Quantitative assessment of musculoskeletal conditions in standard clinical care:
Gespeichert in:
| Format: | Buch |
|---|---|
| Sprache: | English |
| Veröffentlicht: |
Philadelphia [u.a.]
Saunders
2009
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| Schriftenreihe: | Rheumatic disease clinics of North America
35,4 |
| Schlagworte: | |
| Online-Zugang: | Inhaltsverzeichnis |
| Beschreibung: | XIII, S. [687]-875 Ill., graph. Darst. |
| ISBN: | 9781437709346 1437709346 |
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Datensatz im Suchindex
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| adam_text | Titel: Quantitative assessment of musculoskeletal conditions in standard clinical care
Autor: Pincus, Theodore
Jahr: 2009
Quantitative Assessment of Musculoskeletal Conditions in Standard Clinical Care
Contents
Complexities in Assessment of Rheumatoid Arthritis: Absence of a Single Gold
Standard Measure 687
Theodore Pincus, Yusuf Yazici, and Tuulikki Sokka
The clinical approach to patients with inflammatory rheumatic diseases
differs substantially from the approach to patients with many typical
chronic diseases, such as hypertension or diabetes. Further elucidation
of these differences may be informative in efforts to advance quantitative
scientific patient assessment and management in rheumatic diseases,
with improved patient outcomes.
A Biopsychosocial Model to Complement a Biomedical Model: Patient
Questionnaire Data and Socioeconomic Status Usually Are More Significant than
Laboratory Tests and Imaging Studies in Prognosis of Rheumatoid Arthritis 699
Lauren McCollum and Theodore Pincus
Modern medical care is based largely on a paradigm known as a biomed-
ical model, in which a single gold standard high-technology test guides
clinical care. Patients with hypertension, diabetes, osteoporosis, and many
other conditions often are unaware of their status in the absence of data
from objective tests. By contrast, in rheumatoid arthritis (RA) and most
rheumatic diseases, patients generally are aware of symptoms, and infor-
mation from patients often is as or more important to taking direct clinical
decisions than laboratory tests, imaging studies, or even physical examina-
tion data. Physical function on a patient self-report questionnaire generally
is as significant as, or more significant than laboratory, imaging, or physical
examination data in predicting severe outcomes of RA, such as work dis-
ability, costs, and mortality. Patient questionnaires may be viewed as con-
tributing to a complementary biopsychosocial model that can overcome
limitations of the traditional biomedical model in RA and other chronic
diseases. Further relevance of a biopsychosocial model in RA and other
rheumatic diseases is seen in evidence that socioeconomic status, most
easily assessed as formal education level, identifies favorable or unfavor-
able clinical status and prognosis at high levels of significance. Socioeco-
nomic status may be regarded as a surrogate for the importance of patient
actions, in addition to actions of health professionals, in the course and out-
comes of rheumatic and other chronic diseases.
Joint Counts to Assess Rheumatoid Arthritis for Clinical Research and Usual
Clinical Care: Advantages and Limitations 713
Tuulikki Sokka and Theodore Pincus
A joint examination is prerequisite to a diagnosis of rheumatoid arthritis
(RA), and quantitative counts of swollen and tender joints are the most
specific of the 7 RA Core Data Set measures for patient assessment.
Therefore, joint counts are weighted of greater importance than the other
5 Core Data Set measures in American College of Rheumatology response
Contents
criteria and all RA indices in which it is included. Nonetheless, several lim-
itations to the joint count have been recognized: (1) poor reproducibility
with a requirement to be performed by the same observer at each visit;
(2) likelihood to improve with placebo treatment as much or more than
the other 5 RA Core Data Set measures; (3) similar or lower relative
efficiencies than global and patient measures to document differences
between active and control treatments in clinical trials; (4) improvement
over 5 years while joint damage and functional disability may progress;
(5) lower sensitivity in detecting inflammatory activity than ultrasound
and magnetic resonance imaging. Most visits to a rheumatologist do not
include a formal quantitative joint count. Quantitative patient self-report
data are as sensitive to change and as informative about prognosis and
outcomes as joint counts. It may be suggested that a careful qualitative
(nonquantitative) joint examination, supplemented by quantitative self-
report questionnaire scores to interpret physical examination findings,
may be adequate to monitor patients and document changes in status in
busy clinical settings.
Radiographic Measures to Assess Patients with Rheumatoid Arthritis: Advantages
and Limitations 723
Yusuf Yazici, Tuulikki Sokka, and Theodore Pincus
Radiographs present several attractive features for the assessment and
monitoring of patients with rheumatoid arthritis (RA). Radiographic ero-
sions are the closest to a pathognomonic sign in RA. Radiographs provide
a permanent record of permanent damage. Excellent quantitative scoring
systems have been developed by Larsen, Sharp, van der Heijde, Genant,
Rau, and others. However, quantitative radiographic scoring is used only
in research studies and is not included in usual treatment. Furthermore,
magnetic resonance imaging and ultrasonography may be more sensitive
than radiography in detecting abnormalities. Moreover, treatment of
patients with RA should be initiated before evidence of damage. Reports
that biologic therapy is superior to methotrexate in preventing radiographic
progression are accurate for groups of patients, although methotrexate
and other disease-modifying antirheumatic drugs control inflammation in
70% to 80% of patients and most patients present no radiographic
progression with methotrexate. Radiographic findings are also much
less significant and functional measures are far more significant in the pre-
diction of severe outcomes of RA, including costs and mortality. Whereas
prevention of radiographic progression is certainly desirable, it appears
that prevention of functional disability is far more important for successful
patient outcomes.
Laboratory Tests to Assess Patients with Rheumatoid Arthritis: Advantages
and Limitations 731
Theodore Pincus and Tuulikki Sokka
Laboratory tests provide the most definitive information for diagnosing and
managing many diseases, and most patients look to laboratory tests as the
most important information from a medical visit. Most patients who have
rheumatoid arthritis (RA) have a positive test for rheumatoid factor and an-
ticyclic citrullinated peptide (anti-CCP) antibodies, as well as an elevated
erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP). More
Contents
than 30% 40% of patients with RA, however, have negative tests for
rheumatoid factor or anti-CCP antibodies or a normal ESR or CRP. More
than 30% of patients with RA, however, have negative tests for rheumatoid
factor or anti-CCP antibodies, and 40% have a normal ESR or CRP. These
observations indicate that, although they can be helpful to monitor certain
patients, laboratory measures cannot serve as a gold standard for diagno-
sis and management in all individual patients with RA or any rheumatic
disease. Physicians and patients would benefit from an improved under-
standing of the limitations of laboratory tests in diagnosis and manage-
ment of patients with RA.
Patient Questionnaires in Rheumatoid Arthritis: Advantages and Limitations as
a Quantitative, Standardized Scientific Medical History 735
Theodore Pincus, Yusuf Yazici, and Martin J. Bergman
In many chronic diseases, objective gold standard measures such as
blood pressure, cholesterol, and bone densitometry often provide most
of the information used to establish a diagnosis and guide therapy. By
contrast, in inflammatory rheumatic diseases, information from a patient
history usually is considerably more prominent in clinical management.
Patient history data can be recorded as standardized, quantitative scien-
tific data through use of validated self-reported questionnaires. Patient
questionnaires address the primary concerns of patients and their families.
Questionnaire scores distinguish active from control treatments in clinical
trials at similar levels to swollen and tender joint counts or laboratory tests.
Patient questionnaire data are correlated significantly with joint counts, ra-
diographic scores, and laboratory tests, but usually are far more significant
than these measures in the prognosis of severe outcomes of rheumatoid
arthritis (RA), including work disability, costs, and premature death. Limita-
tions of patient questionnaires are based on cultural features involving
variation in responses among ethnic groups, and a need for translation,
although translated questionnaires can be as valuable as a translator.
Patient questionnaires do not replace further medical history, physical
examination, laboratory tests, and imaging data, and they require interpre-
tation in a context of these standard sources of information at any clinical
encounter. Patient questionnaires are useful to monitor patient status in
usual clinical care, with almost no effort on the part of the physician and
staff if distributed by the receptionist in the infrastructure of office practice.
The Disease Activity Score and the EULAR Response Criteria 745
Jaap Fransen and Piet L.C.M. van Riel
The Disease Activity Score (DAS), its modified version the DAS28, and the
DAS-based European League Against Rheumatism (EULAR) response cri-
teria are well-known measures of disease activity in rheumatoid arthritis
(RA). The DAS is a clinical index of RA disease activity that combines infor-
mation from swollen joints, tender joints, the acute phase response, and
general health. The EULAR response criteria classify individual patients
as non-, moderate, or good responders, depending on the extent of
change and the level of disease activity reached. The DAS, DAS28, and
EULAR response criteria have been validated extensively. For daily prac-
tice, it has been shown that a tight control strategy, including measure-
ment of disease activity using the DAS and planned adjustment of
Contents
antirheumatic medication, is an effective strategy for RA. This article sum-
marizes the development and validation of the DAS and DAS28 and their
use in clinical trials and practice for the clinician.
The Simplified Disease Activity Index and Clinical Disease Activity Index to Monitor
Patients in Standard Clinical Care 759
Daniel Aletaha and Josef S. Smolen
Rheumatoid arthritis (RA) disease activity plays a central role in causing
disability directly and via indirect effects mediated through joint damage,
a major sequel of persistent active disease. Evaluation of RA disease
activity is therefore important to predict the outcome and effectiveness
of therapeutic interventions during follow-up. However, disease activity as-
sessment is among the greatest challenges in the care of patients with RA.
The authors regard measurement of activity as an essential element in fol-
lowing the fate of joint diseases such as RA. This evaluation can be facili-
tated by the use of reduced joint counts and simple indices, such as the
Simplified Disease Activity Index (SDAI) and the Clinical Disease Activity In-
dex (CDAI). These scores are validated outcomes for RA and allow the as-
sessment of actual disease activity, response to therapy, and achievement
of particular states such as remission. The simplicity of these scores en-
ables patients to understand the level of their disease activity, as assessed
by the rheumatologist, and to correlate increments and decrements of dis-
ease activity directly with all aspects of the disease. Moreover, remission
criteria of CDAI and SDAI are currently the most stringent.
RAPID3, an Index to Assess and Monitor Patients with Rheumatoid Arthritis,
Without Formal Joint Counts: Similar Results to DAS28 and CDAI in Clinical Trials
and Clinical Care 773
Theodore Pincus, Yusuf Yazici, and Martin J. Bergman
RAPID3 (routine assessment of patient index data 3) is a pooled index
of the 3 patient-reported American College of Rheumatology rheumatoid
arthritis (RA) Core Data Set measures: function, pain, and patient global
estimate of status. Each of the 3 individual measures is scored 0 to 10,
for a total of 30. Disease severity may be classified on the basis of RAPID3
scores: 12 = high; 6.1-12 = moderate; 3.1-6 = low; 3 = remission.
RAPID3 scores are correlated with the disease activity score 28 (DAS28)
and clinical disease activity index (CDAI) in clinical trials and clinical
care, and are comparable to these indices in capacity to distinguish active
from control treatments in clinical trials. RAPID3 on a multidimensional
health assessment questionnaire (MDHAQ) is scored in 5 to 10 seconds,
versus 90 to 94 seconds for a formal 28-joint count, 108 seconds for
a CDAI, and 114 seconds for a DAS28. An MDHAQ can be completed
by each patient at each visit in the waiting room in 5 to 10 minutes, as
a component of the infrastructure of routine care, with minimal effort of
the rheumatologist and staff, to provide RAPID3 scores as well as addi-
tional data including a self-report joint count, fatigue, review of systems,
and recent medical history. In all rheumatic diseases RAP1D3 is able to
provide a baseline quantitative value, and to quantitatively monitor and
document improvement or worsening over time.
Contents
Complex Measures and Indices for Clinical Research Compared with Simple Patient
Questionnaires to Assess Function, Pain, and Global Estimates as Rheumatology
Vital Signs* for Usual Clinical Care 779
Theodore Pincus, Martin J. Bergman, Ross MacLean, and Yusuf Yazici
Indices of multiple measures have been developed to assess and monitor
patients with rheumatic diseases, as no single gold standard measure is
available for diagnosis, prognosis, and monitoring of all individual patients.
Rheumatology indices generally include 4 types of measures from a stan-
dard medical evaluation: patient history, physical examination, laboratory
tests, and imaging studies. Well-characterized indices are available for
rheumatoid arthritis (RA), psoriatic arthritis, systemic lupus erythematosus
(SLE), ankylosing spondylitis, vasculitis, osteoarthritis, fibromyalgia, and
other rheumatic diseases. These indices are complex and applied widely
in clinical research, but rarely are scored in usual rheumatology patient
encounters, which generally are conducted without quantitative data other
than laboratory tests. Information from a patient often is as prominent in
clinical decisions as information from a physical examination or laboratory
tests, and is easily collected as standardized scientific data on patient
questionnaires designed for usual clinical care, which require minimal pro-
fessional effort. Patient-derived data?along with physical examination,
laboratory, and imaging data?are useful rheumatology vital signs to
assess and monitor patient status, provide documentation, and improve
the quality of clinical care, in addition to their possible value for clinical
research. Differences between complex measures for research and simple
questionnaires designed for usual clinical care might be more widely
recognized, to promote quantitative measurement in the infrastructure
of usual rheumatology care.
The HAQ Compared with the MDHAQ: Keep It Simple, Stupid (KISS), with Feasibility
and Clinical Value as Primary Criteria for Patient Questionnaires in Usual Clinical Care 787
Theodore Pincus and Christopher J. Swearingen
The health assessment questionnaire (HAQ) is the questionnaire most
widely used to assess and monitor patients with rheumatic diseases. The
HAQ includes 20 activities grouped into 8 categories of 2 or 3 (and queries
the use of aids and devices and help from another person to perform
these activities), and visual analog scales (VAS) for pain and patient global
estimate of status. Use of the HAQ in usual care over the years has led to
several modifications to develop a multidimensional HAQ (MDHAQ). The
MDHAQ includes 10 activities, one from each category of the HAQ plus 2
complex activities-walk 2 miles or 3 km-all on one side of a page for
easy eyeball review by a clinician; pain, global and fatigue VAS with 21
circles rather than 10-cm lines for ease of scoring; recent medical history;
review of systems; a query about exercise; and scoring templates for the
3 rheumatoid arthritis (RA) Core Data Set patient-reported measures-
physical function, pain, and global estimate-for a routine assessment of
patient index data (RAPID3) composite score. Both the HAQ and MDHAQ
involve 2 sides of one sheet of paper, and are completed by patients in
5 to 10 minutes. The HAQ requires 42 seconds to score, compared with
5 to 10 seconds for RAPID3 on the MDHAQ.
Contents
How to Collect an MDHAQ to Provide Rheumatology Vital Signs (Function, Pain,
Global Status, and RAPID3 Scores) in the Infrastructure of Rheumatology Care,
Including Some Misconceptions Regarding the MDHAQ 799
Theodore Pincus, Alyce M. Oliver, and Martin J. Bergman
Patient history data are prominent in rheumatology patient management
and should be captured at each visit as standard, quantitative, scientific
data by a self-report questionnaire. Patient questionnaire data on a multidi-
mensional health assessment questionnaire (MDHAQ) provide scores for
physical function, pain, global estimate of status, and routine assessment
of patient index data (RAPID3), which may be regarded as rheumatology
vital signs. Patient questionnaires designed for usual clinical care, such
as the MDHAQ, save time and improve the quality and documentation of
the visit for the patient and the physician.
Quantitative Recording of Physician Clinical Estimates, Beyond a Global
and Formal Joint Count, in Usual Care: Applying the Scientific Method, Using
a Simple One-Page Worksheet 813
Theodore Pincus and Martin J. Bergman
Little attention has been directed to quantitation of clinical impressions and
estimates of physicians. This article describes a one-page worksheet for
completion by the physician at each patient visit. It includes a physician global
estimate and estimate of change in status and four quantitative estimates for
the degree of inflammation, degree of organ damage, and degree of fibro-
myalgia or somatization. An estimate of prognosis is recorded, with no ther-
apy and with available therapies. All changes in medications are recorded.
A template is available for a formal 42 joint count. The worksheet requires
fewer than 15 seconds and has proven of considerable value in clinical care.
A Multi-Dimensional Health Assessment Questionnaire (MDHAQ) and Routine
Assessment of Patient Index Data (RAPID3) Scores are Informative in Patients
with All Rheumatic Diseases 819
Theodore Pincus, Anca Dinu Askanase, and Christopher J. Swearingen
Although indices have been developed for many rheumatic diseases in usual
care, they are rarely used in usual care. In most visits to rheumatologists, the
only quantitative data collected are laboratory tests. Patient history data often
are more important in management of patients with rheumatic diseases than
other diseases. A two-page multidimensional health assessment question-
naire (MDHAQ) can be completed by the patient in 5 to 10 minutes
and reviewed by the physician in 10 seconds, with RAPID3 scored in 5 to
10 seconds. The MDHAQ is useful in rtieumatic diseases, to improve manage-
ment documentation and outcomes. MDHAQ data for physical function, pain,
global status, and RAPID3 scores appear preferable to no quantitative data.
FlowsheetsThat Include MDHAQ Physical Function, Pain, Global, and RAPID3 Scores,
Laboratory Tests, and Medications to Monitor Patients with all Rheumatic
Diseases: An Electronic Database for an Electronic Medical Record 829
Theodore Pincus, Arthur M. Mandelin II, and Christopher J. Swearingen
Electronic medical records (EMR) are used increasingly in contemporary
medical care. Function, pain, global status, and RAPID3 scores remain
Contents
important considerations in all rheumatic diseases. Inclusion of these
scores in a flowsheet that also includes laboratory tests and medications
could transform the EMR into a true medical database. Flowsheets are
presented for patients with rheumatologic diagnoses other than rheumatoid
arthritis to illustrate the value of the multidimensional health assessment
questionnaire and RAPID3 scores in an electronic database for an EMR.
A Standard Protocol to Evaluate Rheumatoid Arthritis (SPERA) for Efficient
Capture of Essential Data from a Patient and a Health Professional
in a Uniform Scientific Format 843
Theodore Pincus, Leigh F. Callahan, and Tuulikki Sokka
An efficient, uniform procedure to collect essential data for patients
who have rheumatoid arthritis (RA) using a two- to four-page patient ques-
tionnaire and a three-page form for health professionals is known as
a Standard Protocol to Assess Rheumatoid Arthritis (SPERA). The
two- to four-page patient questionnaire may be a health assessment ques-
tionnaire (HAQ), multidimensional HAQ (MDHAQ), or variant, including
a four-page format used in the Questionnaire in Standard Care of Patients
with Rheumatoid Arthritis (QUEST-RA) program. On each page, the three-
page form for health professionals addresses (1) clinical features of RA; (2)
medications taken currently, and major disease-modifying antirheumatic
drugs (DMARDs) taken previously; and (3) a 42-joint count, with joints
assessed for four variables: swelling, tenderness, deformity/limited
motion, and surgeries, and an entry for no abnormality. A radiographic
scoring sheet may be included for a comprehensive baseline database.
The 15 to 20 minutes needed to complete the SPERA generally produces
efficiency over time in standard clinical care and does not preclude collec-
tion of additional information for clinical research or clinical care. The
SPERA is presented as an example of a possible approach to develop
a uniform common format for collecting core data in usual clinical care.
Quality Control of a Medical History: Improving Accuracy with Patient Participation,
Supported by a Four-Page Version of the Multidimensional Health Assessment
Questionnaire (MDHAQ) 851
Theodore Pincus, Yusuf Yazici, and Christopher J. Swearingen
A method is summarized to improve quality control of the patient history in
the medical record, incorporating the patient as a partner to review and
correct the information. This method has been implemented at every
patient visit to the senior author since 2000, in the infrastructure of usual
medical care, using a database. This procedure engenders a more accu-
rate patient history with no effort on the part of the physician, saving time
for the physician and improving the quality of the medical record.
Criterion Contamination of Depression Scales in Patients with Rheumatoid Arthritis:
The Need for Interpretation of Patient Questionnaires (as All Clinical Measures)
in the Context of All Information About the Patient 861
Theodore Pincus, Afton L. Hassett, and Leigh F. Callahan
The validity of information on a patient questionnaire may not necessarily
be generalizable to all individuals and situations, and may depend on the
Contents
context in which a person provides the information. Examples may be seen
in responses of people with rheumatoid arthritis on the Minnesota Multi-
phasic Personality Inventory (MMPI), on the original Beck Depression In-
ventory (BDI), and on the Centers for Epidemiologic Studies Depression
Scale (CES-D). Several reports have indicated tendencies toward hypo-
chondriasis, depression, and/or hysteria on the MMPI, and tendencies
toward depression on the original BDI and CES-D. However, these
interpretations were based in large part on responses to such statements
as I am in just as good physical health as most of my friends, I can work
about as well as before, and I could not get going. These responses
would suggest psychological concerns in people who have no somatic
disease, the type of subjects in whom these scales were validated, but
would also appear appropriate for people with rheumatoid arthritis, includ-
ing those with no psychological problems. Rheumatologists confirmed
independently the likelihood that people with rheumatoid arthritis would
respond differently from the general population in responding to these
and other statements. This phenomenon, known as criterion contamina-
tion, would explain much, but not all, of elevations in scores on these
scales in patients with rheumatoid arthritis. The BDI was revised in 1996,
as the Beck Depression Inventory-ll (BDI-II), to eliminate the items reflect-
ing somatic disease.
Clues on the MDHAQ to Identify Patients with Fibromyalgia and Similar
Chronic Pain Conditions 865
Theodore Pincus, Afton L. Hassett, and Leigh F. Callahan
Patients with fibromyalgia and chronic pain conditions report high levels
of pain and fatigue, and multiple symptoms. These phenomena may be
recorded quantitatively on a self-report multidimensional health assess-
ment questionnaire (MDHAQ). These responses are likely to differ in
people with fibromyalgia or chronic pain conditions compared with people
with an inflammatory rheumatic disease, such as rheumatoid arthritis. Data
from the MDHAQ provide clues to the presence of fibromyalgia/chronic
pain conditions, including patients with inflammatory diseases who also
have concomitant fibromyalgia/chronic pain conditions.
Index 871
|
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| author_GND | (DE-588)140270884 |
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| bvnumber | BV035977988 |
| classification_rvk | YC 8700 |
| ctrlnum | (OCoLC)501780472 (DE-599)BVBBV035977988 |
| discipline | Medizin |
| format | Book |
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| id | DE-604.BV035977988 |
| illustrated | Illustrated |
| indexdate | 2024-07-09T22:08:54Z |
| institution | BVB |
| isbn | 9781437709346 1437709346 |
| language | English |
| oai_aleph_id | oai:aleph.bib-bvb.de:BVB01-018871931 |
| oclc_num | 501780472 |
| open_access_boolean | |
| owner | DE-355 DE-BY-UBR |
| owner_facet | DE-355 DE-BY-UBR |
| physical | XIII, S. [687]-875 Ill., graph. Darst. |
| publishDate | 2009 |
| publishDateSearch | 2009 |
| publishDateSort | 2009 |
| publisher | Saunders |
| record_format | marc |
| series | Rheumatic disease clinics of North America |
| series2 | Rheumatic disease clinics of North America |
| spelling | Quantitative assessment of musculoskeletal conditions in standard clinical care guest eds. Theodore Pincus ... Philadelphia [u.a.] Saunders 2009 XIII, S. [687]-875 Ill., graph. Darst. txt rdacontent n rdamedia nc rdacarrier Rheumatic disease clinics of North America 35,4 Diagnostiek gtt Kwantitatieve analyse gtt Spier-beenderstelsel gtt Rheumatoide Arthritis (DE-588)4076708-5 gnd rswk-swf Rheumatoide Arthritis (DE-588)4076708-5 s DE-604 Pincus, Theodore Sonstige (DE-588)140270884 oth Rheumatic disease clinics of North America 35,4 (DE-604)BV000625464 35,4 HBZ Datenaustausch application/pdf http://bvbr.bib-bvb.de:8991/F?func=service&doc_library=BVB01&local_base=BVB01&doc_number=018871931&sequence=000002&line_number=0001&func_code=DB_RECORDS&service_type=MEDIA Inhaltsverzeichnis |
| spellingShingle | Quantitative assessment of musculoskeletal conditions in standard clinical care Rheumatic disease clinics of North America Diagnostiek gtt Kwantitatieve analyse gtt Spier-beenderstelsel gtt Rheumatoide Arthritis (DE-588)4076708-5 gnd |
| subject_GND | (DE-588)4076708-5 |
| title | Quantitative assessment of musculoskeletal conditions in standard clinical care |
| title_auth | Quantitative assessment of musculoskeletal conditions in standard clinical care |
| title_exact_search | Quantitative assessment of musculoskeletal conditions in standard clinical care |
| title_full | Quantitative assessment of musculoskeletal conditions in standard clinical care guest eds. Theodore Pincus ... |
| title_fullStr | Quantitative assessment of musculoskeletal conditions in standard clinical care guest eds. Theodore Pincus ... |
| title_full_unstemmed | Quantitative assessment of musculoskeletal conditions in standard clinical care guest eds. Theodore Pincus ... |
| title_short | Quantitative assessment of musculoskeletal conditions in standard clinical care |
| title_sort | quantitative assessment of musculoskeletal conditions in standard clinical care |
| topic | Diagnostiek gtt Kwantitatieve analyse gtt Spier-beenderstelsel gtt Rheumatoide Arthritis (DE-588)4076708-5 gnd |
| topic_facet | Diagnostiek Kwantitatieve analyse Spier-beenderstelsel Rheumatoide Arthritis |
| url | http://bvbr.bib-bvb.de:8991/F?func=service&doc_library=BVB01&local_base=BVB01&doc_number=018871931&sequence=000002&line_number=0001&func_code=DB_RECORDS&service_type=MEDIA |
| volume_link | (DE-604)BV000625464 |
| work_keys_str_mv | AT pincustheodore quantitativeassessmentofmusculoskeletalconditionsinstandardclinicalcare |