Measurement of global functional performance in patients with rheumatoid arthritis using rheumatology function tests

Outcome assessment in patients with rheumatoid arthritis (RA) includes measurement of physical function. We derived a scale to quantify global physical function in RA, using three performance-based rheumatology function tests (RFTs). We measured grip strength, walking velocity, and shirt button speed in consecutive RA patients attending scheduled appointments at six rheumatology clinics, repeating these measurements after a median interval of 1 year. We extracted the underlying latent variable using principal component factor analysis. We used the Bayesian information criterion to assess the global physical function scale's cross-sectional fit to criterion standards. The criteria were joint tenderness, swelling, and deformity, pain, physical disability, current work status, and vital status at 6 years after study enrolment. We computed Guyatt's responsiveness statistic for improvement according to the American College of Rheumatology (ACR) definition. Baseline functional performance data were available for 777 patients, and follow-up data were available for 681. Mean ± standard deviation for each RFT at baseline were: grip strength, 14 ± 10 kg; walking velocity, 194 ± 82 ft/min; and shirt button speed, 7.1 ± 3.8 buttons/min. Grip strength and walking velocity departed significantly from normality. The three RFTs loaded strongly on a single factor that explained ≥70% of their combined variance. We rescaled the factor to vary from 0 to 100. Its mean ± standard deviation was 41 ± 20, with a normal distribution. The new global scale had a stronger fit than the primary RFT to most of the criterion standards. It correlated more strongly with physical disability at follow-up and was more responsive to improvement defined according to the ACR20 and ACR50 definitions. We conclude that a performance-based physical function scale extracted from three RFTs has acceptable distributional and measurement properties and is responsive to clinically meaningful change. It provides a parsimonious scale to measure global physical function in RA

A model of impairment and functional limitation in rheumatoid arthritis

BACKGROUND: We have previously proposed a theoretical model for studying physical disability and other outcomes in rheumatoid arthritis (RA). The purpose of this paper is to test a model of impairment and functional limitation in (RA), using empirical data from a sample of RA patients. We based the model on the disablement process framework. METHODS: We posited two distinct types of impairment in RA: 1) Joint inflammation, measured by the tender, painful and swollen joint counts; and 2) Joint deformity, measured by the deformed joint count. We hypothesized direct paths from the two impairments to functional limitation, measured by the shirt-button speed, grip strength and walking velocity. We used structural equation modeling to test the hypothetical relationships, using empirical data from a sample of RA patients recruited from six rheumatology clinics. RESULTS: The RA sample was comprised of 779 RA patients. In the structural equation model, the joint inflammation impairment displayed a strong significant path toward the measured variables of joint pain, tenderness and swelling (standardized regression coefficients 0.758, 0.872 and 0.512, P ≤ 0.001 for each). The joint deformity impairment likewise displayed significant paths toward the measured upper limb, lower limb, and other deformed joint counts (standardized regression coefficients 0.849, 0.785, 0.308, P ≤ 0.001 for each). Both the joint inflammation and joint deformity impairments displayed strong direct paths toward functional limitation (standardized regression coefficients of -0.576 and -0.564, respectively, P ≤ 0.001 for each), and explained 65% of its variance. Model fit to data was fair to good, as evidenced by a comparative fit index of 0.975, and the root mean square error of approximation = 0.058. CONCLUSION: This evidence supports the occurrence of two distinct impairments in RA, joint inflammation and joint deformity, that together, contribute strongly to functional limitations in this disease. These findings may have implications for investigators aiming to measure outcome in RA

Patrimoni cultural i educació: algunes reflexions didàctiques a la llum dels resultats d’una investigació de camp a les illes balears

Aquesta ponència és fruit del treball de camp desenvolupat al llarg del curs acadèmic 2003/2004 sobre la incidència del patrimoni cultural de les Illes Balears a l’escola (amb especial referència a Mallorca). A la llum dels resultats de la nostra investigació, hem de dir que la qüestió patrimonial té una escassa repercussió en l' ámbit escolar i, no obstant això, o precissament per això, creiem que és necessari aportar informació al professorat sobre la qüestió per tal d’animar els professionals i engrescar-los en la tasca d’usar un dels recursos amb més possibilitats didáctiques i metodològiques que tenen al seu abast. D'altra banda, investigacions d'aquest tipus en altres autonomies podrien donar com resultat una base de dades sobre el patrimoni que integrés totes les publicacions culturals de tots els municipis espanyols, la qual cosa seria de gran utilitat, no sols des d'una perspectiva pedagògica, sinó també cultural, perquè, sens dubte, una base d’aquestes característiques podria ser aprofitada, no sols pels docents, sinó també pels investigadors i visitants i, en general, per qualsevol persona interessada en la temática.Eje: Educación primaria. ReflexionesRed de Universidades con Carreras en Informática (RedUNCI

Patrimoni cultural i educació: algunes reflexions didàctiques a la llum dels resultats d’una investigació de camp a les illes balears

Aquesta ponència és fruit del treball de camp desenvolupat al llarg del curs acadèmic 2003/2004 sobre la incidència del patrimoni cultural de les Illes Balears a l’escola (amb especial referència a Mallorca). A la llum dels resultats de la nostra investigació, hem de dir que la qüestió patrimonial té una escassa repercussió en l' ámbit escolar i, no obstant això, o precissament per això, creiem que és necessari aportar informació al professorat sobre la qüestió per tal d’animar els professionals i engrescar-los en la tasca d’usar un dels recursos amb més possibilitats didáctiques i metodològiques que tenen al seu abast. D'altra banda, investigacions d'aquest tipus en altres autonomies podrien donar com resultat una base de dades sobre el patrimoni que integrés totes les publicacions culturals de tots els municipis espanyols, la qual cosa seria de gran utilitat, no sols des d'una perspectiva pedagògica, sinó també cultural, perquè, sens dubte, una base d’aquestes característiques podria ser aprofitada, no sols pels docents, sinó també pels investigadors i visitants i, en general, per qualsevol persona interessada en la temática.Eje: Educación primaria. ReflexionesRed de Universidades con Carreras en Informática (RedUNCI

Effectiveness of a cognitive behavioral intervention in patients with medically unexplained symptoms: cluster randomized trial

BACKGROUND: Medically unexplained symptoms are an important mental health problem in primary care and generate a high cost in health services.Cognitive behavioral therapy and psychodynamic therapy have proven effective in these patients. However, there are few studies on the effectiveness of psychosocial interventions by primary health care. The project aims to determine whether a cognitive-behavioral group intervention in patients with medically unexplained symptoms, is more effective than routine clinical practice to improve the quality of life measured by the SF-12 questionary at 12 month. METHODS/DESIGN: This study involves a community based cluster randomized trial in primary healthcare centres in Madrid (Spain). The number of patients required is 242 (121 in each arm), all between 18 and 65 of age with medically unexplained symptoms that had seeked medical attention in primary care at least 10 times during the previous year. The main outcome variable is the quality of life measured by the SF-12 questionnaire on Mental Healthcare. Secondary outcome variables include number of consultations, number of drug (prescriptions) and number of days of sick leave together with other prognosis and descriptive variables. Main effectiveness will be analyzed by comparing the percentage of patients that improve at least 4 points on the SF-12 questionnaire between intervention and control groups at 12 months. All statistical tests will be performed with intention to treat. Logistic regression with random effects will be used to adjust for prognostic factors. Confounding factors or factors that might alter the effect recorded will be taken into account in this analysis. DISCUSSION: This study aims to provide more insight to address medically unexplained symptoms, highly prevalent in primary care, from a quantitative methodology. It involves intervention group conducted by previously trained nursing staff to diminish the progression to the chronicity of the symptoms, improve quality of life, and reduce frequency of medical consultations. TRIAL REGISTRATION: The trial was registered with ClinicalTrials.gov, number NCT01484223 [http://ClinicalTrials.gov].S

Rationally Designed Interfacial Peptides Are Efficient In Vitro Inhibitors of HIV-1 Capsid Assembly with Antiviral Activity

Virus capsid assembly constitutes an attractive target for the development of antiviral therapies; a few experimental inhibitors of this process for HIV-1 and other viruses have been identified by screening compounds or by selection from chemical libraries. As a different, novel approach we have undertaken the rational design of peptides that could act as competitive assembly inhibitors by mimicking capsid structural elements involved in intersubunit interfaces. Several discrete interfaces involved in formation of the mature HIV-1 capsid through polymerization of the capsid protein CA were targeted. We had previously designed a peptide, CAC1, that represents CA helix 9 (a major part of the dimerization interface) and binds the CA C-terminal domain in solution. Here we have mapped the binding site of CAC1, and shown that it substantially overlaps with the CA dimerization interface. We have also rationally modified CAC1 to increase its solubility and CA-binding affinity, and designed four additional peptides that represent CA helical segments involved in other CA interfaces. We found that peptides CAC1, its derivative CAC1M, and H8 (representing CA helix 8) were able to efficiently inhibit the in vitro assembly of the mature HIV-1 capsid. Cocktails of several peptides, including CAC1 or CAC1M plus H8 or CAI (a previously discovered inhibitor of CA polymerization), or CAC1M+H8+CAI, also abolished capsid assembly, even when every peptide was used at lower, sub-inhibitory doses. To provide a preliminary proof that these designed capsid assembly inhibitors could eventually serve as lead compounds for development of anti-HIV-1 agents, they were transported into cultured cells using a cell-penetrating peptide, and tested for antiviral activity. Peptide cocktails that drastically inhibited capsid assembly in vitro were also able to efficiently inhibit HIV-1 infection ex vivo. This study validates a novel, entirely rational approach for the design of capsid assembly interfacial inhibitors that show antiviral activity

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Abstract Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries