Once foods in the United States were fortified with vitamin D, rickets appeared to have been conquered, and many considered major health problems from vitamin D deficiency resolved. But vitamin D deficiency is common. This review considers the role of vitamin D in skeletal and nonskeletal health and suggests strategies for the prevention and treatment of vitamin D deficiency.

Vitamin D Deficiency

Background and Purpose—The authors present an overview of the current evidence and management recommendations for evaluation and treatment of adults with acute ischemic stroke. The intended audienc...

/pdf/guidelines-for-the-early-management-of-patients-with-acute-19udbft6e7.pdf

Guidelines for the Early Management of Patients With Acute Ischemic Stroke A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association

Objective The 1987 American College of Rheumatology (ACR; formerly the American Rheumatism Association) classifi cation criteria for rheumatoid arthritis (RA) have been criticised for their lack of sensitivity in early disease. This work was undertaken to develop new classifi cation criteria for RA. Methods A joint working group from the ACR and the European League Against Rheumatism developed, in three phases, a new approach to classifying RA. The work focused on identifying, among patients newly presenting with undifferentiated infl ammatory synovitis, factors that best discriminated between those who were and those who were not at high risk for persistent and/ or erosive disease—this being the appropriate current paradigm underlying the disease construct ‘RA’. Results In the new criteria set, classifi cation as ‘defi nite RA’ is based on the confi rmed presence of synovitis in at least one joint, absence of an alternative diagnosis better explaining the synovitis, and achievement of a total score of 6 or greater (of a possible 10) from the individual scores in four domains: number and site of involved joints (range 0–5), serological abnormality (range 0–3), elevated acute-phase response (range 0–1) and symptom duration (two levels; range 0–1). Conclusion This new classifi cation system redefi nes the current paradigm of RA by focusing on features at earlier stages of disease that are associated with persistent and/or erosive disease, rather than defi ning the disease by its late-stage features. This will refocus attention on the important need for earlier diagnosis and institution of effective disease-suppressing therapy to prevent or minimise the occurrence of the undesirable sequelae that currently comprise the paradigm underlying the disease construct ‘RA’.

/pdf/2010-rheumatoid-arthritis-classification-criteria-an-h6w7bcnbf6.pdf

2010 Rheumatoid arthritis classification criteria: an American College of Rheumatology/European League Against Rheumatism collaborative initiative.

Objective The 1987 American College of Rheumatology (ACR; formerly the American Rheumatism Association) classification criteria for rheumatoid arthritis (RA) have been criticised for their lack of sensitivity in early disease. This work was undertaken to develop new classification criteria for RA. Methods A joint working group from the ACR and the European League Against Rheumatism developed, in three phases, a new approach to classifying RA. The work focused on identifying, among patients newly presenting with undifferentiated inflammatory synovitis, factors that best discriminated between those who were and those who were not at high risk for persistent and/or erosive disease—this being the appropriate current paradigm underlying the disease construct ‘RA’. Results In the new criteria set, classification as ‘definite RA’ is based on the confirmed presence of synovitis in at least one joint, absence of an alternative diagnosis better explaining the synovitis, and achievement of a total score of 6 or greater (of a possible 10) from the individual scores in four domains: number and site of involved joints (range 0–5), serological abnormality (range 0–3), elevated acute-phase response (range 0–1) and symptom duration (two levels; range 0–1). Conclusion This new classification system redefines the current paradigm of RA by focusing on features at earlier stages of disease that are associated with persistent and/or erosive disease, rather than defining the disease by its late-stage features. This will refocus attention on the important need for earlier diagnosis and institution of effective disease-suppressing therapy to prevent or minimise the occurrence of the undesirable sequelae that currently comprise the paradigm underlying the disease construct ‘RA’.

https://ard.bmj.com/content/annrheumdis/69/9/1580.full.pdf

2010 rheumatoid arthritis classification criteria: an American College of Rheumatology/European League Against Rheumatism collaborative initiative.

Objective. The development and validation of Modified Disease Activity Scores (DAS) that include different 28-joint counts.

Methods. These scores were developed by canonical discriminant analyses and validated for criterion, correlational, and construct validity. The influence of disease duration on the composition of the DAS was also investigated.

Results. No influence of disease duration was found. The Modified DAS that included 28-joint counts were able to discriminate between high and low disease activity (as indicated by clinical decisions of rheumatologists).

Conclusion. The Modified DAS are as valid as disease activity scores that include more comprehensive joint counts.

/pdf/modified-disease-activity-scores-that-include-twenty-eight-1x0unex9gh.pdf

Modified disease activity scores that include twenty-eight-joint counts : development and validation in a prospective longitudinal study of patients with rheumatoid arthritis

The emphasis of UK Government policy on primary-care-based services has led to more physiotherapists working in the community. The aims of the present study were to identify the perceived professional, educational and personal needs of community physiotherapists, and to determine good practice in meeting these needs. A survey of physiotherapists working in 15 National Health Service community trusts in the West Midlands was carried out in September 2000. The survey questionnaire was developed through focus groups and mailed to a random sample of 200 community physiotherapists. The response rate was 67%, and the median age group of the respondents was 21-30 years. The participants worked mainly in 'urban but not inner city' areas, most commonly in domiciliary (31%, n = 38) and general practitioner surgery/health centre (26%, n = 32) locations. Fifty-one per cent (n = 66) of respondents had no specific learning objectives for continuing professional development (CPD); those with such objectives were more positive as to their helpfulness than those without them (Mann-Whitney U-test z = 2.519, P = 0.012). Fifty-three per cent (n = 68) also often/very often found it problematic getting cover for their caseloads so that they could take part in CPD activities. Access to library resources and use of computers were problems, as were confidence in appraising literature and opportunities to discuss research evidence with colleagues. Fifty-nine per cent (n = 77) of respondents indicated that they often/very often felt stressed by the size of their caseloads. Colleague support included mentorship, peer review, journal clubs, clinical interest groups and multidisciplinary in-service training; respondents with experience of these resources expressed more positive attitudes to them than those without (Mann-Whitney U-test z = 2.871, P < 0.0005 for each). Forty-two per cent (n = 54) indicated that there were problems with safety issues. This study has identified needs that will have an impact on the ability of community physiotherapists to meet the demands of clinical governance. National Health Service management at all levels has a responsibility to facilitate the education, training and support of community physiotherapists.

Survey of the perceived professional, educational and personal needs of physiotherapists in primary care and community settings.

OBJECTIVES--Examination of the locomotor system is frequently neglected. Therefore, the GALS locomotor screen (Gait, Arms, Legs, Spine) has been proposed by Doherty et al as a practical method of identifying functionally important problems. This study was designed to test whether this screen reflects functional impairment, as measured by accepted health status measures. METHODS--Two observers performed the GALS screen in a total of 83 patients with a variety of musculoskeletal conditions. The examination components of GALS were rated by a simple 0 to 3 scale. Physical ability was further assessed by Health Activity Questionnaire (HAQ), Barthel index and Steinbrocker's ARA classification. RESULTS--For the total patient group, Spearman correlations between GALS and the three functional indices were good (r = 0.62 to 0.71, p 70%, with a kappa statistic k = 0.49 to 0.74. CONCLUSIONS--The GALS screen is a reliable and valid measure of functional ability, compared with standard accepted indices in a variety of musculoskeletal diseases. This supports the proposal for its use as a screening test by general practitioners and medical students.

https://ard.bmj.com/content/annrheumdis/52/12/886.full.pdf

The GALS locomotor screen and disability.

Serotonin transporter, tryptophan hydroxylase, and monoamine oxidase A gene polymorphisms in premenstrual dysphoric disorder.

Although testosterone replacement treatment (TRT) can improve sexual function in many hypogonadal (HG) men with type 2 diabetes (T2DM), some show either no improvement or only in a limited number of domains. Indeed, it is often difficult for the clinician to offer an indication of the likely efficacy of TRT as little data exist on the proportion of TRT-treated men who will demonstrate improvement in domains such as sexual desire (SxD) and erectile function (EF). We describe in men with T2DM: firstly, the likelihood of improved sexual desire (SxD) and erectile function (EF) following TRT at various time points, and secondly, if probability of SxD change predicted likelihood of subsequent EF change. During a 30-week randomized controlled study of testosterone undecanoate (TU), 199 T2DM men with HG (189 men completing) identified from primary care registers (placebo (P): 107, TU: 92) were stratified using baseline total testosterone (TT)/free testosterone (FT) into Mild (TT 8.1-12 nmol/L or FT 0.18-0.25 nmol/L) and Severe HG groups (TT ≤8 nmol/L and FT ≤0.18 nmol/L) and placebo (P)- and TU-treated groups. Associations between TU, SxD and EF were investigated using chi-square and logistic regression analysis. The proportion of men with improved SxD after 6 weeks and EF improvement after 30 weeks was significantly higher following TU treatment compared to P, this particularly evident in Severe HG men. Changes in SxD and EF were significantly associated in all groups. Logistic regression showed that SxD change at 6 weeks predicted of EF change after 30 weeks. Our study confirms TRT leads to changes in SxD and EF at different time points and suggests SxD and EF changes are related. SxD change after 6 weeks predicting EF change at 30 weeks is possibly a useful clinical finding.

https://www.onlinelibrary.wiley.com/doi/pdf/10.1111/andr.12399

Testosterone replacement therapy: improved sexual desire and erectile function in men with type 2 diabetes following a 30-week randomized placebo-controlled study.

Objectives: Patient experience is not routinely measured in rheumatoid arthritis (RA) and noaccepted standardised Patient Reported Experience Measures (PREM) tools currently exist. Commissioningfor Quality in Rheumatoid Arthritis (CQRA) has developed, piloted and validated PREMs forRA and other rheumatic conditions.Methods: Focus groups were held with RA patients to identify key elements of the patient experience. These were mappedagainst the UK Department of Health Patient Experience Framework and a PREM questionnaire developed with questionsspecifically relating to RA and rheumatology services. The RA PREM was piloted and Cronbach’s alpha used to assessinternal consistency. The PREM was modified to capture experience of patients with other rheumatic conditions and furthervalidated.Results: Ten UK sites and 524 patients were included in the RA PREM pilot and validation analysis. The RA PREM reliablycaptured RA patient experience and had good construct validity. Cronbach’s alpha within the multiquestion domainsranged from 0.61 to 0.90 and the percentage agreement ranged from 22.5% to 70.4% with overall care. The modifiedPREM was evaluated in 11 UK sites and 110 patients with a range of rheumatic conditions. Cronbach’s alpha rangedfrom 0.76 to 0.91 and the percentage agreement similarly ranged from 70% to 90% with the question on overall care.Conclusions: The RA PREM and the modified PREM provide new valuable validated tools for capturing the patient experiencein a range of rheumatic conditions. The RA PREM is currently being used in a UK National Clinical Audit ofRheumatoid and Early Inflammatory Arthritis.

Peter W. Jones

Papers

Survey of the perceived professional, educational and personal needs of physiotherapists in primary care and community settings.

The GALS locomotor screen and disability.

Serotonin transporter, tryptophan hydroxylase, and monoamine oxidase A gene polymorphisms in premenstrual dysphoric disorder.

Testosterone replacement therapy: improved sexual desire and erectile function in men with type 2 diabetes following a 30-week randomized placebo-controlled study.

Development and Validation of a Patient Reported Experience Measure (PREM) for Patients with Rheumatoid Arthritis (RA) and other Rheumatic Conditions