Best practice & research. Clinical rheumatology
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Understanding prognosis is important in managing low back pain. In this article, we discuss the available evidence on low back pain prognosis and describe how prognostic evidence can be used to inform clinical decision making. We describe three main types of related prognosis questions: 'What is the most likely course?' (Course studies); 'What factors are associated with, or determine, outcome?' (Prognostic factor or explanatory studies); and 'Can we identify risk groups who are likely to have different outcomes?' (Risk group or outcome prediction studies). ⋯ Important low back pain prognostic factors are related to the back pain episode, the individual and psychological characteristics, as well as the work and social environment. Although numerous studies have developed prediction models in the field, most models/tools explain less than 50% of outcome variability and few have been tested in independent samples. We discuss limitations and future directions for research in the area of low back pain prognosis.
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Best Pract Res Clin Rheumatol · Feb 2010
ReviewDeveloping a minimum standard of care for treating people with osteoarthritis of the hip and knee.
We reviewed three recently published guidelines for the management of osteoarthritis (OA) and considered the evidence and potential for implementation. From this we propose a minimum standard of care, or a 'core set' of interventions, that should be offered to all patients with OA of the hip and/or knee. Eight core recommendations emerged where it is recommended that health-care professionals: Provide advice about, and offer access to appropriate information for OA self-management and lifestyle change; Provide advice about weight loss if patient is overweight or obese and refer to services as required; Provide advice for land-based exercises incorporating aerobic and strengthening components and refer to services as required; Recommend adequate paracetamol for pain relief; Make patients aware that non-steroid anti-inflammatory drugs (NSAIDs) or coxibs can improve symptoms in majority but this comes with potential for harm and that risk potential varies--be aware of and minimise the individual's risk potential; Offer intra-articular steroids for short-term relief of a flare or acute deterioration in symptoms; Offer stronger analgesic relief if prolonged severe symptoms; Offer access to assessment for arthroplasty for consumers with severe symptomatic OA not responding to conservative therapy. An integrated, chronic disease model of care is proposed to best implement OA management and a check list of clinical indicators/performance measures is provided.
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Best Pract Res Clin Rheumatol · Aug 2009
ReviewRespiratory manifestations of systemic lupus erythematosus: old and new concepts.
The respiratory system is commonly involved in systemic lupus erythematosus. Lung disorders are classified as primary (due to lupus) and secondary to other conditions. Pleuritis and pulmonary infections are the most prevalent respiratory manifestations of each type. ⋯ Larger controlled trials of the different therapies in the treatment of those lung manifestations of lupus are needed. Overall malignancy is little increased in lupus, but lung cancer and non-Hodgkin's lymphoma are among the most frequent types of cancer found in these patients. As survival in lupus patients has improved over recent decades, avoiding pulmonary damage emerges as an important objective.
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Churg-Strauss angiitis or syndrome (CSA) is defined as an eosinophil-rich and granulomatous inflammation involving the respiratory tract, and necrotising vasculitis affecting small- to medium-sized vessels, and is associated with asthma and eosinophilia. It is usually classified among the so-called anti-neutrophil antibody (ANCA)-associated systemic vasculitides (AASVs) because of its clinical and pathological features that overlap with those of the other AASVs. However, two recent studies on large cohorts of patients have found that ANCAs, usually P-ANCAs/MPO-ANCAs, were present in only 38% of patients. ⋯ The addition of cyclophosphamide is indicated in treatment of patients with poor-prognosis factors or in patients without poor-prognosis factors but those that are prone to relapses. The length of the maintenance therapy remains to be established. However, the vast majority of patients require long-term corticosteroids treatment to control asthma.
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Best Pract Res Clin Rheumatol · Apr 2009
ReviewHow to perform a critical analysis of a randomised controlled trial.
Given the large amount of medical literature of varying methodological quality, care must be taken when translating the results of randomised controlled trials into clinical practice. To assist in this translation process, we provide a method that involves answering three main questions: 'Can I trust the results?' 'How do I understand the results?' and 'To whom do the results apply?' To answer the first question, we describe important items that help in judging the reliability of the findings. For the second question, we address the clinical and statistical significance of results by looking at the size and precision of the effect. Finally, we raise the issue of external validity and of reporting adverse effects to determine which patients may best benefit from the new intervention.