Health-related quality of life in patients with psoriasis and atopic dermatitis measured with SF-36, DLQI and a subjective measure of disease activity

The impact of skin diseases on health-related quality of life is considerable. It is important to quantify the patient's perspective of the severity of their disease. Health-related quality of life was measured in 366 patients with skin diseases attending the dermatology outpatient clinic in Uppsala, Sweden, from November 1996 to December 1997, with 1 generic (SF-36) and 1 disease-specific (DLQI) health-related quality of life instrument, and a subjective measure of disease activity. The SF-36 mean scores were below those of the age- and gender-matched general population in Sweden. No difference in health-related quality of life was found between men and women or between patients with atopic dermatitis and psoriatic patients. However, patients with psoriatic arthritis had significantly poorer health-related quality of life than both patients with atopic dermatitis and psoriatic patients. The estimated correlations between the instruments were in the expected direction and mostly significant. The results confirm that skin diseases have an adverse impact on patients' health-related quality of life.     

An early cardiac access clinic significantly improves cardiac rehabilitation participation and completion rates in low-risk ST-elevation myocardial infarction patients

Background

Survivors of an acute ST-elevation myocardial infarction (STEMI) remain at high risk for future cardiac events. Cardiac rehabilitation (CR) participation significantly reduces coronary artery disease (CAD) morbidity and mortality risk. Regrettably, poor utilization of CR services post STEMI is common, accentuating a critical action gap in the trajectory of CAD management. The objective of this study was to determine whether integration of an early cardiac access clinic (ECAC), held within 4-14 days of hospital discharge, could improve CR utilization rates following an STEMI.

Methods

Between January 2008 and July 2009, 245 consecutively admitted STEMI patients (19.6% female) deemed low risk following early re-establishment of coronary blood flow, were assigned to the ECAC model. An historic comparison group (n=224) was identified based on all STEMI patient admissions at the same tertiary care facility during the 2007 calendar year that met ECAC eligibility criteria. The primary outcomes were rates of CR referral, orientation attendance, program participation, and completion.

Results

The ECAC cohort had significantly higher rates of CR referral (100% vs 55.8%, P < 0.0001), orientation attendance (96.3 vs 37.1%, P < 0.0001), program participation (87.8% vs 33.5%, P < 0.0001), and completion (71.4% vs 29.9%, P < 0.001) compared to the matched historical comparison group.

Conclusions

The utilization of the ECAC model resulted in an unprecedented (∼3-fold) increase in the number of post-STEMI patients participating in CR. Given the unequivocal mortality and morbidity benefits of CR, adoption of the ECAC model has important clinical and economic relevance.     

Polymyositis and dermatomyositis: pathophysiology

Recent advances have increased the understanding of the pathogenesis of polymyositis and dermatomyositis. Clearly, the pathogenesis is complex, and adaptive (eg, autoimmune) and innate and nonimmune pathways play a role in the disease mechanisms, but the relative contribution may vary between patients and in different phases of the disease. Phenotyping patients using autoantibody profiling has resulted in information on molecular pathways that may be relevant in certain subsets of patients with polymyositis or dermatomyositis, but combining the autoantibody profiles with molecular signatures of innate and nonimmune mechanisms would enhance our ability to classify, diagnose, and treat these disorders more effectively.     

The role of TRAIL in mediating autophagy in myositis skeletal muscle: A potential nonimmune mechanism of muscle damage

Objective

Multinucleated cells are relatively resistant to classic apoptosis, and the factors initiating cell death and damage in myositis are not well defined. We hypothesized that nonimmune autophagic cell death may play a role in muscle fiber damage. Recent reports indicate that TRAIL may induce both NF‐κB activation and autophagic cell death in other systems. We undertook this study to investigate the role of TRAIL in cell death and pathogenesis in vitro and in vivo, using myositis muscle tissues from humans and mice.

Methods

Gene expression profiling was performed in myositis patient and control muscle specimens. Immunohistochemistry analysis was performed to confirm the gene array findings. We also analyzed TRAIL‐induced cell death (apoptosis and autophagy) and NF‐κB activation in vitro in cultured cells.

Results

TRAIL was expressed predominantly in myositis muscle fibers, but not in biopsy specimens from normal or other dystrophic‐diseased muscle. Autophagy markers were up‐regulated in humans with myositis and in mouse models of myositis. TRAIL expression was restricted to regenerating/atrophic areas of muscle fascicles, blood vessels, and infiltrating lymphocytes. TRAIL induced NF‐κB activation and IκB degradation in cultured cells that are resistant to TRAIL‐induced apoptosis but that undergo autophagic cell death.

Conclusion

Our data demonstrate that TRAIL is expressed in myositis muscle and may mediate both activation of NF‐κB and autophagic cell death in myositis. Thus, this nonimmune pathway may be an attractive target for therapeutic intervention in myositis.

     

High degree of kinesiophobia after lumbar disc herniation surgery: a cross-sectional study of 84 patients

Background and purpose

Several studies have investigated outcomes after disc surgery. However, the occurrence of kinesiophobia has not been investigated previously in patients after disc herniation surgery. In this cross-sectional study, we investigated kinesiophobia in patients who had been treated surgically for lumbar disc herniation, and we related the results to established outcome measures.

Patients and methods

10–34 months after surgery, questionnaires were sent to 97 patients who had undergone standardized open discectomy. Outcome measures included Tampa scale for kinesiophobia (TSK); Oswestry disability index (ODI); European quality of life in 5 dimensions (EQ-5D); visual analog scale (VAS) for leg and back pain, work disability, and patient satisfaction; Zung self-rating depression scale (ZDS); pain catastrophizing scale (PCS); and a self-efficacy scale (SES).

Results

36 of 80 patients reported having kinesiophobia. There were statistically significant differences in ODI, EQ-5D, VAS leg and back pain, ZDS, PCS, and SES between patients with and without kinesiophobia.

Interpretation

Half of the patients suffered from kinesiophobia 10–34 months after surgery for disc herniation. These patients were more disabled, had more pain, more catastrophizing thoughts, more symptoms of depression, lower self-efficacy, and poorer health-related quality of life than patients without kinesiophobia.Numerous studies have investigated outcomes after disc surgery and found poor results in 10–35% of the patients, depending on what outcome measure was used (Loupasis et al. 1999, Gotfryd and Avanzi 2009, Lundin et al. 2009). In a summary of outcome assessments for treatment of spinal disorders, the following domains were recommended to be included: back-specific function, generic health status, pain, work disability, and patient satisfaction (Bombardier 2000). Results from a systematic review indicated that socio-demographic, clinical, work-related, and psychological factors predict outcome of lumbar surgery outcome (den Boer et al. 2006).In addition, affective factors, particularly fear, have proven to be central in explaining and in understanding of persistent musculoskeletal pain. 3 terms are used to describe fear in relation to pain: pain-related fear, fear of movement, and kinesiophobia. Pain-related fear is a broad and general term that covers all kinds of fears related to pain (Crombez et al. 1999). Fear of movement/(re)injury is described as “a specific fear of movement and physical activity that is (wrongfully) assumed to cause reinjury” (Vlaeyen et al. 1995a). In the most extreme situation of fear of movement, the expression “kinesiophobia” is used (Kori et al. 1990).Kinesiophobia is considered to play a negative role in the outcome of rehabilitation for patients with low back pain, and a high prevalence of kinesiophobia has been observed in patients with persistent low back pain (Picavet et al. 2002, Lundberg et al. 2004). Since physical activity/exercise is a crucial part of the rehabilitation program after surgery, kinesiophobia is probably a factor that prevents recovery. However, a subgroup analysis of kinesiophobia has not been investigated previously in patients who have undergone disc herniation surgery. We studied kinesiophobia in patients who were treated surgically for lumbar disc herniation, and related the results to established outcome measures.     

Pathogenesis, classification and treatment of inflammatory myopathies

The inflammatory myopathies-collectively, myositis-are a heterogeneous group of chronic muscle disorders that differ in response to immunosuppressive treatment. Insufficient knowledge of the molecular pathways that drive pathogenesis (and underlie the clinical differences between subtypes) has hindered accurate classification, which in turn has been detrimental for clinical research. Nevertheless, new insights into pathogenesis are paving the way for improvements in diagnosis, classification and treatment. Accumulating data suggest that both immune and nonimmune mechanisms cause muscle weakness. Phenotyping of the T cells that accumulate in muscle tissue has identified proinflammatory, apoptosis resistant and cytotoxic CD4(+) and CD8(+) CD28(null) populations. Several myositis-specific autoantibodies have been identified, associated with distinct clinical phenotypes. Thus, adaptive immunity is involved in pathogenesis, and both T and B cells are interesting targets for therapy. Furthermore, genotyping has revealed activation of the type I interferon pathway in patients with dermatomyositis or with expression of particular autoantibodies. Decreased release of Ca(2+) from the sarcoplasmic reticulum, as a consequence of release of proinflammatory cytokines and high mobility group protein B1, might contribute to muscle weakness, and nonimmune mechanisms potentially include a role for endoplasmic reticulum stress, autophagy and hypoxia. Deeper understanding, careful phenotyping of patients-and new classification criteria-will expedite clinical research.