Objectives Little is known about the ideal service delivery model and shortcomings in patient experiences in the NHS for patients with psoriatic arthritis (PsA). The objective of this work was to identify unmet needs perceived within the current health service delivery model for PsA from the UK Psoriatic Arthritis Priority Setting Partnership (PsA-PSP).Methods An online survey was conducted in 2020 and distributed to people with PsA, their carers and clinicians to identify research priorities in PsA. The participants were asked to submit three questions unanswered in PsA research. A proportion of submissions related to health service delivery were identified, which were deemed as out of scope for the main PsA-PSP but nevertheless important to report. Content analysis was used to analyse these submissions separately.Results We reviewed 138 submissions that were not related to the James Lind PSP and research priorities in PsA. Among these, 118 (85.5%) were focused on health service delivery and were classified into five main themes: rheumatology service, primary care navigation, education, holistic care, and ethnicity, diversity and inclusion. Further analysis within the rheumatology service theme revealed additional sub-themes that emphasized integrating multidisciplinary services, improving access to advice lines and ensuring fair access to treatments.Conclusion The five key themes provide valuable insights into the important areas of interest within health service delivery in the UK. By understanding these themes, policymakers, healthcare providers and researchers can better prioritize their efforts and address the specific care needs of people with PsA, their care providers and clinicians.

Abstract Objectives To identify and prioritize the top 10 research questions for PsA. Methods The British Psoriatic Arthritis Consortium (BritPACT) formed a Priority Setting Partnership (PSP) comprising of people living with PsA, carers and clinicians, supported by the James Lind Alliance (JLA). This PSP followed the established three-stage JLA process: first, an online survey of people living with PsA, carers and clinicians to identify PsA questions, asking, ‘What do you think are the most important unanswered questions in psoriatic arthritis research?’ The questions were checked against existing evidence to establish ‘true uncertainties’ and grouped as ‘indicative questions’ reflecting the overarching themes. Then a second online survey ranked the ‘true uncertainties’ by importance. Finally, a workshop including people living with PsA and clinician stakeholders finalized the top 10 research priorities. Results The initial survey attracted 317 respondents (69% people living with PsA, 15% carers), with 988 questions. This generated 46 indicative questions. In the second survey, 422 respondents (78% people living with PsA, 4% carers) prioritized these. Eighteen questions were taken forward to the final online workshop. The top unanswered PsA research question was ‘What is the best strategy for managing patients with psoriatic arthritis including non-drug and drug treatments?’ Other top 10 priorities covered diagnosis, prognosis, outcome assessment, flares, comorbidities and other aspects of treatment (https://www.jla.nihr.ac.uk). Conclusion The top 10 priorities will guide PsA research and enable PsA researchers and those who fund research to know the most important questions for people living with PsA.

Involving research users in setting priorities for research is essential to ensure the outcomes are patient-centred and maximise its value and impact. The Musculoskeletal Disorders Research Advisory Group Versus Arthritis led a research priority setting exercise across musculoskeletal disorders. The Child Health and Nutrition Research Initiative (CHNRI) method of setting research priorities with a range of stakeholders was used, involving four stages and two surveys, to: (1) gather research uncertainties, (2) consolidate these, (3) score uncertainties against importance and impact, and (4) analyse scoring for prioritisation. 213 people responded to the first survey and 285 people to the second, representing clinicians, researchers, and people with musculoskeletal disorders. Key priorities included developing and testing new treatments, better treatment targeting, early diagnosis, prevention, and better understanding and management of pain, with an emphasis on understanding underpinning mechanisms. We present a call to action to researchers and funders to target these priorities.

Objectives We conducted a systematic literature review to assess the adverse event (AE) profile of paracetamol. Methods We searched Medline and Embase from database inception to 1 May 2013. We screened for observational studies in English, which reported mortality, cardiovascular, gastrointestinal (GI) or renal AEs in the general adult population at standard analgesic doses of paracetamol. Study quality was assessed using Grading of Recommendations Assessment, Development and Evaluation. Pooled or adjusted summary statistics were presented for each outcome. Results Of 1888 studies retrieved, 8 met inclusion criteria, and all were cohort studies. Comparing paracetamol use versus no use, of two studies reporting mortality one showed a dose–response and reported an increased relative rate of mortality from 0.95 (0.92 to 0.98) to 1.63 (1.58 to 1.68). Of four studies reporting cardiovascular AEs, all showed a dose–response with one reporting an increased risk ratio of all cardiovascular AEs from 1.19 (0.81 to 1.75) to 1.68 (1.10 to 2.57). One study reporting GI AEs reported a dose–response with increased relative rate of GI AEs or bleeds from 1.11 (1.04 to 1.18) to 1.49 (1.34 to 1.66). Of four studies reporting renal AEs, three reported a dose–response with one reporting an increasing OR of ≥30% decrease in estimated glomerular filtration rate from 1.40 (0.79 to 2.48) to 2.19 (1.4 to 3.43). Discussion Given the observational nature of the data, channelling bias may have had an important impact. However, the dose–response seen for most endpoints suggests a considerable degree of paracetamol toxicity especially at the upper end of standard analgesic doses.

Background: National Institute for Health and Care Excellence (NICE) guidance CG 153 states that all patients with psoriasis should have an annual assessment for PsA and that a validated tool, e.g. the Psoriasis Epidemiology Study (PEST) questionnaire, should be used.If arthritis is suspected, patients should be referred to a rheumatologist for further assessment.It is our belief that this has not yet been taken up by primary care and we aimed to assess the impact of its use in a teaching practice.Methods: A total of 159 patients in a practice of 5100 patients were identified as having psoriasis; 13 of these were already known to have PsA.Letters were sent to all of the rest, advising them of the NICE guidance and enclosing a copy of the PEST questionnaire.A stamped addressed envelope was included for their reply.Any patient scoring 3 was invited to attend for review.Results: Eighty-two of 146 (56%) questionnaires were returned.Two patients felt that the diagnosis of psoriasis was incorrect.Sixteen patients scored 3 and were invited to the surgery for review.Eleven patients attended; on review, 9 were felt to not have an inflammatory arthritis and were not referred.Two were referred to rheumatology after the review.During the study, one patient was referred with uncoded but previously known disease.Two additional patients who were not reviewed were identified as having a previous diagnosis of PsA that was not coded.None of the patients referred have so far had specialist review.Conclusion: It is felt that a reasonable return rate was achieved for the questionnaire.Patients were identified for referral to rheumatology through the use of the PEST questionnaire.The prevalence of psoriasis in our practice of 3% is comparable to the UK prevalence of 2%.Of people with psoriasis in the UK, 14% have PsA.Our practice's prevalence was lower, at 9%.The discrepancy may be accounted for in those who did not return the questionnaire.

Background:Many patients with osteoarthritis (OA) experience side effects with available systemic therapies, some of which can be life threatening. The widespread use of nonsteroidal anti-inflammatory drugs (NSAIDs), often without prescription, is concerning given their potential risks. New treatments for OA are therefore required. This review discusses evidence supporting the use of TDT 064, a drug-free, topical gel containing ultra-deformable phospholipid vesicles (Sequessome vesicles), for OA-associated pain.Scope:Preclinical and clinical studies investigating TDT 064 in patients with OA-associated knee pain were identified in searches of PubMed and congress abstracts.Findings:The ultra-deformable phospholipid vesicles (sequessome vesicles) in TDT 064 pass through the skin intact to reach the synovial space within the joint. The mechanism of action is not yet certain, but the phospholipid-based structure of these ultra-deformable phospholipid vesicles, and the observation that they localize to the cartilage surface, support biolubrication as a possible mechanism of action of TDT 064. Data from randomized, phase III studies in OA knee pain in which TDT 064 was used as the drug-free vehicle control for IDEA-033 (ketoprofen in ultra-deformable phospholipid vesicles) demonstrate a marked and consistent response to TDT 064 in terms of pain, stiffness, and function. In a 12 week study of >1300 patients, the effects of TDT 064 on pain and function were statistically noninferior to those of oral celecoxib, and superior to oral placebo. TDT 064 was well tolerated in all studies, and adverse events were typically mild-to-moderate effects on the skin.Conclusions:Evidence from clinical studies supports the use of TDT 064 as a drug-free topical treatment for patients with OA. Further experience with TDT 064, particularly among patients with comorbidities or NSAID contraindications, will provide more information on its potential use.

Chronic multiple-site joint pain (MSJP) due to osteoarthritis and soft tissue disorders is common in people over 50 years old and associated with poor outcomes. This study examined current pharmacological approaches to MSJP management in primary care. One hundred and fifty general practitioners (GPs) attending an educational seminar participated in an electronic survey (mean response rate 96%). Most GPs reported treating multiple painful joints concurrently (78%) compared with focusing on a single joint (21%). The majority believed there was no difference in analgesia for different disorders when selecting paracetamol (84%), non-steroidal anti-inflammatory drugs (NSAID)/COX-2 inhibitors (57%) or opioids (70%). When optimising therapy, intra-class optimisation (increase NSAID dose 41%, change to another NSAID/COX-2 inhibitor 30%) was preferred to inter-class step up therapy (add opioid 23%, change to opioid 6%). For NSAID gastrointestinal intolerance, the preference was to add a gastro-protective agent (74%). There is a need to better characterise MSJP and examine optimal pharmacotherapy regimens.

Musculoskeletal conditions are common in general practice, but clinicians express poor self confidence in dealing with them. Training in general practice relies on clinical exposure to a range of presentations in order to gain competence. It has been suggested that trainees are exposed to a different case mix from qualified general practices (GPs), due to seeing more minor illness and less chronic disease and that this may be responsible in part for their subsequent lack of confidence. The aims of this study were to analyse the case mix of musculoskeletal conditions encountered by general practice trainees and to compare this to the overall population consulting behaviour. This is a prospective observational study. Thirteen general practices in North East England were recruited. Musculoskeletal disorders encountered by 13 GP trainees (7 junior and 6 senior) were prospectively recorded using a handheld diary. Disorders were classified according to working diagnosis or body region if diagnosis was unclear. Musculoskeletal (MSK) disorders comprised 17 % of consultations, and the distribution of diagnoses of these was in proportion to epidemiological studies of MSK disorders in the UK as they present in primary care. Back pain was the most frequent label with 141 (29 %) consultations with a further 43 (9 %) for neck pain. Inflammatory arthritis accounted for the same number 43 (9 %). Individual joint problems were 115 (24 %) with knee being most common. A specific diagnosis was more likely to be applied when symptoms were more distal and less likely when axial. Trainees are exposed to the same spectrum of MSK disorders as are present in the population as a whole. Case mix does not appear to be a significant factor in low confidence levels in dealing with MSK disorders.

BackgroundPaediatric musculoskeletal (pMSK) disorders are common in clinical practice, but training in their recognition and management is suboptimal at both undergraduate and postgraduate level. Exposure to pMSK conditions is variable in GP training, and there is no standardised curriculum for what GPs should know about pMSK medicine.AimTo attain expert agreement on the gold standard of pMSK skills and knowledge required at completion of GP training.Design and settingModified Delphi process followed by consensus group meeting and focus groups.MethodsTwo iterative rounds of Delphi process conducted by email, followed by a face-to-face meeting of stakeholders. Items with >80% agreement included in final curriculum statement. Member checking by GPs conducted through focus group meetings.ResultsA curriculum covered by 12 overarching statements was developed, with positive feedback from GP educators on the feasibility of delivering the curriculum and usefulness of the items.ConclusionThe introduction of expert-derived learning needs to the GP curriculum on pMSK medicine should help with improving the recognition and management of children with MSK disorders.

Objective To assess self-rated confidence in pediatric musculoskeletal (pMSK) clinical assessment in trainees and experienced doctors in primary care and selected secondary, care specialties to whom children width MSK problems are likely to present.Study design Attendees at programmed postgraduate teaching sessions within a health care region of the United Kingdom completed,in anonymous questionnaire to self-rate confidence in pMSK assessment compared-with other bodily systems and describe exposure to MSK teaching.Results Respondents (n = 346) were qualified from 23 different medical schools (United Kingdom and 9 non-United Kingdom) and included trainees in Primary Care (n = 75), Pediatrics (n = 39), Emergency (n = 39). Orthopedics (n = 40), and experienced doctors in Primary Care (n = 93), and Pediatrics (n = 60). Self-rated confidence in pMSK assessment was low; the majority had "no" or "some" confidence (21% and 53%. respectively). Conversely, most respondents were confident "in most aspects" or "very confident" for cardiovascular, respiratory. and abdominal systems. pMSK ranked lowest below all other systems. Most respondents (92%) recalled some teaching of adult MSK medicine. mostly at undergraduate level. Fewer (51%) recalled,my teaching of pMSK medicine.Conclusions Self-rated confidence in pMSK assessment was lowest, compared with other bodily systems. within doctors to whom children with MSK problems are likely to present. Core clinical skills are learnt at undergraduate level. and this study reflects poor levels of pMSK training which needs to be addressed. (J Pediatr 2009,154:267-71)

Treatment of rheumatoid arthritis (RA) with disease-modifying anti-rheumatic drugs (DMARDs) has proven to be effective at controlling disease activity, reducing joint erosions, reducing cardiovascular mortality and improving quality of life. It is important that patients with RA are reviewed early and considered for treatment with these drugs [1, 2]. The paper by Edwards et al. [3] looks at the use of DMARDs in RA using information from the General Practice Research Database (GPRD). This is a database that currently contains the primary care records of approximately 9 million individuals from almost 400 practices throughout the UK [4]. The practices who contribute data to the GPRD have to meet certain standards for coding/data quality. This paper provides an interesting epidemiological review of the use of DMARDs in primary care using data from the GPRD. It concludes that only 50% of patients coded as having a diagnosis of RA had been prescribed at least one DMARD between June 1987 and June 2002. Prednisolone was prescribed by primary care physicians in up to 50% of RA patients in any one year and 28.7% of those patients who did not receive a DMARD did receive one or more course of oral prednisolone. How should we interpret these data? At face value it would appear that patients with RA captured in this survey are not receiving adequate treatment with DMARDs. In secondary care in Newcastle, for example, between 1984 and 2000 the proportion of RA patients receiving DMARDs rose from approximately 40% to 80% (Dr D. Walker, personal communication). The reliability of the diagnosis of RA in the database may be of concern despite the GPRD having already been validated in a number of other areas. The paper comments that the ‘diagnosis of RA was recorded in a pragmatic way by general practitioners (GPs) in the patients’ notes’. How many of these patients actually meet the 1987 American College of Rheumatology criteria for the diagnosis of RA is unknown, and if patients have not been assessed by a consultant rheumatologist at some stage there is scope for misdiagnosis. For example, patients who have non-inflammatory arthritis but a positive rheumatoid factor may be coded incorrectly as RA. The incidence and prevalence of RA, however, are similar to the statistics for many populations, and DMARD usage trends mirror those in secondary-care prescribing, both points suggesting that the information from the database could be accurate. If the diagnosis of RA is correct, then are there other reasons that could explain why only 50% of patients have been prescribed DMARDs? One reason is that the disease in some patients may be in remission. Evidence from the Norfolk Arthritis Register, a well-validated inception cohort, shows that roughly 18% of patients diagnosed with RA (according to the ACR criteria) are in drug-free disease remission after 3 yr [5]. They define remission as no soft-tissue joint swelling and no recent treatment with DMARDs/steroids. When they looked at patients with undifferentiated polyarthritis, 32% were found to be in remission. Some studies quote higher remission rates in undifferentiated polyarthritis—up to 54% was reported in an American study [6]. If the diagnosis is correct in the GPRD then disease remission could account for at least some of the patients not on DMARDs, and if the GPRD diagnoses included patients with undifferentiated disease it could account for almost all of the 50%. These patients may, in the past, have been discharged from secondary care and, if they have had no further joint problems, re-referral and/or treatment may not have been considered. With current secondary-care practice, these patients would probably not be discharged from follow-up and would instead be kept under annual review. Another reason that could contribute to patients not being on DMARDs, is that there may be a small number of patients who are not suitable (e.g. frail, elderly patients) or who may not wish to have DMARD treatment and that exemption codes (i.e. a code present in the patient’s notes identifying that DMARD treatment has been considered to be inappropriate) may not have been used or requested in the search. The authors also state that ‘the prescribing of all medication is generally performed by GPs making it unlikely that DMARD prescribing has been missed’. This is not true in all parts of the country, which could lead to an underestimate of prescribing according to the GPRD data. A further interpretation of these results is that patients with RA are being under-treated by today’s standards. Are the messages that ‘patients with RA should be treated with DMARDs’ and that ‘patients with possible RA should be referred to secondary care early’ getting through to GPs? As Edwards et al. comment, there is evidence to show that GPs are well aware of the importance of early referral to secondary care for consideration of DMARD treatment, although there is a significant amount of literature in the rheumatological journals highlighting musculoskeletal medicine as an area of educational need for GPs. It is important, though, that primary care education does not just focus on the management and treatment of RA, as it needs to be focused on and relevant to the conditions seen in the community. Schön, in his work The Reflective Practitioner [7], describes the difference in professional working environments as being that ‘there is a high, hard ground where practitioners can make effective use of research-based theory and technique, and there is a swampy lowland where situations are confusing ‘‘messes’’ incapable of technical solution’. The high, hard ground is comparable to secondary care and the swampy lowland to primary care. Schön goes on to say that the practitioner who works on the high, hard ground can ‘practice rigorously’ but is ‘constrained to deal with problems of relatively little social importance’ and that those who work in the swampy lowlands deal with the ‘problems of greatest human concern’ and ‘describe their methods of inquiry’ as using ‘experience, trial and error, intuition, and muddling through’. This nicely describes the difference between the work of primary and secondary care and highlights the importance that not only should GP education cover all areas of musculoskeletal medicine but that the focus should be relevant to primary care and also recognize the complexity of problems that present. Evidence shows that general practice trainees (now called registrars) in the UK do not receive much formal musculoskeletal training. They also rate what they do receive as inadequate [8, 9]. Few registrars (around 16% in one study [8, 9]) have a rheumatology post as part of their vocational training scheme and, unfortunately, with regards to hospital training posts, there