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Sam Norton
University of Hertfordshire
United Kingdom

Publications Authored By Sam Norton

Haemodialysis patients are at risk of serious health complications; yet, treatment non-adherence remains high. Warnings about health risks associated with non-adherence may trigger defensive reactions. We studied whether an intervention based on self-affirmation theory reduced resistance to health-risk information and improved fluid treatment adherence.Read More

In a cluster randomised controlled trial, 91 patients either self-affirmed or completed a matched control task before reading about the health-risks associated with inadequate fluid control.
Patients' perceptions of the health-risk information, intention and self-efficacy to control fluid were assessed immediately after presentation of health-risk information. Interdialytic weight gain (IDWG), excess fluid removed during haemodialysis, is a clinical measure of fluid treatment adherence. IDWG data were collected up to 12 months post-intervention.
Self-affirmed patients had significantly reduced IDWG levels over 12 months. However, contrary to predictions derived from self-affirmation theory, self-affirmed participants and controls did not differ in their evaluation of the health-risk information, intention to control fluid or self-efficacy.
A low-cost, high-reach health intervention based on self-affirmation theory was shown to reduce IDWG over a 12-month period, but the mechanism by which this apparent behaviour change occurred is uncertain. Further work is still required to identify mediators of the observed effects.

Disabil Rehabil
Disabil Rehabil 2016 Aug 24:1-14. Epub 2016 Aug 24.
a Health Psychology Section, Institute of Psychiatry, Psychology and Neuroscience, King's College London , London , UK.

Two-thirds of the people with multiple sclerosis (pwMS) experience pain. Medications provide minimal relief, and current non-pharmacological interventions lack a clear conceptualization of MS pain. This study explored the potential efficacy of a telephone-supported hybrid cognitive behavior therapy and acceptance and commitment therapy self-management intervention for pwMS based on an empirically supported model of MS pain using a replicated single-case series design.Read More

Seven pwMS with varied demographic and disease characteristics completed the 8-week home-based program alongside 3 hours of telephone support. Online questionnaires were completed every four days for 16 weeks (4-weeks baseline, 8-weeks treatment, 4-weeks follow-up). The primary outcomes were pain severity and pain interference. Psychological process variables drawn from the MS pain model were also completed, and post-treatment qualitative interviews conducted.
Simulation modeling analysis (SMA) showed three patients had large improvements in pain outcomes, two showed no change and two worsened. Five participants showed significant change on various psychological process variables. Change in pain catastrophizing was the most consistent finding.
The findings suggest a self-management program for MS pain with minimal therapy support may be effective for some pwMS, but not those with more complex comorbidities. The participants suggested web-based delivery may simplify the approach, and therapist telephone contact was highly valued. Implications for Rehabilitation This case series suggests a hybrid CBT/ACT self-management workbook program for MS pain improves severity and impact of pain in some pwMS. Pain-related catastrophizing reduced in most pwMS, whilst change in other ACT and CBT process variables varied across the individuals. PwMS feedback suggests a tailored web-based delivery of the program with therapist telephone support may be optimal. PwMS with serious co-morbid depression and very advanced disease may not respond well to this self-management approach.

Arthritis Care Res (Hoboken)
Arthritis Care Res (Hoboken) 2016 Aug 26. Epub 2016 Aug 26.
Early Rheumatoid Arthritis Study, Department of Rheumatology, St Albans City Hospital, St Albans, UK.

To examine secular trends in demographic, clinical manifestations and comorbidity on first presentation of RA prior to DMARD treatment.
2701 patients were recruited over 25years to two UK-based RA inception cohorts: the Early RA Study (9 centres; 1986-2001) and the Early RA Network (23 centres; 2002-2012). Trends in demographic and baseline clinical/laboratory and radiographic variables and comorbidities were estimated using mixed effects models, including random effects for recruitment centre.Read More

Age-at-onset increased from 53.2 to 57.7 years in 1990 and 2010 respectively (2.6 months/year; 95% CI 1.2-4.1). Gender-ratio, the proportion living in deprived areas and smoking status were unchanged (p>0.05) and there were no changes in the proportion seropositive or erosive at baseline (p>0.05). After controlling for treatment at the time of assessment, ESR reduced and haemoglobin increased over time (p<0.05), however HAQ, DAS, DAS28, and joint counts were unchanged (p>0.05). The overall prevalence of comorbidity increased from 29.0% in 1990 to 50.7% in 2010, mainly due to cardiovascular and non-cardiac vascular conditions including hypertension. There was a significant increase in BMI (0.15 units/year; 95% CI 0.11-0.18), resulting in an increase in the prevalence of obesity from 13.3% in 1990 to 33.6% in 2010.
Age-at-onset and comorbidity burden, especially obesity have increased at RA presentation over 25 years, reflecting wider demographic trends at the population level. In contrast there were no accompanying changes in disease severity assessed by composite markers of disease activity, radiographic erosions, seropositivity or HAQ at presentation. Treatment strategies in early RA should take greater account of the impact of co-morbidity on outcomes. This article is protected by copyright. All rights reserved.

BMJ Open
BMJ Open 2016 7;6(6):e011548. Epub 2016 Jun 7.
Faculty of Life Sciences and Medicine, Division of Health and Social Care Research, Department of Physiotherapy, King's College London, London, UK.

Chronic low back pain (CLBP) is a common condition and source of significant suffering, disability and healthcare costs. Current physiotherapy treatment is moderately effective. Combining theory-based psychological methods with physiotherapy could improve outcomes for people with CLBP.Read More

The primary aim of this randomised controlled trial (RCT) is to evaluate the efficacy of Physiotherapy informed by Acceptance and Commitment Therapy (PACT) on functioning in patients with CLBP.
The PACT trial is a two-armed, parallel-group, multicentre RCT to assess the efficacy of PACT in comparison with usual physiotherapy care (UC). 240 patients referred to physiotherapy with CLBP will be recruited from three National Health Service (NHS) hospitals trusts. Inclusion criteria are: age ≥18 years, CLBP ≥12-week duration, scoring ≥3 points on the Roland-Morris Disability Questionnaire (RMDQ) and adequate understanding of spoken and written English to participate. Patients will be randomised to PACT or UC (120 per arm stratified by centre) by an independent randomisation service and followed up at 3 and 12 months post randomisation. The sample size of 240 will provide adequate power to detect a standardised mean difference of 0.40 in the primary outcome (RMDQ; 5% significance, 80% power) assuming attrition of 20%. Analysis will be by intention to treat conducted by the trial statistician, blind to treatment group, following a prespecified analysis plan. Estimates of treatment effect at the follow-up assessments will use an intention-to-treat framework, implemented using a linear mixed-effects model.
This trial has full ethical approval (14/SC/0277). It will be disseminated via peer-reviewed publications and conference presentations. The results will enable clinicians, patients and health service managers to make informed decisions regarding the efficacy of PACT for patients with CLBP.
ISRCTN95392287; Pre-results.

BMC Musculoskelet Disord
BMC Musculoskelet Disord 2016 23;17:224. Epub 2016 May 23.
Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.

This study aimed to assess the accuracy of the Short-Form Health Survey (SF-36) mental health subscale (MH) and mental component summary (MCS) scores in identifying the presence of probable major depressive or anxiety disorder in patients with rheumatoid arthritis.
SF-36 data were collected in 100 hospital outpatients with rheumatoid arthritis. MH and MCS scores were compared against depression and anxiety data collected using validated measures as part of routine clinical practice.Read More

Sensitivity and specificity of the SF-36 were established using receiver operating characteristic (ROC) curve analysis, and area under the curve (AUC) compared the performance of the SF-36 components with the 9-item Patient Health Questionnaire (PHQ9) for depression and the 7-item Generalised Anxiety Disorder (GAD7) questionnaire for anxiety.
The MH with a threshold of ≤52 had sensitivity and specificity of 81.0 and 71.4 % respectively to detect anxiety, correctly classifying 73.5 % of patients with probable anxiety disorder. A threshold of ≤56 had sensitivity and specificity of 92.6 and 73.2 % respectively to detect depression, correctly classifying 78.6 % of patients, and the same threshold could also be used to detect either depression or anxiety with a sensitivity of 87.9 %, specificity of 76.9 % and accuracy of 80.6 %. The MCS with a threshold of ≤35 had sensitivity and specificity of 85.7 and 81.9 % respectively to detect anxiety, correctly classifying 82.8 % of patients with probable anxiety disorder. A threshold of ≤40 had sensitivity and specificity of 92.3 and 70.2 % respectively to detect depression, correctly classifying 76.3 % of patients. A threshold of ≤38 could be used to detect either depression or anxiety with a sensitivity of 87.5 %, specificity of 80.3 % and accuracy of 82.8 %.
This analysis may increase the utility of a widely-used questionnaire. Overall, optimal use of the SF-36 for screening for mental disorder may be through using the MCS with a threshold of ≤38 to identify the presence of either depression or anxiety.

Br J Health Psychol
Br J Health Psychol 2016 May 30. Epub 2016 May 30.
Psychology Department, Institute of Psychiatry, Psychology & Neuroscience, King's College London, UK.

To explore putative mediators of a mindfulness-based intervention to decrease distress in people with multiple sclerosis (MS) and to explore the patients' perspectives on this intervention.
We used an explanatory mixed methods design incorporating quantitative data from a pilot randomized control trial and a qualitative interview study with people who completed the mindfulness intervention.
People with MS (n = 40) completed standardized measures of distress (outcome), and acceptance, decentring, self-compassion, and self-efficacy (potential mediators).Read More

Semi-structured interviews (n = 15) of patients' experiences of the mindfulness intervention were analysed deductively and inductively.
Decentring post-intervention explained 13% of the 3-month change in distress and between 27% and 31% of concurrent changes in distress. Acceptance changed only slightly, and as a result, the indirect effect accounts for only 2% of future distress and between 3% and 11% of concurrent distress. Qualitative data showed that acceptance and self-compassion needed more time to develop, whereas decentring could be implemented readily after being introduced in the sessions. Self-efficacy also had a large mediating effect. Participants in their interviews talked about group dynamics and prior expectations as essential elements that determine their engagement with the course and their level of satisfaction.
Mindfulness interventions for people with a chronic progressive condition may benefit from focusing on helping them to accept daily challenges and teach them to recognize their thoughts and feelings, allowing time for acceptance and self-compassion to develop. Group dynamics also play a fundamental role in the success of the mindfulness interventions. Statement of Contribution What is already known on this subject? Mindfulness courses improve psychological well-being for people with chronic conditions. Mindfulness courses have been successful in improving psychological well-being and symptom management for people with multiple sclerosis but we do not know how these courses work. What does this study add? Decentering and self-efficacy appear to be key mechanisms leading to reduced distress. Acceptance and self-compassion may need more time and practice to develop. Group dynamics and expectations of the mindfulness courses were also important elements of mindfulness.

Mult. Scler.
Mult Scler 2016 Apr 31;22(5):677-84. Epub 2015 Jul 31.
Health Psychology Section, Institute of Psychiatry, Psychology and Neuroscience, King's College London, UK

Fatigue is one of the most distressing symptoms of multiple sclerosis (MS). Measuring MS fatigue poses a number of challenges. Many measures confound definitions of severity and impact of fatigue and/or lack psychometric validation in MS.Read More

To evaluate the psychometric properties of an 11-item fatigue severity measure, the Chalder Fatigue Questionnaire (CFQ) in MS including validity of the factor structure, internal reliability, discriminant validity and sensitivity to change.
Data were pooled from four previous studies investigating MS fatigue using the CFQ (n=444). Data analysis included confirmatory factor analysis to determine the factor structure and model fit, correlations to assess discriminant validity and effects sizes to determine sensitivity to change.
A bi-factor model with one general fatigue factor, incorporating two smaller group factors (mental and physical fatigue) had good model fit and appeared the most appropriate factor structure underlying the CFQ scale. The CFQ had high internal consistency, showed small to moderate correlations with impact of fatigue and mood, and was sensitive to change across low and high intensity behavioural interventions.
The CFQ measuring a composite of physical and mental fatigue severity (i.e. a total score) is a psychometrically sound measure of fatigue severity in MS.

Ann Behav Med
Ann Behav Med 2016 Apr;50(2):285-96
Health Psychology Section, Institute of Psychiatry, Psychology, and Neuroscience, King's College London, Guy's Campus, London, SE1 9RT, UK.

Evidence supports the validity of individual components of the psychological flexibility model in the context of chronic pain. However, there is a need to test the inter-relationships amongst measures of individual components of psychological flexibility in a more integrative manner. In particular, research is needed to examine whether a model with discrete facets as proposed is indeed reflected in data from currently used assessment measures in people with chronic pain.Read More

This cross-sectional study investigated the underlying structure of measures of processes of psychological flexibility amongst individuals with chronic pain and the associations between this measurement model and patient functioning.
Five-hundred and seventy-three adults with chronic pain completed measures of pain, physical and social functioning, mental health, depression and processes of psychological flexibility, including acceptance, cognitive defusion, decentering and committed action. Confirmatory factor analyses tested lower-order, higher-order and bifactor models to examine the structure of psychological flexibility process measures.
A single general factor reflecting openness explained variability in items across all of the psychological flexibility process measures. In addition to this general factor, distinct decentering and committed action group factors emerged in the data. As expected, the general factor was strongly correlated with measures of social functioning, mental health and depression.
Future research is needed to determine the most useful means by which the presence of the general factor can be reflected in the measurement and theory of psychological flexibility.

Rheumatology (Oxford)
Rheumatology (Oxford) 2016 Mar 8. Epub 2016 Mar 8.
Postgraduate Medicine, University of Hertfordshire, Hatfield, Rheumatology Department, St Albans City Hospital, St Albans, UK

To evaluate, firstly, all published data on baseline and annual progression rates of radiographic damage from all longitudinal observational cohorts, and secondly, the association of standard clinical and laboratory parameters with long-term radiographic joint damage.
A comprehensive search of the literature from 1975 to 2014, using PubMed, SCOPUS and Cochrane databases, identified a total of 28 studies that investigated long-term radiographic progression, and 41 studies investigating predictors of long-term radiographic progression. This was submitted and approved by PROSPERO in February 2014 (Registration Number: CRD42014007589).Read More

Meta-analysis indicated an overall baseline rate of 2.02%, and a yearly increase of 1.08% of maximum damage. Stratified analysis found that baseline radiographic scores did not differ significantly between cohorts recruiting patients pre- and post-1990 (2.01% vs 2.03%; P > 0.01); however, the annual rate of progression was significantly reduced in the post-1990 cohorts (0.68% vs 1.50%; P < 0.05). High levels of acute phase markers, baseline radiographic damage, anti-CCP and RF positivity remain consistently predictive of long-term radiographic joint damage.
Critical changes in treatment practices over the last three decades are likely to explain the reduction in the long-term progression of structural joint damage. Acute phase markers and presence of RF/anti-CCP are strongly associated with increased radiographic progression.

To examine the association between disease activity in early rheumatoid arthritis (RA), functional limitation and long-term orthopaedic episodes.
Health Assessment Questionnaire (HAQ) disability scores were collected from two longitudinal early RA inception cohorts in routine care; Early Rheumatoid Arthritis Study and Early Rheumatoid Arthritis Network from 1986 to 2012. The incidence of major and intermediate orthopaedic surgical episodes over 25 years was collected from national data sets.Read More

Disease activity was categorised by mean disease activity score (DAS28) annually between years 1 and 5; remission (RDAS≤2.6), low (LDAS>2.6-3.2), low-moderate (LMDAS≥3.2-4.19), high-moderate (HMDAS 4.2-5.1) and high (HDAS>5.1).
Data from 2045 patients were analysed. Patients in RDAS showed no HAQ progression over 5 years, whereas there was a significant relationship between rising DAS28 category and HAQ at 1 year, and the rate of HAQ progression between years 1 and 5. During 27 986 person-years follow-up, 392 intermediate and 591 major surgeries were observed. Compared with the RDAS category, there was a significantly increased cumulative incidence of intermediate surgery in HDAS (OR 2.59 CI 1.49 to 4.52) and HMDAS (OR 1.8 CI 1.05 to 3.11) categories, and for major surgery in HDAS (OR 2.48 CI 1.5 to 4.11), HMDAS (OR 2.16 CI 1.32 to 3.52) and LMDAS (OR 2.07 CI 1.28 to 3.33) categories. There was no significant difference in HAQ progression or orthopaedic episodes between RDAS and LDAS categories.
There is an association between disease activity and both poor function and long-term orthopaedic episodes. This illustrates the far from benign consequences of persistent moderate disease activity, and supports European League Against Rheumatism treat to target recommendations to secure low disease activity or remission in all patients.

The aim of this analysis is to examine the longitudinal impact of symptoms of depression/anxiety on treatment response, long-term disease activity and physical disability in RA.
Secondary analysis of clinical trial data was performed. Data were collected at baseline and at 6-monthly intervals for 2 years.Read More

The EuroQoL (EQ-5D(TM)) indicated depression/anxiety symptom severity. Our primary outcomes of interest were (i) DAS-28 and (ii) physical disability measured via the HAQ. Secondary outcomes were: tender and swollen joint counts, patient global assessment, ESR and odds of reaching clinical remission. Multilevel models were used to assess the impact of baseline and persistent depression/anxiety on outcomes over 2 years.
Data from 379 patients were included. After adjusting for covariates, baseline depression/anxiety symptoms were associated with increased DAS-28 outcomes and increased tender joint counts. Persistent depression/anxiety symptoms were associated with increased DAS-28 scores, HAQ scores, tender joint counts and patient global assessment of disease activity, and reduced odds of reaching clinical remission. Patients with symptoms of depression/anxiety at baseline also showed a 50% reduction in prednisolone treatment effect, in comparison with patients with no symptoms of depression/anxiety at baseline.
Baseline and persistent symptoms of depression/anxiety are associated with poorer health outcomes over time, as well as reduced treatment response. Mental health should be routinely measured both in clinical practice and in research, and managed alongside rheumatological disease to optimize health outcomes. Further research is required to examine whether treatment of mental disorders can improve rheumatological outcomes.

Psychol Health
Psychol Health 2015 26;30(11):1361-85. Epub 2015 Aug 26.
a Department of Psychological Medicine , The University of Auckland , Auckland , New Zealand.

This paper aims to systematically review the use and performance of the Brief Illness Perception Questionnaire (Brief IPQ).
Electronic databases were searched for papers administering the Brief IPQ published in peer-reviewed journals. Data were extracted from the results for meta-analysis.Read More

Use by illness population, country, language and study design. The questionnaire's concurrent validity, predictive validity, sensitivity to change, discriminant validity and mean scores for different populations were summarised.
The review included 188 papers. The Brief IPQ has been administered to patients from age 8 to over 80, with a wide range of illnesses, in 26 languages from 36 countries. Pooled correlations between illness perceptions and depression, anxiety, blood glucose levels and quality of life were consistent with previous research and theory (range .25-.49 for consequences, identity and emotional representations; -.12 to -.27 for personal control). All items were able to predict some outcomes up to one-year follow-up. Each subscale demonstrated sensitivity to change after intervention in randomised controlled trials with the personal control and causal items showing most frequent change.
The Brief IPQ is widely used and has good psychometric properties. More studies should include and analyse the causal item.

Soc Psychiatry Psychiatr Epidemiol
Soc Psychiatry Psychiatr Epidemiol 2015 May 20;50(5):777-86. Epub 2014 Nov 20.
Health Service and Population Research Department (Box P029), Institute of Psychiatry, Psychology and Neuroscience, King's College London, De Crespigny Park, Denmark Hill, London, SE5 8AF, UK,

No individualised standardised measure of staff support for mental health recovery exists.
To develop and evaluate a measure of staff support for recovery.

initial draft of measure based on systematic review of recovery processes; consultation (n = 61); and piloting (n = 20).Read More

Psychometric evaluation: three rounds of data collection from mental health service users (n = 92).
INSPIRE has two sub-scales. The 20-item Support sub-scale has convergent validity (0.60) and adequate sensitivity to change. Exploratory factor analysis (variance 71.4-85.1 %, Kaiser-Meyer-Olkin 0.65-0.78) and internal consistency (range 0.82-0.85) indicate each recovery domain is adequately assessed. The 7-item Relationship sub-scale has convergent validity 0.69, test-retest reliability 0.75, internal consistency 0.89, a one-factor solution (variance 70.5 %, KMO 0.84) and adequate sensitivity to change. A 5-item Brief INSPIRE was also evaluated.
INSPIRE and Brief INSPIRE demonstrate adequate psychometric properties, and can be recommended for research and clinical use.

Transplantation 2014 Dec;98(11):1182-9
1 Department of Transplantation, Guy's Hospital, London, United Kingdom. 2 Health Psychology Section, Institute of Psychiatry, King's College London, Guy's Hospital, London, United Kingdom. 3 NHS Blood and Transplant, Organ Donation and Transplantation Directorate, Stoke Gifford, Bristol, United Kingdom. 4 Queen Alexandra Hospital, Hampshire, United Kingdom. 5 South London and Maudsley NHS Foundation Trust, York Clinic, Guy's Hospital, London, United Kingdom. 6 Address correspondence to: Nizam Mamode, F.R.C.S., Department of Transplantation, 6th Floor Renal Offices, Borough Wing, Guy's Hospital, Great Maze Pond, London, SE1 9RT, United Kingdom.

Unspecified (nondirected altruistic) kidney donation is becoming increasingly common in the United Kingdom. Questions regarding motivation and characteristics of these donors persist, alongside concerns about regret and long-term psychosocial outcomes. The aims of this study were to compare psychosocial and physical outcomes in unspecified kidney donors (UKDs) versus specified kidney donors (SKDs).Read More

We performed a cross-sectional study, in which a detailed assessment of psychosocial outcomes was made using validated questionnaires. Additional questions specific to donation were also asked, including questions regarding motivation, regret, and anonymity.
One hundred ninety responses were received from 296 participants studied (110 UKDs [74.3%] vs. 80 SKDs [54.1%], P<0.001). Unspecified kidney donors were older (54 years vs. 44 years; P<0.001), predominantly white (99.1% vs. 78.5%; P<0.001), and donated more recently (1.3 years vs. 2.6 years; P<0.001). There was no difference in psychiatric history or personality type, or current depression, anxiety, stress, self-esteem, or well-being between the groups (P>0.05). Unspecified kidney donors were more engaged in other altruistic behaviours (P<0.001). There was no difference in physical outcomes, although UKDs recovered quicker (P<0.001). Regret was low (3.7% UKDs vs. 7.5% SKDs; P=0.078).
This study has demonstrated that UKDs have comparable physical and psychosocial outcomes to SKDs. These favorable outcomes may be, in part, because of the rigorous evaluation process which currently includes a mental health assessment. We conclude that the program can continue to expand safely across the United Kingdom.

Hemodialysis patients are at risk of serious health complications, yet treatment non-adherence remains high.
Warnings about health risks associated with non-adherence may trigger defensive reactions. We studied whether an intervention based on self-affirmation theory (Steele 1988) reduced patients' resistance to health-risk information and improved adherence.Read More

One hundred twelve patients either self-affirmed or completed a matched control task before reading about the risks associated with a lack of phosphate control. Serum phosphate was collected from baseline up to 12 months.
Self-affirmed patients had significantly reduced serum phosphate levels at 1 and 12 months. However, contrary to the predictions derived from self-affirmation theory, self-affirmed participants and controls did not differ in their evaluation of the health-risk information, behavioural intention or self-efficacy.
A low-cost, high-reach health intervention based on self-affirmation theory was shown to reduce serum phosphate over a 12 month period. Further work is required to identify mediators of the observed effects.

Semin. Arthritis Rheum.
Semin Arthritis Rheum 2014 Oct 9;44(2):131-44. Epub 2014 May 9.
Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal Research, Institute of Inflammation and Repair, The University of Manchester, Manchester Academic Health Science Centre, Stopford Building, Oxford Rd, Manchester M13 9PT, UK. Electronic address:

The Health Assessment Questionnaire is widely used for patients with inflammatory polyarthritis (IP) and its subset, rheumatoid arthritis (RA). In this study, we evaluated the progression of HAQ scores in RA (i) by systematically reviewing the published literature on the methods used to assess changes in functional disability over time and (ii) to study in detail HAQ progression in two large prospective observational studies from the UK.
Data from two large inception cohorts, ERAS and NOAR, were studied to determine trajectories of HAQ progression over time by applying latent class growth models (LCGMs) to each dataset separately.Read More

Age, sex, baseline DAS28, symptom duration, rheumatoid factor, fulfilment of the 1987 ACR criteria and socio-economic status (SES) were included as potential predictors of HAQ trajectory subgroup membership.
The literature search identified 49 studies showing that HAQ progression has mainly been based on average changes in the total study population. In the HAQ progression study, a LCGM with four HAQ trajectory subgroups was selected as providing the best fit in both cohorts. In both the cohorts, older age, female sex, longer symptom duration, fulfilment of the 1987 ACR criteria, higher DAS28 and lower SES were associated with increased likelihood of membership of subgroups with worse HAQ progression.
Four distinct HAQ trajectory subgroups were derived from the ERAS and NOAR cohorts. The fact that the subgroups identified were nearly identical supports their validity. Identifying distinct groups of patients who are at risk of poor functional outcome may help to target therapy to those who are most likely to benefit.

Semin. Arthritis Rheum.
Semin Arthritis Rheum 2014 Oct 29;44(2):123-30. Epub 2014 May 29.
Department of Rheumatology, King׳s College Hospital, London, UK.

The assessment of health-related quality-of-life (HRQoL) in rheumatoid arthritis (RA) is becoming increasingly common in both research and clinical practice. One of the most widely used tools for measuring HRQoL is the Medical Outcomes Study 36-item Short-Form Health Survey (SF-36). We conducted a systematic review examining the impact of RA on HRQoL, measured through the SF-36.Read More

MEDLINE and Embase were searched for observational studies reporting mean and standard deviation scores for each domain of the SF-36 in adult RA patients. Studies were reviewed in accordance with PRISMA guidelines, and a random-effects meta-analysis was performed.
In total, 31 studies were eligible for inclusion in the meta-analysis, including 22,335 patients. Meta-analyses found that pooled mean HRQoL score for the SF-36 physical component summary was 34.1 (95% CI: 22.0-46.1) and mental component summary was 45.6 (95% CI: 30.3-60.8). Increased age was associated with reduced physical function and physical component summary (PCS) scores but improved mental health and mental component summary (MCS) scores. Female gender was associated with improved scores on role physical, bodily pain and PCS but reduced mental health and MCS scores. Longer disease duration was associated with improved MCS. Patients with RA have a substantially reduced HRQoL in comparison to both other physical illnesses and in comparison to normative datasets from UK and USA populations.
RA has a substantial impact on HRQoL. This supports recent NICE guidelines stipulating that RA patients should be regularly assessed for the impact their disease has on HRQoL and appropriate management provided.

Lancet Neurol
Lancet Neurol 2014 Aug;13(8):788-94
Institute of Public Health, University of Cambridge, Cambridge, UK. Electronic address:

Recent estimates suggesting that over half of Alzheimer's disease burden worldwide might be attributed to potentially modifiable risk factors do not take into account risk-factor non-independence. We aimed to provide specific estimates of preventive potential by accounting for the association between risk factors.
Using relative risks from existing meta-analyses, we estimated the population-attributable risk (PAR) of Alzheimer's disease worldwide and in the USA, Europe, and the UK for seven potentially modifiable risk factors that have consistent evidence of an association with the disease (diabetes, midlife hypertension, midlife obesity, physical inactivity, depression, smoking, and low educational attainment).Read More

The combined PAR associated with the risk factors was calculated using data from the Health Survey for England 2006 to estimate and adjust for the association between risk factors. The potential of risk factor reduction was assessed by examining the combined effect of relative reductions of 10% and 20% per decade for each of the seven risk factors on projections for Alzheimer's disease cases to 2050.
Worldwide, the highest estimated PAR was for low educational attainment (19·1%, 95% CI 12·3-25·6). The highest estimated PAR was for physical inactivity in the USA (21·0%, 95% CI 5·8-36·6), Europe (20·3%, 5·6-35·6), and the UK (21·8%, 6·1-37·7). Assuming independence, the combined worldwide PAR for the seven risk factors was 49·4% (95% CI 25·7-68·4), which equates to 16·8 million attributable cases (95% CI 8·7-23·2 million) of 33·9 million cases. However, after adjustment for the association between the risk factors, the estimate reduced to 28·2% (95% CI 14·2-41·5), which equates to 9·6 million attributable cases (95% CI 4·8-14·1 million) of 33·9 million cases. Combined PAR estimates were about 30% for the USA, Europe, and the UK. Assuming a causal relation and intervention at the correct age for prevention, relative reductions of 10% per decade in the prevalence of each of the seven risk factors could reduce the prevalence of Alzheimer's disease in 2050 by 8·3% worldwide.
After accounting for non-independence between risk factors, around a third of Alzheimer's diseases cases worldwide might be attributable to potentially modifiable risk factors. Alzheimer's disease incidence might be reduced through improved access to education and use of effective methods targeted at reducing the prevalence of vascular risk factors (eg, physical inactivity, smoking, midlife hypertension, midlife obesity, and diabetes) and depression.
National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care for Cambridgeshire and Peterborough.

J Behav Med
J Behav Med 2014 Jun 30;37(3):524-32. Epub 2013 Mar 30.
Health Psychology Section, Psychology Department, Institute of Psychiatry, King's College London, 5th Floor Bermondsey Wing, Guy's Hospital Campus, London Bridge, London, SE1 9RT, UK,

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.Read More

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.

Menopause 2014 Jun;21(6):574-8
From the Institute of Psychiatry, King's College London, London, UK.

Cognitive-behavior therapy (CBT) has been found in recent randomized controlled trials (MENOS1 and MENOS2) to reduce the impact of hot flushes and night sweats (HFNS). In the MENOS2 trial, group CBT was found to be as effective as self-help CBT in reducing the impact of HFNS. This study investigates for whom and how CBT works for women in the MENOS2 trial.Read More

This study performed a secondary analysis of 140 women with problematic HFNS who were recruited to the MENOS2 trial: 48 were randomly assigned to group CBT, 47 were randomly assigned to self-help CBT, and 45 were randomly assigned to usual care. Self-report questionnaires were completed at baseline, 6 weeks postrandomization, and 26 weeks postrandomization. Potential moderators and mediators of treatment effects on the primary outcome-hot flush problem rating-were examined using linear mixed-effects models and path analysis, respectively.
CBT was effective at reducing HFNS problem rating regardless of age, body mass index, menopause status, or psychological factors at baseline. Fully reading the manual in the self-help CBT arm and completing most homework assignments in the group CBT arm were related to greater improvement in problem rating at 6 weeks. The effect of CBT on HFNS problem rating was mediated by changes in cognitions (beliefs about coping/control of hot flushes, beliefs about night sweats and sleep) but not by changes in mood.
These findings suggest that CBT is widely applicable for women having problematic HFNS, regardless of sociodemographic or health-related factors, and that CBT works mainly by changing the cognitive appraisal of HFNS.

Maturitas 2014 May 2;78(1):56-61. Epub 2014 Mar 2.
Institute of Psychiatry, King's College London, UK. Electronic address:

Cognitive behaviour therapy (CBT) has been found to reduce the impact of menopausal symptoms, hot flushes and night sweats. This study investigates the moderators and mediators of CBT for women who had problematic menopausal symptoms following breast cancer treatment.
Analysis of 96 patients with breast cancer induced menopausal symptoms recruited to the MENOS1 trial; 47 were randomly assigned to Group CBT and 49 to usual care.Read More

Questionnaires were completed at baseline, 9 and 26 weeks post randomisation. Potential moderators and mediators, including sociodemographic, clinical and psychological factors, of the treatment effect on the primary outcome were examined.
Hot Flush Problem Rating.
CBT was effective at reducing problem rating at 9 weeks regardless of age, BMI, time since breast cancer diagnosis, menopausal status at time of diagnosis, or type of cancer treatment (radiotherapy or chemotherapy or endocrine treatment). The treatment effect was significantly greater in women not receiving chemotherapy, those with higher levels of psychological distress at baseline and for non-white women. Beliefs about control/coping with hot flushes were the main mediators of improvement in problem rating following CBT. Beliefs about hot flushes in a social context, depressed mood and sleep problems were also identified as mediators.
These findings suggest that CBT is widely applicable for breast cancer patients who are experiencing treatment related menopausal symptoms, and that CBT works mainly by changing beliefs and improving mood and sleep.

To assess whether there have been any secular changes in orthopedic interventions in patients with rheumatoid arthritis (RA) since 1986, as examined in 2 early rheumatoid arthritis (RA) inception cohorts with up to 25 years of followup.
The study examined orthopedic data from the UK Early RA Study (1986-1999, 9 centers; n = 1,465) and the UK Early RA Network (2002-2012, 23 centers; n = 1,236) with linkage to national data sets (Hospital Episode Statistics, National Joint Registry, and Office of National Statistics). Clinical and laboratory measures and hand and foot radiographs were standardized and obtained yearly in both cohorts.Read More

The use of disease-modifying antirheumatic drugs (DMARDs), corticosteroids, and biologic therapies reflected the contemporary conventional practices and guidelines of the time frames examined. Recruitment years were grouped into 6 periods, and interventions were classified into major, intermediate, and minor categories.
A total of 1,602 orthopedic surgical procedures were performed in 770 patients (29%) over a maximum of 25 years of followup. The 25-year cumulative incidence rate of major interventions was 21.7% (range 19.4-24.0%), and that of intermediate interventions was 21.5% (range 17.8-25.5%). There was a decline in the 10-year cumulative incidence of intermediate surgeries over time (P < 0.001), but not of major/minor surgery. This decline coincided with a gradual shift from sequential monotherapy to combination DMARD therapies and biologic agents in recent recruitment periods.
Orthopedic surgery is an important and common outcome in RA. Only the rates of hand/foot surgery showed a consistent decline from 1986 to 2011. Possible explanations include differences in the pathophysiologic processes affecting the joints, variations in the responses to therapy between large-joint and small-joint destructive processes, and changes in service provision and thresholds for surgery over time.

BMC Med 2014 31;12:192. Epub 2014 Oct 31.
Department of Public Health and Primary Care, University of Cambridge, Cambridge, CB1 8RN, UK.

Evidence suggests that amongst people with dementia there is a high prevalence of comorbid medical conditions and related complaints. The presence of dementia may complicate clinical care for other conditions and undermine a patient's ability to manage a chronic condition. The aim of this study was to scope the extent, range and nature of research activity around dementia and comorbidity.Read More

We undertook a scoping review including all types of research relating to the prevalence of comorbidities in people with dementia; current systems, structures and other issues relating to service organisation and delivery; patient and carer experiences; and the experiences and attitudes of service providers. We searched AMED, Cochrane Library, CINAHL, PubMed, NHS Evidence, Scopus, Google Scholar (searched 2012, Pubmed updated 2013), checked reference lists and performed citation searches on PubMed and Google Scholar (ongoing to February 2014).
We included 54 primary studies, eight reviews and three guidelines. Much of the available literature relates to the prevalence of comorbidities in people with dementia or issues around quality of care. Less is known about service organisation and delivery or the views and experiences of people with dementia and their family carers. There is some evidence that people with dementia did not have the same access to treatment and monitoring for conditions such as visual impairment and diabetes as those with similar comorbidities but without dementia.
The prevalence of comorbid conditions in people with dementia is high. Whilst current evidence suggests that people with dementia may have poorer access to services the reasons for this are not clear. There is a need for more research looking at the ways in which having dementia impacts on clinical care for other conditions and how the process of care and different services are adapting to the needs of people with dementia and comorbidity. People with dementia should be included in the debate about the management of comorbidities in older populations and there needs to be greater consideration given to including them in studies that focus on age-related healthcare issues.

Rheumatology (Oxford)
Rheumatology (Oxford) 2013 Nov 8;52(11):2016-24. Epub 2013 Aug 8.
ERAS, Rheumatology Department, St Albans City Hospital, Waverley Road, St Albans AL3 5PN, UK.

This study aimed to identify subgroups with distinct trajectories of functional (HAQ) progression over 10 years following diagnosis of RA and identify baseline characteristics associated with the trajectories and their prognostic value for mortality.
Between 1986 and 1998, 1460 patients with RA symptoms <2 years and prior to disease-modifying treatment (DMARDs) were recruited to an inception cohort (Early RA Study). Standard clinical, functional and laboratory assessments were performed at presentation and annually.Read More

Deaths were tracked by the National Health Service Central Register. Growth mixture modelling was used to identify distinct trajectories of HAQ score progression and survival analysis employed to compare all-cause mortality across the trajectory classes.
Four HAQ score progression classes were identified: moderate increasing (46%), low stable (6%), moderate stable (28%) and high stable (20%). Only the moderate-increasing class exhibited an accelerated decline in function over normal ageing. Compared with the moderate-increasing class, individuals with high-stable HAQ scores were more likely to be female, have more severe disease and other coexistent conditions. Low-stable class patients were more likely to be male and report less pain. The high-stable class had increased risk of mortality compared with the moderate-increasing class after adjusting for potential confounding factors, whereas low-stable and moderate-stable classes were at reduced mortality risk.
The effect of RA on function is set within the first few years and is affected by comorbidity. Identifying distinct groups of patients may help to target those at greater risk of poor functional outcome and mortality.

Ann Behav Med
Ann Behav Med 2013 Feb;45(1):78-88
Health Psychology Section, Psychology Department, Institute of Psychiatry, King's College London, UK.

Depression in the dialysis population is common, but trajectories of depression symptoms are unknown.
This study aims to (1) examine whether different patterns of depression symptoms exist over the first year of dialysis and (2) to understand if illness perceptions are associated with observed trajectories of depression symptoms.
Incident dialysis patients (n = 160) completed the Beck Depression Inventory II and the Revised Illness Perception Questionnaire soon after starting dialysis and again at 6 and 12 months.Read More

Latent class growth modelling identified distinct groups of depression symptom trajectories.
Three depression trajectories were identified: "low-reducing" (62 %), "moderate-increasing" (21.8 %) and "high-reducing" (16.2 %). Higher levels of depression were associated with a poorer understanding of the illness (coherence) and perceptions that kidney failure has severe consequences and a more cyclical timeline. Beliefs that treatment controlled kidney failure decreased over time in patients with increasing depression symptoms.
Distinct patterns of depression symptoms are associated with illness perceptions. The potential to identify common patterns of depression symptoms may help target treatments at those most likely to benefit.

Rheumatology (Oxford)
Rheumatology (Oxford) 2013 Jan 19;52(1):99-110. Epub 2012 Oct 19.
ERAS, Rheumatology Department, St Albans City Hospital, St Albans, Hertfordshire AL3 5PN, UK.

To study the prevalence at diagnosis and cumulative incidence of comorbidity in RA, associations with clinical features and impact on outcome.
Standard clinical, laboratory and radiological measures of RA, and details of comorbidity and extra-articular features were recorded at baseline and yearly in an inception cohort of 1460 patients with recently diagnosed RA from nine regions in the UK. The General Practice Research Database was used to compare the incidence of common comorbid conditions (International Classification for Disease-10 codes).Read More

Baseline prevalence was 31.6% and 8.6% for all comorbidities and extra-articular features, respectively, and 15-year cumulative incidence was 81% and 53%, respectively. Rates of hypertension [standardized incidence ratio (SIR) = 1.61; 95% CI 1.43, 1.79] and ischaemic heart disease (SIR = 1.60; 95% CI 1.35, 1.84) were raised compared with figures for the general population, as was stroke in females (SIR = 1.34; 95% CI 1.02, 1.77) and chronic obstructive pulmonary disorder in males (SIR = 1.63; 95% CI 1.17, 2.26). Comorbidity was associated with risk of both all-cause and cardiovascular mortality (hazard ratio = 1.09; 95% CI 1.02, 1.17) and increased rates of functional decline over 10 years (b = 0.011; 95% CI 0.004, 0.019). Comorbidity was not related to disease activity or structural damage.
Significant comorbidity was present at the outset of RA, increasing with follow-up, mainly in cardiovascular, non-cardiac vascular and respiratory systems. Specific conditions (e.g. hypertension) occurred more frequently than in the general population. Comorbidity was related to mortality and functional decline, and more intensive therapies may need consideration in these patients. As many co-existent conditions are amenable to preventative/therapeutic measures, comorbidity needs earlier detection and management in order to reduce its impact on outcome in RA.

J Psychosom Res
J Psychosom Res 2013 Jan 18;74(1):74-81. Epub 2012 Nov 18.
Psychology Department, Institute of Psychiatry, King's College London, UK.

To systematically evaluate the latent structure of the Hospital Anxiety and Depression Scale (HADS) through reanalysis of previous studies and meta confirmatory factor analysis (CFA).
Data from 28 samples were obtained from published studies concerning the latent structure of the HADS. Ten models were considered, including eight previously identified models and two bifactor models.Read More

The fit of each model was assessed separately in each sample and by meta CFA. Meta CFA was conducted using all samples and using subgroups consisting of community samples, cardiovascular disease samples and samples from studies administering the English language version of the HADS.
A bifactor model including all items loading onto a general distress factor and two orthogonal anxiety and depression group factors provided the best fit for the majority of samples. Meta CFA provided further support for the bifactor model with two group factors. This was the case using all samples, as well as all subgroup analyses. The general distress factor explained 73% of the covariance between items, with the (autonomic) anxiety and (anhedonic) depression factors explaining 11% and 16%, respectively.
A bifactor structure provides the most acceptable empirical explanation for the HADS correlation structure. Due to the presence of a strong general factor, the HADS does not provide good separation between symptoms of anxiety and depression. We recommend it is best used as a measure of general distress.

BMC Public Health
BMC Public Health 2013 2;13. Epub 2013 Jan 2.
Institute of Public Health, University of Cambridge, Cambridge, UK.

Population ageing over the first half of this century is likely to lead to dramatic increases in the prevalence of dementia. This will affect all regions of the world, but particularly developing regions. Dementia projections have been used extensively to support policy.Read More

It is therefore important these projections are as accurate as possible.
In this paper we provide a commentary on studies projecting the future prevalence of dementia for the world or for individual continents. We identify some important limitations of the methods used in published projections and provide recommendations to improve the accuracy of future projections, and allow for the checking of the accuracy of the predictions.
Accurate projections of dementia incidence, at both the global and local level, are essential for healthcare planners.

Clin J Am Soc Nephrol
Clin J Am Soc Nephrol 2012 Dec 6;7(12):2002-9. Epub 2012 Sep 6.
Lister Renal Unit, Stevenage, Herts, United Kingdom.

Benefits of dialysis in elderly dependent patients are not clearcut. Some patients forego dialysis, opting for conservative kidney management (CKM). This study prospectively compared quality of life and survival in CKM patients and those opting for dialysis.Read More

Quality-of-life assessments (Short-Form 36, Hospital Anxiety and Depression Scale, and Satisfaction with Life Scale) were performed every 3 months for up to 3 years in patients with advanced, progressive CKD (late stage 4 and stage 5).
After 3 years, 80 and 44 of 170 patients had started or were planned for hemodialysis (HD) or peritoneal dialysis, respectively; 30 were undergoing CKM; and 16 remained undecided. Mean baseline estimated GFR ± SD was similar (14.0 ± 4.0 ml/min per 1.73 m(2)) in all groups but was slightly higher in undecided patients. CKM patients were older, more dependent, and more highly comorbid; had poorer physical health; and had higher anxiety levels than the dialysis patients. Mental health, depression, and life satisfaction scores were similar. Multilevel growth models demonstrated no serial change in quality-of-life measures except life satisfaction, which decreased significantly after dialysis initiation and remained stable in CKM. In Cox models controlling for comorbidity, Karnofsky performance scale score, age, physical health score, and propensity score, median survival from recruitment was 1317 days in HD patients (mean of 326 dialysis sessions) and 913 days in CKM patients.
Patients choosing CKM maintained quality of life. Adjusted median survival from recruitment was 13 months shorter for CKM patients than HD patients.

Psychol Health Med
Psychol Health Med 2012 3;17(5):578-88. Epub 2012 Feb 3.
School of Psychology, University of Hertfordshire, Hatfield, UK.

The purpose of this study was to examine the factor structure of the Revised Illness Perceptions Questionnaire (IPQ-R) in a sample of 374 end-stage renal disease (ESRD) patients. A confirmatory factor analysis of the IPQ-R, including the illness identity subscale, demonstrated adequate model fit for the factor structure as originally defined by (Moss-Morris, R., Weinman, J.Read More

, Petrie, K. J., Horne, R., Cameron, L. D., & Buick, D. (2002). The revised Illness Perception Questionnaire (IPQ-R). Psychology & Health, 17 (1), 1-16.) Modifying the a-priori IPQ-R factor structure by removing two items with low factor loadings and specifying a path between personal control and item 23 had marginally better fit. A separate exploratory factor analysis of the causal items indicated three factors relating to Biological, Psychological and Behavioural causes. These findings provide evidence towards the validity and reliability of the IPQ-R as a suitable measure of illness perceptions in the context of ESRD.

Psychol Health Med
Psychol Health Med 2012 23;17(4):427-39. Epub 2011 Nov 23.
Centre for Lifespan and Chronic Illness Research, University of Hertfordshire, Hatfield, UK.

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).Read More

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.

Rheumatology (Oxford)
Rheumatology (Oxford) 2012 Jan 16;51(1):169-75. Epub 2011 Nov 16.
ERAS, c/o Rheumatology Department, St Albans City Hospital, Waverley Road, St Albans AL3 5PN, UK.

Clinical remission is now a realistic goal in managing RA following the introduction of biologic agents. As there are limited data on sustained remission in conventionally treated RA, this study examines prevalence and predictive factors of sustained remission in a pre-biologic inception cohort of RA.
Patients with recent onset RA and before use of DMARDs were recruited from nine centres.Read More

Standard clinical and radiological assessments were recorded at baseline and yearly. Point remission was defined by DAS of <1.6, and sustained remission if DAS was <1.6 at all 3-, 4- and 5-year follow-ups. Sustained remission was compared with baseline features, with mortality and with radiological and functional progression in 704 patients.
Point remission at 3, 4 and 5 years was 25, 26 and 22%, respectively. Eleven per cent (n = 78) had sustained remission. Male sex, short duration of symptoms and less tender joints at baseline were independent predictors of sustained remission. These patients had fewer DMARD therapies and less radiographic progression by 5 years. Mean HAQ decreased from 0.79 to 0.13 (P < 0.001) in sustained remission, compared with an increase from 0.92 to 1.1 (P < 0.001) in the non-remission group.
Sustained clinical remission by 5 years with conventional DMARDs was 11%, half as likely as point remission. Prognostic factors were similar to comparable studies and simple to measure. Patients in sustained clinical remission showed less structural damage and better functional outcomes.

Nephron Clin Pract
Nephron Clin Pract 2011 11;119(3):c205-13. Epub 2011 Aug 11.
Centre for Lifespan and Chronic Illness Research, University of Hertfordshire, Hatfield, UK.

Patients with end-stage renal disease (ESRD) receiving haemodialysis are at risk of cardiovascular disease and bone disorders related to high levels of serum phosphate (PO(4)). Phosphate binders are an important treatment; however, non-adherence remains a significant issue. This study investigates whether patients' beliefs about medicines predict intentional non-adherence to phosphate binders.Read More

This was a cross-sectional study of ESRD patients (n = 76). Non-adherence was measured in two ways: (1) the self-report Medication Adherence Questionnaire (MAQ) and (2) 3-month average level of serum phosphate. The Beliefs about Medicines questionnaire was used to assess general and specific beliefs towards phosphate medicines.
Eleven (14.5% of 76) patients reported being intentionally non-adherent to phosphate binders. Patients' beliefs that phosphate binders were less necessary were significantly associated with intentional self-reported non- adherence. Furthermore, patients with greater concerns about phosphate binders had higher serum phosphate levels.
Assessing patient beliefs about medicines is a reliable indicator of intentional non-adherence to treatment with phosphate binders. These findings may help in identifying ways in which adherence rates to phosphate binders can be improved.

J Psychosom Res
J Psychosom Res 2011 Nov 29;71(5):290-5. Epub 2011 Jun 29.
Centre for Lifespan & Chronic Illness Research, University of Hertfordshire, UK.

As with other chronic physical illness, rates of depressive disorder are high in rheumatoid arthritis (RA). The aim of the current study was to identify distinct trajectories of psychological distress over 10 years in a cohort of RA patients recruited very early in the course of the disease.
Psychological distress as measured by the Hospital Anxiety and Depression Scale total score was assessed annually in a subgroup of 784 patients enrolled in a multi-centre RA inception cohort (Early RA Study).Read More

A latent growth mixture modelling (GMM) approach was used to identify distinct psychological distress patterns.
Four distinct psychological distress trajectories were observed: low-stable (68%), high-stable (12%), high-decreasing (9%) and low-increasing (11%). Symptoms of pain, stiffness and functional impairment were significantly associated with levels of psychological distress at the time of diagnosis and after 3 years; serological markers of disease activity (ESR and CRP) were not.
Although the majority of individuals developing RA experience little or no impact of the effects of the disease on their psychological well-being, a significant proportion experience high levels of distress at some point which may be related to their subjective appraisal of their condition. Assessment and treatment of psychological distress should occur synchronously with somatic symptoms.

J Psychosom Res
J Psychosom Res 2011 Sep 30;71(3):148-53. Epub 2011 Mar 30.
School of Psychology, University of Hertfordshire, UK.

We sought to examine several competing factor structures of the Beck Depression Inventory-II (BDI) in a sample of patients with End-Stage Renal Disease (ESRD), in which setting the factor structure is poorly defined, though depression symptoms are common. In addition, demographic and clinical correlates of the identified factors were examined.
The BDI was administered to clinical sample of 460 ESRD patients attending 4 UK renal centres.Read More

Competing models of the factor structure of the BDI were evaluated using confirmatory factor analysis.
The best fitting model consisted of general depression factor that accounted for 81% of the common variance between all items along with orthogonal cognitive and somatic factors (G-S-C model, CFI=.983, TLI=.979, RMSEA=.037), which explained 8% and 9% of the common variance, respectively. Age, diabetes, and ethnicity were significantly related to the cognitive factor, whereas albumin, dialysis adequacy, and ethnicity were related to the somatic factor. No demographic or clinical variable was associated with the general factor.
The general-factor model provides the best fitting and conceptually most acceptable interpretation of the BDI. Furthermore, the cognitive and somatic factors appear to be related to specific demographic and clinical factors.

Rheumatology (Oxford)
Rheumatology (Oxford) 2010 Aug 11;49(8):1483-9. Epub 2010 Mar 11.
ERAS, Rheumatology Department, St Albans City Hospital, Waverley Road, St Albans AL3 5PN, UK.

Pulmonary complications of RA are well described. Although some are benign, interstitial lung disease (ILD) has a poor prognosis. Few RA inception cohorts have reported the natural history of ILD related to RA (RA-ILD).Read More

We examine its incidence, outcome and prognostic indicators.
Extra-articular features and comorbidity have been recorded yearly in a well-established inception cohort of RA with a 20-year follow-up. Standard clinical, laboratory and radiological measures of RA were recorded at baseline and yearly. Details of deaths were provided by a national central register.
Out of 1460 patients, 52 developed RA-ILD, half either at baseline or within 3 years of onset. The annualized incidence was 4.1/1000 (95% CI 3.0, 5.4) and the 15-year cumulative incidence 62.9/1000 (95% CI 43.0, 91.7). Incidence of RA-ILD was associated with older age, raised baseline ESR and HAQ. Evidence to implicate any drug effect (e.g. MTX) was lacking. Of these patients, 39 died, attributed to RA-ILD in 28. Median survival following diagnosis of RA-ILD was 3 years.
RA-ILD is an important and early feature of RA. It is related to disease activity and has a poor prognosis. Further studies are required to determine whether screening for pulmonary disease would identify these patients at an earlier stage.

J Plast Reconstr Aesthet Surg
J Plast Reconstr Aesthet Surg 2010 Feb 13;63(2):e201. Epub 2009 Jun 13.
Plast. Reconstr. Surg.
Plast Reconstr Surg 2007 Aug;120(2):457-8
Department of Plastic Surgery, Royal London Hospital, London, United Kingdom.