Objectives
In people with rheumatoid arthritis (RA), mental health problems are common, but often not recognized or treated, contributing to increased morbidity and mortality. Most studies examining ...the impact of mental health problems in RA have focused on depression. We aimed to determine the association between anxiety, and disease activity and quality of life (QoL) in people with RA.
Methods
A systematic review and meta-analysis were performed. A protocol was registered with PROSPERO (CRD2-17062580). Databases (Web of Science, PsycINFO, CINAHL, Embase, Medline) were searched for studies examining the association between anxiety and disease activity and QoL, in adults with RA, from inception to February 2019. Primary outcome measures were DAS28 and SF-36. Eligibility screening and data extraction were completed by two reviewers. Disagreements were resolved by discussion or a third reviewer. Quality assessment was carried out using the Newcastle-Ottawa Scale.
Results
From 7712 unique citations, 60 articles were assessed for eligibility. The final review included 20 studies involving 7452 people with RA (14 cross-sectional, 6 cohort). Eleven examined disease activity, 6 reported QoL outcome measures and 3 included both. Anxiety was associated with increased disease activity and worse QoL. Meta-analysis showed anxiety to be correlated with increased DAS28 scores (
r
= 0.23, CI 0.14, 0.31) and reduced physical (
r
= − 0.39, CI − 0.57, − 0.20) and mental QoL (− 0.50, CI − 0.57, − 0.43).
Conclusions
Anxiety in people with RA is associated with increased disease activity and worse QoL. Improved recognition and management of comorbid anxiety may help to improve outcomes for people with RA.
Key Points
• This is the first systematic review and meta-analysis to examine the relationship between anxiety and disease activity and QoL in people with RA.
• Anxiety was associated with higher disease activity both cross-sectionally and at up to 12-month follow-up.
• Anxiety may have a more significant impact on disease activity in early RA, highlighting the importance of early recognition and management of comorbid anxiety.
• People with anxiety had poorer self-reported physical and mental QoL, although there was some heterogeneity in study findings, particularly for physical QoL (I
2
= 78.5%).
Evidence from the Global Burden of Disease studies suggests that osteoarthritis (OA) is a significant cause of disability globally; however, it is less clear how much of this burden exists in ...low-income and lower middle-income countries. This study aims to determine the prevalence of OA in people living in low-income and lower middle-income countries. Four electronic databases (MEDLINE, EMBASE, CINAHL and Web of Science) were systematically searched from inception to October 2018 for population-based studies. We included studies reporting the prevalence of OA among people aged 15 years and over in low-income and lower middle-income countries. The prevalence estimates were pooled across studies using random effects meta-analysis. Our study was registered with PROSPERO, number CRD42018112870.The search identified 7414 articles, of which 356 articles were selected for full text assessment. 34 studies were eligible and included in the systematic review and meta-analysis. The pooled prevalence of OA was 16·05% (95% confidence interval (CI) 12·55–19·89), with studies demonstrating a substantial degree of heterogeneity (
I
2
= 99·50%). The pooled prevalence of OA was 16.4% (CI 11·60–21.78%) in South Asia, 15.7% (CI 5·31–30·25%) in East Asia and Pacific, and 14.2% (CI 7·95–21·89%) in Sub Saharan Africa. The meta-regression analysis showed that publication year, study sample size, risk of bias score and country-income categories were significantly associated with the variations in the prevalence estimates. The prevalence of OA is high in low-income and lower middle-income countries, with almost one in six of the study participants reported to have OA. With the changing population demographics and the shift to the emergence of non-communicable diseases, targeted public health strategies are urgently needed to address this growing epidemic in the aging population.
Complementary and alternative medicine (CAM) is very popular with patients frequently combining it with orthodox health care. The high prevalence of CAM use and satisfaction with CAM reported by ...patients directly challenges an orthodox system that can only approve such use if it results from the application of biomedical concepts and science. Studies highlighting this as a cultural, sociological and historical phenomenon emphasise the value of choice for consumers of health care. Musculoskeletal conditions typify common problems for which the effectiveness of orthodox care is often unclear. We postulated that the reasons people give for using or not using CAM for musculoskeletal conditions, would therefore indicate the full range of expectations that people have of health care. Furthermore, these reasons would indicate how much people feel orthodox health care is or is not meeting their expectations. Therefore, this study aims to investigate people's reasons for choosing or avoiding CAM for non-traumatic musculoskeletal conditions.
A systematic search and narrative synthesis was conducted of published qualitative and quantitative studies related to CAM and non-traumatic musculoskeletal conditions.
We identified 169 relevant papers detailing 152 separate studies, from which 1486 justifications were extracted concerning CAM use. Content analysis resulted in 11 distinct categories across four themes: practical aspects of care, clinical effectiveness, non-clinical outcomes of care, and a person's philosophy of illness and care. People provided similar rationales for both using and avoiding CAM, emphasising that, whilst CAM is perceived by many patients with musculoskeletal conditions to fill gaps in care (such as practitioner time or quality of the therapeutic relationship), orthodox care also seeks to deliver these aspects of care. However, people who used CAM also highlighted its alignment with their general philosophy and ideas about illness and health care, and often emphasised CAM's capacity to give them control over their condition and its treatment.
Currently, CAM appears to have a significant role for patients with common painful long-term conditions in providing choices to enable individual needs to be met.
Introduction The demand for musculoskeletal (MSK) care is rising, and is a growing challenge for general practice. Direct access to physiotherapy and other healthcare services may offer appropriate ...care for MSK pain patients but there is uncertainty regarding the effectiveness or efficiency of this approach in practice. This study aimed to review the evidence regarding characteristics, outcomes, barriers and facilitators of MSK triage and direct access services. Methods A comprehensive search of eight databases (including MEDLINE, EMBASE, and Cochrane library) up to February 2018 was conducted to identify studies (trials, cohorts and qualitative evidence) on direct access services for MSK in primary care settings. Using predefined inclusion and exclusion criteria, titles, abstracts, and subsequent full texts were independently screened by reviewers. Methodological quality of eligible studies was assessed using the mixed methods appraisal tool, and extracted data regarding study characteristics and results were independently reviewed. A narrative synthesis and grading of evidence was undertaken. Approaches to MSK triage and direct access were profiled along with their respective outcomes of care relating to patient-oriented and socioeconomic outcomes. Barriers and facilitators of each model of direct access services were also highlighted. Results 9010 unique citations were screened, of which 26 studies were eligible. Three approaches (open access, combination and service pathway models) to MSK triage and direct access shared similar goals but were heterogeneous in application. MSK patients using direct access showed largely similar characteristics (age, sex and duration of symptoms) compared to GP-led care, although they were often younger, slightly more educated and with better socio-economic status than patients seen through GP-led care. Although many studies showed limitations in design or methods, outcomes of care (patient oriented outcomes of pain, and disability) did not show large differences between direct access and GP-led care. In most studies direct access patients were reported to have lower healthcare utilisation (fewer physiotherapy or GP consultations, analgesics or muscle relaxants prescriptions, or imaging procedures) and less time off work compared to GP-led care. Discussion This study provides insight into the current state of evidence regarding MSK triage and direct access services and highlights potential implications for future research, healthcare services planning, resource utilisation and organising care for MSK patients in primary care. There is consistent, although limited, evidence to suggest that MSK triage and direct access services lead to comparable clinical outcomes with lower healthcare consumption, and can help to manage GP workload. However, due to the paucity of strong empirical data from methodologically robust studies, a scale up and widespread roll out of direct access services cannot as yet be assumed to result in long term health and socio-economic gains. PROSPERO-ID: CRD42018085978.
Background
Mental health problems experienced by older adults (60+ years of age) may remain hidden due to individual and system‐level barriers. Opportunities to support early identification and ...management are therefore crucial. The National Health Service recommends wider public services that are embedded within local communities, but are not traditionally part of the healthcare landscape (i.e., ‘nontraditional’), could facilitate engagement with healthcare by members of the public. Evidence for interventions involving Fire and Rescue, Police, Library services and postal workers, as nontraditional providers of mental health services, has not been synthesized previously. This review aims to understand how, why and in what contexts mental health interventions delivered by these nontraditional providers, to older adults, work.
Methods
A realist review of interventions to identify and/or manage mental health problems (depression with or without anxiety) experienced by older adults. Systematic, cluster and iterative literature searches were conducted. Intervention evidence was appraised for rigour and explanatory relevance and then coded to inform context‐mechanism‐outcome configurations (CMOCs). A public advisory group supported our initial evidence search strategy and definition of key terms. This review is registered with PROSPERO (CRD42020212498).
Results
Systematic searches revealed a dearth of evidence reporting mental health interventions delivered by nontraditional providers. Our scope was adjusted to consider interventions delivered by Fire and Police services only and for wider health and wellbeing concerns (e.g., dementia, falls prevention, mental health crises). Forty‐three pieces of evidence were synthesized. Key themes included: legitimizing expanded roles, focusing on risk, intervention flexibility and organization integration; further subthemes are described. Themes map onto CMOCs and inform a preliminary programme theory. Findings were transposed to mental health contexts.
Conclusions
Findings highlight challenges and opportunities for Fire and Police services, as nontraditional providers, to deliver interventions that identify and/or manage mental health problems among older adults. Our programme theory explains what could work, how, for whom and also by whom (i.e., which public services). Further empirical evidence is needed to test interventions, understand acceptability and inform implementation.
Patient or Public Contribution
A public advisory group comprising older adults with lived experience of mental health problems and informal caregivers contributed to the original application, reviewed the scope and informed the approach to dissemination.
Background
Numerous systematic reviews have attempted to synthesize evidence on prognostic factors for predicting future outcomes such as pain, disability and return‐to‐work/work absence in neck and ...low back pain populations.
Databases and datatreatment
An umbrella review of systematic reviews was conducted to summarize the magnitude and quality of the evidence for each prognostic factor investigated. Searches were limited to the last 10 years (2008‐11th April 2018, updated 28th September 2020). A two‐stage approach was undertaken: in stage one, data on prognostic factors was extracted from systematic reviews identified from the systematic search that met the inclusion criteria. Where a prognostic factor was investigated in ≥1 systematic review and where 50% or more of those reviews found an association between the prognostic factor and one of the outcomes of interest, it was taken forward to stage two. In stage two, additional information extracted included the strength of association found, consistency of effects and risk of bias. The GRADE approach was used to grade confidence in the evidence.
Results
Stage one identified 41 reviews (90 prognostic factors), with 35 reviews (25 prognostic factors) taken forward to stage two. Seven prognostic factors (disability/activity limitation, mental health; pain intensity; pain severity; coping; expectation of outcome/recovery and fear‐avoidance) were judged as having moderate confidence for robust findings.
Conclusions
Although there was conflicting evidence for the strength of association with outcome, these factors may be used for identifying vulnerable subgroups or people able to self‐manage. Further research can investigate the impact of using such prognostic information on treatment/referral decisions and patient outcomes.
Human brain organization is built upon a more ancient adaptation, the large brain of simian primates: on average, monkeys and apes have brains twice as large as expected for mammals of their size, ...principally as a result of neocortical enlargement. Testing the adaptive benefit of this evolutionary specialization depends on finding an association between brain size and function in primates. However, most cognitive capacities have been assessed in only a restricted range of species under laboratory conditions. Deception of conspecifics in social circumstances is an exception, because a corpus of field data is available that encompasses all major lines of the primate radiation. We show that the use of deception within the primates is well predicted by the neocortical volume, when observer effort is controlled for; by contrast, neither the size of the rest of the brain nor the group size exert significant effects. These findings are consistent with the hypothesis that neocortical expansion has been driven by social challenges among the primates. Complex social manipulations such as deception are thought to be based upon rapid learning and extensive social knowledge; thus, learning in social contexts may be constrained by neocortical size.
Background:
There are currently many treatment options for patients with subacromial shoulder conditions (SSCs). Clinical decision-making regarding the best treatment option is often difficult. This ...study aims to evaluate the comparative effectiveness of treatment options for relieving pain and improving function in patients with SSCs.
Methods:
Eight databases including MEDLINE, Embase, CINAHL, AMED, PEDro, Cochrane Database of Systematic Reviews and World Health Organization (WHO) International Clinical Trials Registry were searched from inception until April 2020. Randomised clinical/controlled trials of adult patients investigating the effects of nonsurgical (e.g. corticosteroid injections, therapeutic exercise, shockwave therapy) and surgical treatment for SSCs, compared with each other, placebo, usual care or no treatment, were retrieved. Pairs of reviewers screened studies independently, quality appraised eligible studies using the Cochrane risk of bias tool, extracted and checked data for accuracy. Primary outcomes were pain and disability in the short term (⩽3 months) and long term (⩾6 months). Direct and indirect evidence of treatment effectiveness was synthesised using random-effects network meta-analysis.
Results:
The review identified 177 eligible trials. Summary estimates (based on 99 trials providing suitable data, 6764 patients, 20 treatment options) showed small to moderate effects for several treatments, but no significant differences on pain or function between many active treatment comparisons. The primary analysis indicated that exercise and laser therapy may provide comparative benefit in terms of both pain and function at different follow-up time-points, with larger effects found for laser in the short term at 2–6 weeks, although direct evidence was provided by one trial only, and for exercise in the longer term standardised mean difference (SMD) 0.39, 95% confidence interval (CI) 0.18, 0.59 at 3–6 months compared with control. Sensitivity analyses excluding studies at increased risk of bias confirmed only the comparative effects of exercise as being robust for both pain and function up until 3-month follow-up.
Conclusion:
Current evidence shows small to moderate effect sizes for most treatment options for SSCs. Six treatments had a high probability of being most effective, in the short term, for pain and function acupuncture, manual therapy, exercise, exercise plus manual therapy, laser therapy and Microcurrent (MENS) (TENS), but with low certainty for most treatment options. After accounting for risk of bias, there is evidence of moderate certainty for the comparative effects of exercise on function in patients with SSCs. Future large, high-quality pragmatic randomised trials or meta-analyses are needed to better understand whether specific subgroups of patients respond better to some treatments than others.
Abstract
Background
Bisphosphonate medications, including alendronate, ibandronate and risedronate administered orally and zoledronate, administered intravenously, are commonly prescribed for the ...treatment of osteoporosis based on evidence that, correctly taken, bisphosphonates can improve bone strength and lead to a reduction in the risk of fragility fractures. However, it is currently unclear how decisions to select between bisphosphonate regimens, including intravenous regimen, are made in practice and how clinicians support patients with different treatments.
Methods
This was an interpretivist qualitative study. 23 semi-structured telephone interviews were conducted with a sample of general practitioners (GPs), secondary care clinicians, specialist experts as well as those providing and leading novel treatments including participants from a community intravenous (IV) zoledronate service. Data analysis was undertaken through a process of iterative categorisation.
Results
The results report clinicians varying experiences of making treatment choices, as well as wider aspects of osteoporosis care. Secondary care and specialist clinicians conveyed some confidence in making treatment choices including on selecting IV treatment. This was aided by access to diagnostic testing and medication expertise. In contrast GPs reported a number of challenges in prescribing bisphosphonate medications for osteoporosis and uncertainty about treatment choice. Results also highlight how administering IV zoledronate was seen as an opportunity to engage in broader care practices.
Conclusion
Approaches to making treatment decisions and supporting patients when prescribing bisphosphonates for osteoporosis vary in practice. This study points to the need to co-ordinate osteoporosis treatment and care across different care providers.
Supported self-management interventions for patients with musculoskeletal (MSK) conditions may not adequately support those with limited health literacy, leading to inequalities in care and variable ...outcomes. The aim of this study was to develop a model for inclusive supported self-management intervention(s) for MSK pain that take account of health literacy.
A mixed methods study with four work-packages was conducted: work package 1: secondary analysis of existing data to identify potential targets for intervention; work package 2: evidence synthesis to assess effective components of self-management interventions taking into account health literacy; work package 3: views of community members and healthcare professionals (HCPs) on essential components; work package 4: triangulation of findings and an online modified Delphi approach to reach consensus on key components of a logic model.
Findings identified targets for intervention as self-efficacy, illness perceptions, and pain catastrophizing. A range of intervention components were identified (e.g. information in diverse formats offered at specific times, action planning and visual demonstrations of exercise). Support should be multi-professional using a combination of delivery modes (e.g. remote, face-to-face).
This research has developed a patient-centred model for a multi-disciplinary, multi-modal approach to supported self-management for patients with MSK pain and varying levels of health literacy. The model is evidence-based and acceptable to both patients and HCPs, with potential for significant impact on the management of MSK pain and for improving patient health outcomes. Further work is needed to establish its efficacy.
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