This study extends previous work to consider whether individuals with rheumatoid arthritis (RA) can be categorised into groups with similar illness representations. Data from 227 RA patients attending outpatient clinics were collected prospectively at two time points, 6 months apart. The optimal number of illness representation groups at the baseline assessment was identified using latent profile analysis. Two groups of individuals sharing similar illness perception profiles were identified. The smaller group (43%), characterised by a negative representation of their illness, attributed more symptoms to their condition and reported stronger perceptions of the consequences, chronicity and cyclicality of their condition, and lower control compared to the positive representation group (57%). Cross-sectionally, membership of the negative representation group was associated with higher levels of pain and functional disability and, longitudinally, with increases in levels of pain, functional disability and distress. These data highlight the central role of illness perceptions in RA and suggest that individuals with RA can be categorised into groups with similar illness representations.
What's known on the subject? and What does the study add?• Erectile dysfunction (ED) is often associated with endothelial dysfunction. It is also recognized as a marker for underlying vascular disease. There are missed opportunities to address cardiovascular risk factors in these men.• Simvastatin administered for 6 months improves sexual health-related quality of life in men aged Ն40 years with untreated ED. It reduces the risk of future cardiovascular events via a reduction in serum cholesterol in men with ED. A non-significant trend towards improving erectile function suggests longer trials with a more potent statin may be required. There is high probability (>80%) of simvastatin being cost-effective in men with ED. Enquiry about erectile function provides the opportunity to address cardiovascular risk factors. Objective• To evaluate the effectiveness and cost-effectiveness of simvastatin on erectile function and health-related quality of life in men aged Ն40 years with erectile dysfunction (ED). Patients and Methods• ED is common in men aged Ն40 years and impacts upon their overall health-related quality of life and that of their partners.• Men aged Ն40 years who were not receiving lipid lowering or anti-hypertensive medication and not at high cardiovascular risk were recruited from 10 general practices in the East of England. • In total, 173 eligible men with untreated ED were randomized to double-blind treatment with 40 mg of simvastatin or placebo once daily for 6 months. Data were collected at three points over 30 weeks.• The main outcome was erectile function (International Index of Erectile Function-5 score). Secondary outcomes included male ED-specific quality of life (MED-QoL), quality-adjusted life years (QALYs) using the generic Euroqol measure (EQ-5D), endothelial function, cardiovascular risk, cholesterol and health service costs. Results• There was no significant difference in erectile function between the simvastatin and placebo groups (mean change, 1.28 vs 0.07, z = 1.1, p = 0.27), although a significant improvement in MED-QoL was observed (5% vs 2%, z = 2.09, p = 0.04).• Both 10-year cardiovascular risk and low-density lipoprotein were reduced (cardiovascular risk, z = -3.67, p < 0.001; low-density lipoprotein, z = -5.46, p < 0.001), with no consistent change in endothelial function.• The frequency of sexual encounters is correlated with improved erectile function.• The joint distribution of costs and QALY benefits indicates that the probability of simvastatin being cost-effective for willingness-to-pay thresholds of £20 000 and £30 000 is 86% and 83%, respectively. Conclusions• Identifying men with ED provides an opportunity to modify future cardiovascular risk and to improve MED-QoL by treating them with 40 mg of simvastatin.• The joint analysis of costs and QALY benefits suggests that there is high probability that simvastatin is a cost-effective strategy in men with ED. Sexual Medicine• The findings could influence urological and primary care practice by including questions on ED during ...
Psychological distress in rheumatoid arthritis (RA) is associated with adverse clinical outcomes, and appears highly related to patients' illness perceptions. This study aimed to investigate the association between illness perceptions, psychological distress, positive outlook and physical outcomes in RA. Two hundred and thirty patients aged >18 years and prescribed at least one disease-modifying anti-rheumatic drug (DMARD) were recruited from outpatient clinics across Hertfordshire (England). Patients completed a questionnaire that assessed psychological distress and positive outlook (depression, anxiety and positive outlook scale), illness perceptions (IPQ-R) and functional disability (health assessment questionnaire). Information regarding prescribed medication and disease activity [disease activity score (DAS28)] was collected from medical notes. Psychological distress, but not positive outlook, was associated with functional disability and DAS28. After controlling for sex, age and DAS28, perceptions of greater symptomatology (identity) and lesser understanding of RA (coherence) were significantly associated with increased psychological distress. Perceptions of greater treatment control were associated with greater positive outlook, but only for those with low DAS28. Coherence was also associated with positive outlook. These findings indicate that illness perceptions may influence psychological distress and positive outlook in RA patients, and may therefore be a useful basis for future psychological interventions.
Insufficient cerebral O 2 supply leads to brain cell damage and loss of brain cell function. The relationship between the severity of hypoxemic brain cell damage and the loss of electrocortical brain activity (ECBA), as measure of brain cell function, is not yet fully elucidated in near-term newborns. We hypothesized that there is a strong relationship between cerebral purine and pyrimidine metabolism, as measures of brain cell damage, and brain cell function during hypoxemia. Nine near-term lambs (term, 147 d) were delivered at 131 (range, 120-141) d of gestation. After a stabilization period, prolonged hypoxemia (fraction of inspired oxygen, 0.10; duration, 2.5 h) was induced. Mean values of carotid artery blood flow, as a measure of cerebral blood flow, and ECBA were calculated over the last 3 min of hypoxemia. At the end of the hypoxemic period, cerebral arterial and venous blood gases were determined and CSF was obtained. CSF from 11 normoxemic siblings was used for baseline values. HPLC was used to determine purine and pyrimidine metabolites in CSF, as measures of brain cell damage. Concentrations of purine and pyrimidine metabolites were significantly higher in hypoxemic lambs than in their siblings, whereas ECBA was lower in hypoxemic lambs. Significant negative linear relationships were found between purine and pyrimidine metabolite concentrations and, respectively, cerebral O 2 supply, cerebral O 2 consumption, and ECBA. We conclude that brain cell function is related to concentrations of purine and pyrimidine metabolites in the CSF. Reduction of ECBA indeed reflects the measure of brain damage due to hypoxemia in near-term newborn lambs. Despite the increase in survival of preterm infants, long-term morbidity has not changed (1). Hypoxia-ischemia-related brain damage is an important contributor to perinatal mortality and long-term morbidity in survivors (2).The immature brain is very vulnerable to disturbances in cerebral oxygenation and hemodynamics. Cerebral O 2 supply depends on both CaO 2 and CBF. Cerebral hypoxia is defined as an insufficient O 2 supply to the brain, resulting from either hypoxemia (decreased CaO 2 ) or hypoperfusion (decreased CBF). During hypoxemia, the brain is considered to be protected adequately from injury by an increase in CBF to preserve cerebral O 2 supply and to stabilize brain metabolism, unless cerebral ischemia occurs from supervening systemic hypotension. With the neuronal oxygen and glucose debts arising from severe hypoxemia, oxidative metabolism shifts to anaerobic glycolysis, with its inefficient generation of highenergy phosphate reserves, necessary to maintain cellular ionic gradients and other metabolic processes. However, when hypoxemia progresses, cellular energy failure ultimately occurs, which, if not promptly reversed, results in decreased neuronal viability and death of the cell (3).During insufficient cerebral O 2 supply, an accumulation of purine metabolites, which are the degradation products from high-energy phosphate compounds (ATP, ADP, and AMP),...
Adequate cerebral perfusion is necessary to preserve cerebral O(2) supply in order to maintain brain cell function. Our aim was to assess the influence of gestational age on the response of cerebral hemodynamics to hypoxemia and to determine thresholds of cerebral O(2) supply for preservation of brain cell function in preterm born lambs. Lambs were delivered by hysterotomy at 141 (n=5), 134 (n=5) or 127 (n=7) days of gestation. Decreases in arterial oxygen content (CaO(2)) were induced by stepwise reduction of the fraction of O(2) in inspired air (FiO(2)). Mean arterial blood pressure (MABP), carotid artery blood flow (Qcar), and electrocortical brain activity as a measure of brain cell function, were continuously recorded. Cerebral arterial blood gases were analyzed at the end of each hypoxemic level to calculate CaO(2) and cerebral O(2) supply. In contrast to 141-day lambs, MABP could not be maintained in 134-day and 127-day lambs at levels of severe hypoxemia. Increases in Qcar were observed at levels of moderate hypoxemia in all gestational age-groups. Albeit Qcar increased further at levels of severe hypoxemia in the 141-day lambs, Qcar declined under these conditions in the 134-day and 127-day lambs. The threshold of cerebral O(2) supply for the preservation of brain cell function was however similar in all gestational age-groups (1.7 ml/min). It is concluded that the ability to maintain cerebral function during hypoxemia depends upon the ability to preserve cerebral O(2) supply by means of cerebral hemodynamic compensatory mechanisms, which are not fully matured until 96% of gestation.
Background Lung cancer is the leading cause of cancer death in the world. A significant minority of lung cancer patients have never smoked (14% in the UK, and ranging from 10% to 25% worldwide). Current evidence suggests that never‐smokers encounter delays during the diagnostic pathway, yet it is unclear how their experiences and reasons for delayed diagnoses differ from those of current and former smokers. This rapid review assessed literature about patient experiences in relation to symptom awareness and appraisal, help‐seeking, and the lung cancer diagnostic pathway, comparing patients with and without a smoking history. Methods MEDLINE, PsychINFO and Google Scholar were searched for studies (2010‐2020) that investigated experiences of the pathway to diagnosis for patients with and without a smoking history. Findings are presented using a narrative synthesis. Results Analysis of seven quantitative and three qualitative studies revealed that some delays during symptom appraisal and diagnosis are unique to never‐smokers. Due to the strong link between smoking and lung cancer, and low awareness of non‐smoking related lung cancer risk factors and symptoms, never‐smokers do not perceive themselves to be at risk. Never‐smokers are also likely to evaluate their experiences in comparison with other non‐smoking related cancers, where prognosis is likely better, potentially leading to lower satisfaction with healthcare. Conclusion Never‐smokers appear to have different experiences in relation to symptom appraisal and diagnosis. However, evidence in relation to help‐seeking, and what is driving diagnostic delays for never‐smoker patients specifically is lacking.
Dopamine D2 receptor agonists represent a first line treatment option in young patients with signs and symptoms of idiopathic Parkinson's disease. An association between the use of D2 receptor agonists in Parkinson's disease patients and heart failure has been reported. The identification of the underlying mechanism is needed to minimize the resultant cardiovascular morbidity. In a phase I clinical trial, a D2 receptor agonist (pramipexole) was administered to 52 healthy male subjects following a dose escalation scheme. Serial measurements of resting blood pressure, heart rate, and derived parameters including pulse pressure, pulsatile stress, and rate pressure product were analysed. Statistically significant and clinically relevant increases in most of the assessed parameters were found. Ten subjects were removed prematurely from the trial because of clinically significant increases in blood pressure and/or heart rate requiring immediate intervention with IV rescue medications including a selective β-1 blocker. The observed drug-related changes in vital signs were of clinical relevance and might explain some of the cardiovascular morbidity reported in patients receiving D2 receptor agonist in clinical settings. We suggest that the additional use of a β-1 blocking agent might mitigate the risk of cardiovascular morbidity among patients receiving long-term D2 receptor agonists.
Introduction: Reported levels of adherence to prophylaxis among young people with haemophilia (YPH) vary widely and are predominately based on estimations made by healthcare professionals and parents. Reasons for (non)adherence among YPH in particular have not been evidenced. Aim: to examine experiences in relation to prophylaxis with YPH themselves, and barriers and facilitators to their adherence. Methods: 11 Participants were recruited in five haemophilia centres across England and Wales. All patients who met the inclusion criteria (aged 12-25, diagnosed with haemophilia, on prophylaxis) were approached during a routine check-up appointment, and all participants who agreed to take part were interviewed. Interviews were audio recorded, transcribed and analysed using Interpretative Phenomenological Analysis. Results: Self-reported adherence to prophylaxis was good. Few participants admitted to intentionally skipping injections although they reported sometimes forgetting. However, due to the increasingly personalised and flexible approach to prophylaxis, adherence is not straightforward to define. Barriers to adherence included a busy lifestyle, dislike of the intravenous injection, venous access issues, anxiety or stress and being out of one's normal routine. Support was an important facilitator to adherence, including support from health professionals at the haemophilia centre as well as friends. Parents appear to be very involved with their child's haemophilia management, even after they leave home. Conclusion: What this study adds is that the increasingly flexible and personalised approach to managing prophylaxis in haemophilia may sometimes lead to confusion around treatment frequency and dosing. This may lead to accidental non-adherence, which is distinct from both skipping and forgetting. Advice from haemophilia teams may not always be consistent and is likely to be interpreted differently by different individuals. Some additional training and education of patients and their families to increase their knowledge and skills around prophylaxis may reduce this confusion and therefore is likely to improve adherence further.
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