Biomedical subjects

Sjef van der Linden

Publications and source records attributed to Sjef van der Linden.

26 records · Page 2Linked to original sources

PubMed2002

COBRA combination therapy in patients with early rheumatoid arthritis: long-term structural benefits of a brief intervention.

OBJECTIVE: The Combinatietherapie Bij Reumatoide Artritis (COBRA) trial demonstrated that step-down combination therapy with prednisolone, methotrexate, and sulfasalazine (SSZ) was superior to SSZ monotherapy for suppressing disease activity and radiologic progression of rheumatoid arthritis (RA). The current study was conducted to investigate whether the benefits of COBRA therapy were sustained over time, and to determine which baseline factors could predict outcome. METHODS: All patients had participated in the 56-week COBRA trial. During followup, they were seen by their own rheumatologists and were also assessed regularly by study nurses; no treatment protocol was specified. Disease activity, radiologic damage, and functional ability were the primary outcome domains. Two independent assessors scored radiographs in sequence according to the Sharp/van der Heijde method. Outcomes were analyzed by generalized estimating equations on the basis of intent-to-treat, starting with data obtained at the last visit of the COBRA trial (56 weeks after baseline). RESULTS: At the beginning of followup, patients in the COBRA group had a significantly lower mean time-averaged 28-joint disease activity score (DAS28) and a significantly lower median radiologic damage (Sharp) score compared with those in the SSZ monotherapy group. The functional ability score (Health Assessment Questionnaire [HAQ]) was similar in both groups. During the 4-5 year followup period, the time-averaged DAS28 decreased 0.17 points per year in the SSZ group and 0.07 in the COBRA group. The Sharp progression rate was 8.6 points per year in the SSZ group and 5.6 in the COBRA group. After adjustment for differences in treatment and disease activity during followup, the between-group difference in the rate of radiologic progression was 3.7 points per year. The HAQ score did not change significantly over time. Independent baseline predictors of radiologic progression over time (apart from treatment allocation) were rheumatoid factor positivity, Sharp score, and DAS28. CONCLUSION: An initial 6-month cycle of intensive combination treatment that includes high-dose corticosteroids results in sustained suppression of the rate of radiologic progression in patients with early RA, independent of subsequent antirheumatic therapy.

Adult↗

PubMed2002

Determination of the minimal clinically important difference in rheumatoid arthritis joint damage of the Sharp/van der Heijde and Larsen/Scott scoring methods by clinical experts and comparison with the smallest detectable difference.

OBJECTIVE: To assess the minimal clinically important difference (MCID) in joint damage on hand and foot radiographs of patients with early rheumatoid arthritis (RA) as assessed with the Sharp/van der Heijde and Larsen/Scott methods, and to study how the smallest detectable difference (SDD) relates to the MCID for each method. METHODS: The judgments of an international panel of experts on the clinical relevance of progression of joint damage as seen on sets of radiographs obtained at 1-year intervals in 4 clinical settings (early versus late RA and mild versus high disease activity) were used as the external criterion, which was compared with the progression scores as determined by the 2 scoring methods. Progression scores with the highest combined sensitivity and specificity for detecting clinically relevant progression represented the MCID. Subsequently, the sensitivity and specificity of the scoring methods were determined when using the SDD as the threshold for relevant progression, and these were compared with the sensitivity and specificity of the MCID. RESULTS: The panel judged changes in joint damage around the level of the SDD (5.0) of the Sharp/van der Heijde method as minimal clinically important, resulting in satisfactory sensitivity (mean 79%) and specificity (mean 84%) for detecting clinically important progression in the 4 clinical settings when using the SDD as the threshold value. The MCID (mean 2.3) of the Larsen/Scott method was much smaller than its SDD (5.8), and the sensitivity for detecting clinically important progression by applying the SDD as threshold was consequently low (mean 51%), accompanied by high specificity (mean 99%). CONCLUSION: This study suggests that the SDD of the Sharp/van der Heijde method can be used as the MCID, i.e., as the threshold level for individual response criteria. The SDD of the Larsen/Scott method, however, turned out to be too insensitive to use as the threshold for individual clinically relevant change.

Arthritis, Rheumatoid↗

PubMed2002

Assessment of fatigue in patients with ankylosing spondylitis: a psychometric analysis.

OBJECTIVES: To investigate whether the single-item fatigue question of the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) and the Multidimensional Fatigue Inventory (MFI) are appropriate instruments to measure fatigue in ankylosing spondylitis (AS); to identify factors that influence fatigue in AS; and to assess how fatigue in all its aspects is associated with quality of life in AS. METHODS: A total of 812 patients with AS were included. Patients completed questionnaires on disease activity (BASDAI), functional ability (Bath Ankylosing Spondylitis Functional Index [BASFI]), global well-being (Bath Ankylosing Spondylitis Global Score [BAS-G]), overall perceived health (EuroQoL visual analog scale), and quality of life (Ankylosing Spondylitis Quality of Life questionnaire, and Short Form 36 [SF-36]). Patients were dichotomized into a F+ group (fatigue = major symptom) if the BASDAI fatigue score was > 5.0 and a F- group (fatigue = minor symptom) if the fatigue score was < 5.0. Reproducibility was assessed with intraclass correlation coefficients, and responsiveness was calculated according to 3 different methods. Logistic regression analysis was used to determine which factors were associated with fatigue. Multiple regression analysis was used to investigate whether fatigue contributes in explaining quality of life. RESULTS: Fifty-three percent of the patients were assigned to the F+ group. They scored significantly worse compared with the F- group with respect to each dimension of the MFI and to all other questionnaires studied (all P < 0.001). The BASDAI fatigue question, as well as each separate dimension of the MFI, showed moderate to good reproducibility (0.57-0.75) and responsiveness (0.23-0.96). Fatigue was, in the opinion of the patients, highly associated with pain (70% of patients) and stiffness (54% of patients). Logistic regression analysis showed that scores on BASDAI, BASFI, BAS-G, and mental health status (SF-36) were independently associated with fatigue (R(2) = 0.52). Multiple regression analysis showed that scores on the BASDAI fatigue question were significantly associated with quality of life. With the 5 MFI dimensions as explanatory variables, different aspects of fatigue were associated with different domains of quality of life. CONCLUSIONS: Fatigue as a major symptom of AS can effectively be measured with either a single-item question on the intensity of fatigue or with the MFI. The MFI, however, provides more insight into specific dimensions of fatigue. Fatigue appears to be associated with the level of disease activity, functional ability, global well-being, and mental health status. In addition, fatigue negatively influences different aspects of quality of life.

Adult↗

PubMed2002

Reproducibility of clinical performance assessment in practice using incognito standardized patients.

BACKGROUND: The reproducibility of authentic assessment methods has been investigated for objective structured clinical examinations (OSCEs) and video assessment in general practice, but not for assessment with incognito standardized patients. PURPOSE: To investigate the reproducibility of assessment with incognito standardized patients. METHODS: A total of 27 Dutch rheumatologists in 16 hospitals were each visited by 8 incognito standardized patients presenting with different rheumatological disorders. After each visit, the standardized patient completed a case-specific checklist containing items on medical history, physical examination and management. Over a 20-month period, 254 incognito visits took place, of which 201 were first visits. The standardized patient was detected by the rheumatologist in 2 cases only. These encounters were not included in the analysis. Generalizability theory was used to investigate the reproducibility of the assessment. RESULTS: One fifth of the variance can be attributed to variation between rheumatologists. The largest variance is due to the variation in difficulty among cases. A reproducible assessment requires 3 hours of testing time (6 cases) if it is obtained through a norm-referenced interpretation of scores and 7 hours of testing time (14 cases) if it is obtained through an absolute interpretation of scores. CONCLUSION: The reproducibility of performance assessment in clinical practice by incognito standardized patients is similar to that of other authentic measurements for the assessment of clinical competence and performance.

Analysis of Variance↗

PubMed2002

Seronegative spondyloarthritides.

Epidemiological studies on the spondyloarthritides have been hindered in the past by the lack of adequate classification criteria for the whole group of these diseases. Using the Amor and the European Spondyloathropathy Study Group (ESSG) criteria the total prevalence of such diseases has been found to be higher than estimated in the past. The prevalence of ankylosing spondylitis varies across populations, but closely parallels the frequency of HLA B27-associated subtypes. The lack of well established criteria for reactive arthritis and the varying expression of its clinical manifestations are the principal reasons for the under-reporting of the true prevalence and incidence of this type of spondyloarthritis. Few data exist on the prevalence and incidence of psoriatic arthritis. A recent European study on an inception cohort of patients having inflammatory bowel disease has evaluated the prevalence of spondyloarthritis using the ESSG criteria. Of the patients studied, 18% met these criteria. Undifferentiated spondyloarthritis is one of the most frequent spondyloarthritides. It also includes a number of different subtypes.

Adult↗

PubMed2002

A randomized clinical trial comparing fitness and biofeedback training versus basic treatment in patients with fibromyalgia.

OBJECTIVE: To compare the therapeutic effects of physical fitness training or biofeedback training with the results of usual care in patients with fibromyalgia (FM). METHODS: One hundred forty-three female patients with FM (American College of Rheumatology criteria) were randomized into 3 groups: a fitness program (n = 58), biofeedback training (n = 56), or controls (n = 29). Half the patients in the active treatment groups also received an educational program aimed at improving compliance. Assessments were done at baseline and after 24 weeks. The primary outcome was pain [visual analog scale (VAS)]. Other endpoints were the number of tender points, total myalgic score (dolorimetry), physical fitness, functional ability (Arthritis Impact Measurement Scale and Sickness Impact Profile), psychological distress (Symptom Checklist-90-Revised), patient global assessment (5 point scale), and general fatigue (VAS). RESULTS: Baseline scores were similar in all 3 groups. Altogether 25 (17.5%) patients dropped out; they were similarly distributed over all groups: 14 patients after randomization and 11 (8%) during the study. A true high impact level for fitness training was not attained by any patient. After treatment, no significant differences in change scores of any outcome were found between the groups (ANOVA, p > 0.05). All outcome measures showed large variations intra- and interindividually. The educational program did not result in higher compliance with training sessions (62% vs 71%). Analysis of the subgroup of subjects with a high attendance rate (> 67%) also showed no improvement. CONCLUSION: In terms of training intensity and maximal heart rates, the high impact fitness intervention had a low impact benefit. Therefore effectiveness of high impact physical fitness training cannot be demonstrated. Thus compared to usual care, the fitness training (i.e., low impact) and biofeedback training had no clear beneficial effects on objective or subjective patient outcomes in patients with FM.

Adult↗

PubMed2002

High or low intensity aerobic fitness training in fibromyalgia: does it matter?

OBJECTIVE: To determine the efficacy of training in fibromyalgia (FM), we compared the effects of high intensity fitness training (HIF) and low intensity fitness training (LIF). METHODS: Thirty-seven female patients with FM were randomly allocated to either a HIF group (n = 19) or a LIF group (n = 18). Four patients (1 HIF group, 3 LIF group) refused to participate after randomization but before the start of the intervention. They were excluded from the analysis. Assessments were performed at baseline and after 20 weeks of HIF or LIF. The primary outcome was patient's global assessment [on 100 mm visual analog scale (VAS)]. Secondary endpoints were pain, number of tender points, total myalgic score, physical fitness, health status, and psychological distress. RESULTS: One patient in the HIF group (n = 18) and 2 in the LIF group (n = 15) stopped training sessions during the course of the study. Nine of 18 patients in the HIF group compared to 8 of 15 patients in the LIF group achieved a participation rate of 67% or more. Most important reasons for nonadherence were postexercise pain and fatigue, time consumption, and stress. The VAS for global well being improved slightly from 64 to 56 mm in the HIF group, and did not change in the LIF group (58 to 61 mm) (p = 0.07). The Wmax (physical fitness) changed modestly from 110 to 123 watt in the HIF group, and from 97 to 103 watt in the LIF group (p = 0.3). VAS for pain increased from 53 to 64 mm in the HIF group and from 52 to 54 mm in the LIF group. The large standard deviations around mean change in global assessments, number of tender points, total myalgic score, and psychological distress (by SCL-90) severely influenced the power to detect within- and between-group differences. Analysis limited to those patients who accomplished a high attendance rate (> 67%) showed similar results. CONCLUSION: High intensity physical fitness training compared to low intensity physical fitness training leads to only modest improvements in physical fitness and general well being in patients with FM, and does not positively affect psychological status and general health.

Adult↗

PubMed2002

Doctor-patient interaction: standardized patients' reflections from inside the rheumatological office.

OBJECTIVE: To assess appreciation and quality of doctor-patient interaction by exploring standardized patients' (SP) opinions on aspects of the interaction between doctors and standardized patients. METHODS: A focus group interview was organized with SP who had completed 254 incognito visits to 26 Dutch rheumatologists in a study assessing rheumatologists' daily practice performance; 13 of 16 SP attended the interview. Patients discussed aspects of interaction with the physicians. The interview was audiotaped and transcribed literally. Recurring themes were identified. RESULTS: Participants were on the whole very satisfied with the rheumatological care received. Factors contributing to satisfaction included "being approached as a person," "being treated respectfully," and "being given enough room to mention all complaints." On the other hand, SP were struck by the variation in performance among the rheumatologists. CONCLUSION: Physicians may not be aware of the influence of their behavior on patients. Most critical comments from patients regarding communication and behavior were on small things, which should not be too difficult to change in daily practice.

Aged↗