What constitutes uncertainty in systemic lupus erythematosus and rheumatoid arthritis?

Patient uncertainty is associated with conditions with no known cause or cure, such as systemic lupus erythematosus (SLE) and rheumatoid arthritis (RA), and despite its potential role in chronic illness management, it is still a poorly understood concept. This study constitutes an in-depth investigation of patient uncertainty in SLE and RA. We conducted (i) structured interviews with a sample of rheumatology health care professionals (HCPs) (n = 8) and (ii) in-depth, semi-structured interviews with a sample of SLE (n = 17) and RA (n = 15) patients. Interviews were audio-taped, transcribed verbatim and analysed thematically using detailed line-by-line coding. Patient uncertainty was conceptualised in a framework of five domains: symptoms and prognosis, medical management, self-management, impact and social functioning. Even though these five domains were present in both the SLE and RA data, there were some differences at the sub-domain level. Several sources of uncertainty were put forward by the HCPs and subsequently confirmed in the patient interviews including the illness trajectory, age, gender and timing. Patients reported uncertainty relative to various aspects of their illness, its management and impact. Finally, HCPs discussed the behavioural and psychosocial impact of uncertainty, which further suggests its important role in patient management.

What do we know about self-reported fatigue in systemic lupus erythematosus?

Fatigue is one of the most complex and ill understood symptoms of chronic illness often reported as the number one complaint by patients with systemic lupus erythematosus (SLE). This paper aims to provide a comprehensive review of the literature on fatigue in SLE. A pool of 55 relevant articles was retrieved via electronic searches of six databases including MEDLINE, EMBASE, CINAHL, AMED, PsychINFO and PubMed. Fatigue in the studies reviewed was assessed by a range of self-report instruments, the content of which is varied. The results displayed a consensus on the high prevalence of fatigue in SLE, which is significantly higher when compared with controls. The aetiology of fatigue appears to be multifactorial. Disease activity is not always significantly associated with fatigue, in comparison with other secondary features of SLE and psychological variables. The literature is limited by the cross-sectional nature of most of the studies, which does not permit for any firm conclusion regarding the direction of causal relationships to be made. The high prevalence of fatigue in SLE emphasizes the need for further detailed prospective research to inform the understanding of its aetiology, course and management.

A maximally sensitive clinical decision rule to reduce the need for radiography in mandibular trauma.

INTRODUCTION: To identify clinical symptoms and signs that exclude the presence of mandibular fracture in patients presenting with mandibular trauma and thus devise a clinical decision rule that will rule out the need for radiography in some patients. PATIENTS AND METHODS: A prospective study was conducted of consecutive patients with a possible diagnosis of mandibular fracture who attended a city-centre emergency department between July 2000 and December 2001. Clinical symptoms and signs were recorded for each patient using a predesigned proforma. Radiographic evaluation of a suspected mandibular fracture consisted of lateral-oblique and postero-anterior mandibular views. The presence of a fracture was based on the interpretation of the X-rays by a radiologist who was blinded to the clinical probability of a fracture. Data were initially analysed using the chi-square test. Recursive partitioning was then performed to create a maximally sensitive decision tree. RESULTS: 280 patients were included in the study, 65 of whom had a mandibular fracture. A maximally sensitive decision rule was found that identified 5 parameters (malocclusion, trismus, broken teeth, pain with mouth closed, step deformity) whose absence excluded mandibular fracture. This rule has a sensitivity of 100% and specificity of 39% in identifying patients with mandibular fracture. If applied to our patient cohort, this rule would have saved 83 radiographs without missing any fractures. CONCLUSIONS: A simple decision rule is presented that can be used to exclude the need for radiography in a subset of patients with mandibular trauma.

Foot pump prophylaxis for deep venous thrombosis-rate of effective usage following knee and hip arthroplasty.

We recorded the usage of foot pumps during the post-operative period in 29 patients undergoing knee or hip arthroplasty and made 621 recordings. Effective utilisation of foot pumps was seen in 37.2% of cases. There was a gradual reduction in correct utilisation with each day that passed post-operatively (day 1, 60.4%; day 2, 48.8%; day 3, 28.8%; day 4, 21.4%; day 5, 23%). This gradual reduction was statistically significant ( P=0.001) and mainly occurred between the second and third post-operative days. Effective usage was 60.2% overall at night and 36.4% during the day. Our results question the efficiency of foot pumps in deep venous thrombosis prophylaxis in the context of a true clinical setting.