Jan Tore Gran

Total Mortality is Increased in Rheumatoid Arthritis. A 17-Year Prospective Study

Abstract: The purpose of this study was to determine the total and cause-specific mortality in rheumatoid arthritis (RA) patients compared to a control population in northern Norway. One hundred and eighty-seven patients with RA and 930 population controls matched for age, gender and municipality were followed until death or for a maximum of 17 years. The total mortality in RA patients was twice that of their controls (MRR = 2.0, 95% CI = 1.6-2.5). Patients possessing serum rheumatoid factors did not have a higher relative mortality than the seronegative patients. There was no statistically significant increased mortality from cancer or cardiovascular diseases. Indications for a higher death rate in RA patients than in controls were found for infection and sudden death.

An epidemiological survey of the signs and symptoms of ankylosing spondylitis

An epidemiological survey of ankylosing spondylitis (AS) was performed in Tromsø, Northern Norway. Altogether 27 cases of AS were found, and the symptoms and signs of these subjects were compared to those of persons with back pain but not suffering from AS (NON-AS). The symptoms which differentiated best between AS and NON-AS were: back pain which awakened the subject at night and made him leave the bed, back pain not relieved by lying down but improved by exercise, back pain of 3 months duration or more and morning stiffness lasting 0.5 hours or more. Reduced lateral mobility of the lumbar spine, a total spinal extension of 20° or less and a total spinal flexion of 40° or less were signs of acceptable value for the diagnosis of AS. Clinical criteria for the diagnosis of AS, to be used both in the clinical management of patients with back complaints and in population surveys of AS are suggested.SummaryAn epidemiological survey of ankylosing spondylitis (AS) was performed in Tromsø, Northern Norway. Altogether 27 cases of AS were found, and the symptoms and signs of these subjects were compared to those of persons with back pain but not suffering from AS (NON-AS). The symptoms which differentiated best between AS and NON-AS were: back pain which awakened the subject at night and made him leave the bed, back pain not relieved by lying down but improved by exercise, back pain of 3 months duration or more and morning stiffness lasting 0.5 hours or more. Reduced lateral mobility of the lumbar spine, a total spinal extension of 20° or less and a total spinal flexion of 40° or less were signs of acceptable value for the diagnosis of AS. Clinical criteria for the diagnosis of AS, to be used both in the clinical management of patients with back complaints and in population surveys of AS are suggested.

Prednisolone maintenance dose in relation to starting dose in the treatment of polymyalgia rheumatica and temporal arteritis - A prospective two-year study in 273 patients

Objective. To describe the maintenance dose and annual cessation rate of oral corticosteroids in relation to the starting dose in patients with polymyalgia rheumatica (PMR) and temporal arteritis (TA). Methods. A prospective two-years observational study of 273 patients with PMR and TA followed by rheumatologists. Results. Mean daily maintenance dose of prednisolone during the first and second year was 5.7 mg and 4.3 mg for PMR, 6.6 mg and 4.1 mg for TA, and 8.3 mg and 4.7 mg for PMR with TA. There was a strong association between the initial dose and maintenance dose. The rate of steroid cessation after two years in PMR was 24%, in TA 16%, and in PMR with TA 5%. Conclusion. Low initial dose of prednisolone is associated with low maintenance dose. This is important as the majority of patients with PMR and TA will be treated for more than two years.

The Prevalence of HLA-B27 in Northern Norway

The incidence of the tissue antigen HLA-B27 has been studied in 176 consecutive blood donors in Tromsø, Northern Norway. The prevalence of HLA-B27 was 15.9%, which was significantly higher than that found in Southern Norway (10%). The frequency of 15.9% is comparable to the prevalence of this antigen found in Northern Sweden (16.6%) and Finland (14-16%).

HLA Dr Antigens in Rheumatoid Arthritis

The prevalence and possible prognostic significance of HLA-DR antigens have been studied in 129 patients with seropositive (RF-positive) classical rheumatoid arthritis (RA). HLA-DR4 was increased in RA, whilst HLA-DR2 was decreased, though it was not associated with either low titres of RF or with good prognosis. HLA-DR3-positive patients had the highest prevalence of antibodies to nuclear antigens, and the antigen correlated negatively to the presence of subcutaneous nodules, bony erosions and familial RA. RA patients possessing DR3 thus had some of the characteristics of SLE. HLA-DR5 was not present in male RA patients. An absence of familial RA was observed among DRw8-positive patients.

CLINICAL, EPIDEMIOLOGIC, AND THERAPEUTIC ASPECTS OF ANKYLOSING SPONDYLITIS

Ankylosing spondylitis (AS) almost invariably starts before the age of 50, and clinical features suggestive of AS in older age should lead to consideration of other rheumatic disorders. Clinical manifestations of extraskeletal tissue such as renal amyloidosis and lung disease may occur. However, the detection of amyloidosis may not invariably infer poor prognosis, and associated lung disease may include apical fibrosis and also interstitial lung disease. Although the clinical significance and pathogenesis of osteoporosis in AS remain unclear, reduced bone mass may be found in a significant number of patients. Population surveys on AS have shown a correlation between the population frequency of HLA B27 and prevalence of AS. However, neither B27 subgroup distribution nor low frequency of B27 can explain the rarity of AS among certain African regions. Also representing an area of future research is the detection of both disease-related variables and sociomedical factors influencing the final outcome of this disease.

Referrals from General Practice to an Outpatient Rheumatology Clinic: Disease Spectrum and Analysis of Referral Letters

Abstract: Our objective was to study the demographic characteristics of patients referred from general practitioners to a rheumatology outpatient clinic and to analyse the content and quality of the referral letters. During a 12-month period 346 randomly chosen referral letters of new patients from GPs to a rheumatology outpatient clinic were evaluated. The mean age of the 346 referred patients (73.1% females and 26.9% males) was 45.5 years and 17.8% were 60 or older. Mean disease duration at the time of referral was 50.9 months (1–432 months). Only about 10% of the patients referred had a disease duration of 1 month or less. The current clinical problem was appropriately presented in 95% of the referral letters. In only 0.9% of referrals had there been a prior phone consultation. Altogether, 95.1% of the referrals were as a result of diagnosis or treatment, and in nearly half the cases a diagnosis of inflammatory rheumatic disease was suggested. In 23% of the letters the result of clinical examinations were missing.  Laboratory tests such as serum rheumatoid factor, antinuclear antibodies and HLA-B27 were used by GPs to screen for rheumatic disease in general. A lack of correlation between clinical manifestations and subsequently requested laboratory examinations was frequently found in the referral letters, exemplified by the use of HLA-B27 in rheumatoid arthritis and serum rheumatoid factors in ankylosing spondylitis. These results show that among GPs the threshold for referring patients to a rheumatology outpatient clinic appears rather high, and that patients are subjected to long observation periods before referral. A more frequent use of phone consultations and an improvement in the diagnostic skills of GPs may positively influence the selection of patients for referral and shorten the long waiting lists in rheumatology. This need for improvement was further strengthened by GPs’ inappropriate use of laboratory tests.

Diagnosis and definition of primary Sjögren's syndrome.

During the last years, several sets of criteria for the diagnosis and classification of primary Sjo¨grens syndrome (SS) have been promulgated. So far none has achieved universal acceptance. It is conceivable that the lack of pathognomonic features of SS and the frequent coexistence of SS with other connective tissue di-seases partly explain the lack of agreement. Regardless of criteria preference the final diagnosis of SS should reflect the definition of the syndrome, being an inflammatory and autoimmune rheumatic disease. It is therefore suggested that any criteria employed should include a mandatory combination of measurements of exocrine dysfunction, histological confirmation of inflammation, serological evidence of autoimmunity and exclusion of diseases mimicking primary Sjo¨grens syndrome.

Causes of death in polymyalgia rheumatica. A prospective longitudinal study of 315 cases and matched population controls.

Objective: To determine causes of death in patients with pure polymyalgia rheumatica (PMR) compared to matched population controls. Methods: In a population based study from 1987–1997, 315 patients were diagnosed with PMR. The patients were each randomly assigned four population controls, totally 1260 controls. The date and causes of death were identified from the data files at Statistics Norway up to the end of 1997. Results: A total of 65 cases (20.6%) with PMR died compared to 338 (26.8%) among the controls (mortality rate ratio (MRR)=0.73, 95% CI 0.56–0.97, p=0.03). No statistically significant difference was found between patients and controls with regard to mortality from coronary heart disease or stroke (MRR=0.78, 95% CI 0.52–1.18), cancer (MRR=0.59, 95% CI 0.30–1.17), and other causes (MRR=0.75, 95% CI 0.48–1.17). Conclusion: The increased survival found in patients with PMR could not be explained by reduction in any particular cause of death.

Current therapy of polymyalgia rheumatica.

Polymyalgia rheumatica is characterized by muscular pain and stiffness developing almost exclusively in individuals older than 50 years. Most likely, survival is similar to that of the general population, and perceivably neither malignant diseases nor cardiovascular disorders occurs more frequently than expected. Thus, the main aim of treatment is symptomatic relief and the benefit of such interventions should always be weighed against the possible risks of drug induced side effects. The review addresses the therapeutic options in polymyalgia rheumatica, and focuses on oral corticosteroids, intramuscular and intravenous methylprednisolone, deflazacort, and methotrexate.