A fracture of the distal radius is a commonly occurring fracture and accounts for a third of all fractures in the elderly. Thus far, one year estimates of pain and disability following a fracture of the distal radius have been reported on Canadian populations. The primary aim of this study is to investigate the prevalence of pain and disability in a UK population one year post fracture of the distal radius.A cross-sectional survey was undertaken, of all subjects suffering a fracture of the distal radius between October 2005 and February 2006 in Nottingham, UK. Primary outcomes used were the VAS for pain and the DASH for disability. Prevalence of pain and disability were calculated and odds ratios presented for associations between demographics, pain and disability.93/264 (35%) subjects responded to the questionnaire. 6 subjects did not fulfill the inclusion criteria and were excluded from further analysis. 11% of subjects reported moderate to very severe pain. 16% of subjects reported moderate to very severe disability. Statistically significant associations were found between pain medication usage for the wrist fracture and moderate to very severe pain . Moderate to very severe disability was associated with older age  and pain medication usage for the wrist fracture . Working was associated with a reduction in risk of moderate to very severe disability .This study demonstrates that there are a small proportion of patients who are still suffering moderate to very severe pain and disability one year post fracture of the distal radius. The study also demonstrates that there are significant associations between characteristics of the patients and the level of pain and disability. This highlights the need for further research into the most appropriate management of these patients in order to reduce this burden of pain and disability, particularly as this is a predominantly elderly patient group. Fractures are one of the most common reasons for attendance at the Accident and Emergency (A & E) department of any hospital, making it a very expensive aspect of any health care system . FracturA fracture of the distal radius (FDR) is an injury which occurs predominantly in older females and is usually caused by a fall onto an outstretched hand . An annuFollowing any injury a certain level of pain can be anticipated and the FDR is no exception. Chronic pain can be described as pain which persists beyond the point at which the tissues would be expected to heal . No geneDisability is another consequence of a FDR, particularly as it largely affects the elderly population. The disability, resulting from a FDR, may be the inability to perform activities of daily living such as dressing or cooking, meaning the difference between independent living and the demand for social care. This creates an even greater economic strain on the individual and society than just the burden of treatment for the fracture alone. Canadian estimates show that 16% of patients, following a FDR, will experience some form of disability making this a huge public health burden . HoweverA cross sectional postal survey, using a battery of standardised questionnaires, was targeted at any patient who suffered a FDR between 5th October 2005 and 28th February 2006, in the Nottingham district of the UK. Potential research subjects (n = 268) were identified by a search through the computerised medical documentation kept at the University Hospital Nottingham, Queens Medical Centre campus (QMC). Patients included were those adults who had experienced a FDR which was diagnosed via x-ray on admission to the A and E department, one year before the time of the study. Patients were excluded if they had been admitted for multiple fractures of the upper limb at the time of injury and if they were below the age of 18 years at the time of the study.264 subjects met the inclusion criteria of the study and an invitation questionnaire was posted to them with a covering letter; patient information sheet and consent form inviting them to take part in the study. If they wished to take part, they were asked to complete the questionnaire and consent form and return them both, in a pre-stamped addressed envelope provided. Recruitment was encouraged by sending a reminder letter to patients two weeks after the invitation letter. On receipt of the completed questionnaire and consent form, the patients' medical records were obtained. These were scrutinised to identify the type of fracture they had experienced and what management they had received.The battery of questionnaires requested demographic information including information on present medication usage for the wrist injury and the main outcome measures of the Disability of the Arm Shoulder and Hand . For the continuous variables (DASH and VAS scores), non normal distributions were seen, therefore, the data were summarised using the non parametric descriptors median and Inter-quartile ranges (IQR).The raw VAS data gave a score out of 10 for each patient. In order to make this score more meaningful the raw VAS score was converted to ordinal data following the methodology described by MacDermid et al (2003) . Once thThe raw DASH scores gave a score out of 100 for each patient; this was the percentage disability score and were converted to categorical groups of – no disability (0%), minimal disability (1 – 20%), mild disability (21 – 40%), moderate disability (41 – 60%), severe disability 61 – 80%), very severe disability (81% – 100%) similarly following the methodology described by MacDermid et al (2003) . A further limitation of the present study was that it was only based on one area of the UK and therefore, it is difficult to make comparisons or generalisations to other areas of the UK. Further research could focus on surveying other regions of the UK to look for trends in prevalence.This research shows that a proportion of patients, from this sample, are suffering moderate to very severe pain (11%) and moderate to very severe disability (16%) one year after their injury. Older age, non-working status and pain medication usage are all associated with, or a consequence of, poor outcome one year after injury. Pain and disability are a significant issue for these patients highlighting the public health implications and the need for further study of appropriate management strategies. This is of particular importance as these patients are primarily elderly females who will be requiring some form of social assistance, whether that is from the state or as a burden on family and friends.The authors declare that they have no competing interests.CM carried out the design, ethical approval, methodology, data collection, statistical analysis and draft of the manuscript. JLB participated in the design of the study and the statistical analysis. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:DASH questionnaire. Questionnaire sent to patientsClick here for fileVAS. Questionnaire sent to patientsClick here for file


Anterior cervical discectomy with fusion (ACDF) is challenging with respect to both patient selection and choice of surgical procedure. The aim of this study was to evaluate the clinical outcome of ACDF, with respect to both patient selection and choice of surgical procedure: fusion with an autologous iliac crest graft (AICG) versus fusion with an artificial cage made of polyetheretherketone (PEEK).This was a non-randomized prospective single-center outcome study of 258 patients who underwent ACDF for cervical disc degeneration (CDD). Fusion was attained with either tricortical AICG or PEEK cages without additional anterior plating, with treatment selected at surgeon's discretion. Radicular pain, neck-pain, headache and patient satisfaction with the treatment were scored using the visual analogue scale (VAS).The median age was 47.5 (28.3-82.8) years, and 44% of patients were female. 59% had single-level ACDF, 40% had two level ACDF and 1% had three-level ACDF. Of the patients, 181 were fused with AICG and 77 with a PEEK-cage. After surgery, the patients showed a significant reduction in radicular pain (ΔVAS = 3.05), neck pain (ΔVAS = 2.30) and headache (ΔVAS = 0.55). Six months after surgery, 48% of patients had returned to work: however 24% were still receiving workers' compensation.Using univariate and multivariate analyses we found that high preoperative pain intensity was significantly associated with a decrease in pain intensity after surgery, for all three pain categories. There were no significant correlations between pain relief and the following patient characteristics: fusion method (AICG or PEEK-cage), sex, age, number of levels fused, disc level fused, previous neck surgery (except for neck pain), previous neck trauma, or preoperative symptom duration. Two hundred out of the 256 (78%) patients evaluated the surgical result as successful. Only 27/256 (11%) classified the surgical result as a failure. Patient satisfaction was significantly associated with pain relief after surgery.ACDF is an effective treatment for radicular pain in selected patients with CDD after six months follow up.Because of similar clinical outcomes and lack of donor site morbidity when using PEEK, we now prefer fusion with PEEK cage to AICG.Lengthy symptom duration was not a negative prognostic marker in our patient population.The number of patients who returned to work 6 months after surgery was lower than expected. The vast majority of patients with symptomatic cervical disc degeneration (CDD) respond well to conservative treatment . For nonThe gold standard for ACDF has been fusion with an AICG -10. ThisWe prospectively registered all ACDF patients followed in our department from 2003-2005 and used this information to address the following questions.1. What improvement in clinical outcomes can be expected after ACDF for CDD with regard to radicular pain, neck pain, headache, and return to work?2. Did the gradual shift from fusion with AICG to fusion with PEEK cage, in our department during the study period, influence outcomes?3. Do symptom duration or other preoperative clinical variables correlate with outcome after ACDF for CDD in our series?This was a prospective single-center study of patients who underwent single-, two-, or three- level ACDF for CDD. The study was performed at the Oslo University Hospital-Rikshospitalet in Oslo from 2003 to 2005. All surgeons were asked to participate in a prospective registration of clinical parameters. During this period, 390 patients  were eligible for inclusion and we obtained complete preoperative and follow-up data for 258 patients (66.1%) (study group). Only the 258 patients with complete data sets were included in the analysis.The inclusion criteria were1. One or more of the following symptoms and signs of CDD:a. Persistent severe radicular pain not responding to conservative management for three months.b. Cervical radiculopathy with progressive paresis.c. Selected cases with myelopathy secondary to cervical spinal canal stenosis that can be adequately decompressed with ACDF.d. Selected cases with mainly neck pain and headache and less radicular pain.2. MRI- documented CDD with compression of cervical nerve roots or spinal cord, which most likely explain the clinical symptoms and signs.The exclusion criteria were1. Cervical trauma within the past four weeks.2. Cervical neoplasia.3. Ongoing cervical infection.The diagnostic work-up included1. Clinical and neurological examination.2. Cervical MRI .In all patients, we used an anterior approach to the cervical spine with a right-sided skin incision, as originally described by Robinson and Smith . A self-In most patients, an operating microscope was used and the disc was removed with a high-speed drill . Removal of the posterior longitudinal ligament and the final decompression of the nerve roots were performed using small rongeurs. Bilateral nerve root decompression was always performed, even in patients with unilateral symptoms. After the procedure, distraction was applied using the Shadow-line Distraction System . Fusion was attained with either tricortical AICG or PEEK cages , at the discretion of the surgeon. After removal of the Shadow-line distracters, the screw holes were plugged with bone wax  to prevent postoperative bleeding. Wound drainage was not routinely used. A single dose of cephalothin (30 mg/kg), which was used as infection prophylaxis, was administered 15- 30 min before the skin incision -21.The tricortical AICG was harvested from the right iliac crest. Care was taken to preserve the anterior 2 cm of the iliac crest and the lateral cutaneous femoral nerve. The bone grafts were harvested using an oscillating saw and a graft cutter, and the bone bed was waxed with bone wax . Wound drainage was not routinely used, and the surrounding soft tissue was infiltrated with 20 ml of bupivacaine after wound closure.The patients were observed in a recovery unit for the first 4 - 6 h after surgery, and were then transferred to the regular neurosurgical ward. All patients were mobilized with a stiff collar within 24 h after surgery. Almost all patients were discharged from our hospital to the referring neurological department 48-72 h after surgery. All patients were encouraged repeatedly to participate in normal activities 6-14 weeks after surgery. A final clinical examination was performed 6 months after surgery in our outpatient clinic.The parameters registered the day before surgery included age, sex, symptom duration before surgery (months), previous surgery for CDD, previous neck trauma, working status, radicular pain, neck pain, headache, myelopathy (yes/no), and paresis . Each ofAs the clinical impact of changes in VAS scores less than ± 2 is unclear, we estimated the number of patients that had changes in VAS scores of more than ± 2 for the three pain categories ,25. The We have previously published our complications in 390 consecutive ACDF operations, which included 278 patients fused with AICG and 112 patients fused with a PEEK graft [For linear regression analysis, we first performed a univariate analysis, followed by multivariate modeling introducing all the variables, in an exploratory fashion. The linearity assumption of the linear regression was checked using a plot of the fitted regression line compared with a locally weighted nonparametric scatterplot of the outcome variable against the predictor. Homoscedasticity was checked by graphing residuals versus predicted and observed values. Finally, normality of residuals was checked using boxplots, histograms, and quantile plots of residuals. Ordinal variables were also checked for linearity using a nested likelihood ratio test.Some of our variables displayed heteroscedasticity, therefore, we repeated the analyses using both the Huber-White sandwich estimator of variance relaxing the homoscedasticity assumption and bootstrapped regressions with 1.000 repetitions. The results of these analyses were in agreement with the findings of our traditional regression results, which allowed us to take a relaxed stance toward the heteroscedastic findings in some of our models. Standard paired t-tests, chi-squared, and z-tests for proportions were also used. Significance was set at alpha < 0.05. The Stata v10.1  software was used in all analyses.The Data Protection Officials of the Rikshospitalet approved the study. All patients gave signed informed consent for entry of the data into the database and for the subsequent prospective study.Of the 390 patients eligible for inclusion in this study , we obtained complete preoperative- and follow-up data for 258 patients 66.1%) (study group). The patient characteristics for both groups are included in Table %  patients had normal muscular strength at the time of surgery. At follow-up, 233/249 (94%) patients had normal muscular strength.Of the 45 patients with clinical evident myelopathy at the time of surgery, only 16 (35.6%) had persistent myelopathy 6 months after surgery.At the onset of symptomatic CDD, 80% of patients were employed fulltime, 3% received workers ' compensation for CDD, 4% received workers ' compensation for reasons other than CDD, 8% received a disability pension, and 5% were students, housewives, retired, or unemployed. At the time of surgery, 66% of patients had received workers ' compensation for 1 month or more. The median sick leave before surgery was 5.0 (0-150) months. Six months after surgery, 48% of patients had returned to work: however 24% were still receiving workers ' compensation. The percentage of patients receiving a disability pension increased from 8%, before the onset of symptomatic CDD, to 21% 6 months postoperatively. The increase in the number of patients receiving a disability pension was, related to CDD in all cases but one.At the 6-month postoperative control, all patients were asked to score their satisfaction with the surgical result using a VAS scale. The mean reported VAS score was 8.42, and 200/256 (78%) patients reported a score > 8 (success). Only 27/256 (11%) patients reported a VAS score < 5, which indicate that the operation did not fulfil their expectations (failure). Patient satisfaction was then correlated to other measures of surgical outcome at 6 months  patients evaluated the surgical result as successful. Only 27/256 (11%) patients classified the surgical result as a failure. A 78% success rate after surgery for CDD must be regarded as acceptable. Patient satisfaction is often evaluated using the Odom Criteria . This saIn our series, we found a significant correlation between high preoperative pain intensity and decrease in pain intensity after surgery, for all three pain categories. We found no significant correlation between symptom reduction after ACDF and sex, age, number of levels fused, disc level fused, fusion method (AICG or PEEK), previous neck surgery (except for neck pain), previous neck trauma or preoperative symptom duration. The most likely explanation for the lack of identification of prognostic factors is that we selected the best candidates for surgery based on previous knowledge ,5. HowevAnterior cervical decompression and fusion with autologous bone graft has been the standard treatment for CDD for more than 50 years . In receThere is no clear consensus regarding the optimal surgical procedure for CDD ,36-38. W• The patients were not randomized to fusion with either AICG or PEEK-cage. The type of fusion was in each case decided by the surgeon. This may cause a bias in the material.• Ideally the outcome after ACDF for CDD should have been compared with an equivalent group managed with conservative measures.• The follow-up evaluation was done by the surgeons and not an independent investigator, this may have influenced the final result.• ACDF is an effective treatment for radicular pain in selected patients with CDD .• Because of similar clinical outcome and lack of donor site morbidity when using PEEK, we now prefer fusion with PEEK-cage to AICG.• Lengthy symptom duration was not a negative prognostic marker in our patient population.• The number of patients who returned to work 6 months after surgery was lower than expected.The authors did not receive financial support in conjunction with the generation of this article. The authors have no personal or institutional financial interest in drugs, materials, or devices described in this article.libb@ulleval.no; Data collection, statistics, data analysis, discussion and writing. PAR; rnpl@uus.no; Statistics, discussion and writing. JS: jarle.sundseth@rikshospitalet.no; Data collection and discussion. EH; heej@uus.no; Data collection, statistics, data analysis, discussion and writing. All authors have read and approved the final manuscript.BL; The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2482/10/10/prepub


This study aims to contribute to the knowledge of the influence of comorbidity in OA. The objectives of the study were (i) to describe the prevalence of comorbidity and (ii) to describe the relationship between comorbidity  and limitations in activities and pain in elderly patients with knee or hip OA using a comprehensive inventory of comorbidity.t-tests and one-way ANOVA.A cross-sectional cohort study was conducted, in which 288 elderly patients with hip or knee osteoarthritis were included. Apart from demographic and clinical data, information about comorbidity, limitations in activities  and pain (VAS) was collected by questionnaires and tests. Statistical analyses included descriptive statistics, multivariate regression techniques, Almost all patients suffered from at least one comorbid disease, with cardiac diseases, diseases of eye, ear, nose, throat and larynx, other urogenital diseases and endocrine/metabolic diseases being most prevalent. Morbidity count and severity index were associated with more limitations in activities and with more pain. The presence of most of the moderate or severe diseases and obesity was associated with limitations in activities or with pain.The results of this study emphasize the importance of comorbidity in the rehabilitation of elderly patients with osteoarthritis of the hip or knee. Clinical practitioners should be aware of the relationship of comorbidity with functional problems in OA patients. Elderly patients with osteoarthritis (OA) frequently suffer comorbidity. Comorbidity refers to the coexistence of other conditions with a defined index disease ,2. OA isThere is evidence that comorbidity is related to disability in general populations -13. StudApart from the studies on obesity, none of the former studies assessed the relationship between the presence of specific diseases and limitations in activities. This is surprising since some diseases, in combination with OA, might be associated with limitations in activities, whereas others might not . The majThe objectives of the study were (i) to describe the prevalence of comorbidity and (ii) to describe the relationship between comorbidity  and limitations in activities and pain in elderly patients with knee or hip OA using a comprehensive inventory of comorbidity.A cross-sectional study was conducted in 288 patients with knee or hip OA. The study was approved by the Medical Ethical Committee of the VU University Medical Centre, Amsterdam, the Netherlands.Patients were recruited from three rehabilitation centres and two hospitals . The present study is part of a larger research program on rehabilitation of elderly patients with OA of the hip or knee. For this reason, we focussed on rehabilitation centres and hospitals in recruiting patients. Inclusion criteria were: (a) diagnosis of hip or knee OA by medical specialist according to radiological criteria (only if X-rays were available) or clinical criteria of the American College of Rheumatology; (b) 50 years of age or older; (c) referral to hospital or rehabilitation centre less than a year before inclusion; (d) at least moderate functional problems   and (e) Initially, 775 patients with osteoarthritis of the hip or knee that visited the department in the year prior to inclusion were contacted by mail and were asked to participate in the study. Of those patients that volunteered (n = 364), 288 were included. 76 patients were excluded because they did not meet the inclusion criteria. Reasons of exclusion were age (n = 2), language (n = 4), less than moderate functional problems (n = 48) and referral longer than one year before inclusion (n = 22). Analyses showed that there were no differences between the group of patients that were initially contacted (N = 775) and the patients that were included in the study (N = 288) with regard to age and gender. Some differences were found in the location of OA. Compared to our study population, patients that were initially contacted suffered less frequently from both hip and knee OA (6.2%) and more frequently from knee OA (59.5%) and hip OA (34.3%).Measurements were carried out by means of tests, questionnaires and interviews. Assessments were performed on test locations by the researcher or the research assistant.Demographic and clinical data were collected for each patient including age, gender, height, weight, location of OA, duration of complaints, other joint complaints, level of education and marital state. If available, X-rays of the hip and knee that were recorded in the year prior to inclusion were scored on joint space width and osteophytes, following a standardized procedure ,23. A 0–Limitations in activities were measured using the physical functioning subscale of the MOS 36 item Short Form Health Survey (SF-36) ,25, a 102), BMI ≥ 30 kg/m2.Information about comorbidity was gathered in an interview with the patient using the Cumulative Illness Rating Scale (CIRS) ,29,30. TDescriptive statistics were used to describe the presence and severity of comorbidity and limitations in activities and pain. Furthermore, the relation between comorbidity and limitations in activities and pain was determined using multivariate linear regression analyses. Dependent variables were the WOMAC physical functioning score, SF-36 physical functioning score, the timed walking test and the VAS pain score. Comorbidity variables (morbidity count and severity index) and possible confounders or effect-modifiers (age and sex) were entered stepwise. Only those variables that influenced both comorbidity and functioning were added into the regression analyses as confounders. Correlations showed that apart from age and gender, other variables such as BMI, marital state, education and other musculoskeletal disorders, were not associated with comorbidity and functioning.T-tests for independent samples were performed to analyse differences in limitations and pain between patients that suffered from specific diseases  and those who did not suffer from these diseases. The presence of a specific disease was defined by a score of 2 or more on the CIRS. Oneway-ANOVA was used to analyse differences in limitations in activities and pain between patients with normal weight, overweight patients and patients with obesity. The 11.5 version of SPSS was used.If significant interaction was identified (p < 0.05), stratified analyses were performed. Baseline characteristics of the study population are presented in Table The mean score for physical functioning was 45.15 (sd = 21.62) on the SF-36 physical functioning domain (range 0–100) and 61.01 (sd = 17.76) on the WOMAC physical functioning domain (range 0–100). The mean number of seconds for the 10 meter timed walking test was 10.36 (sd = 4.11). The mean pain score was 4.81 (sd = 2.56) on the VAS.For detailed results on comorbidity, the reader is referred to Table Furthermore, the mean BMI was 27.8 (sd = 4.5). The majority (51.7%) of the patients were overweight (BMI between 25 and 30) and 23.6% suffered from obesity. Only 13% of the patients had no other joint complaints. Frequently occurring other joint complaints were hand and back problems, respectively 56.3% and 65.6%. Analyses for the knee and hip OA separately revealed similar results.As Table Table 2ranged from 0.032 to 0.139 for morbidity count, from 0.058 to 0.185 for morbidity count of moderate or severe diseases and from 0.056 to 0.114 for severity index.Although significant associations were found, comorbidity only accounted for a small part of the variance in limitations in activities and pain. RIn summary, morbidity count (having more diseases and having more moderate or severe diseases) and severity index were associated with more limitations in activities and with more pain. Comorbidity, however, accounts for only a small percentage of the variance in limitations in activities and pain. Analyses for knee and hip OA separately reveal similar results.Because a stronger association was found for morbidity count with CIRS score ≥ 2 than for morbidity count with CIRS score ≥ 1 and because moderate or severe comorbidity accounted for a larger part of the variance, Table The objectives of the study were (i) to describe the prevalence of comorbidity and (ii) to describe the relationship between comorbidity and imitations in activities and pain in elderly patients with knee or hip OA using a comprehensive inventory of comorbidity. In this study we focussed on the cross-sectional relationship between the presence of coexistent diseases according to the CIRS and limitations inn activities and pain, measured by recommended instruments , in patiA study in the Netherlands showed that in a general population of people aged 55 years and older, the mean score on the SF-36 ranged from 60.0 (age > 85) to 72.7 (age 55–65) . So, comAlmost all patients 98.6%) suffered from at least one comorbid disease, with cardiac diseases, diseases of ear, eye, throat and larynx, urogenital diseases and endocrine/metabolic diseases being most prevalent. The prevalence of comorbidity in this study population is high, compared to earlier research. A likely explanation is that diseases which do not interfere with normal life and which have an excellent prognosis (CIRS score 1) also contribute to the prevalence. For example wearing glasses or contact lenses is seen as comorbidity since these patients score 1 on CIRS #4. If the prevalence of comorbidity is calculated for diseases that interfere with normal activity and with a poorer prognosis (CIRS ≥ 2), then the prevalence is 84.4%. This is still higher than reported in earlier studies on comorbidity in OA. A potential explanation is that in this study a comprehensive list for comorbidity, which includes all possible disease categories, is used. In earlier research, limited lists of comorbidity were applied ,15,33. M.6% suffeIn the present study, evidence is provided that comorbidity is negatively associated with limitations in activities and pain. These results confirm earlier research, in which morbidity count was associated with disability, pain and quality of life ,5,8. FurSome methodological issues need to be considered. Firstly, because all patients suffered from OA and the influence of comorbidity in an OA population was studied, CIRS category #10 was excluded from the analyses. CIRS category #10 does not only include OA, but also other musculoskeletal and skin diseases. Consequently, information about those types of diseases from the CIRS cannot be presented or included in the analyses. In an attempt to give some information about other joint complaints a question, which comprised of neck, shoulder, hand, back, foot and other complaints, was added. Analyses revealed that patients who suffer other joint complaints, in particular neck complaints, report more limitations in activities on the SF-36 and the WOMAC. They also reported more pain on the WOMAC and the VAS. Secondly, in this study self-reported comorbidity, rather than comorbidity assessed by a physician, was used. One should be aware, that self-reported comorbidity could be influenced by personal or mood characteristics. However, positive correlations were found between self-reported comorbidity measures and comorbidity from medical record reviews . ThirdlyPatients included in this study were recruited from hospitals and rehabilitation centers. Results are important for this specific group of patients, since it is expected that with the aging of the population an increasing number of elderly people with osteoarthritis will need rehabilitation.The prevalence of comorbidity in this population of elderly patients with hip or knee OA was high and an association between comorbidity and limitations and pain was established. Comorbidity, however, accounted for only a small percentage of the variance and can therefore not be considered as the only important aspect in an elderly population that may contribute to limitations in activities and pain. Other aspects related to aging, such as physical impairments  and cognitive impairments, but also social network and psychosocial variables, are expected to play an important role in limitations in activities and pain in elderly patients with hip or knee OA. More scientific knowledge of the impact of those factors is needed and further research should elaborate on these aspects.The results of this study emphasize the importance of comorbidity in the rehabilitation of elderly patients with osteoarthritis of the hip or knee. Clinical practitioners should be aware of the relationship of comorbidity with functional problems in OA patients.The authors declare that they have no competing interests.GMvD contributed to conception and design of the study, the acquisition of data, the analyses and interpretation of data and drafting and revising the manuscript; CV contributed to the analyses and interpretation of data, drafting and revising the manuscript and gave final approval of the manuscript; FS contributed to the analyses and interpretation of data, drafting and revising the manuscript and gave final approval of the manuscript; HH contributed to the acquisition of data and revising the manuscript and gave final approval of the manuscript; JPJB contributed to the acquisition of data and revising the manuscript and gave final approval of the manuscript; HA contributed to the acquisition of data and revising the manuscript and gave final approval of the manuscript; JHMD contributed to the acquisition of data and revising the manuscript and gave final approval of the manuscript; GJL contributed to conception and design of the study and revising the manuscript and gave final approval of the manuscript; JD contributed to conception and design of the study, analyses and interpretation of data and drafting and revising the manuscript and gave final approval of the manuscript.The pre-publication history for this paper can be accessed here:


As impact of literature concerning this subject is scarce, the objectives of this study were to assess whether the Health Related Quality of Life (HRQoL) is decreased in patients with painful temporomandibular disorders as compared to the HRQoL in the general population, and to evaluate to what extent pain duration affects HRQoL.Data concerning physical and mental health were retrieved from patients with painful temporomandibular disorders. Assessment tools used were: the Mandibular Function Impairment Questionnaire (MFIQ), the Short-Form-36 (SF-36), the Hospital Anxiety and Depression Schedule (HADS), and the General Health Questionnaire (GHQ). In order to examine the influence of the duration of pain on HRQoL, the total sample was divided into three different subgroups. Subgroup 1 consisted of patients with complaints existing less than one year. Patients with complaints from 1 to 3 years were allocated to the second group. The 3rd subgroup included patients with complaints longer than 3 years.The total sample consisted of 95 patients . On most physical and social functioning items, groups 2 and 3 scored significantly worse than the general population. On the other hand, none of the groups differed from the general population when comparing the mental items. Duration of pain was significantly correlated with SF-36 subscale physical functioning and the mandibular impairment.Patients with TMD pain less than one year score better than compared to the population norm. With a longer duration of pain, mental health scores and role limitations due to emotional problems do not appear to be seriously affected by reduced physical health, while social functioning appears to be considerably affected. Temporomandibular disorders (TMDs) comprise a group of disorders that affect the temporomandibular joint (TMJ), the masticatory muscles, or both. TMDs involve musculoskeletal pain, disturbances in the mandibular movement patterns, and/or impairment in functional movement . Pain isIt is generally accepted that quality of life is negatively affected by chronic pain ,8. The iMurray et al.  describeLeResche et al.  studied It is not clear whether and, if so, how (chronic) pain related to TMDs influences HRQoL, and whether pain duration is of influence. It may be hypothesized that when pain has just begun, this will mainly affect physical factors such as physical functioning. When the pain lasts for a longer period, and treatment so far has failed to relieve the pain, it may start to have more impact on the emotional behaviour, social factors and HRQoL. However, whether this is the case is yet not clear. Information concerning the influence of pain and its persistence on HRQoL may guide (the emphasis of) treatment in these patients. Therefore, the aims of this study were to assess whether the HRQoL is decreased in orofacial pain patients as compared to the general population, and to study the effect of duration of pain on HRQoL.rd subgroup consisted of patients with complaints longer than 3 years. Secondly, the influence of the duration of pain was studied using results of the total sample in regression analysis. During their first visit to the clinic, patients were informed about the study and the content of the questionnaires. When patients were willing to participate, they were requested to fill in an informed consent.Patients were recruited from the department of Oral and Maxillofacial Surgery of the University Medical Center Groningen. The group consisted of 95 patients consecutively consulting the TMD/Orofacial Pain section for their orofacial pain problems. The inclusion criteria were age over 16 years, no language barrier, and the presence of a painful temporomandibular disorder as classified according to the RDC/TMD ,16. FromQuality of life has been described by the World Health Organisation as " ... an individual's perception of their position in life in the context of the culture and value system of which they live with the relation to their goals, expectations, standards and concerns." This concept incorporates different aspects of individuals, including physical health, psychological state, level of independence, social relationships, personal beliefs and their relationship to salient features of the environment .During the second visit to the clinic, patients were instructed how to complete the questionnaires. Subsequently, patients were left alone to complete the questionnaires. When necessary, unclear test items could be clarified by the interviewer. Only Dutch versions of the questionnaires were used.physical functioning , role limitations due to physical health problems , bodily pain (BP), general health (GH) perceptions, vitality , social functioning (SF), role limitations due to personal or emotional problems (RE measuring the effect of the emotions on work and daily activities) and general mental health (MH including anxiety and depression). The scores on every subscale range from 0-100, with higher scores indicating better health states. Reference values were used to compare the results of the group in question. The reference values were taken from a Dutch study, which consisted of a random Dutch sample of 1742 persons, which is used as the reference group . To . To 6]. The first group did score significantly higher ("better") on the scale "physical functioning", compared to the population norm. This finding could be explained by possible underestimation of the physical situation, when patients visit a hospital and are allocated to a study group that answers questions about health. Patients with pain or function problems that have arisen within the last year, may tend to focus on these problems in an opposite manner than patients who have a longer experience with these problems. In addition, the scale bodily pain was not significantly different from the reference value. Because of the relatively short existence of pain, patients may underestimate or underrate the consequences of their disorders on the measured scales. They may be convinced that (pain) symptoms will be transient and, therefore, patients will not allow them to affect the physical items. Patients may also feel the need to convince the doctor that the symptoms are purely physical, and want to display that statement in the answers of the subscales.bodily pain", "general health" and "vitality") the second and third group scored significantly worse than reference values. In addition, in the third group the items physical functioning and role physical were also worse than reference values. This physical impairment was confirmed by the FIRS scores, indicating moderate function impairment. So the mandibular function was lowered in all three groups. The GHQA score, which represents the somatic general health, is significantly lower ("worse") in the third group, which is in accordance with the scores on the SF-36. With significantly lower scores on the physical scales of the SF-36, the second and third subgroup did not score significantly lower on the mental scales.By contrast, on SF-36 physical health items  in group 2 is not only higher compared to group 1, but also compared to group 3. Patients who experience complaints for a short time may not be seriously affected, but when pain persists, psychological distress will be more pronounced. Later, when patients are used to the pain or when they are sufficiently reassured about their health status, the psychological distress will return to lower values again. This is in accordance with the score on the mental health item of the SF-36, which is better in the third group compared to the second group.Between the different pain duration groups, statistically significant differences were found only on a few scales. Comparing "better" scores from the first group with "worse" scores from the third group, leads in the According to our findings, it may seem that patients with a shorter duration of pain seem to underrate their physical impairment or at least do not consider it to be relevantly impaired, as the scores are "better" compared with a healthy reference group. Patients with longer lasting pain at least longer than one year, have more pronounced physical problems. The role limitations due to emotional problems or the mental health seem to be hardly affected, however. It has been suggested that psychological functioning is merely related to patients' beliefs and coping strategies rather than to the physical impairment . On the physical functioning and the mandibular impairment (FIRS). So with a longer duration of pain, the somatic well-being is considered worse. It remains unclear whether the physical discomfort has worsened during its existence or whether the discomfort is only rated worse due to its longer existence. Other subscales and other scores did not show significant correlation with duration of pain, which may be explained by a large range of duration of pain in contrast to the smaller scale range of the scores on other subscales and the other questionnaires.In addition to the analysis with three subgroups, we calculated Pearson correlation coefficients with data from all patients. This revealed a significant correlation between the whole range duration of pain with the subscale One factor that may be of influence on the results is the age. In our sample, no difference was found between the three groups. Besides TMD pain, other pain condition could play a role in HRQoL. Of the studied sample totally five had an accompanying chronic condition. In the second group, two suffered also from rheumatoid arthritis. In the third group, one patient suffered from rheumatoid arthritis, one from hernia and one from low back pain. These conditions could have influenced the questionnaire outcomes, although the number of patients is a slight minority compared to the total sample size, therefore we argued this to be of negligible influence.A limitation of this study could be the large female predominance, which is than in the general population, which may hamper the generalizability of the results. However, a predominance of female gender in TMDs is also found in epidemiological research . In addiIn patients with chronic pain conditions, such as most TMD pains, it has been demonstrated that psychological factors are better predictors of treatment outcome on the long-term than physical findings are ,28. WhenThe authors declare that they have no competing interests.GHET conceptualized and designed the study, acquired the data and participated in data analysis, and drafted the manuscript;JJR, ETV, BS contributed in data analysis and participated in revising the manuscript critically for important intellectual content.All authors read and approved the final manuscript.


The NDI, COM and NPQ are evaluation instruments for disability due to NP. There was no Spanish version of NDI or COM for which psychometric characteristics were known. The objectives of this study were to translate and culturally adapt the Spanish version of the Neck Disability Index Questionnaire (NDI), and the Core Outcome Measure (COM), to validate its use in Spanish speaking patients with non-specific neck pain (NP), and to compare their psychometric characteristics with those of the Spanish version of the Northwick Pain Questionnaire (NPQ).Translation/re-translation of the English versions of the NDI and the COM was done blindly and independently by a multidisciplinary team. The study was done in 9 primary care Centers and 12 specialty services from 9 regions in Spain, with 221 acute, subacute and chronic patients who visited their physician for NP: 54 in the pilot phase and 167 in the validation phase. Neck pain (VAS), referred pain (VAS), disability , catastrophizing (CSQ) and quality of life (SF-12) were measured on their first visit and 14 days later. Patients' self-assessment was used as the external criterion for pain and disability. In the pilot phase, patients' understanding of each item in the NDI and COM was assessed, and on day 1 test-retest reliability was estimated by giving a second NDI and COM in which the name of the questionnaires and the order of the items had been changed.Minutes needed to fill out the questionnaires : NDI. 4 , COM: 2.1 . Reliability: : NDI: 0.88 . COM: 0.85 . Sensitivity to change: Effect size for patients having worsened, not changed and improved between days 1 and 15, according to the external criterion for disability: NDI: -0.24, 0.15, 0.66; NPQ: -0.14, 0.06, 0.67; COM: 0.05, 0.19, 0.92. Validity: Results of NDI, NPQ and COM were consistent with the external criterion for disability, whereas only those from NDI were consistent with the one for pain. Correlations with VAS, CSQ and SF-12 were similar for NDI and NPQ , and slightly lower for COM . Correlation between NDI and NPQ: r = 0.84 on day 1, r = 0.91 on day 15. Correlation between COM and NPQ: r = 0.63 on day 1, r = 0.71 on day 15.Comprehensibility of NDI and COM were good. Although most psychometric characteristics of NDI, NPQ and COM are similar, those from the latter one are worse and its use may lead to patients' evolution seeming more positive than it actually is. NDI seems to be the best instrument for measuring NP-related disability, since its results are the most consistent with patient's assessment of their own clinical status and evolution. It takes two more minutes to answer the NDI than to answer the COM, but it can be reliably filled out by the patient without assistance.Clinical Trials Register NCT00349544. Mechanical, non-specific or common neck pain (NP) may have an impact on the functional status of the patient, interfering with basic activities such as sleeping or personal care, as well as on many work-related activities. In fact, NP is a common cause of disability and work absenteeism .Although pain may lead to disability, those are two different dimensions that should be assessed separately . In the The Neck Disability Index (NDI) and the Northwich Park Questionnaire are two questionnaires for measuring NP-related disability ,4. Both Dimensions explored in the NPQ are neck pain intensity, interference of neck pain with sleep, interference with sleep of pins and needles or numbness in the arms at night, duration of symptoms, carrying objects, reading and watching television, working and/or doing housework, social activities, driving and a comparison of current state with the last time the questionnaire was completed . DimensiThe Core Outcome Measure (COM) was first proposed as a set of outcome measures for low back pain patients . An adapHowever, only a modified Spanish version of the NPQ existed for measuring NP-related disability in Spanish speaking patients , and theTherefore, the objectives of this study were: 1) To translate into Spanish and culturally adapt the NDI and COM, 2) to validate their use among Spanish neck pain patients, 3) to compare their psychometric characteristics with those of the NPQ.The study was carried out in three phases: the first was translation into Spanish and cultural adaptation of the NDI and COM; the second was a pilot study to assess the comprehensibility and reproducibility of those Spanish versions; and the third was a validation study to determine their metric characteristics and to compare them with those of the NPQ.The same methods were followed separately for both the NDI and COM questionnaires. Each questionnaire was translated into Spanish by two different and independent native Spanish speakers, who had no medical knowledge and were both unaware of the purpose of the translation and of the fact that another translator was doing the same task. Both Spanish translations were then compared for inconsistencies. The two translations were then retranslated, also blindly and independently, into English by two native English speakers. Each of the English translations was then compared with the original English questionnaire and checked for inconsistencies.The Spanish version of the questionnaire was then separately reviewed and fine tuned by a bilingual team including the four translators, eight primary care physicians, four back specialists, and three methodologists  on Oct 5Exclusion criteria were: functional illiteracy , treated or untreated central nervous system impairment, direct trauma to the neck, and criteria for referral to surgery or for suspecting a potential systemic disease. Criteria for referral to surgery were defined as clinically relevant motor weakness or disabling pain radiating down the arm for at least 6 weeks in spite of conservative treatment, caused by a nerve root compression demonstrated by magnetic resonance (MRI) or computed tomography (CT) studies. Reasons for suspecting a potential underlying systemic disease were defined as oncologic disease during the previous 5 years, constitutional symptoms -unexplained weight loss, fever, chills-, history of intravenous drug use, or immunocompromised host.16The sample size of the pilot study was established at 50 patients. According to the available evidence on low back pain patients, the limit between acute and subacute pain was established at 14 days ,15, and Patients were seen the day of admission to the study (day 1) and 14 days later day 15). At the first visit, the following variables were recorded on the data collection form: sex, age, socioeconomic level, family situation, academic level, work status, duration of the current work status, chronicity of pain  ,15,16, p. At the In addition, diagnostic procedures and treatments that patients had undergone were recorded, and those subjects in whom cervical disc herniations had been observed on MRI or CT scans were identified Table .At both visits, patients were given two separate Visual Analogue Scales (VAS)  for measAll self-assessment questionnaires were given by administrative staff and the patients filled them out on their own and alone, without the presence of staff or accompanying persons. Requests for aid in interpretation of the items in the NDI and COM questionnaires were registered. The completed instruments were then given to the treating physician, who stapled scales and questionnaires onto the patient's data collection form.Patients were told that several questionnaires were going to be given, and were asked to notify the staff in case that any of them was given twice. On day 1, each patient was given a first NDI and COM questionnaire. The time needed for answering each one was recorded. To assess repeatability, patients were asked to fill out the VAS, RMQ and SF12, and at least 30 min. after having answered the NDI and COM the patient was given a second version of those questionnaires. Questionnaires in this second set were printed in differently colored paper, listed the items in a different order and were not titled "NDI" and "COM", but "NID" and "CSC6". Finally, the clinician filled out a standardized questionnaire asking each patient about his or her interpretation of the meaning of each of the items in the NDI and the COM.It was decided that sentences for which more than 10% of patients in the pilot study needed clarification or misinterpreted the meaning would be reviewed before undertaking the validation study. Such review would be made by the bilingual team that developed the first version, based on the patients' suggestions and on the comments from the clinicians administering the questionnaire and interviewing the patients. It was also decided that if that team felt that potential modifications in the questionnaire were relevant enough, data gathered from patients included in the pilot phase would not be used for the objectives of the validation phase.Data were entered in the database at a centralized coordination office. Entry of data was done independently by two administrative assistants, who double-checked that the data they were entering coincided with the scores of the two VAS scales and the NPQ, NDI, NID, COM, CSC6, CSQ, and SF-12 questionnaires.The validation phase was performed in 12 Health Care Centers from 7 different regions in Spain, including two regions from which no Center had participated in the pilot phase. Ten Centers belong to the Spanish National Health System (SNHS) and two to not-for-profit Foundations working for SNHS. All the Centers are involved in the Spanish Back Pain Research Network. Participating Centers included 3 primary care centers and 9 specialty centers in rehabilitation, neuroreflexotherapy, orthopedic surgery, rheumatology and neurosurgery, five of which did not participate in the pilot phase.The validation study was carried out with subjects who consulted for neck pain between April 6, 2006 and Feb 1, 2007. In order to ensure a sufficient number of acute, subacute and chronic patients, the sample size was established at 150 with a minimum of 15 in each of the three subgroups . The only differences with methods used in the pilot phase were: 1) the time needed to fill out the NDI and COM was not registered, 2) only one version of the questionnaires was given (NID and CSC6 were not used), and 3) patients were not asked about their comprehension of each item in the questionnaires.Comprehension was determined in the pilot study by the patients' answers to the questions exploring their understanding of each item on the NDI and COM questionnaires, and was measured in both the pilot and validation studies by the patients' requests for aid in interpretation and by the number of items which were not answered in each questionnaire.The distribution of answers across categories was assessed for each item, and potential ceiling and floor effects were estimated by calculating the percentage of subjects indicating the maximum and minimum possible scores for the NDI, COM and NPQ questionnaires.Sensitivity to change was estimated by calculating the effect size of NDI, NPQ and COM in patients that, according to external criteria for pain and disability, had worsened, not changed or improved between days 1 and 15. Worsening and improvement in pain and disability were defined as any negative or positive change in the corresponding external criterion. For each questionnaire, effect size was calculated as the difference between scores on day 1 and 15, divided by the standard deviation of the score on day 1. According to this method, an effect size < 0.20 corresponds to no change, 0.20–0.49 to a small change, 0.50 to 0.79 to a moderate change and ≥ 0.80 to a great change -23.Test-retest reliability was measured in the pilot phase, comparing the results of the first and second NDIs, identified respectively as "NDI" and "NID", and the results of the first and second COM, identified respectively as "COM" and "CSC6". Reliability was assessed through the kappa index for answers given to the same items in both versions of each questionnaire. The reliability of the total score was assessed through the intraclass correlation coefficient  and the Cronbach's alpha was used to evaluate internal consistency of the NDI and NPQ . Since CA total of 221 patients were eligible and none were excluded. Fifty-four patients were recruited for the pilot study and 167 for the validation study. Forty-two (19.0%) showed images of cervical disc herniation on MRI. For the pilot study, 23 patients were recruited from primary care centers and 31 from the hospital setting. For the validation study, 20 patients were recruited from primary care centers and 147 from the hospital setting , and for the Spanish version of the COM, it was 2.1 min. .In relation to the NDI, at the end of the pilot phase 10 patients had asked for aid in the interpretation of questions No. 3 , No. 8 , No. 1 , No. 2  No. 7  and No. 9 , with 4 patients asking for help with two questions. In addition, 8 patients did not answer question No. 8 because they did not drive. Only four patients misunderstood the meaning of the following questions: N° 4 , No. 5  and No. 7 .In relation to the COM, 10 patients asked for aid in interpretation of questions N° 6 , No. 5 , No. 4 , No. 3 , No. 2 , No. 1b  and No. 1a , with one patient requesting help with 4 questions, one with 3 questions and three with 2 questions. Only one patient (1.9%) misunderstood the meaning of question No. 6. Therefore, the wording of the NDI and COM remained unchanged for the validation phase.No patient notified the staff of having identified the NDI and the NID questionnaires, or the COM and the CSC6, as being the same. Cronbach's alfa was 0.89 for the NDI, 0.91 for the NID, 0.84 for the NPQ, 0.73 and 0.84 for the pain and disability subscales of COM, respectively, and 0.62 and 0.90 for the pain and disability subscales of CSC6, respectively.In relation to the NDI, a comparison of the scores of both versions of the questionnaire yielded the following results [median ]: NDI: 36.9 , NID: 35.0 , with 68.5% of answers being identical in both questionnaires, and an intraclass correlation coefficient for both of 0.88 . The limits of agreement between NDI and NID were 1.25 ± 18.33 ]: COM: 3.0 , CSC6: 2.8 , with 76.4% of answers being identical in both questionnaires, and an intraclass correlation coefficient for both of 0.85 . One item had a moderate concordance of 0.54 (No. 6), two a substantial concordance of between 0.61 and 0.80 (Nos. 1a and 3), and four  an almost perfect concordance greater than 0.80 . The limAll of the items of NDI, NPQ and COM had answers distributed across all categories. For the NDI, the lowest observed score was 4% , and the highest one was 86% . For the COM, the lowest observed score was 1.2 points  and the highest one was 5.0 . For the NPQ, the lowest observed score was 5.6% , and the highest was 84.4%  Table .Results of NDI, NPQ and COM were consistent with the external criterion for disability, so that values for those questionnaires were higher as patient's self-perception of disability increased Table . HoweverEffect size of NDI, NPQ and COM for patients having worsened, not changed or improved according to external criteria for pain and disability are shown in Tables Tables Results from this study show that the Spanish versions of both NDI and COM are comprehensible and appropriate instruments. In addition, they show that NDI, NPQ and COM are internally consistent and valid instruments to measure neck pain patients' disability, that floor and ceiling effects are not a major concern for any of those questionnaires and that they can be used in routine clinical conditions. In fact, this study was performed in routine conditions, no patient left the NDI and NPQ questionnaires unanswered, and only 4 out of 221 (1.8%) left the COM unanswered , the first version was taken once answered and before handing out the second one, and both versions listed the questions in a different order. Although the change in the order of the questions might alter the results, because a patient may consider a previous question when answering the next, it was felt that this risk was worthwhile in order to avoid recall bias. This method for testing reliability had previously proven feasible and valid in our environment -31. In fIn some previous studies, patients' subjective classification of their clinical evolution during the study period has been used as the external criterion -36. ThatFor the NDI and NPQ, scores of items not applicable in one particular patient  are homogeneously distributed among the other dimensions. From the theoretical point of view, this might question the validity of comparisons among patients in which different dimensions are applicable. However, this is a common feature in the Oswestry Disability Index (ODI), from which both questionnaires derive, and previous studies have shown those questionnaires to be valid and reliable ,4,14.The representativity of the sample is not a major concern. Participants were recruited in 9 different Spanish regions representing the entire cultural and economic spectrum of the country, both in the primary care and hospital setting, and the sample included acute, subacute and chronic patients with symptoms ranging from very mild to very severe Tables  and 2.The National Spanish Academy of the Language is a multi-national agency integrated by both Castillian and Mexican experts in Spanish. It ensures that academic language, dictionaries, and semantic and grammatical rules are homogeneous throughout the Spanish speaking world. Therefore, these versions of the NDI and COM questionnaires may be used in any Spanish speaking country, although some minor finetuning may be necessary in order to adapt it to the specific terms that may be more commonly used in informal language in some specific cultural environments.In conclusion, this study shows that the Spanish versions of both NDI and COM are comprehensible and reliable, that Spanish versions of NDI, NPQ and COM are internally consistent and valid, and that it is feasible to use any of those questionnaires in routine practice. In addition, they show that NDI is the most sensitive to change and the only questionnaire to reflect patients' evolution according to their own perception. This suggests that NDI is the best option to measure NP-related disability. It requires two more minutes than the COM to fill out, but it can be answered by the patient in the waiting room without assistance.The author(s) declare that they have no competing interests.FMK conceived the study and participated in its design, data collection, coordination and in the drafting of the manuscript. JB, JS and SG collaborated in coordination and data collection. AR, AM, VA, JZ and AC performed the statistical analysis and participated in the drafting of the manuscript. VA also participated in the design of the study. The rest of the authors of the study collaborated in its coordination and data collection. All authors revised the design, revised the draft manuscript and read and approved its final version.The pre-publication history for this paper can be accessed here:Appendix 1. Spanish version of the NDI questionnaire. The translated and validated version of the Spanish NDI questionnaire.Click here for fileAppendix 2. Spanish version of the COM questionnaire. The translated and validated version of the Spanish COM questionnaire.Click here for fileBland & Altman Method (NDI and COM). The figure represents a comparison of the scores of both versions of the NDI and COM questionnaires.Click here for file


Patients with acute chest pain are often referred to the emergency ward and extensively investigated. Investigations are costly and could induce unnecessary complications, especially with invasive diagnostics. Nevertheless, chest pain patients have high mortalities. Fast identification of high-risk patients is crucial. Therefore several strategies have been developed including specific symptoms, signs, laboratory measurements, and imaging.The Quick Identification of acute Chest pain Study (QICS) will investigate whether a combined use of specific symptoms and signs, electrocardiography, routine and new laboratory measures, adjunctive imaging including electron beam (EBT) computed tomography (CT) and contrast multislice CT (MSCT) will have a high diagnostic yield for patients with acute chest pain. All patients will be investigated according a standardized protocol in the Emergency Department. Serum and plasma will be frozen for future analysis for a wide range of biomarkers at a later time point. The primary endpoint is the safe recognition of low-risk chest pain patients directly at presentation. Secondary endpoint is the identification of a wide range of sensitive predictive clinical markers, chemical biomarkers and radiological markers in acute chest pain patients. Chemical biomarkers will be compared to quantitative CT measurements of coronary atherosclerosis as a surrogate endpoint. Chemical biomarkers will also be compared in head to head comparison and for their additional value.This will be a very extensive investigation of a wide range of risk predictors in acute chest pain patients. New reliable fast and cheap diagnostic algorithm resulting from the test results might improve chest pain patients' prognosis, and reduce unnecessary costs and diagnostic complications. Frequently new onset chest pain is a sign of myocardial ischemia or even (threatening) myocardial infarction. Despite continuous improvements in diagnostic tools it can still be difficult to differentiate between a benign and a potential hazardous nature of acute chest pain. Percentages as high as 5% of chest pain patients presenting in the emergency room suffer or will suffer from myocardial infarction without being recognized as having an acute coronary syndrome (ACS) at presentation . The conOne of the introduced diagnostic techniques developed is electron beam computed tomography (EBT) scan investigating the presence of coronary calcium. EBT scanning and evaluating takes less than 20 minutes , and hasAnother type of CT scanning in coronary artery disease (CAD) has evolved over the last decade. Multi slice CT (MSCT) using contrast has made a true revolution in non invasive coronary imaging, resulting in near optimal coronary stenosis detection in recent studies in experienced hands and under optimal conditions . 16-slicAccurate detection of (significant) coronary stenoses could predict short-term cardiac risk. Correct identification of the nature of atherosclerotic plaques, especially cholesterol rich, dissected or thrombotic plaques could be direct proof of ACS in chest pain patients. BecauseThere is accumulating evidence that basal inflammatory activity represents atherosclerotic disease . TherefoMyocardial ischemia is the result of ACS. A problem might be that the ECG in the acute stadium and stress testing in a later stadium may not be diagnostic. Because ischemia should be detected as early as possible because of possible lethal complications, ischemic biomarkers could be very important for diagnostic purposes. Testing of biomarkers becomes more easy, cheaper and faster, and multimarker testing in ACS has already proven prognostic value . On the Table Biomarkers in acute chest pain patients could be related to: 1) inflammation, 2) oxidative stress; 3) fibrous cap degradation; 4) coagulation or trombocyte aggregation; 5) ischemia. The experience and opinions of which is the best biomarker reflecting one of the mentioned components in coronary syndromes is continuously changing. After inclusion of about 500 patients, we will test the biomarkers that will be considered the most reliable marker for a wide range of the mentioned components. We will use biomarkers that can be measured after defrosting, and are proven to be reliable and quickly measurable. Because opinions and measurement techniques are constantly changing, we are awaiting future developments before deciding which biomarkers are of interest .We hypothesize that in acute chest pain patients a combination of biomarkers evaluating the above mentioned components in ACS would accurately predict the existence of advanced systemic and coronary atherosclerosis, the presence of an ACS, and the prognosis of the patients in the QICS at least one-year follow-up will be assessed by visits at the out-patient clinic and by consultation of the municipal population registry. Extreme high biomarkers values due to acute non-cardiac inflammation should be excluded. We will test individual biomarkers and a profile of biomarkers head tot head against outcome, calcium score, presentational symptoms and traditional risk factors. We will also test individual biomarkers and profiles of biomarkers on top of calcium score, presentational symptoms and traditional risk factors.The primary objective is to evaluate whether a negative calcium score and/or a favourable biomarker profile can rule out the chance of a cardiac event in the following years. We hypothesize that EBT/MSCT and/or a biochemical profile can accurately rule out cardiac chest pain fast,  and diagnose patients who will survive without myocardial infarctions in the following year. By ruling out myocardial ischemia it would prevent unnecessary hospital admittance and invasive or extensive ischemia testing, with all its costs and potential complications. Secondary objective is the identification of sensitive predictive markers in acute chest pain patients. We will test, presentational symptoms, traditional risk factors, individual biomarkers, a profile of biomarkers, coronary calcium score, coronary stenosis/plaque volume. Biomarkers will be retrospectively tested after defrosting of deep frozen blood taken on presentation.All patients presenting with new onset acute chest pain in the emergency department will enter the flowchart as shown in figure - New onset acute chest pain without diagnostic ECG testing- If there is a diagnostic ECG for ischemia, including ST elevation myocardial infarction, no further delay is warranted and patients will be treated accordingly without CT analysis. Registration of baseline characteristics, collection of blood to be frozen and follow up will be obtained.- If there is diagnostic testing of a non cardiac cause of chest pain, or chest pain is evidently not cardiac, patients will be transferred to other specialists without cardiac CT testing.- The existence of a life-threatening disease with a life expectancy of less than 6 months.All chest pain patients without exclusion criteria and without cardiac history will undergo an EBT for coronary artery calcium assessment. A coronary calcium score > 10 is considered positive and will be evaluated by ischemia testing after ruling out infarction by troponin testing 6 hours after the start of chest pain. A coronary calcium score > 400 is considered to justify MSCT testing in order to rule out CAD. Depending on MSCT results and clinical findings during further hospital admittance coronary angiography will be performed.The prognostic value of EBT calcium score will be evaluated during follow up. In case MSCT is performed, plaque characteristics will be evaluated and related to follow up. Biomarkers will be tested and related to follow up as well as to CT findings.Scans will be performed with an e-Speed EBT scanner , in the dual 1.5 mm slice mode with an image acquisition time of 50 ms or 100 ms depending on patient size. EBT data will be collected during end-inspiratory breath hold. The non-enhanced scan will be ECG-triggered at 42% of the R-R interval. A set of 40 continuous axial coupes will be obtained starting directly under the trachea bifurcation until under the heart. Calcification will be defined as four adjacent pixels with density >130 Hounsfield units. Coronary artery calcification score will be calculated according to the method of Agatston using dedicated software.All patients are imaged with a 64-slice MDCT scanner (Siemens) after premeditation with oral beta-blocker and/or intravenous metoprolol when needed. Thoracic CT angiography with retrospective gating will subsequently be performed with a single biphasic injection of 130 mL of iso-osmolar contrast material (100 mL at 5 mL/sec and 30 mL at 3 mL/sec) in caudal-to-cranial acquisition. Coronary, aortic, and pulmonary arterial attenuation values will be obtained. Coronary venous and right atrial enhancement will be evaluated to assess whether there is interference with coronary artery evaluation.® 400, Bracco, Italy) will be injected in an antecubital vein. Bolus triggering will be used for timing with the region of interest set in the descending aorta. A 50 ml saline bolus will follow the contrast bolus to maintain a compact bolus and to reduce the necessary amount of contrast. All patients will be treated with sublingual nitroglycerin (0.4 mg) just prior to the scan protocol.A retrospectively ECG-triggered DSCT scan  with contrast enhancement will be made with a beam current of 340 mAs/rot, tube voltage of 120 kV, and a rotation time of 0.33 s for both tubes. ECG pulsing window will be 20–70% of the RR-interval for all patients. Scans will be made with a slice thickness of 3.0 mm with a 64 × 0.6 collimation. Scan direction will be was cranio-caudal starting above the coronary ostia and ending at the diaphragm below all cardiac structures. For the contrast enhanced scans 73 ml of non-ionic contrast agent , as having non-significant disease , or as having significant stenosis .This is a single center prospective open trial.We will perform an interim analysis using after 100 and 500 patients.Patient recruitment has started in January 2006 and is expected to be completed in July 2009. Analysis and reporting is to be completed in November 2009.The study will take place at the University Medical Center Groningen a referral center for primary PCI in STEMI patients, serving an area in the North of the Netherlands with approximately 1,2 million inhabitants.A multimarker strategy in the evaluation of acute chest pain patients seems promising.  In additThe present study set-up may further elucidate the value of the proposed combination of biocemical and non-invasive diagnostics.None declared by the authors.Financial competing interests: None declared. The study is not financially funded and not reimbursed by any other organization. Participation of the authors is completely voluntarily and ideological, in article writing as well as in additional radiological and biochemical testing. We will use the frozen blood specimens anonymously for biomarker testing.HMW: data collection, and analysis, writing the manuscript; principle investigator. GdJ: EBT and MSCT data collection and analysis, RAT: has made substantial contributions to concept and design of the study, has been involved in drafting the manuscript and revising it critically for important intellectual content; principle investigator, WN MD: practical implementation, has made substantial contributions to conception and design, and acquisition of data, IP: has been involved in drafting the manuscript and revising it critically for important intellectual content and has given intellectual input from biochemistry department, IvdH: intellectual input from cardiology department; has been involved in drafting the manuscript and revising it critically for important intellectual content, MO: has been involved in drafting the manuscript and revising it critically for important intellectual content and has given intellectual input from radiology department, FZ: has been involved in drafting the manuscript and revising it critically for important intellectual content. All authors have given final approval of the version to be published.The pre-publication history for this paper can be accessed here:


Fibromyalgia (FM) is a prevalent and disabling disorder characterised by widespread pain and other symptoms such as insomnia, fatigue and depression. Catastrophisation is considered to be a key clinical symptom in FM; however, few studies have investigated how contextual factors, such as catastrophisation, might contribute to the duration of the pain. The present research examined the relationship among pain, catastrophic thinking and FM impact, as a function of stage of chronicity.N = 46); Group B ; and Group C . The three subscales of the Pain Catastrophising Scale (PCS), rumination, magnification, and helplessness, were used as predictors of dysfunction. The Fibromyalgia Impact Questionnaire and the McGill Pain Questionnaire were also administered. A hierarchical regression analysis was performed on the entire sample and, subsequently, for each group to determine the effect of the continuous process variables (castastrophising and pain) on the stages of chronicity.In this cross-sectional study, the sample of 328 patients diagnosed with FM was divided into 3 groups based on level of chronicity: Group A . For Group A, a regression analysis revealed that rumination predicted FM impact beyond the variance accounted for by age and pain. Both magnification and helplessness predicted impact in Group B, and helplessness was a significant predictor of impact in Group C.Total score and PCS subscales were strongly associated with pain and impact in all the stages of chronicity in FM patients (These findings provide preliminary evidence that stage of chronicity is an important moderator of psychological vulnerability for FM impact and should be taken into account by tailoring psychological interventions. Fibromyalgia (FM) is defined by the American College of Rheumatology (ACR) as chronic >3 months), widespread pain  and tenderness in at least 11 of 18 tender points ,3. Most  months, Psychological treatments seem to have beneficial short-term effects on the key symptoms of FM, but these effects largely disappear over the long term. Most studies to date have addressed the role of psychological factors in the development of chronic pain following acute pain ,12. SeveIndeed, it has been proposed that the development of FM involves an interaction between the experience of pain and catastrophising, but it is unclear when and how this cognitive construct first becomes important . ConsequIt is also unclear whether the three components of catastrophising  contribute equally to the prediction of dysfunction in FM or whether certain components are more predictive than others. Information concerning the relative importance of the components of catastrophising could help treatment providers to tailor interventions to facilitate positive outcomes.The aim of the present research was to replicate and extend the findings of Sullivan  with regThis was a multi-centre, cross-sectional study.The study sample consisted of 328 patients from the Pain Clinic, Santander (Spain) and 8 primary care centres in Zaragoza (Spain) during the year 2009. To be included in the study, patients were required to fulfil several inclusion criteria: 1) be between 18 and 65 years old; (2) be able to understand and read Spanish; (3) meet the ACR criteria for primary FM [ be betweEach participant was interviewed and asked to provide information about a number of demographic and pain-related variables, including age, work status, duration of FM diagnosis, medications and other medical treatments.The PCS is a 13-item scale designed to assess the catastrophising cognitions of individuals by asking them to reflect on thoughts or feelings associated with past painful experiences . It can The McGill Pain Questionnaire (MPQ) was used as a measure of pain severity . It consThe Fibromyalgia Impact Questionnaire (FIQ) is a 10-item self-report questionnaire developed to measure the health status of FM patients . The firThe study questionnaires and protocol were approved by the Ethical Committee of the regional health authority, and the patients signed consent forms attesting to their willingness to participate. After consenting to the study, recruited patients were given a battery of questionnaires to complete. These questionnaires included a pain form for demographic variables, the FIQ, the PCS and the MPQ.N = 46), those in Group B had received the diagnosis between 2 and 4 years ago (N = 59), and the members of Group C had carried the diagnosis for more than 4 years (N = 223).Patients were classified into 1 of 3 groups on the basis of the chronicity of their FM disorder. Patients in Group A had been diagnosed less than 2 years ago  and in primary care centres in Zaragoza .There are no previous studies assessing the distribution of disease chronicity in patients with FM. The large sample size was chosen to ensure a minimum of 45 patients in each group. Therefore, patients were recruited from both a tertiary care setting , and percentages were calculated for categorical variables . Analysis of variance (ANOVA) was used to compare the three chronicity groups. Pearson correlations were used to assess the relationship between pain catastrophising  and other psychometric variables such as pain (measured with MPQ) and impact of FM (measured with FIQ). A hierarchical regression analysis was performed on the entire sample to determine the effect of the continuous process variables (castastrophising and pain) on FM impact. All analyses were conducted with SPSS 15.No patients were rejected because of severe Axis I or Axis II psychiatric disorder. Only two patients (0.006%) refused to participate in the study. The study sample consisted of 328 patients (93.9% women and 6.1% men), aged 18-77 years , and all of them self-described as from the European ethnic group. On average, the patients had been suffering from FM for 11.3 years (range 6 months - 40 years), and 22.8% had been granted an invalidity pension.First, the data were summarised and explored. The mean scores on the measures were compared across the stages of chronicity using Pearson Correlation Coefficients. Mean and standard deviations for demographic and dependent variables are found in Table Following these analyses, the moderational effect of the stage of chronicity was tested, as in the original paper , using ar= 0.48, F = 95.9, p < 0.001. The PCS subscales were entered in Step 3 of the analysis and contributed 8% to the prediction of impact, r= 0.56, F = 48.0, p < 0.001. The three interaction terms were entered in the final step of the analysis, but they did not contribute any additional variance to the prediction of FM impact.Firstly, the hierarchical regression analysis was performed on the entire sample to test whether any of the interactions between chronicity and the three catastrophising components was more predictive of FM impact than the individual PCS subscales. Age was entered in Step 1 of the analysis but did not contribute significant variance. Pain severity was entered in Step 2 and contributed 24% of variance to the prediction of FM impact, F = 17.91, p < 0.001. In Step 2 of the analysis, age was entered but did not contribute significant variance. The three subscales of the PCS were allowed to compete for entry in the next step of the analysis, and only the rumination subscale met criteria in the regression equation, F = 38.09, p < 0.001. Rumination accounted for 36% of the variance in ratings of FM impact beyond that accounted for by pain.Secondly, the nature of interactions was explored with separate multiple regressions for each level of chronicity. Pain intensity was used as a covariate in order to address whether the catastrophising components contributed to the variance in function beyond the variance accounted for by pain. The results of regression analyses predicting dysfunction in the three chronicity groups are presented in Table F = 19.53, p < 0.001. When the three PCS scales were allowed to compete in the next step of the analysis, both magnification  and helplessness  met criteria for entry in the regression equation, and they accounted for roughly the same percentage of the variance  in ratings of impact when controlling for pain.For Group B, pain was entered in Step 1 and accounted for 25% of the variance in disability ratings, F = 57.0, p < 0.001. The helplessness subscale of the PCS was entered next because it was the only one that met minimum criteria for entry in the regression equation, F = 51.17, p < 0.001. It accounted for an additional 12% of the variance.For Group C, pain was also entered in Step 1 and accounted for 21% of variance, Most reviews of the current literature conclude that psychological interventions in patients with FM are relatively limited -10. To iAlthough considerable research has been conducted to elucidate the vulnerability factors associated with pain-related disability, the role of vulnerability-relevant contextual factors has not been systematically investigated.The purpose of the present study was to test the role of FM impact in relation to a thinking process that often accompanies, and appears to worsen, the experience of unremitting pain, namely, catastrophising, as a function of stage of chronicity (i.e. number of years since the FM diagnosis). From the current perspective, the influence of catastrophising on FM impact was considered to be variable and dependent on the context  in which the catastrophising thoughts occur.Accordingly, the findings of the present study provide preliminary evidence that the psychological correlates of FM impact change over time. Specifically, regression analyses revealed that stage of chronicity moderated the relationship between the PCS subscales and FM impact. In the group of patients who had been diagnosed with FM for fewer than 2 years, rumination accounted for significant unique variance in FM impact. Magnification and helplessness predicted FM impact over and above the variance accounted for pain severity for patients who had been diagnosed for 2-4 years, and helplessness was the strongest predictor of FM impact in the group of patients diagnosed for more than 4 years.Additionally, results are concordant with what was expected. Patients who have suffered from FM for less than 2 years are characterised by exaggerated threat appraisals (rumination), which may contribute to the development of an overly cautious or fearful approach to physical activity. In patients who have suffered from FM for more than 4 years, helplessness appraisals may accentuate the impact on function These results are also in line with those of previous studies on chronic pain, in which rumination was the best predictor of severity of disability in patients who had been experiencing pain for approximately 3 years , and helThe present findings suggest that interventions that consider stage of chronicity as a moderator of vulnerability for impact may yield more positive outcomes than standardised approaches to the management of FM. Cognitive therapies should be more focused on specific assessments (threat or helplessness) depending on the context to optimise treatment outcomes These findings also suggest that there is an additional facet to consider with regard to the relationship between catastrophising and FM impact, one that derives from a contextual view of how thoughts will variably influence behaviour dependent upon history, situation and, of course, stage of chronicity.type of intervention important but also the timing of treatment. The findings accentuate the significance of early detection and treatment of patients who are at risk of developing FM and related problems [Finally, it is notable that catastrophising was a stronger predictor of FM impact than pain itself for the three different stages of chronicity and that catastrophising remained constant over time, despite the fact that FM impact increased. These findings suggest that not only is the problems . InterveAs Sullivan has pointed out , the resThe findings of this study highlight the important contribution of contextual factors in prolonging the pain condition, and as such, they have clinical implications for the assessment of FM. The study of contextual determinants of psychological vulnerability will play a role in the development of tailored interventions. Recent developments of Contextual Therapies aimed at pain acceptance have shown that such therapies are relevant in the treatment of chronic pain ,33. BaseThe authors declare that they have no competing interests.BR, BC and JGC conceived the project. BC and RM performed the clinical diagnosis of fibromyalgia. YLdH, MR and BR collected the data. BR conducted the statistical analysis, and all authors interpreted the results, drafted the manuscript, and read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2474/11/251/prepub


Sir,Oral mucositis is an inflammatory-like process of the oral mucosa due to radiotherapy and chemotherapy. This is characterized by atrophy of squamous epithelial tissue, vascular damage, and inflammatory infiltration concentrated at the basement region. This becomes evident of aching ulcerative abrasions of mouth and even throat. Pain and dysphagia  due to oral mucositis may further debilitate the immunocompromised patients. Patients having acute oral mucositis will find it extremely tough to perform simple everyday mouth-related actions like chewing, biting, talking, swallowing, drinking, sipping, etc.Treatment of mucositis is still limited to the reduction of severity of pain and discomfort due to mucositis. Several anesthetics, analgesics, and mucosal agents have been used.The main challenges to the palliative care professionals posed by the patients with extensive and severe ulcerative lesions in the oropharynx are to maintain the nutrition and hydration, involve them in conversation, and expect them to communicate with the team. Keeping the above facts in mind and observing the severity of mucositis pain experienced by many patients led us to initiate the study using oral morphine solution as oral morphine rinse.Ten patients with extensive oral mucositis admitted in palliative care ward were recruited for the study. Regular pain assessment was done by visual analog scale at the time of admission and everyday in the ward. Oral morphine solution used as rinse for the study is prepared according to Royal Marsden Hospital formula at the pharmacy in palliative care unit. The solution has strength of 5 mg morphine sulphate in 15 ml of diluent solution given every 2 h[All patients experienced good pain relief after 15 min of oral rinse and this lasted for 30–60 min. It was observed that the mouth opening had increased by 0.5–1.5 cm. Two patients complained of itching and burning sensation at the site of the lesion after 24 h; two patients had bleeding during rinsing; and one patient complained of giddiness.[1Oral morphine solution used as oral rinse is prepared according to the Royal Marsden Hospital formula using morphine sulphate powder. This solution is prepared at pharmacy in palliative care unit and dispensed according to the patients’ requirements.Patients included in this study had come with the complaints of odynophagia, oral mucositis pain, and severe trismus. Patients were given 5 mg morphine sulphate in 15 ml of diluent solution[Patients were able to open their mouth by 0.5–1.5 cm; however the intensity of mucositis-related pain, though less, was persisting. Pain relief was achieved to the maximum of 1 h after oral rinse. As patients were not relieved of pain with oral rinse alone, they were administered with routine immediate release morphine solution as per WHO analgesic ladder along with oral rinse for effective continuous relief of pain.A combination of oral morphine rinse every 2 h along with the intake of morphine solution every 4 h proved to be effective in relieving the pain of mucositis and improving the opening of their mouth.