparing the 5 lowest-ranking scenarios with the 5 highest-ranking scenarios (P < .001).

Conclusion

Our prototype instrument may be effective at assessing team effectiveness during trauma resuscitations. This instrument may prove useful for assessing team competency skills, providing timely feedback to teams, and examining the relationship between effective team function and clinically important outcomes. Further, it may be applicable to other high-acuity, time-sensitive clinical situations.
Expanding the SOAP Note to SOAPS (With S for Safety): A New Era in Real-time Safety Education
Authors: Weiss Patrice M. , Lara-Torre Eduardo , Murchison Amanda B. , Spotswood Laurie
Published: December 2009

The challenges inherent in medical education are multiple, including recognition of different learning styles among students, incorporation of the Accreditation Council for Graduate Medical Education competencies and outcomes measurement into the curriculum, and compliance with mandated duty hours along with a heightened awareness of patient safety required by our regulatory institutions. With the requirement that safety become an explicit part of the residency curriculum across all specialties, educators are charged with innovative ways of achieving this goal. The following commentary addresses this need and suggests an innovative approach to the traditional daily rounds' SOAP (subjective, objective, assessment, and plan) note to incorporate a second S for safety. The use of a SOAPS note elevates each encounter by integrating quality and error avoidance as a component of care. This method teaches the next generation of physicians the importance of patient safety as an integral part of every doctor-patient interaction.
Making Sense: Duty Hours, Work Flow, and Waste in Graduate Medical Education
Authors: Bush Roger W. , Philibert Ingrid
Published: December 2009

Parsimony, and not industry, is the immediate cause of the increase of capital. Industry, indeed, provides the subject which parsimony accumulates. But whatever industry might acquire, if parsimony did not save and store up, the capital would never be the greater.

Adam Smith, The Wealth of Nations, book 2, chapter 31

In 2003, the Accreditation Council for Graduate Medical Education implemented resident duty hour limits that included a weekly limit and limits on continuous hours. Recent recommendations for added reductions in resident duty hours have produced concern about concomitant reductions in future graduates' preparedness for independent practice. The current debate about resident hours largely does not consider whether all hours residents spend in the educational and clinical-care environment contribute meaningfully either to residents' learning or to effective patient care. This may distract the community from waste in the current clinical-education model. We propose that use of “lean production” and quality improvement methods may assist teaching institutions in attaining a deeper understanding of work flow and waste. These methods can be used to assign value to patient- and learner-centered activities and outputs and to optimize the competing and synergistic aspects of all desired outcomes to produce the care the Institute of Medicine recommends: safe, effective, efficient, patient-centered, timely, and equitable. Finally, engagement of senior clinical faculty in determining the culture of the care and education system will contribute to an advanced social-learning and care network.
Burnout During Residency Training: A Literature Review
Authors: IsHak Waguih William , Lederer Sara , Mandili Carla , Nikravesh Rose , Seligman Laurie , Vasa Monisha , Ogunyemi Dotun , Bernstein Carol A.
Published: December 2009

Objective

Burnout is a state of mental and physical exhaustion related to work or care giving activities. Burnout during residency training has gained significant attention secondary to concerns regarding job performance and patient care. This article reviews the relevant literature on burnout in order to provide information to educators about its prevalence, features, impact, and potential interventions.

Methods

Studies were identified through a Medline and PsychInfo search from 1974 to 2009. Fifty-one studies were identified. Definition and description of burnout and measurement methods are presented followed by a thorough review of the studies.

Results

An examination of the burnout literature reveals that it is prevalent in medical students (28%–45%), residents (27%–75%, depending on specialty), as well as practicing physicians. Psychological distress and physical symptoms can impact work performance and patient safety. Distress during medical school can lead to burnout, which in turn can result in negative consequences as a working physician. Burnout also poses significant challenges during early training years in residency. Time demands, lack of control, work planning, work organization, inherently difficult job situations, and interpersonal relationships, are considered factors contributing to residents' burnout. Potential interventions include workplace-driven and individual-driven measures. Workplace interventions include education about burnout, workload modifications, increasing the diversity of work duties, stress management training, mentoring, emotional intelligence training, and wellness workshops. Individual-driven behavioral, social, and physical activities include promoting interpersonal professional relations, meditation, counseling, and exercise.

Conclusions

Educators need to develop an active awareness of burnout and ought to consider incorporating relevant instruction and interventions during the process of training resident physicians.
Simulation for the Training of Human Performance and Technical Skills: The Intersection of How We Will Train Health Care Professionals in the Future
Authors: Hamman William R. , Beaubien Jeffrey M. , Beaudin-Seiler Beth M.
Published: December 2009

Aims

The aims of this research are to begin to understand health care teams in their operational environment, establish metrics of performance for these teams, and validate a series of scenarios in simulation that elicit team and technical skills. The focus is on defining the team model that will function in the operational environment in which health care professionals work.

Methods

Simulations were performed across the United States in 70- to 1000-bed hospitals. Multidisciplinary health care teams analyzed more than 300 hours of videos of health care professionals performing simulations of team-based medical care in several different disciplines. Raters were trained to enhance inter-rater reliability.

Results

The study validated event sets that trigger team dynamics and established metrics for team-based care. Team skills were identified and modified using simulation scenarios that employed the event-set-design process. Specific skills (technical and team) were identified by criticality measurement and task analysis methodology.

Discussion

In situ simulation, which includes a purposeful and Socratic Method of debriefing, is a powerful intervention that can overcome inertia found in clinician behavior and latent environmental systems that present a challenge to quality and patient safety. In situ simulation can increase awareness of risks, personalize the risks, and encourage the reflection, effort, and attention needed to make changes to both behaviors and to systems.
The ACGME Resident Survey Aggregate Reports: An Analysis and Assessment of Overall Program Compliance
Authors: Holt Kathleen D. , Miller Rebecca S.
Published: December 2009

Background

The Accreditation Council for Graduate Medical Education (ACGME) uses a 29-question Resident Survey for yearly residency program assessments. This article describes methodology for aggregating Resident Survey data into 5 discrete areas of program performance for use in the accreditation process. This article also describes methodology for setting thresholds that may assist Residency Review Committees in identifying programs with potential compliance problems.

Methods

A team of ACGME staff and Residency Review Committee chairpersons reviewed the survey for content and proposed thresholds (through a modified Angoff procedure) that would indicate problematic program functioning.

Results

Interrater agreement was high for the 5 content areas and for the threshold values (percentage of noncompliant residents), indicating that programs above these thresholds may warrant follow-up by the accrediting organization. Comparison of the Angoff procedure and the actual distribution of the data revealed that the Angoff thresholds were extremely similar to 1 standard deviation above the content area mean.

Conclusion

Data from the ACGME Resident Survey may be aggregated into internally consistent and consensually valid areas that may help Residency Review Committees make more targeted and specific judgments about program compliance.
Residents' Perspectives on Professionalism
Authors: Krain Lewis P. , Lavelle Ellen
Published: December 2009

Background

Research defining professionalism exists, yet little is known about how residents view this important attribute for medical practice. Knowing more about residents' interpretations of professionalism and about how they value professionalism would enhance definitions and facilitate support for the development of professionalism skills and behaviors at the graduate level.

Purpose

The purpose of this phenomenological study was to investigate how residents think about professionalism, how they value it, and how it plays out in their educational lives.

Methods

This study uses qualitative methods, employing 5 focus groups representative of a range of disciplines. Methods include providing unstructured prompts, member checking and informant feedback to support credibility, and content analysis to discern significant patterns.

Results

Content analysis supported that residents highly value professionalism and see it as a complex construct, dependent on the situation, discipline, and on personal experience. Challenges to professionalism are common in graduate medical education and a great concern for residents.

Conclusions

Physician educators often discuss professionalism as an overarching concept in medicine, especially in classes during the preclinical years. Although some general principles are applicable, residents relate more deeply to aspects of professionalism that concern their own clinical practice, situation, and specialty. Implications for measurement of professional skills and for further research are included in this report.
One Possible Future for Resident Hours: Interns' Perspective on a One-Month Trial of the Institute of Medicine Recommended Duty Hour Limits
Authors: Tessing Stephanie , Amendt Andria , Jennings Jeanine , Thomson Joanna , Auger Katherine A. , Gonzalez del Rey Javier A.
Published: December 2009

Background

In December 2008, the Institute of Medicine (IOM) released the report of a consensus committee recommending added limits on resident duty hours.

Methods

Perceptions of interns participating in a 1-month trial implementation of the IOM-recommended duty hour limits in one large pediatric residency program during March 2009 were aggregated.

Results

Interns experienced benefits from the shift-based schedule, including reduced hours and more nights at home. These were accompanied by shortcomings of the new schedule, most prominently increased intensity during the hours worked, weaknesses in sign-outs and handing off of tasks, and inability to know and “own” all patients on the interns' team. The experiment also changed the role and the level of engagement expected from attending physicians.

Conclusions

The trial implementation of the IOM-recommended limits highlighted that to adapt to additional reduction in hours, residency education needs a significant culture change, including better sign-outs, improved organization of bedside and didactic education, and attention to the added work intensity of a team-based model with daily admissions. Ultimately this may require an adjustment in residents' workload and different expectations and models of support from attending physicians.
Failure to Thrive: Pediatric Residents Weigh In on Feasibility Trial of the Proposed 2008 Institute of Medicine Work Hour Restrictions
Authors: Auger Katherine A. , Sieplinga Kira R. , Simmons Jeffrey M. , Gonzalez del Rey Javier A.
Published: December 2009

Background

In December 2008 the Institute of Medicine (IOM) released a report recommending limits on resident hours that are considerably more restrictive than the current Accreditation Council for Graduate Medical Education duty hour standards.

Intervention

In March 2009, a large pediatric residency program implemented a 1-month trial of a schedule and team structure fully congruent with the IOM recommendations to study the implications of such a schedule.

Methods

Comparison of the interns' experience in the trialed intervention schedule was made to interns working a traditional schedule with every fourth night call.

Results

The residents on the intervention schedule averaged 7.8 hours of sleep per 24-hour period compared to 7.6 hours for interns in a traditional schedule. Participation in bedside rounds and formal didactic conferences was decreased in the intervention schedule. Several factors contributed to increased perceived work intensity for interns in the intervention schedule. Redistribution of work during busy shifts altered the role of senior residents and attending physicians which may have a negative effect on senior residents' ability to develop skills as supervisors and educators.

Conclusions

The trial implementation suggests it is possible to implement the proposed duty hour limits in a pediatric residency, but it would require a significant increase in the resident workforce (at least 25% and possibly 50%) to care for the same number of patients. Furthermore, the education model would need to undergo significant changes. Further trials of the IOM recommendations are needed prior to widespread implementation in order to learn what works best and causes the least harm, disruption, and unnecessary cost to the system.
The Revolution in Medical Education—The Role of Simulation
Authors: Satava Richard M.
Published: December 2009

The last major change in medical education was the Flexner Report, over a century ago. Since that time, iterative improvements have occurred to the question-and-answer and “see one, do one, teach one” educational environment. However, multiple external forces—from the 80-hour work week to the emphasis on patient safety to competing demands on student and faculty time—have raised calls for a fundamental revamping of the entire medical educational process. Fortunately, new methods, curricula, and processes, such as Accreditation Council for Graduate Medical Education competencies or Objective Structured Assessment of Technical Skills, as well as innovative technologies such as web-based learning and simulation, have provided opportunities to support the revolution in medical education that will be responsive to national priorities, the public concern, and, most of all, to patient safety.
Systematic assessment of inflammation by magnetic resonance imaging in the posterior elements of the spine in ankylosing spondylitis
Authors: Maksymowych Walter P. , Crowther Sean M. , Dhillon Suhkvinder S. , Conner‐Spady Barbara , Lambert Robert G. W.
Published: December 2009

Objective

Magnetic resonance imaging (MRI) is sensitive for scoring inflammatory lesions in the spine, but attention has primarily focused on vertebral bodies, and no study has systematically examined the posterior elements. We aimed to systematically determine the frequency and distribution of inflammatory changes in the posterior elements of the spine using MRI, and to assess the reliability of their detection and their impact on discrimination of spinal MRI.

Methods

We scanned 32 patients recruited to placebo‐controlled trials of anti–tumor necrosis factor therapy. Inflammatory lesions were detected by systematic review of consecutive sagittal STIR slices of the entire spine. Two readers evaluated pretreatment and posttreatment scans, blinded to treatment and time point. Inflammation was scored dichotomously (present/absent) in each posterior structure. Reproducibility was assessed by calculating random model variance components and generalizability coefficients, and discrimination by using Guyatt's effect size.

Results

Most patients (87.5%) had ≥1 lesion in the posterior elements (mean ± SD number of affected spinal levels per patient 6.7 ± 5.3), and they were detected most frequently in the thoracic spine. Interobserver reproducibility for total lesion count was very good to excellent for lesions in the thoracic spine and transverse and spinous processes. The addition of a simple dichotomous method for scoring posterior element inflammation substantially enhanced the discrimination observed using established MRI methods for scoring vertebral body inflammation.

Conclusion

Inflammatory lesions in the posterior elements were present in the majority of patients with AS, and standard MRI protocols of the spine should be modified to ensure adequate visualization of posterolateral structures.
Magnetic resonance imaging grading system for active and chronic spondylarthritis changes in the sacroiliac joint
Authors: Madsen Karen Berenth , Jurik Anne Grethe
Published: December 2009

Objective

To develop a new grading method to quantify activity and chronic spondylarthritis (SpA) changes in the sacroiliac (SI) joints identified by magnetic resonance imaging (MRI), taking into account the complex joint anatomy, and to compare the findings with radiographic changes.

Methods

A total of 37 patients (15 men, 22 women) fulfilling the European Spondylarthropathy Study Group criteria for SpA were examined by MRI of the SI joint using a semicoronal T1‐weighted and T1‐weighted fat‐saturated (T1FS) sequence, a semiaxial STIR sequence, and postcontrast semicoronal and semiaxial T1FS sequences. The images were assessed independently by 2 radiologists for presence of bone marrow edema and enhancement, fatty marrow deposition, and joint erosion at both the cartilaginous and the ligamentous joint portion. Conventional radiographs were scored in accordance with the modified New York criteria.

Results

Inter‐ and intraobserver agreements for grading activity and chronic changes were good, with kappa values between 0.72 and 0.86 and between 0.83 and 0.90, respectively. Nearly half of the disease activity changes were due to inflammation in the ligamentous joint portion, which was significantly related to ankylosing spondylitis (AS). Patients with AS had significantly higher erosion and fatty marrow deposition scores than patients with nonprimary AS forms of SpA. The degree of erosion by MRI was significantly related to radiographic stages.

Conclusion

Separate assessment of the ligamentous joint portion by MRI may be valuable for differentiating AS from nonprimary AS forms of SpA. Erosive changes on MRI were significantly related to radiographic changes, implying a possibility for substituting radiography with MRI.
Development and validation of a case ascertainment tool for ankylosing spondylitis
Authors: Weisman Michael H. , Chen Lan , Clegg Daniel O. , Davis John C. , Dubois Robert W. , Prete Pamela E. , Savage Laurie M. , Schafer Laura , Suarez‐Almazor Maria E. , Yu Hsing‐Ting , Reveille John D.
Published: December 2009

Objective

Ankylosing spondylitis (AS) diagnosis is often delayed. The availability of effective biologic agents for treating AS has increased the importance of early diagnosis. We tested questions derived from a comprehensive literature review and an advisory board in a case–control study designed to identify patients with AS from among patients with chronic back pain (CBP).

Methods

Question items were cognitively tested among patients with AS, and then in case–control studies for validation and creation of a scoring algorithm and question item reduction. AS cases were recruited from a known database, and CBP subjects (controls) were recruited from clinics, employers, and from the SpineUniverse Web site. We used individual question items in a multivariate framework to discriminate between people with and without AS.

Results

Forty‐three questions yielded 24 items for analyses; 12 of these were entered into a multivariate regression model. Individual items yielded odds ratios ranging from 0.07 to 30.31. Question items with a significant positive relationship to AS included male sex, neck or hip pain/stiffness, longer pain duration, decreased pain/stiffness with daily physical activity, pain relief within 48 hours of nonsteroidal antiinflammatory drugs, and diagnosis of iritis. The tool demonstrated a sensitivity of 67.4 and a specificity of 94.6. The tool was developed from clinically and radiologically diagnosed AS cases and therefore is designed to distinguish AS cases among CBP subjects. In addition, ∼54% of the AS cases in the study were treated with biologic agents, which may impact questionnaire responses.

Conclusion

This tool can identify undiagnosed patients with AS and, potentially, those at an earlier stage in their disease course.
A comparison of strength training, self‐management, and the combination for early osteoarthritis of the knee
Authors: McKnight Patrick E. , Kasle Shelley , Going Scott , Villanueva Isidro , Cornett Michelle , Farr Josh , Wright Jill , Streeter Clara , Zautra Alex
Published: December 2009

Objective

To assess the relative effectiveness of combining self‐management and strength training for improving functional outcomes in patients with early knee osteoarthritis.

Methods

We conducted a randomized intervention trial lasting 24 months at an academic medical center. Community‐dwelling middle‐aged adults (n = 273) ages 35–64 years with knee osteoarthritis, pain, and self‐reported physical disability completed a strength training program, a self‐management program, or a combined program. Outcomes included 5 physical function tests (leg press, range of motion, work capacity, balance, and stair climbing) and 2 self‐reported measures of pain and disability.

Results

A total of 201 participants (73.6%) completed the 2‐year trial. Overall, compliance was modest for the strength training (55.8%), self‐management (69.1%), and combined (59.6%) programs. The 3 groups showed a significant and large increase from pre‐ to posttreatment in all of the physical functioning measures, including leg press (d = 0.85), range of motion (d = 1.00), work capacity (d = 0.60), balance (d = 0.59), and stair climbing (d = 0.59). Additionally, all 3 groups showed decreased self‐reported pain (d = −0.51) and disability (d = −0.55). There were no significant differences among the groups.

Conclusion

Middle‐aged, sedentary persons with mild early knee osteoarthritis benefited from strength training, self‐management, and the combination program. These results suggest that both strength training and self‐management are suitable treatments for the early onset of knee osteoarthritis in middle‐aged adults. Self‐management alone may offer the least burdensome treatment for early osteoarthritis.
Long‐term outcome and prognostic factors of juvenile dermatomyositis: A multinational, multicenter study of 490 patients
Authors: Ravelli Angelo , Trail Lucia , Ferrari Cristina , Ruperto Nicolino , Pistorio Angela , Pilkington Clarissa , Maillard Susan , Oliveira Sheila K. , Sztajnbok Flavio , Cuttica Ruben , Beltramelli Matilde , Corona Fabrizia , Katsicas Maria Martha , Russo Ricardo , Ferriani Virginia , Burgos‐Vargas Ruben , Magni‐Manzoni Silvia , Solis‐Valleoj Eunice , Bandeira Marcia , Zulian Francesco , Baca Vicente , Cortis Elisabetta , Falcini Fernanda , Alessio Maria , Alpigiani Maria Giannina , Gerloni Valeria , Saad‐Magalhaes Claudia , Podda Rosanna , Silva Clovis A. , Lepore Loredana , Felici Enrico , Rossi Federica , Sala Elena , Martini Alberto
Published: December 2009

Objective

To investigate the long‐term outcome and prognostic factors of juvenile dermatomyositis (DM) through a multinational, multicenter study.

Methods

Patients consisted of inception cohorts seen between 1980 and 2004 in 27 centers in Europe and Latin America. Predictor variables were sex, continent, ethnicity, onset year, onset age, onset type, onset manifestations, course type, disease duration, and active disease duration. Outcomes were muscle strength/endurance, continued disease activity, cumulative damage, muscle damage, cutaneous damage, calcinosis, lipodystrophy, physical function, and health‐related quality of life (HRQOL).

Results

A total of 490 patients with a mean disease duration of 7.7 years were included. At the cross‐sectional visit, 41.2–52.8% of patients, depending on the instrument used, had reduced muscle strength/endurance, but less than 10% had severe impairment. Persistently active disease was recorded in 41.2–60.5% of the patients, depending on the activity measure used. Sixty‐nine percent of the patients had cumulative damage. The frequency of calcinosis and lipodystrophy was 23.6% and 9.7%, respectively. A total of 40.7% of the patients had decreased functional ability, but only 6.5% had major impairment. Only a small fraction had decreased HRQOL. A chronic course, either polycyclic or continuous, consistently predicted a poorer outcome. Mortality rate was 3.1%.

Conclusion

This study confirms the marked improvement in functional outcome of juvenile DM when compared with earlier literature. However, many patients had continued disease activity and cumulative damage at followup. A chronic course was the strongest predictor of poor prognosis. These findings highlight the need for treatment strategies that enable a better control of disease activity over time and the reduction of nonreversible damage.
Genotoxicity of anti–tumor necrosis factor therapy in patients with juvenile idiopathic arthritis
Authors: Demirkaya Erkan , Cok Ismet , Durmaz Emre , Ulutas Onur K. , Ayaz Nuray Aktay , Besbas Nesrin , Özen Seza
Published: December 2009

Objective

To assess the possible effects of both inflammation and the anti–tumor necrosis factor agents (anti‐TNF) on DNA damage with a specific assay, and their effects on the repair capacity of DNA.

Methods

From a group of 20 children with juvenile idiopathic arthritis (JIA), 16 patients who completed the study and 16 control subjects were evaluated. DNA damage and repair capacity were analyzed by the comet assay at the level of peripheral lymphocytes before anti‐TNF (etanercept) injections and on the 15th, 90th, and 180th days after the first injection.

Results

The amount of damage as detected by the aforementioned assay was higher in patients with JIA compared with controls. On the 15th day after the initial anti‐TNF injection, there was a decrease in the mean DNA tail length of JIA patients, however on the 90th day an increase was observed; thereafter, an upward trend was observed until the end of the study. JIA patients had a DNA repair capacity that was significantly less than that of controls.

Conclusion

The results of the comet technique suggests that JIA patients already have increased basal DNA damage before anti‐TNF therapy; they are more sensitive to the DNA damage produced by H2O2, and have a less efficient DNA repair system in comparison with control cells. After an initial improvement at 2 weeks, parameters of genotoxicity worsened, and DNA repair was further impaired 6 months after the addition of an anti‐TNF agent to treatment.
A modified sharp score demonstrates disease progression in established psoriatic arthritis
Authors: Ravindran J. , Cavill C. , Balakrishnan C. , Jones S. M. , Korendowych E. , McHugh N. J.
Published: December 2009

Objective

To use a modified Sharp score (MSS) to measure radiologic progression and to assess its relationship to other radiologic features, peripheral joint disease, and physical function in psoriatic arthritis (PsA).

Methods

Two sets of hand radiographs (median interval 5.75 years) in 139 patients with established PsA were scored using an MSS. Seventy‐four patients had standardized clinical joint and Health Assessment Questionnaire (HAQ) scores and other radiologic features of PsA documented at baseline and followup (median interval 5 years).

Results

Radiologic damage was present in 58% of patients at baseline and 74% at followup. The median MSS and its components, erosion score and joint space abnormality score, were significantly greater at followup (P < 0.001). The median MSS progression was +1.08 units/year. There was strong correlation between MSS and clinical joint scores at baseline and followup (r = 0.72 and r = 0.81, respectively). There was weak correlation between MSS and HAQ at baseline (r = 0.29), but stronger correlation at followup (r = 0.48). There was a strong association between MSS and other characteristic radiologic features of PsA (bony proliferation, periostitis, bony ankylosis) at baseline and followup (P < 0.001). However, the presence of soft‐tissue swelling on radiographs at baseline was the only radiologic parameter associated with an increased rate of change of MSS (corrected P < 0.006).

Conclusion

The MSS shows good construct validity with measures of peripheral joint involvement such as clinical joint scores and other radiologic features of PsA, and is able to demonstrate that radiologic damage is progressive beyond early disease.
Physician preference motivates the use of anti–tumor necrosis factor therapy independent of clinical disease activity
Authors: Curtis Jeffrey R. , Chen Lang , Harrold Leslie R. , Narongroeknawin Pongthorn , Reed George , Solomon Daniel H.
Published: December 2009

Objective

Physician preference has previously been shown to be an important determinant of prescription patterns, independent of patient‐specific factors. We evaluated whether physician preference was important in the decision to select anti–tumor necrosis factor (anti‐TNF) therapy rather than nonbiologic disease‐modifying antirheumatic drugs (DMARDs) among rheumatoid arthritis (RA) patients initiating a new RA medication.

Methods

Using data from the Consortium of Rheumatology Researchers of North America, we identified RA patients who had never taken biologics initiating either anti‐TNF therapy or a DMARD in 2001–2008. Physician preference for the use of anti‐TNF agents was calculated using data from the preceding calendar year for each physician's other RA patients. Multivariable logistic regression with generalized estimating equations accounted for clustering of patients within the physician practice and evaluated the relationship between physician preference and receipt of anti‐TNF therapy, controlling for patient‐related factors and disease activity using the Clinical Disease Activity Index.

Results

We identified 1,532 RA patients initiating anti‐TNF therapy or a DMARD. In models adjusting for tender and swollen joint counts and global disease activity, physician preference for the use of anti‐TNF therapy was an independent predictor of receipt of these agents. Patients of physicians in the highest and middle tertiles of physician preference had a 2.50 (95% confidence interval [95% CI] 1.76–3.56) and 1.70 (95% CI 1.22–2.39) greater likelihood of receiving anti‐TNF medications, respectively.

Conclusion

Physician preference is an important determinant of patients' receipt of anti‐TNF therapy and may be useful to examine in future studies of RA treatment patterns, costs, and medication safety.
Dehydroepiandrosterone (DHEA) substitution treatment for severe fatigue in DHEA‐deficient patients with primary Sjögren's Syndrome
Authors: Virkki Liisa M. , Porola Pauliina , Forsblad‐d'Elia Helena , Valtysdottir Sigridur , Solovieva Svetlana A. , Konttinen Yrjö T.
Published: December 2009

Objective

Primary Sjögren's syndrome (SS) is characterized by fatigue and low levels of serum dehydroepiandrosterone/dehydroepiandrosterone sulfate (DHEA/DHEAS). Our aim was to study whether SS patients with severe fatigue and low serum DHEAS values benefit from DHEA substitution (50 mg/day).

Methods

A multicenter, investigator‐based, powered, randomized controlled clinical trial (crossover, washout design) using fatigue as the primary outcome measure was performed on patients with primary SS (n = 107) who had a general fatigue score ≥14 on the 20‐item Multiple Fatigue Inventory (MFI‐20), combined with age‐ and sex‐adjusted serum DHEAS values below the mean. Fatigue was assessed using MFI‐20 subscales, i.e., general fatigue, physical fatigue, mental fatigue, reduced motivation, and activity (scale 4–20), and with a visual analog scale (VAS; scale 0–100).

Results

In an intent‐to‐treat analysis, a 50‐mg DHEA substitution dose and placebo similarly improved fatigue. All of the MFI‐20 subscales and the fatigue VAS improved from the baseline levels as a result of treatment (P < 0.001), but with negligible differences between these 2 treatments. The mean between‐treatment difference was −0.1 for general fatigue (the primary outcome measure), 0.0 for physical fatigue, 0.0 for mental fatigue, 0.0 for reduced motivation, 0.3 for reduced activity, and 2.2 for the fatigue VAS. None of these differences was statistically significant.

Conclusion

Similar to earlier results using pharmacologic doses, substitution treatment with 50 mg of DHEA in DHEA‐deficient and severely tired primary SS patients does not help against fatigue better than placebo. This may relate to the prohormone nature of DHEA and its recently described defective intracrine tissue‐specific conversion to active sex steroids in SS.