Work disability remains a major problem in rheumatoid arthritis in the 2000s: data from 32 countries in the QUEST-RA Study

Introduction: Work disability is a major consequence of rheumatoid arthritis (RA), associated not only with traditional disease activity variables, but also more significantly with demographic, functional, occupational, and societal variables. Recent reports suggest that the use of biologic agents offers potential for reduced work disability rates, but the conclusions are based on surrogate disease activity measures derived from studies primarily from Western countries. Methods: The Quantitative Standard Monitoring of Patients with RA (QUEST-RA) multinational database of 8,039 patients in 86 sites in 32 countries, 16 with high gross domestic product (GDP) (>24K US dollars (USD) per capita) and 16 low-GDP countries (<11K USD), was analyzed for work and disability status at onset and over the course of RA and clinical status of patients who continued working or had stopped working in high-GDP versus low-GDP countries according to all RA Core Data Set measures. Associations of work disability status with RA Core Data Set variables and indices were analyzed using descriptive statistics and regression analyses. Results: At the time of first symptoms, 86% of men (range 57%-100% among countries) and 64% (19%-87%) of women <65 years were working. More than one third (37%) of these patients reported subsequent work disability because of RA. Among 1,756 patients whose symptoms had begun during the 2000s, the probabilities of continuing to work were 80% (95% confidence interval (CI) 78%-82%) at 2 years and 68% (95% CI 65%-71%) at 5 years, with similar patterns in high-GDP and low-GDP countries. Patients who continued working versus stopped working had significantly better clinical status for all clinical status measures and patient self-report scores, with similar patterns in high-GDP and low-GDP countries. However, patients who had stopped working in high-GDP countries had better clinical status than patients who continued working in low-GDP countries. The most significant identifier of work disability in all subgroups was Health Assessment Questionnaire (HAQ) functional disability score. Conclusions: Work disability rates remain high among people with RA during this millennium. In low-GDP countries, people remain working with high levels of disability and disease activity. Cultural and economic differences between societies affect work disability as an outcome measure for RA.

COOP/WONCA Charts as a Screen for Mental Disorders in Primary Care

PURPOSE most people with mental disorders receive treatment in primary care. The charts developed by the Dartmouth Primary Care Cooperative Research Network (COOP) and the World Organization of National Colleges, Academies, and Academic Associations of General Practitioners/Family Physicians (WONCA) have not yet been evaluated as a screen for these disorders, using a structured psychiatric interview by an expert or considering diagnoses other than depression. We evaluated the validity and feasibility of the COOP/WONCA Charts as a mental disorders screen by comparing them both with other questionnaires previously validated and with the assessment of a mental health specialist using a structured diagnostic interview. METHODS We trained community health workers and nurse assistants working in a collaborative mental health care model to administer the COOP/WONCA Charts, the 20-item Self-Reporting Questionnaire (SRQ-20), and the World Health Organization Five Well-Being Index (WHO-5) to 120 primary care patients. A psychiatrist blinded to the patients' results on these questionnaires administered the SCID, or Structured Clinical Interview for the DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition). RESULTS The area under the receiver operating characteristic curve was at least 0.80 for single items, a 3-item combination, and the total score of the COOP/WONCA Charts, as well as for the SRQ-20 and the WHO-5, for screening both for all mental disorders and for depressive disorders. The accuracy, sensitivity, specificity, and positive and negative predictive values of these measures ranged between 0.77 and 0.92. Community health workers and nurse assistants rated the understandability, ease of use, and clinical relevance of all 3 questionnaires as satisfactory. CONCLUSIONS One-time assessment of patients with the COOP/WONCA Charts is a valid and feasible option for screening for mental disorders by primary care teams.

Acupuncture and Temporomandibular Disorders: A 3-Month Follow-up EMG Study

Objectives: The purpose of this study was to investigate the levels of electromyographic (EMG) activation and maximal molar bite force before and after a 3-month acupuncture therapy in individuals with temporomandibular disorder (Helkimo Index) from a pool of subjects attending the Special Care Course of the Ribeirao Preto Dental School, Sao Paulo University, Brazil. Design: All 17 patients, aged between 37 and 50 years (44.2 +/- 4.84 years), with an average weight of 71 +/- 9.45 kg and height of 1.64 +/- 0.07 m, were clinically examined with regard to pain and dysfunctions of the masticatory system. The temporomandibular acupuncture points of needling were IG4, E6, E7, B2, VB14, VB20, ID18, ID19, F3, E36, VB34, E44, R3, and HN3. EMG measures were acquired before and after the treatment using a MyoSystem-BR1 electromyographer. The data collected at rest, protrusion, left and right laterality, and clenching were normalized by maximum voluntary contraction. Maximal bite force in right and left molar regions were registered using a dynamometer with a capacity of up to 1000 N, adapted for oral conditions. The highest value out of three recordings was considered to be the individual's maximal bite force. The results were statistically analyzed using the paired t test (SPSS version 15.0) during the comparison before and after treatment. Results: We found decreased EMG activity at rest, protrusion, left and right laterality, and clenching; as well as increased values of maximal bite force after acupuncture treatment. Conclusions: Acupuncture promoted alterations in the EMG activity of masticatory muscles, increased maximal molar bite force, and led to remission of the subjects' painful symptomatology.

Gender Differences in Life Expectancy and Disability-Free Life Expectancy Among Older Adults in Sao Paulo, Brazil

Background: Research on life expectancy has demonstrated the negative impact of disability on the health of older adults and its differential effects on women as evidenced by their higher disabled life expectancy (DLE). The goal of the present study was to investigate gender differences in total life expectancy (TLE), disability-free life expectancy (DFLE), and DLE; examine gender differences on personal care assistance among older adults in Sao Paulo, Brazil; and discuss the implications for public policies. Methods: The sample was drawn from two waves (2000, 2006) of the dataset of Salud, Bienestar, y Envejecimiento, a large longitudinal study conducted in Sao Paulo (n = 2,143). The study assessed disability using the activities of daily living (ADL). The interpolation of Markov Chain method was used to estimate gender differences in TLE, DLE, and DFLE. Findings: TLE at age 60 years was approximately 5 years longer for women than men. Women aged 60 years were expected to live 28% of their remaining lives twice the percentage for men with at least one ADL disability. These women also lived more years (M = 0.71, SE = 0.42) with three or more ADL disabilities than men (M = 0.82, SE = 0.16). In terms of personal care assistance, women received more years of assistance than men. Conclusion: Among older adults in Sao Paulo, women lived longer lives but experienced a higher and more severe disability burden than men. In addition, although women received more years of personal assistance than men, women experienced more unmet care assistance needs. Copyright (C) 2011 by the Jacobs Institute of Women`s Health. Published by Elsevier. Inc.

Language disorders in dementia of the Alzheimer type

The language profile of a group of 18 Alzheimer patients is documented and their performance on a standard aphasia test battery compared to a group of institutionalized, nonneurologically impaired control subjects matched for age, sex, and educational level. The Alzheimer patients scored significantly lower than the controls in the areas of verbal expression, auditory comprehension, repetition, reading, and writing. Articulation abilities were the same in each group. A language deficit was evident in all Alzheimer patients. The language disorder exhibited resembled a transcortical sensory aphasia. Syntax and phonology remained relatively intact but semantic abilities were impaired. The results support the inclusion of a language deficit as a diagnostic criterion of Alzheimer's disease.

Biomechanical consequences of impairment: A taxonomically valid basis for classification in a unified disability athletics system

Developing a unified classification system to replace four of the systems currently used in disability athletics (i.e., track and field) has been widely advocated. The diverse impairments to be included in a unified system require severed assessment methods, results of which cannot be meaningfully compared. Therefore, the taxonomic basis of current classification systems is invalid in a unified system. Biomechanical analysis establishes that force, a vector described in terms of magnitude and direction, is a key determinant of success in all athletic disciplines. It is posited that all impairments to be included in a unified system may be classified as either force magnitude impairments (FMI) or force control impairments (FCI). This framework would provide a valid taxonomic basis for a unified system, creating the opportunity to decrease the number of classes and enhance the viability of disability athletics.

Immunology of multiple sclerosis

Multiple sclerosis (MS) is an autoimmune disease of the central nervous system (CNS) leading to demyelination, axonal damage, and progressive neurologic disability. The development of MS is influenced by environmental factors, particularly the Epstein-Barr virus (EBV), and genetic factors, which include specific HLA types, particularly DRB1*1501-DQA1*0102-DQB1*0602, and a predisposition to autoimmunity in general. MS patients have increased circulating T-cell and antibody reactivity to myelin proteins and gangliosides. It is proposed that the role of EBV is to infect autoreactive B cells that then seed the CNS and promote the survival of autoreactive T cells there. It is also proposed that the clinical attacks of relapsing-remitting MS are orchestrated by myelin-reactive T cells entering the white matter of the CNS from the blood, and that the progressive disability in primary and secondary progressive MS is caused by the action of autoantibodies produced in the CNS by ­meningeal lymphoid follicles with germinal centers.

Review of diagnostic screening instruments for alcohol and other drug use and other psychiatric disorders

In recent years there has been a growing recognition that many people with drug or alcohol problems are also experiencing a range of other psychiatric and psychological problems. The presence of concurrent psychiatric or psychological problems is likely to impact on the success of treatment services. These problems vary greatly, from undetected major psychiatric illnesses that meet internationally accepted diagnostic criteria such as those outlined in the Diagnostic and Statistical Manual (DSM-IV) of the American Psychiatric Association (1994), to less defined feelings of low mood and anxiety that do not meet diagnostic criteria but nevertheless impact on an individual’s sense of wellbeing and affect their quality of life.