Chest pain in general practice: incidence, comorbidity and mortality

BACKGROUND: Chest pain is a common symptom that presents the primary care physician with a complex diagnostic and therapeutic challenge. AIMS: To evaluate the natural history and management of patients diagnosed with chest pain of unspecified type or origin in primary care. DESIGN: Population-based case-control study. METHODS: The study included 13,740 patients with a first diagnosis of unspecified chest pain and 20,000 age- and sex-matched controls identified from the UK General Practice Research Database. Odds ratios (ORs) and 95% confidence intervals (CIs) were computed using unconditional logistic regression. Risk estimates were adjusted for age, sex and number of physician visits. RESULTS: The incidence of a new diagnosis of chest pain was 15.5 per 1000 person-years and increased with age, particularly in men. The risk of a chest pain diagnosis was greatest in patients with prior diagnoses of coronary heart disease (OR: 7.1; 95% CI: 6.1-8.2) and gastroesophageal reflux disease (OR: 2.0; 95% CI: 1.7-2.3). In the year after diagnosis, chest pain patients were more likely than controls to be newly diagnosed with coronary heart disease (OR: 14.9; 95% CI: 12.7-17.4) and heart failure (OR: 4.7; 95% CI: 3.6-6.1). A new diagnosis of chest pain was associated with an increased risk of death in the following year (RR: 2.3; 95% CI: 1.9-2.8). CONCLUSIONS: Some causes of chest pain are underdiagnosed in primary care. This is of particular consequence for the minority of chest pain patients with cardiac disease.     

The effect of Helicobacter pylori eradication on chronic use of acid-suppressant medication by patients in general practice; a randomised, double-blind study

OBJECTIVE: To study the feasibility of tapering long-term acid-suppressant drugs (ASD) use in chronic dyspeptic patients in relation to Helicobacter pylori eradication. DESIGN: Prospective randomised double-blind study. METHOD: Patients from 54 general-practitioner practices in the Amsterdam area were studied in the period 1 April 1997 - 30 September 1999 after selection on the basis of their use of acid suppressants for a period of at least 8 weeks. After gastroscopy the patients with a peptic ulcer (PUD) and H. pylori were treated with eradication therapy and patients without an ulcer but with H. pylori were randomised for eradication or placebo treatment. After a gradual reduction of acid suppressants over a 3-week period following the intervention, the patients kept a diary for 24 weeks of the quantities of acid suppressants and antacids they used. RESULTS: Of the 1083 patients approached, 434 were prepared to undergo the gastroscopy. Data for the follow-up period were available for 186 of the 227 H. pylori-positive patients. Of them 61% stopped ASD use during follow-up. The mean daily ASD dosage per patient decreased by 85% from 1.85 to 0.27 units (p < 0.05), with minimal antacids use. Of the 75 patients with peptic-ulcer disease 86% stopped ASD use. In patients with functional dyspepsia no difference in ASD use was observed after successful H. pylori eradication or placebo. Patients with mild reflux disease (GERD) used more ASD after H. pylori eradication than after placebo (p < 0.05). CONCLUSION. After H. pylori eradication many patients with PUD stopped ADS use, while GERD patients used more ASD than after placebo. A gradual withdrawal of long-term ASD use, supported by antacids and on-demand use of low-dosage ASD, facilitated reduction of ASD use during 6 months.     

Comparison of two different approaches for the analysis of data from a prospective cohort study: an application to work related risk factors for low back pain

Aims: To compare the results of a traditional approach using standard regression for the analysis of data from a prospective cohort study with the results of generalised estimating equations (GEE) analysis.

Methods: The research was part of a three year prospective cohort study on work related risk factors for low back pain. The study population consisted of a cohort of 1192 workers with no low back pain at baseline. Information on work related physical and psychosocial factors and the occurrence of low back pain was obtained by means of questionnaires at baseline and at the three annual follow up measurements. In a traditional standard logistic regression model, physical and psychosocial risk factors at baseline were related to the cumulative incidence of low back pain during the three year follow up period. In a GEE logistic model, repeated measurements of the physical and psychosocial risk factors were related to low back pain reported at one measurement point later.

Results: The traditional standard regression model showed a significant effect of flexion and/or rotation of the upper part of the body (OR = 1.8; 95% CI: 1.2 to 3.0), but not of moving heavy loads (OR = 1.4; 95% CI: 0.7 to 3.1). The GEE model showed a significant effect of both flexion and/or rotation of the upper part of the body (OR = 2.2; 95% CI: 1.5 to 3.3) and moving heavy loads (OR = 1.5; 95% CI: 1.0 to 2.4). No significant associations with low back pain were found for the psychosocial work characteristics with either method, but the GEE model showed weaker odds ratios for these variables than the traditional standard regression model.

Conclusions: Results show that there are differences between the two analytical approaches in both the magnitude and the precision of the observed odds ratios.

     

Childhood and early adult predictors of risk of incident back pain: Ontario Child Health Study 2001 follow-up

Musculoskeletal disorders of the back and spine are a leading cause of disability in working-age populations. There is limited information on the potential consequences of childhood socioeconomic and health status on the risk of incident back pain in early adulthood. The authors describe factors associated with having had a first episode of back pain during the past year in the Ontario Child Health Study, a prospective cohort study of children who were aged 4-16 years at the time of enrollment in 1983 and were resurveyed in 2001. Respondents reporting a first episode of back pain (n=143) were compared with respondents who had never experienced back pain (n=896). The annual incidence of a first episode of back pain in this sample of young adults was 74.7/1,000. Following adjustment for age, sex, childhood conditions, childhood health status, and measures of early adult health, behavior, socioeconomic status, and work environment, the risk of incident back pain was associated with both low (odds ratio (OR)=1.86, 95% confidence interval (CI): 1.14, 3.03) and moderate/high (OR=1.85, 95% CI: 1.07, 3.02) levels of psychological distress, current heavy smoking (OR=1.85, 95% CI: 1.10, 3.10), lower levels of parental education in childhood (OR=1.72, 95% CI: 1.06, 2.80), and emotional or behavioral disorders in childhood (OR=1.87, 95% CI: 1.02, 3.41). The associations of low childhood socioeconomic status and childhood emotional and behavioral disorders with risk of incident back pain in early adulthood are important findings with implications for better understanding the etiology of soft-tissue disorders.     

北京地区肠易激综合征的流行病学研究:一个整群、分层、随机的调查

目的 对北京市肠易激综合征（ＩＢＳ）的患病率及危险因素进行研究。方法 用整群、分层、单纯随机抽样方法,对北京市常住人口中１８￣７０岁的２４８６人进行问卷调查作为初筛,了解按Ｍａｎｎｉｎｇ标准加以补充及按罗马标准判断的有症状人群的检出率,再对筛出有症状的部分人在医院进行以排除结肠器质性疾病为目的的精查,根据精查的正确率对普查结果校正后估算出点患病率。对发病有关的危险因素作单因素和多因素分析,并对部分     

Development and psychometric evaluation of the patient assessment of upper gastrointestinal symptom severity index (PAGI-SYM) in patients with upper gastrointestinal disorders

Objective: Describe the development and evaluation of a new self-report instrument, the patient assessment of upper gastrointestinal disorders-symptom severity index (PAGI-SYM) in subjects with gastroesophageal reflux disease (GERD), dyspepsia, or gastroparesis. Methods: Recruited subjects with GERD (n=810), dyspepsia (n=767), or gastroparesis (n=169) from the US, France, Germany, Italy, the Netherlands, and Poland. Subjects completed the PAGI-SYM, SF-36, a disease-specific HRQL measure (PAGI-QOL), and disability day questions. Two-week reproducibility was evaluated in 277 stable subjects. We evaluated construct validity by correlating subscale scores with SF-36, PAGI-QOL, disability days, and global symptom severity scores. Results: The final 20-item PAGI-SYM has six subscales: heartburn/regurgitation, fullness/early satiety, nausea/vomiting, bloating, upper abdominal pain, and lower abdominal pain. Internal consistency reliability was good ( =0.79 0.91); test–retest reliability was acceptable (Intraclass correlation coefficients =0.60 0.82). PAGI-SYM subscale scores correlated significantly with SF-36 scores (all p < 0.0001), PAGI-QOL scores (all p < 0.0001), disability days (p< 0.0001), and global symptom severity (p < 0.0001). Mean PAGI-SYM scores varied significantly in groups defined by disability days (all p < 0.0001), where greater symptom severity was associated with more disability days. Conclusions: Results suggest the PAGI-SYM, a brief symptom severity instrument, has good reliability and evidence supporting construct validity in subjects with GERD, dyspepsia, or gastroparesis.     

Prognostic factors related to recurrent low-back pain and sickness absence

OBJECTIVES: This study aimed at determining the prognostic factors related to the recurrence of low-back pain and future sickness absence due to low-back pain. METHODS: Data were used from a prospective cohort study in a working population with a 3-year follow-up period. They were collected with annual questionnaires. A generalized estimating equation model was used to study the relation between pain characteristics, individual characteristics, and work-related factors and the recurrence of low-back pain or sickness absence due to low-back pain in the following year. Adjustments were made for potential confounders. RESULTS: All the pain characteristics [odds ratios (OR) varying from 1.4 to 2.4], flexion and rotation of the upper part of the body [OR 1.6, 95% confidence interval (95% CI) 1.1-2.5], low decision authority (OR 1.6, 95% CI 1.0-2.6), and low job satisfaction (OR 1.5, 95% CI 1.0-2.3), increased the risk of recurrent low-back pain. High disability due to low-back pain (OR 2.6, 95% CI 1.2-5.7), low co-worker support (OR 4.1, 95% CI 1.6-10.5), and low job satisfaction (OR 2.4, 95% CI 1.3-4.5) were predictors of sickness absence due to low-back pain. Lifting weights did not influence the risk of recurrences or sick leave. CONCLUSIONS: According to this study, high disability due to low-back pain is a prognostic factor for recurrent low-back pain and future sickness absence due to low-back pain. In addition, the following work-related factors predict a poor prognosis of low-back pain: flexion or rotation of the trunk, low job satisfaction, low decision authority, and low social support.     

Risk factors for sick leave due to musculoskeletal disorders among self-employed Dutch farmers: a case-control study

BACKGROUND: In Dutch agriculture, musculoskeletal disorders are a main cause of sick leave. Among self-employed insured farmers, neck, shoulder, upper extremity, and back disorders accounted for 30% of the claims for sick leave of less than 1 year This case-control study set out to identify and quantify risk factors for sick leave due to musculoskeletal disorders among self-employed Dutch farmers. METHODS: Sick leave, claimed at an insurance company from 1998 to 2001 for back (SL-BP, n = 198) or neck/shoulder/upper extremity trouble (SL-EXT, n = 89) was analyzed; the controls did not file any claim in this period (n = 816). RESULTS: Multivariate analysis showed that risk factors for SL-BP were increased age (OR = 1.06 per year, CI = 1.04-1.09), body mass index (BMI) >27 (OR = 1.93, CI = 1.2-3.2), smoking (OR = 1.90, CI = 1.2-2.9), former pain (OR = 3.28, CI = 2.1-5.1), tractor driving >1,000 hr/year (OR = 2.44, CI = 1.0-6.4), and "high work pace and workload" (OR = 1.59, CI = 1.0-2.4). SL-EXT was associated with pig (OR = 3.63, CI = 1.4-9.7), mushroom (OR = 6.14, CI = 1.4-27.2), or dairy/pig farming (OR = 4.56, 1.1-19.5), while age (OR = 1.10, CI = 1.06-1.14), smoking (OR = 1.79, CI = 1.0-3.2), and former pain (OR = 3.37, CI = 1.9-6.1) were also contributing. CONCLUSIONS: Prevention of sick leave of self-employed farmers should focus on life style (obesity, smoking), reducing older farmers' exposure to physical load, exposure to long-term tractor driving. Specific attention should be paid to animal and mushroom farmers.     

Women, drugs and HIV/AIDS: results of a multicentre European study

BACKGROUND: In the light of rising human immunodeficiency virus (HIV) incidence rates amongst women in Western Europe, a multicentred, cross-sectional study was undertaken to explore the multitude of possible factors associated with HIV in a population of female injecting drug users (IDU). METHODS: Face-to-face interviews were conducted with 1198 female IDU recruited from a variety of settings in Paris, Madrid, Rome, London and Berlin. Their HIV status was determined from antibody testing of blood or saliva samples or from written confirmation of HIV test results from a physician. A hierarchical logistic regression model was used to identify direct and indirect associations between socioeconomic factors, marginalization and risk behaviour with HIV prevalence. RESULTS: The HIV prevalence in the sample of female IDU was 27.8% (range: 1.4% in London and 52.6% in Madrid). Factors independently associated with HIV prevalence in the regression analysis included: age >25 years (OR = 2.0-2.9), left full-time education before age 14 (OR = 2.4), no fixed address (OR = 2.2), previous imprisonment (OR = 1.4), commercial sex (OR = 1.3), having a regular HIV positive sexual partner (OR = 6.6), ever shared needles (OR = 1.5) and any sexually transmitted disease (STD) infection in the last year (OR = 1.7). CONCLUSIONS: The sexual behaviour and partners of female IDU in Western Europe are as important a component in explaining the HIV epidemic in this population as other risk factors, including high-risk drug taking behaviour. Homeless IDU women may be an important residual risk group warranting future preventive interventions and women with a history of STD should be a particular target for health education. Differences in HIV prevalence across cities are very large and may be related to differences in harm reduction policies.     

FD和IBS病人中抑郁、焦虑患病率及其影响因素

目的：了解综合医院门诊功能性消化不良（functional dyspepsia，FD）和肠易激综合征（irritable bowel syndrome，IBS）患者中抑郁症、焦虑症的息病率；探讨其可能的危险因素。方法：调查成都市三家综合医院内FD和IBS门诊患者；对医院焦虑抑郁量表（HAD）评分≥9分的患者由精神科医生使用Hamilton量表进一步确诊。使用SPSS12．0和SAS8．0软件分析结果。结果：调查病例208例，男性75例，女性133例。其中FD患者100例，IBS患者108例。焦虑或抑郁的患病率25．48％，其中单纯抑郁患病率19．71％，单纯焦虑患病率22．12％，抑郁合并焦虑的患病率16．35％。可能的危险因素有：伴随有其它器质性疾病、发生生活事件、自觉目前健康状况差，离婚、丧偶或分居及中壮年人群，其OR值分别为2．590，2．782，4．096，3．569和3．877。结论：FD和IBS病人中抑郁症、焦虑症的患病率高，抑郁症和焦虑症共病率高；伴随有其它器质性疾病、发生生活事件、自觉目前健康状况差、离婚、丧偶或分居以及中壮年人群是可能的危险因素。     

Pain tolerance in upper limb disorders: findings from a community survey

Aims: To test the hypothesis that non-specific upper limb pain arises from altered pain perception with reduced tolerance of sensory stimuli. Methods: Subjects undergoing clinical examination as part of a community based survey of upper limb disorders were invited to return for an assessment of pain tolerance. A standardised algorithm was used to classify the 94 participants according to whether they had specific upper limb disorders (n = 22), non-specific arm pain (n = 15), or no arm pain (n = 57). Pain tolerance was assessed at three anatomical sites in each arm in response to electrocutaneous stimulation with alternating currents up to a maximum of 10 mA at three frequencies (5, 250, and 2000 Hz). A proportional odds model was used to compare pain tolerance thresholds according to sex, age, and diagnosis. Results: Women were less tolerant of pain than men (OR 0.13) and tolerance also declined with age (OR for one year increase in age 0.97). After allowance for sex and age, there was no indication that pain tolerance was lower in subjects with non-specific arm pain than in those with specific upper limb disorders or those who had no arm pain. Conclusions: The study hypothesis was not supported. However, before the hypothesis is dismissed, it should be tested further in patients with more severe and disabling arm pain.     

重复人工流产相关危险因素的横向研究

目的:探讨首次人工流产女性与重复人工流产女性之间不同的个体行为和社会经济差异,确定重复流产的相关危险因素。方法:调查2009年8月～2010年7月接受人工流产治疗服务女性1 132名,年龄20～49岁,采用回归分析方法研究重复流产的相关危险因素。结果:接受问卷调查女性的重复流产率为48.45%,调查一年间重复流产率为15.85%;重复流产的危险因素,包括生育史(OR=2.45),未婚或缺乏感情基础(OR=2.14),无业或失业(OR=1.66),吸烟或成瘾性药物使用(OR=1.43),低学历教育水平(OR=1.5)。其中部分女性(n=135)认为在经济条件允许或者建立婚姻关系后愿意继续妊娠。还有部分女性认为流产后未能获得相关避孕咨询,或采取不恰当的避孕方法,是重复流产的重要原因。结论:较高的女性重复流产比例,使开展流产后计划生育服务成为提高女性健康和生育质量的重要手段。虽然可以确定一些重复流产的相关危险因素,但是女性受到身心侵害的几率较高,所以预防非意愿妊娠需要全社会关心和努力。     

A survey of latent tuberculosis infection among laboratory healthcare workers in New York City.

OBJECTIVE: To determine the prevalence of positive tuberculin skin tests (TSTs), incidence of TST conversion, risk factors for positive TSTs, and history of active TB among HCWs in microbiology laboratories in New York City. DESIGN: Two-year survey from May 1999 to June 2001. SETTING: Nineteen microbiology laboratories. RESULTS: During the first year, interviews were conducted with 345 laboratory HCWs (mean, 18 HCWs per site; range, 2 to 51) to assess the prevalence of positive TSTs, but 3 (1%) could not recall their result and were excluded from further analyses. The mean age of the remaining 342 HCWs was 48 years; 68% (n = 233) were female, 54% (n = 183) received bacille Calmette-Guerin (BCG) vaccination, and 71% (n = 244) were foreign born. The prevalence of a positive TST was 57% (n = 196), but only 20% (n = 39) of the HCWs received isoniazid. The incidence of TST conversion in the second year of the study was 1% (1 of 108). Multivariate analysis identified age (odds ratio [OR] per year, 1.05; 95% confidence interval [CI95], 1.02-1.08), foreign birth (OR, 3.80; CI95, 1.98-7.28), BCG immunization (OR, 4.89; CI95, 2.72-8.80), and employment in a mycobacteriology laboratory (OR, 2.14; CI95, 1.25-3.68) as risk factors for a positive TST. Only one HCW had been treated for active TB. CONCLUSIONS: The prevalence of positive TSTs was high among laboratory HCWs, but the TST conversion rate was low. Higher rates of treatment for latent TB infection are desirable.     

Risk factors for development of systemic lupus erythematosus: allergies,infections, and family history

We examined risk factors for systemic lupus erythematosus (SLE) in 265 recently diagnosed patients in North Carolina and South Carolina and 355 control subjects identified through driver's license records and frequency matched to patients by age, sex, and state. Analyses were limited to exposures before diagnosis (cases) or reference year (control subjects). SLE patients were more likely than control subjects to report a history of allergy to medications (odds ratio [OR] 3.1, 95% confidence interval [CI], 2.1-4.5), particularly to antibiotics. SLE risk increased with history of shingles (OR 2.5, 95% CI 1.1-5.9) and with frequent (more than once per year) cold sores in the 3 years before diagnosis (OR 2.8, 95% CI 1.4-5.4). There was little association with history of mononucleosis, a marker of late infection with Epstein-Barr virus, implanted medical devices, or hepatitis B vaccination. History of lupus in parents or siblings was associated with an increased risk (OR 3.3, 95% CI 1.2-8.6). Further research is needed to clarify whether medication allergies and specific infectious agents are involved in the etiology of SLE. Published by Elsevier Science Inc.     

Risk factors for community-acquired pneumonia in German adults: the impact of children in the household

The objective of this case-control study was to identify the main risk factors for community-acquired pneumonia (CAP) in a German adult population. A self-administered questionnaire was given to CAP cases provided by the German competence network CAPNETZ and population-based, randomly selected controls (sex- and age-matched). Multivariate analysis showed that in addition to known risk factors such as previous CAP [odds ratio (OR) 1.6, 95% confidence interval (CI) 1.3-2.1], more than one respiratory infection during the previous year (OR 3.6, 95% CI 2.9-4.5), chronic pulmonary diseases (OR 2.3, 95% CI 1.7-3.0), number of comorbidities (OR 1.6, 95% CI 1.4-1.9), and number of children in the household (2 children: OR 2.2, 95% CI 1.5-3.4; > or = 3 children: OR 3.2, 95% CI 1.5-7.0) were independent risk factors for CAP. This was pronounced in particular in people aged < or = 65 years. The most likely explanation for this finding is higher exposure to infectious agents.     

The Role of Calcium, 25-Hydroxyvitamin D,and Parathyroid Hormone in Irritable Bowel Syndrome: A Bidirectional Two-Sample Mendelian Randomization Study

Several observational studies have indicated the potential associations among calcium, vitamin D (Vit-D), and irritable bowel syndrome (IBS). However, the causal relationship deduced from these studies is subject to residual confounding factors and reverse causation. Therefore, we aimed to explore the bidirectional causal effects among serum calcium, Vit-D, PTH, and IBS at the genetic level by a two-sample Mendelian randomization (MR) analysis of the datasets from IEU OpenGWAS database. Sensitivity analyses were performed to evaluate the robustness. The estimates were presented as odds ratios (ORs) with their 95% confidence intervals (CIs). The results of the inverse variance weighted method did not reveal any causal relationship between the genetically predisposed calcium (OR = 0.92, 95% CI: 0.80–1.06, p = 0.25) and Vit-D (OR = 0.99, 95% CI: 0.83–1.19, p = 0.94) level and the risk of IBS. The bidirectional analysis demonstrated that genetic predisposition to IBS was associated with a decreased level of PTH (beta: −0.19, 95%CI: −0.34 to −0.04, p = 0.01). In conclusion, the present study indicates no causal relationship between the serum calcium and Vit-D concentrations and the risk of IBS. The potential mechanisms via which IBS affects serum PTH need to be further investigated.     

北京市海淀区社区居民胃食管反流病的流行病学调查

目的 了解北京市海淀区胃食管反流病(GERD)及其相关症状的分布情况,探讨可能的危险因素,并分析其与既往疾病的相关关系.方法 2008年6-9月,采用多阶段抽样法,对海淀区18～80岁的2615名常住居民进行问卷调查,内容包括基本信息、伴发疾病及反流性疾病问卷.结果 海淀区人群GERD的患病率为8.4%(220/2615),单纯胃灼热、单纯反流、两个症状均有的现患率分别为1.0%(25/2615),6.2%(163/2615)和1.2%(32/2615).多因素分析发现,GERD的可能危险因素有生活在农村(OR=2.237,95%CI:1.422～3.517)、女性(OR=1.456,95%CI:1.085～1.955)、高学历(OR=1.242,95%CI:1.001～1.542)、工作生活压力大(OR=1.277,95%CI:1.089～1.497)、精神状态差(OR=1.320,95%CI:1.046～1.665)和有胃肠病家族史(OR=1.594,95%CI:1.075～2.365);胃灼热症状的危险因素有居住在农村(OR=2.481,95%CI:1.278～4.818)、女性(OR=1.747,95%CI:0.902～3.386)、饮酒(OR=1.838,95%CI:0.916～3.690)、不运动(OR=2.091,95%CI:1.131～3.867)和精神状态差(OR=1.657,95%CI:1.123～2.446);反流症状的可能危险因素有生活在农村(OR=2.171,95%CI:1.326～3.556)、女性(OR=1.505,95%CI:1.102～2.056)、高学历(OR=1.347,95%CI:1.063～1.706)、工作生活压力大(OR=1.317,95%CI:1.113～1.558)、精神状态差(OR=1.266,95%CI:0.992～1.616)和有胃肠病家族史(OR=1.739,95%CI:1.163～2.600).GERD、胃灼热和反流症状与既往病史如焦虑症、抑郁症、消化性溃疡、胃炎、炎症性肠病、肾病有较强的关联.结论 GERD及其相关症状在该地区有一定程度的流行,它与不健康的生活方式、精神心理问题等相关,需要在社区开展有效的干预措施.     

Demoralisation, distress and pain in older Western Australians

OBJECTIVE: To assess the relationship of psychiatric morbidity, morale, physical activity and the presence of pain in older people. METHOD: Older people attending senior citizens' clubs were administered the 28-item General Health Questionnaire (GHQ-28), the Revised Philadelphia Geriatric Centre Scale (RPGCS) and five self-report questions from the Brief Disability Questionnaire. They also rated the presence of pain on a five-point scale. Multiple and logistic regression were used to adjust for socio-demographic factors and identify variables independently associated with psychological status and morale. RESULTS: Of 112 people approached, 86% agreed to take part (n = 96). The sample showed a wide range in total GHQ scores (mean = 2.9, range = 0-19) and RPGCS scores (mean = 2.3, range = 1.1-3.0). Twenty-one per cent had psychological distress as defined by a score of > or = 6 on the GHQ-28 (n = 19). Fifty-four respondents (56%) reported low morale as defined by a score < 2 on the RPGCS. There was a close relationship between psychological distress, low morale on the RPGCS (OR = 5.5 [1.5-20.5]) and moderate to severe pain (OR = 5.3 [1.8-15.9]). When adjusted odds ratios were calculated to control for confounding factors, moderate to severe pain remained independently associated with psychological distress (OR = 1.6 [1.3-2.4] p = 0.02), and limitations in daily activities with low morale (OR = 3.64 (1.001-8.4) p = 0.05). CONCLUSIONS: There is a close relationship between physical disability, low morale and psychological distress. IMPLICATIONS: An increased index of suspicion for psychological distress is warranted in all older people with physical disability, particularly in the presence of moderate to severe pain.