Bjørn Straume

Ongoing disease activity and changing categories in a long‐term nordic cohort study of juvenile idiopathic arthritis

OBJECTIVE To describe the disease characteristics, long-term course, and outcome of patients with juvenile idiopathic arthritis (JIA) in a population-based setting. METHODS Consecutive cases of JIA from defined geographic areas of Denmark, Finland, Sweden, and Norway in whom disease onset occurred in 1997-2000 were included in a prospective, multicenter cohort study. The study was designed to be as close to a population-based study as possible, with centers participating only if they were able to include in their catchment area all children in whom JIA was diagnosed. RESULTS Of 500 children included, 440 (88.0%) had repeated visits, with the last visit occurring at least 7 years after disease onset (median 98 months, range 84-147 months). Changes in the International League of Associations for Rheumatology category were observed in 10.8% of the children, and, in addition, extended oligoarthritis developed in 34.7% of the group with oligoarticular JIA. During the observation period, 58.0% of the children were treated with disease-modifying antirheumatic drugs, including biologic medications. Ongoing disease activity was mostly mild, but some JIA-related damage developed in 22.9% of the children. At the last followup visit, remission off medication was observed in 42.4% of the children, 8.9% were in remission on medication, and 48.7% were not in remission. The highest rates of remission were observed in patients with persistent oligoarticular JIA and in those with systemic JIA. CONCLUSION In this long-term prospective study of JIA in a population-based Nordic setting, ongoing disease was evident in a majority of the children. The present results underline the need to identify early predictors of outcome, to further improve therapy, and to continue long-term followup of patients with JIA.

Hereditary angio-oedema: new clinical observations and autoimmune screening, complement and kallikrein-kinin analyses.

Objectives. To study clinical and laboratory manifestations of hereditary angio‐oedema (HAE).

Legal drug use in a general population: Association with gender, morbidity, health care utilization, and lifestyle characteristics☆

Legal drug use was assessed by a questionnaire to 15,986 men and women participating in the Finnmark Health Survey 1987-1988. Logistic regression analysis was used to quantify the relationships between legal drug use and gender, morbidity, utilization of health services, and lifestyle and sociodemographic characteristics. Drug use was higher in women than men, but the gender difference decreased with age. Women used more drug groups than men, and the gender difference increased with number of drugs used. Participating in outdoor activities was associated with lower use of drugs in both men and women. The data support the notion that alcohol use plays a more important role in the prediction of drug use in men compared with women. A significant gender difference in the consumption of legal drugs do persist after adjusting for co-morbidity and utilization of health services. Overall, this analysis shows that drug use depends on need (morbidity), followed by use of health services and lifestyle. Sociodemographic variables were shown to have minor influence.

Eclampsia in Scandinavia: incidence, substandard care, and potentially preventable cases

Background. Description of incidence, clinical signs, symptoms, and consequences of eclampsia in Scandinavia, and assessment of substandard care and potential preventability. Methods. A descriptive cohort study including all women giving birth in a 2‐year period (mid‐1998–mid‐2000) in Scandinavia. Notifications of eclampsia cases were obtained from all obstetric units at 3‐monthly intervals. All patient files were reviewed, and systematic audit was performed to identify potentially preventable cases by using predefined criteria. Main outcome measures. Signs and symptoms preceding the eclamptic seizure, the standard of medical care, maternal and perinatal morbidity, and mortality were all recorded. Potentially preventable cases through improved care and cases eligible for primary prophylactic magnesium sulfate (MgSO4) were estimated. Results. The incidence of eclampsia was 5.0/10 000 maternities (CI = 4.3–5.7/10 000). Eighty‐six percent had a diagnosis of pre‐eclampsia before the seizure. Nine of 10 had at least one physical complaint before the first seizure, severe headache being the most common symptom, occurring in two‐thirds. Most seizures (90%) occurred after admission to hospital. By audit, 89 cases (42%) were classified as having received substandard care. Prophylactic use of magnesium sulfate might have reduced the number of eclampsia cases by 35 (17%). Conclusions. Eclampsia occurred mainly in hospital and the majority of women had symptoms heralding the seizure. In retrospect, nearly half of the cases were found potentially preventable by timely intervention, improved medical care, and systematic use of prophylactic treatment with MgSO4.

A prospective study of sex steroids, sex hormone-binding globulin, and non-vertebral fractures in women and men : the Tromsø Study

OBJECTIVES As bone fragility is partly the result of sex hormone deficiency, we sought to determine whether circulating sex steroids or sex hormone-binding globulin (SHBG) predicts non-vertebral fractures. METHODS Forearm bone mineral density (BMD), total estradiol and testosterone, calculated free levels, and SHBG were measured in 1386 postmenopausal women and 1364 men aged 50-84 years at baseline in the Tromsø Study (1994-1995). Non-vertebral fractures were documented between 1994 and 2005. RESULTS During 8.4 years (range 0.01-10.4) of follow-up, 281 women and 105 men suffered non-vertebral fractures. For both sexes, fracture cases had lower BMD and higher SHBG, but sex steroids were not lower. Each standard deviation (s.d.) increase in SHBG increased non-vertebral fracture risk in women (hazards ratio (HR) 1.17; 95% confidence interval (CI) 1.03-1.33) and men (HR 1.26; 95% CI 1.03-1.54). After further adjustment for BMD, the risk was not statistically significant in women (HR 1.09; 95% CI 0.95-1.24) or men (HR 1.22; 95% CI 0.99-1.49). Each s.d. decrease in BMD increased fracture risk in women (HR 1.36; 95% CI 1.19-1.56) and men (HR 1.41; 95% CI 1.15-1.73). Fracture rates were highest in participants with SHBG in the highest tertile and BMD in the lowest tertile and were 37.9 and 17.0 per 1000 person-years in women and men respectively. However, in both sexes the combination of BMD and SHBG was no better predictor of fracture risk than BMD alone. Sex steroids were not associated with fracture risk. CONCLUSIONS Measurements of sex steroids or SHBG are unlikely to assist in decision making regarding fracture risk susceptibility.

Peptic Ulcer and Non-ulcer Dyspepsia—a Disease and a Disorder

In a cross-sectional survey for coronary risk factors, 14,390 middle-aged men and women answered a questionnaire concerning life-style, diet and disease, including peptic ulcer (PU) and dyspeptic symptoms. The overall lifetime prevalence of reported PU was 5.3% in men and 2.1% in women. The prevalence of reported dyspeptic symptoms, consistent with non-ulcer dyspepsia (NUD), was 22.6% in men and 18.1% in women. Reporting of both PU and NUD was significantly associated with sex and age, NUD less marked than PU. PU and NUD differed substantially with respect to associations with psychologic, social, life-style, and dietary variables. PU was strongly associated with age, a family history of peptic ulcer, body mass index, and smoking. NUD, on the other hand, showed closest association to psychological factors and social conditions. This difference between PU and NUD might be of aetiological and therefore clinical significance, and calls for therapeutic trials in NUD patients with interventions different from the traditional peptic ulcer treatments.

Levonorgestrel‐impregnated intrauterine device as treatment for endometrial hyperplasia: a national multicentre randomised trial

The purpose of this study was to investigate if the levonorgestrel‐impregnated intrauterine device (LNG‐IUS, Mirena®) is safe and effective as therapy for low‐risk and medium‐risk endometrial hyperplasia compared with oral medroxyprogesterone (MPA).

Serum Group I Pepsinogens and Gastrin in Relation to Gastric H+ and Pepsin Outputs before and after Subcutaneous Injection of Pentagastrin

A conventional pentagastrin test was carried out in 25 patients with dyspeptic complaints, and gastric H+ and pepsin outputs were determined. Blood was drawn before the intubation and 5 and 30 min after subcutaneous injection of pentagastrin, and serum group I pepsinogens (PG I) and serum gastrin were determined by radioimmunoassay methods. A significant correlation was found between serum PG I, on the one hand, and basal gastric pepsin, output as well as pentagastrin-stimulated gastric H+ and pepsin outputs, on the other. Basal serum gastrin was also significantly correlated to pentagastrin-stimulated gastric pepsin output as well as to serum PG I. Pentagastrin failed to induce an increase in serum PG I during the first 30 min.

Aetiology of peptic ulcer: a prospective population study in Norway.

STUDY OBJECTIVE--To analyse simultaneously the effect of several risk factors for peptic ulcer. DESIGN--Cohort study where all patients with new or incident peptic ulcers in a well defined population were registered for a seven year period. The follow up started with a comprehensive health survey including a questionnaire on diet, lifestyle, psychological and social conditions, and health. Relative risks, both sex specific and separate, for gastric and duodenal ulcers were estimated from proportional hazard regression analysis. SETTING--A population based survey conducted in the municipality of Tromsø, northern Norway. PARTICIPANTS--In 1980, a total of 21,440 men and women, aged 20 to 54 years and 20 to 49 years respectively, were invited to participate. A total of 14,667 people attended and returned the questionnaire. MAIN RESULTS--A total of 328 people had their first peptic ulcer in the follow up period. Age, cigarette smoking, first degree relatives with peptic ulcer, and low educational level were shared risk factors for peptic ulcer in both men and women. In men, frequent upper respiratory infections increased the risk of gastric ulcer and drinking a great deal of milk increased the risk of duodenal ulcer. None of the other dietary variables, including coffee and alcohol consumption, contributed significantly to the risk. Use of analgesics was not a risk factor, and none of the psychological indicators analysed carried any significant risk. CONCLUSIONS--Age, inheritance, and cigarette smoking are all important risk factors for peptic ulcer. The increased risk associated with low educational background indicate that social strains, comprising lifestyle and diet habits, are part of the multifactorial aetiology of peptic ulcer. No support was found for the assumption that peptic ulcer disease is a psychosomatic disorder. This study did not support the view that duodenal and gastric ulcers have different aetiologies-rather it showed a similarity in risk patterns.

Biomarkers of Chronic Uveitis in Juvenile Idiopathic Arthritis: Predictive Value of Antihistone Antibodies and Antinuclear Antibodies

Objective. To study the predictive value of antinuclear autoantibody (ANA) tests and antihistone antibodies (AHA) as risk factors for development of chronic asymptomatic uveitis of insidious onset in juvenile idiopathic arthritis (JIA). Methods. ANA by indirect immunofluorescence using HEp-2 cells (IF-ANA), ELISA for ANA (E-ANA), and AHA were analyzed in sera of 100 children with recent-onset JIA and in 58 control sera. Clinical features, including age at onset, JIA subgroup, and presence of uveitis, were recorded in this prospective population-based cohort study. Results. E-ANA was positive in 4 of the 100 sera, and was not associated with uveitis. Chronic uveitis developed in 16 children with JIA: in 14 of 68 positive for IF-ANA ≥ 80, and in 13 of 44 positive for AHA ≥ 8 U/ml. IgM/IgG AHA were found in higher proportions in children with uveitis (mean 12.4 U/ml) than in those with JIA and no uveitis (mean 6.9 U/ml) or in healthy controls (mean 4.3 U/ml). Conclusion. No association was found between E-ANA and uveitis, and most IF-ANA-positive sera were E-ANA-negative. E-ANA is not clinically relevant in this setting and should never be used to determine frequencies of eye examinations to detect new uveitis in JIA. AHA ≥ 8 U/ml, IF-ANA titer ≥ 320, and young age at onset of arthritis were significant predictors for development of chronic uveitis. The diagnostic value of AHA ≥ 8 U/ml as a biomarker of chronic uveitis in JIA is very similar to IF-ANA ≥ 80.