What does a primary care annual review for RA include? A national GP survey

Letter to the edito

The association between GP consultations for non-specific physical symptoms in children and parents: a case-control study

BACKGROUND: Non-specific physical symptoms (NSPS) such as abdominal pain, headache and musculoskeletal pain are widespread in the community, and are common reasons for visiting a general practitioner (GP). Causes of NSPS are multifactorial, but may include parental influences. OBJECTIVE: To investigate associations between GP consultations for NSPS in parents and their children. METHODS: Matched case-control study using GP consultation data from 12 GP practices in the United Kingdom. Participants were 1328 children who consulted a GP for NSPS in 2009 (cases), 3980 controls who consulted a GP in 2009 but not for NSPS, plus parents of cases and controls (n = 8354). PRIMARY OUTCOME MEASURE: child consultation status for NSPS. RESULTS: Maternal consultation for NSPS was associated with significantly increased odds of their child consulting for NSPS (odds ratio (OR) 1.51, 95% confidence intervals (CI) 1.33, 1.73); there was no significant association with paternal consultations (OR 0.87, 95% CI 0.71, 1.08). Each additional maternal consultation for NSPS was associated with an increase in the rate ratio for number of consultations for NSPS in the child by 1.03 (95% CI 1.01, 1.05). This overall association was clearest in maternal-child consultations for painful NSPS and for specific bodily systems including gastrointestinal, musculoskeletal and neurologic symptoms. CONCLUSIONS: Maternal GP consultation for NSPS is associated with increased odds of GP consultations for NSPS in children. This study included a large sample of children and parents and used medical records data which is not subject to recall bias. However, analysis was based on medical records, thus the presence of NSPS not leading to consultations is unknown. Medical practitioners managing children with NSPS need to be aware of this association

Widespread pain and depression are key modifiable risk factors associated with reduced social participation in older adults: A prospective cohort study in primary care.

In older adults, reduced social participation increases the risk of poor health-related quality of life, increased levels of inflammatory markers and cardiovascular disease, and increased mortality. Older adults frequently present to primary care, which offers the potential to deliver interventions at the point of care to increase social participation. The aim of this prospective study was to identify the key modifiable exposures that were associated with reduced social participation in a primary care population of older adults.The study was a population-based prospective cohort study. Participants (n = 1991) were those aged ≥65 years who had completed questionnaires at baseline, and 3 and 6-year follow-ups. Generalized linear mixed modeling framework was used to test for associations between exposures and decreasing social participation over 6 years.At baseline, 44% of participants reported reduced social participation, increasing to 49% and 55% at 3 and 6-year follow-up. Widespread pain and depression had the strongest independent association with reduced social participation over the 6-year follow-up period. The prevalence of reduced social participation for those with widespread pain was 106% (adjusted incidence rate ratio 2.06, 95% confidence interval 1.72, 2.46), higher than for those with no pain. Those with depression had an increased prevalence of 82% (adjusted incidence rate ratio 1.82, 95% confidence interval 1.62, 2.06). These associations persisted in multivariate analysis.Population ageing will be accompanied by increasing numbers of older adults with pain and depression. Future trials should assess whether screening for widespread pain and depression, and targeting appropriate treatment in primary care, increase social participation in older people

Comorbidity clusters in people with gout: an observational cohort study with linked medical record review

Objective. To investigate how comorbid conditions cluster in patients with gout in a UK primary care population. Methods. A cross-sectional study was performed using baseline data from a primary-care-based prospective observational cohort of people aged >= 18 years with gout. Participants with gout were identified through primary care medical records. Factor analysis was performed to obtain distinct clusters of comorbidity variables including obesity, hypertension, diabetes mellitus, hyperlipidaemia, coronary heart disease, heart failure, chronic kidney disease (CKD) and cancer. Hierarchical cluster analysis of patient observations was also performed to identify homogenous subgroups of patients based on combinations of their comorbidities. Results. Four distinct comorbidity clusters (C1-C4) were identified in 1079 participants [mean (S.D.) age 65.5 years (12.5); 909 (84%) male]. Cluster C1 (n = 197, 18%) was the oldest group and had the most frequent attacks of gout; 97% had CKD. Participants in C2 (n = 393, 36%) had isolated gout with few comorbidities but drank alcohol more frequently. In cluster C3 (n = 296, 27%), hypertension, diabetes mellitus, hyperlipidaemia, coronary heart disease and/or CKD were prevalent, and urate-lowering therapy was prescribed more frequently than in other clusters. All patients in C4 (193, 18%) had hypertension and were more likely to be obese than other clusters. Conclusion. Four distinct comorbidity clusters were identified. People with multiple comorbidities were more likely to receive allopurinol. Tailoring of treatments depending on cluster and comorbidities should be considered

Correction to: The association between anxiety and disease activity and quality of life in rheumatoid arthritis: a systematic review and meta-analysis.

The authors of the published original version of the above article wanted to correct the below text in the Abstract section

Diabetes as a Prognostic Factor in Frozen Shoulder: A Systematic Review.

Objective: To summarize evidence from longitudinal observational studies to determine whether diabetes (types 1 and 2) is associated with the course of symptoms in people with frozen shoulder. Data Sources: A systematic literature search of 11 bibliographic databases (published through June 2021), reference screening, and emailing professional contacts. Study Selection: Studies were selected if they had a longitudinal observational design that included people diagnosed with frozen shoulder at baseline and compared outcomes at follow-up (>2wk) among those with and without diabetes at baseline. Data Extraction: Data extraction was completed by 1 reviewer using a predefined extraction sheet and was checked by another reviewer. Two reviewers independently judged risk of bias using the Quality in Prognostic Factor Studies tool. Data Synthesis: A narrative synthesis, including inspection of forest plots and use of the prognostic factor Grading of Recommendations, Assessment, Development and Evaluations framework. Twenty-eight studies satisfied the inclusion criteria. Seven studies were judged to be at a moderate risk of bias and 21 at a high risk of bias. Diabetes was associated with worse multidimensional clinical scores (moderate certainty in evidence), worse pain (low certainty in evidence), and worse range of motion (very low certainty in evidence). Conclusions: This review provides preliminary evidence to suggest that people with diabetes may experience worse outcomes from frozen shoulder than those without diabetes. If high-quality studies can confirm the findings of this review, then clinicians should monitor patients with frozen shoulder with diabetes more closely and offer further treatment if pain or lack of function persists long-term

Health-related quality of life in gout in primary care: baseline findings from a cohort study

Objectives: To examine gout-related, comorbid, and sociodemographic characteristics associated with generic and disease-specific health-related quality of life (HRQOL) in gout. Methods: Adults with gout from 20 general practices were mailed a questionnaire containing the Health Assessment Questionnaire-Disability Index (HAQ-DI), Short-Form-36 Physical Function subscale (PF-10), Gout Impact Scale (GIS), and questions about gout-specific, comorbid and sociodemographic characteristics. Variables associated with HRQOL were examined using multivariable linear regression models. Results: A total of 1184 completed questionnaires were received (response 65.9%). Worse generic and gout-specific HRQOL was associated with frequent gout attacks (>= 5 attacks PF-10 beta = -4.90, HAQ-DI beta = 0.14, GIS subscales beta = 8.94, 33.26), current attack (HAQ-DI beta = 0.15, GIS beta = -1.94, 18.89), oligo/polyarticular attacks (HAQ-DI beta = 0.11, GIS beta = 0.78, 7.86), body pain (PF-10 beta = -10.68, HAQ-DI beta = 0.29, GIS beta = 2.61, 11.89), anxiety (PF-10 beta = -1.81, HAQ-DI beta = 0.06, GIS beta = 0.38, 1.70), depression (PF-10 beta = -1.98, HAQ-DI beta = 0.06, GIS 0.42, 1.47) and alcohol non-consumption (PF-10 beta = -16.10, HAQ-DI beta = 0.45). Gout-specific HRQOL was better in Caucasians than non-Caucasians (GIS beta = -13.05, -13.48). Poorer generic HRQOL was associated with diabetes mellitus (PF-10 beta = -4.33, HAQ-DI beta = 0.14), stroke (PF-10 beta = -12.21, HAQ-DI beta = 0.37), renal failure (PF-10 beta = -9.43, HAQ-DI beta = 0.21), myocardial infarction (HAQ-DI beta = 0.17), female gender (PF-10 beta = -17.26, HAQ-DI beta = 0.43), deprivation (PF-10 beta = 7.80, HAQ-DI beta = 0.19), and body mass index >= 35 kg/m(2) (PF-10 beta = -6.10, HAQ-DI beta = 0.21). Conclusions: HRQOL in gout is impaired by gout-specific, comorbid, and sociodemographic characteristics, highlighting the importance of comorbidity screening and early urate-lowering therapy. Both gout specific and generic questionnaires identify the impact of disease-specific features on HRQOL but studies focusing on comorbidity should include generic instruments

The clinical and cost effectiveness of steroid injection compared with night splints for carpal tunnel syndrome: the INSTINCTS randomised clinical trial study protocol.

BACKGROUND: Patients diagnosed with idiopathic mild to moderate carpal tunnel syndrome (CTS) are usually managed in primary care and commonly treated with night splints and/or corticosteroid injection. The comparative effectiveness of these interventions has not been reliably established nor investigated in the medium and long term. The primary objective of this trial is to investigate whether corticosteroid injection is effective in reducing symptoms and improving hand function in mild to moderate CTS over 6 weeks when compared with night splints. Secondary objectives are to determine specified comparative clinical outcomes and cost effectiveness of corticosteroid injection over 6 and 24 months. METHOD/DESIGN: A multicentre, randomised, parallel group, clinical pragmatic trial will recruit 240 adults aged ≥18 years with mild to moderate CTS from GP Practices and Primary-Secondary Care Musculoskeletal Interface Clinics. Diagnosis will be by standardised clinical assessment. Participants will be randomised on an equal basis to receive either one injection of 20 mg Depo-Medrone or a night splint to be worn for 6 weeks. The primary outcome is the overall score of the Boston Carpal Tunnel Questionnaire (BCTQ) at 6 weeks. Secondary outcomes are the BCTQ symptom severity and function status subscales, symptom intensity, interrupted sleep, adherence to splinting, perceived benefit and satisfaction with treatment, work absence and reduction in work performance, EQ-5D-5L, referral to surgery and health utilisation costs. Participants will be assessed at baseline and followed up at 6 weeks, 6, 12 and 24 months. The primary analysis will use an intention to treat (ITT) approach and multiple imputation for missing data. The sample size was calculated to detect a 15 % greater improvement in the BTCQ overall score in the injection group compared to night-splinting at approximately 90 % power, 5 % two-tailed significance and allows for 15 % loss to follow-up. DISCUSSION: The trial makes an important contribution to the evidence base available to support effective conservative management of CTS in primary care. No previous trials have directly compared these treatments for CTS in primary care populations, reported on clinical effectiveness at more than 6 months nor compared cost effectiveness of the interventions. TRIAL REGISTRATION: Trial registration: EudraCT 2013-001435-48 (registered 05/06/2013), ClinicalTrials.gov NCT02038452 (registered 16/1/2014), and Current Controlled Trials ISRCTN09392969 (retrospectively registered 01/05/2014)

Predictors of pain interference and potential gain from intervention in community dwelling adults with joint pain: A prospective cohort study.

INTRODUCTION: There is little research on identifying modifiable risk factors that predict future interference of pain with daily activity in people with joint pain, and the estimation of the corresponding population attributable risk (PAR). The present study therefore investigated modifiable predictors of pain interference and estimated maximum potential gain from intervention in adults with joint pain. METHODS: A population-based cohort aged ≥50 years was recruited from eight general practices in North Staffordshire, UK. Participants (n = 1878) had joint pain at baseline lasting ≥3 months and indicated no pain interference. Adjusted associations of self-reported, potentially modifiable prognostic factors (body mass index, anxiety/depressive symptoms, widespread pain, inadequate joint pain control, physical inactivity, sleep problems, smoking and alcohol intake) with onset of pain interference 3 years later were estimated via Poisson regression, and corresponding PAR estimates were obtained. RESULTS: Inadequate joint-specific pain control, insomnia and infrequent walking were found to be independently significantly associated with the onset of pain interference after 3 years, with associated PARs of 6.3% (95% confidence interval -0.3, 12.4), 7.6% (-0.4, 15.0) and 8.0% (0.1, 15.2), respectively, with only the PAR for infrequent walking deemed statistically significant. The PAR associated with insomnia, infrequent walking and inadequate control of joint pain simultaneously was 20.3% (8.6, 30.4). CONCLUSIONS: There is potential to reduce moderately the onset of pain interference from joint pain in the over-50s if clinical and public health interventions targeted pain management and insomnia, and promoted an active lifestyle. However, most of the onset of significant pain interference in the over-50s, would not be prevented, even assuming that these factors could be eliminated