182 research outputs found
Use of over-the-counter supplements, sleep aids, and analgesic medicines in rheumatology: results of a cross-sectional survey
No full textObjectivesPain, fatigue, and sleep are common symptoms in patients with Rheumatic and Musculoskeletal diseases (RMDs) that may prompt the use of over-the-counter (OTC) supplements, sleep aids, and analgesics as self-management strategies. This study evaluated the prevalence of OTC supplements, sleep aids, pain relievers and the financial burden associated with their use in rheumatology.MethodsA web-based survey developed with patients, was administered in rheumatology clinics in an English hospital. Participants shared demographic information and detailed their use of OTC supplements, sleep aids, and pain relief in the past week. The data was analysed using descriptive statistics and logistic regression models to identify influencing factors.ResultsIn total 876 people consented to participate in the survey. Over half of patients (54.5%) reported daily supplement intake, typically spending £10/month (IQR 5-20), ranging up to £200 per month. The most commonly administered supplements were vitamin D, multivitamins, vitamin C, vitamin B/B complex, Omega 3/ 6 supplements, with multiple overlaps. Prescription, OTC, or non-prescription pain relief was reported by 82% of respondents, with sleep aids being used by 13%. Of the 327 patients who took NSAIDs, 165 (50.4%) also reported taking OTC supplements, while among the 131 patients using opioids (20.5%), 66 (50.3%) reported supplement use, some of which have documented interactions.ConclusionThe administration of OTC supplements, pain relief, and sleep aids is common in patients with RMDs. Health care professionals should be encouraged to proactively ask about these during consultations especially from a drug safety perspective, but also to provide timely, reliable advice about such strategies that may be sought by patients.<br/
Evaluation of an alternative way of river bank protection in the Meghna Estuary
No full textAfter the disastrous floods in Bangladesh in 1987 the Flood Action Plan (FAP) was initiated. The FAP was a co-ordinated action to study the flood problems of Bangladesh. The Meghna Estuary Study (MES) was drawn up as a component of the FAP. The overall goal of MES is to ensure the physical safety and social security of the people living in the coastal areas and on the islands of the Meghna Estuary. This goal is to be realised by retaining and increasing knowledge of the hydraulic and morphological processes and by developing appropriate techniques for efficient land reclamation as well as effective river bank protection. In particular during the monsoon season erosion of the river banks occurs throughout the Meghna Estuary. The erosion causes direct land loss (including loss of livelihood and impoverishment) and, where embankments are eroded, results in flooding of homesteads and agricultural land. Looking at the planform development of the Lower Meghna it is expected that in future years the eastern river bank of the Lower Meghna river starting south of Chandpur up to Haimchar is going to be subject to severe erosion. The river banks are highly erosive due to the non-cohesiveness of the sediments, the small particle size and the high flow velocities. Previous studies carried out have shown that protection of the river bank using conventional river bank protection methods is not generally economically viable at the current level of economic development in Bangladesh. It is expected that at the current level of economic development in Bangladesh alternative Iow cost bank protection measures are the only viable option to protect the river banks against erosion on a large scale. Nevertheless it must be stated that the circumstances are severe and the possibilities and necessary know-how have to be assessed by further research and execution of experiments. Under MES several pilot projects have been executed to study alternative ways of river bank protection. In part I of this study the author has studied the application of flexible bottom screens in combination with permeable spurs. In part II the application of bottom screens to create a roughness field is subject of discussion. Both studies are conducted under the responsibility of the Technical University Delft. One of the pilot projects executed by MES is the Hanar Char erosion control pilot scheme in which flexible bottom screens and permeable spurs are applied as an alternative way of river bank protection. This pilot scheme was executed from March to July 1999 and is part of the proposed Haimchar erosion control pilot project, which covers the complete eastern river bank from Chandpur up to Haimchar. However, up till August 2000 only a part of the Haimchar erosion control pilot project has been executed. The objective of this study is to determine whether flexible bottom screens and permeable spurs are an effective way of river bank protection in the river dominated part of the Meghna Estuary. This is done by studying the available literature and the influence of the structures on the flow pattern and morphology. Flexible bottom screens Flexible bottom screens show great analogy with so called bottom vanes which are placed at a certain angle of attack with the flow. The vanes cause the passing flow to attain a circular motion downstream from it. The sediment-rich bottom flow is directed to the river bank and the erosive upper current is directed towards the centre of the river. In the available literature on bottom vanes the distinction is made between vanes placed at a small angle of attack with the flow and vanes placed at a high angle of attack with the flow.Hydraulic EngineeringCivil Engineering and Geoscience
Improving disease misclassification and prevalence estimates by linking primary and secondary care electronic health records:an illustration from arthritis research
No full textPrevalence estimates using primary care data health identify cases via code lists. Validation studies can discover and exclude false positives, but it is often difficult or impossible to find false negatives. This study aimed, using the example of psoriatic arthritis (PsA), to examine the extent of and adjust for misclassification by linking primary care records with text-mined outpatient letters from a North-West regional hospital (2014-2019). 245 cases of PsA were identified among 188,286 adults registered with primary care, giving an observed prevalence of 0.13% [95%CI 0.11%-0.15%]. Among a subgroup of 7,532 primary care patients attending the hospital rheumatology clinic, 202 had a primary care PsA code: 188 were confirmed as true PsA, while 14 were false positives. Primary care codes failed to identify 196 hospital-diagnosed PsA cases, leading to a more than two-fold underestimation. The adjusted prevalence, accounting for misclassification, was 0.25% [95% CI 0.21%-0.28%]. Linking primary care with hospital records identified false positives and negatives, enabling correction of prevalence estimates. This highlights the value of text-mining hospital letters to replace the national absence of coded secondary care diagnosis data from outpatient departments, and the importance of considering the impact of false negatives.</p
Comparative Risk of Severe Constipation in Patients Treated With Opioids for Non-cancer Pain: A Retrospective Cohort Study In Northwest England
No full textBackground Constipation is a frequent adverse event associated with opioid medications that can have a considerable impact on patients’ quality of life. In patients who require opioids for pain relief, less is known about the risk conferred by specific opioids given their diverse pharmacology and the effect of daily dose and potency. The aim of the study was to evaluate the comparative risk of severe constipation by opioid type and dose in patients with non-cancer pain admitted to hospital.Methods We conducted a retrospective cohort study using hospital electronic health records in Northwest England between December 1, 2009, and December 31, 2020. Patients who were ≥18 years and without a history of cancer were included. Opioid exposure was measured using administered drug information in hospital. The outcome was a severe constipation event defined as administration of an enema or suppository. Incidence rates by opioid use status, type of opioid class, and morphine milligram equivalent (MME) per day were calculated, and a Cox regression model was used to determine associations with incident constipation after adjusting for confounders. ResultsThe study included 80,475 eligible patients who were administered an opioid in hospital. Compared to codeine, morphine (HR 1.59, 95% CI 1.45-1.74), oxycodone (HR 1.46, 95% CI 1.32-1.63), fentanyl (HR 1.37, 95% CI 1.14-1.64), and combination opioids (HR 1.85, 95% CI 1.66-2.06) were associated with a higher risk of constipation in the fully adjusted models. Tramadol demonstrated a significantly lower risk compared to codeine (HR 0.80, 95% CI 0.64-1.00). Higher opioid doses of more than ≥ 50MME/day in comparison to <50MME/day were associated with an increased risk of constipation (compared to <50MME/day, 50 to <120 MME/day: HR 1.95, 95% CI 1.78-2.15; ≥120 MME/day: HR 1.45, 95% CI 1.32-1.60).ConclusionsMorphine, oxycodone, fentanyl and combination opioids administration were associated with a significantly higher risk of severe constipation compared to codeine. Tramadol was associated with the lowest risk of the outcome compared to codeine. Patients on ≥50MME/day experienced a higher risk of severe constipation compared to those on <50 MME/day. These results can be used to guide better shared decisions with patients to balance benefit and harms of specific opioid types and doses.
A study of possible bank protection measures near the Meghna Bridge, Bangladesh
No full textIn 1990, in Bangladesh, the "Meghna roads and highway bridge"was finisthed. This bridge is the first one in a series of two Bridges replacing the ferries over the Upper Meghna River. During construction, and also after the finalization of the Bridge, it was revealed that the designers of this Bridge underestimated the power of the Upper Meghna River here. This revealed itself in various aspects. The most severe ones are the slope failure just upstream from the Bridge which occurred already during the construction, the collapse of (parts of) the slope protection of one of the Bridge's abutments (eight months after the finalization) and the present danger induced by the morphological planform changes of the river just upstream of the Bridge. In the future this could lead to outflanking of the Bridge by the River. This study discusses the various possible measures which can be taken to safeguard the Meghna Bridge on the long term. Firstly, in part I of this report, the present situation at the location of the Meghna Bridge is described and analyzed. Subsequently, in part I I of this Report, a design study is conducted. Designs, solving the present problems, are elaborated onto a detailed design level. These designs are all elaborated with the specific characteristics of Bangladesh being a developing country in mind. Therefore an important aspect during the design study is the use of local resources (both technical as labour) as much as possible. The design study resulted in three final alternatives. These alternatives are evaluated by means of a Multi Criteria Analysis for their non-monetary criteria. Taking also into account the costs estimates for all alternatives resulted in the recommendation of "alternative I I I ". This "alternative III" consists of the following. A series of six groynes is foreseen in the river bend just upstream of the Bridge and a guide bank structure replaces the damaged abutment of the Bridge. A remarkable aspect of this finally recommended design is the fact that all projected structures are to be constructed with a core of sand cement stone and concrete blocks as slope protection. Instead of the (almost classical) method of a soil core with a slope protection of fascine mattresses etc., which is also elaborated being one of the alternatives, it is concluded that the application of sand cement stone as construction material here is the best option. This is explained by a combination of reasons. As the country of Bangladesh is located in one of the largest deltas in the world its soil consists mainly of the fine alluvial deposits as (rather fine) sand. Therefore rock and boulders are rather scarce construction materials here. Another important aspect is the fact that Bangladesh is a developing country. Therefore "high tech" construction techniques as dredging in deep water and the placing of elements under water are locally not (yet) widely known and available. Using sand cement stone and concrete blocks as construction materials requires only simple construction techniques. Another merit is the fact that in the structures rather steep slopes can be applied which results in a (relative) saving of material and therefore results in low costs. These (and others) reasons finally resulted in the recommendation of the mentioned alternative.Hydraulic EngineeringCivil Engineering and Geoscience
Promonitor for therapeutic drug monitoring in patients with severe rheumatoid arthritis treated with adalimumab in England and Wales
No full textUnilateral breast oedema in a case of non-rheumatic giant left atrium
No full textGiant left atrium (GLA) is a well-described entity in association with rheumatic heart disease. However, mitral valve prolapse is an extremely unusual cause of GLA, especially without the compressive symptoms it can often accompany. We discuss a case of a 78-year-old lady with no prior history of rheumatic heart disease with these findings with the unusual presentation of accompanied unilateral breast oedema as a manifestation of heart failure. This case illustrates the investigations and treatment options for GLA and the need for prompt assessment as it increases the risk of sudden death; therefore, its presence warrants careful evaluation and surgical intervention when appropriate. © The Author 2009. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved
Enzyme-linked immunosorbent assays for monitoring TNF-alpha inhibitors and antibody levels in people with rheumatoid arthritis: a systematic review and economic evaluation
No full textBACKGROUND: Rheumatoid arthritis is a chronic autoimmune disease that primarily causes inflammation, pain and stiffness in the joints. People with severe disease may be treated with biological disease-modifying anti-rheumatic drugs, including tumour necrosis factor-α inhibitors, but the efficacy of these drugs is hampered by the presence of anti-drug antibodies. Monitoring the response to these treatments typically involves clinical assessment using response criteria, such as Disease Activity Score in 28 joints or European League Against Rheumatism. Enzyme-linked immunosorbent assays can also be used to measure drug and antibody levels in the blood. These tests may inform whether or not adjustments to treatment are required or help clinicians to understand the reasons for treatment non-response or a loss of response.METHODS: Systematic reviews were conducted to identify studies reporting on the clinical effectiveness and cost-effectiveness of using enzyme-linked immunosorbent assays to measure drug and anti-drug antibody levels to monitor the response to tumour necrosis factor-α inhibitors [adalimumab (Humira
®; AbbVie, Inc., North Chicago, IL, USA), etanercept (Enbrel
®; Pfizer, Inc., New York, NY, USA), infliximab (Remicade
®, Merck Sharp & Dohme Limited, Hoddesdon, UK), certolizumab pegol (Cimzia
®; UCB Pharma Limited, Slough, UK) and golimumab (Simponi
®; Merck Sharp & Dohme Limited)] in people with rheumatoid arthritis who had either achieved treatment target (remission or low disease activity) or shown primary or secondary non-response to treatment. A range of bibliographic databases, including MEDLINE, EMBASE and CENTRAL (Cochrane Central Register of Controlled Trials), were searched from inception to November 2018. The risk of bias was assessed using the Cochrane ROBINS-1 (Risk Of Bias In Non-randomised Studies - of Interventions) tool for non-randomised studies, with adaptations as appropriate. Threshold and cost-utility analyses that were based on a decision tree model were conducted to estimate the economic outcomes of adding therapeutic drug monitoring to standard care. The costs and resource use were considered from the perspective of the NHS and Personal Social Services. No discounting was applied to the costs and effects owing to the short-term time horizon of 18 months that was adopted in the economic analysis. The impact on the results of variations in testing and treatment strategies was explored in numerous clinically plausible sensitivity analyses.
RESULTS: Two studies were identified: (1) a non-randomised controlled trial, INGEBIO, that compared standard care with therapeutic drug monitoring using Promonitor
® assays [Progenika Biopharma SA (a Grifols-Progenika company), Derio, Spain] in Spanish patients receiving adalimumab who had achieved remission or low disease activity; and (2) a historical control study. The economic analyses were informed by INGEBIO. Different outcomes from INGEBIO produced inconsistent results in both threshold and cost-utility analyses. The cost-effectiveness of therapeutic drug monitoring varied, from the intervention being dominant to the incremental cost-effectiveness ratio of £164,009 per quality-adjusted life-year gained. However, when the frequency of testing was assumed to be once per year and the cost of phlebotomy appointments was excluded, therapeutic drug monitoring dominated standard care.
LIMITATIONS: There is limited relevant research evidence and much uncertainty about the clinical effectiveness and cost-effectiveness of using enzyme-linked immunosorbent assay-based testing for therapeutic drug monitoring in rheumatoid arthritis patients. INGEBIO had serious limitations in relation to the National Institute for Health and Care Excellence scope: only one-third of participants had rheumatoid arthritis, the analyses were mostly not by intention to treat and the follow-up was 18 months only. Moreover, the outcomes might not be generalisable to the NHS.CONCLUSIONS: Based on the available evidence, no firm conclusions could be made about the cost-effectiveness of therapeutic drug monitoring in England and Wales.FUTURE WORK: Further controlled trials are required to assess the impact of using enzyme-linked immunosorbent assays for monitoring the anti-tumour necrosis factors in people with rheumatoid arthritis.STUDY REGISTRATION: This study is registered as PROSPERO CRD42018105195.FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in
Health Technology Assessment; Vol. 25, No. 8. See the NIHR Journals Library website for further project information.
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Latent Class Trajectory Modeling of 2‐Component Disease Activity Score in 28 Joints Identifies Multiple Rheumatoid Arthritis Phenotypes of Response to Biologic Disease‐Modifying Antirheumatic Drugs
Get PDFObjectives: To determine whether using a re‐weighted disease activity score that better reflects joint synovitis, the 2‐component DAS28 (2C‐DAS28), based on 28‐swollen joint count and C‐reactive protein, produces more clinically relevant treatment outcome trajectories compared with the standard 4 component DAS28 (4C‐DAS28). Methods: Latent class mixed modelling (LCMM) of response to biologic treatment was applied to 2,991 patients with RA about to commence bDMARD treatment from the Biologics in Rheumatoid Arthritis Genetics and Genomics Study Syndicate (BRAGGSS) cohort using both 4C‐DAS28 and 2C‐DAS28 as outcomes. Identified patient groups with similar trajectories were compared in terms of pre‐treatment baseline characteristics – including disability, comorbidities ‐ and follow‐up characteristics – including anti‐drug antibody (ADAb) events, adherence to treatments and blood drug levels, We compared the trajectories obtained using the 4C and 2C scores to determine which characteristics were better captured by the 2CDAS28 compared with the 4C‐DAS28 trajectories. Results: Using the 4C‐DAS28 we identified 3 trajectory groups, which is consistent with previous reports. We show that the 4C‐DAS28 captures information relating to depression. Using the 2C‐DAS28, 7 trajectory groups were identified; among them, distinct groups of non‐responders had a higher incidence of respiratory comorbidities and a higher proportion of ADAb events. We also identified a group of participants for which the 2C‐DAS28 disease activity score remained relatively low and which was enriched for patients who were non‐adherent to treatment. This highlights the utility of both the 4C and 2C‐DAS28 for monitoring different components of disease activity. Conclusions: Here we show that the 2C‐DAS28 modified disease activity score defines important biological and clinical phenotypes associated with treatment outcome in RA and characterizes important underlying response mechanisms to biologic drugs
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