Ulla Lindqvist

Physical activity and quality of life in subjects with chronic disease: Chronic obstructive pulmonary disease compared with rheumatoid arthritis and diabetes mellitus

Objective. Chronic diseases interfere with the life situation of the affected person in different ways. The aim was to compare the burden of disease in three chronic diseases – chronic obstructive pulmonary disease (COPD), rheumatoid arthritis (RA), diabetes mellitus (DM) – and in healthy subjects, with a particular interest in physical activity, quality of life, and psychological health. Design. Cross-sectional, observational study. Setting and subjects. Postal survey questionnaire to a stratified, random population of 68 460 subjects aged 18–84 years in Sweden. The subjects included were 40–84 years old (n = 43 589) and data were analysed for COPD (n = 526), RA (n = 1120), DM (n = 2149) and healthy subjects (n = 6960). Result: Some 84% of subjects with COPD, 74% (RA), 72% (DM), and 60% in healthy subjects (p < 0.001, COPD versus RA, DM, and healthy subjects) had a physical activity level considered too low to maintain good health according to guidelines. Quality of life (EuroQol five-dimension questionnaire, EQ-5D) was lower in COPD and RA than in DM. Anxiety/depression was more common in subjects with COPD (53%) than in those with RA (48%) and DM (35%) (p < 0.001, COPD versus RA and DM), whereas mobility problems were more common in RA (55%) than COPD (48%) and DM (36%) (p < 0.001, RA versus COPD and DM). All differences between groups remained significant after adjusting for age, sex, and socioeconomic background factors. Conclusion. Subjects with chronic diseases had a low level of physical activity, most evident in subjects with COPD. COPD and RA had a higher negative impact on quality of life than DM. Our results indicate that increased attention regarding physical inactivity in subjects with chronic diseases is needed to minimize the burden of disease.

Early psoriatic arthritis: short symptom duration, male gender and preserved physical functioning at presentation predict favourable outcome at 5-year follow-up. Results from the Swedish Early Psoriatic Arthritis Register (SwePsA)

Objective The Swedish Early Psoriatic Arthritis Register describes the course of early psoriatic arthritis (PsA) in a real life clinical setting in Sweden. The aim of this study was to obtain information on predictors of clinical outcomes over a 5-year period with special focus on effects of gender, joint patterns, diagnostic delay and initial disease activity. Methods In six centres, patients with signs suggestive of PsA were included in the Swedish Early Psoriatic Arthritis Register within 2 years of symptom onset. CASPAR (classification for psoriatic arthritis) criteria were fulfilled by 197 patients who had passed the 5-year follow-up. Disease activity was measured by the Disease Activity Score including 28 joints (DAS28) and the Disease Activity Index for Psoriatic Arthritis (DAPSA). Remission and minimal disease activity (MDA) were used as outcome measures. Results Mean age at inclusion was 46 years, younger in male than female patients (43 vs 48 years). Mean DAS28 was 3.7 and 3.0 at inclusion and 2.8 and 2.1 at follow-up for women and men, respectively—significantly higher in women at both visits. Likewise, DAPSA scores were significantly higher in women. The degree of improvement (change in DAS28 and DAPSA) was similar. Men achieved MDA or remission (50% vs 33%, 25% vs 13%, respectively) more often, and women had significantly more polyarthritis at inclusion (49% vs 27%) and after 5 years (25% vs 15%). Axial or mono/oligoarticular disease was predominant in men. Independent predictors of MDA at the 5-year follow-up were: shorter symptom duration; greater general well-being (global visual analogue scale); and low Health Assessment Questionnaire at inclusion. Conclusions In early PsA, short delay between onset of symptoms and diagnosis, preserved function, and male gender are the most important predictors of favourable clinical outcome at the 5-year follow-up. Early recognition of PsA and active treatment may be important, particularly in women with polyarticular disease.

Urinary excretion of hyaluronan in man

A specific assay for hyaluronan (hyaluronic acid) has been applied to the determination of the polysaccharide in urine. The excretion in 22 healthy subjects was 330 micrograms/24 h (SD 77). The excretion was correlated with body weight and was therefore somewhat higher in males than in females. The molecular weight of the main fraction of urinary hyaluronan was in the range of 4000 to 12,000 in accordance with the hypothesis that it originates from blood and arises by glomerular filtration. A small fraction was of higher molecular weight and could have been produced in the urinary tract. Hyaluronan in male and female urine displayed the same molecular weight distributions. Patients with rheumatoid arthritis and primary biliary cirrhosis showed a two-fold and three-fold increase, respectively, of hyaluronan in urine with concurrently high levels of the polysaccharide in serum. A patient with Werners syndrome displayed a ten-fold increase of the polysaccharide in both serum and urine.

Sleep disturbances in outpatients with ankylosing spondylitis - a questionnaire study with gender implications

OBJECTIVE To study the sleep pattern in ankylosing spondylitis, and to investigate gender differences in sleep, pain, and fatigue. METHODS Forty-three male and 27 female patients with ankylosing spondylitis completed a sleep questionnaire and the results were compared with earlier findings in 3,558 persons randomly selected from the general population. RESULTS Too little sleep was reported by 80.8% of the female and 50.0% of the male patients, compared to 28.8% and 21.8% respectively in the reference group (p<0.0001). The main reason was pain in the pre-sleep and sleep-periods (p<0.0001). Daytime fatigue was a major problem (p<0.0001). Higher correlation was found between pain and daytime fatigue than between sleep disturbance and daytime fatigue. CONCLUSION Sleep disturbance is a significant problem in ankylosing spondylitis. The disturbance is closely related to pain at bedtime and during the night. Gender differences exist in the subjective sleep disturbance, fatigue, and pain.Objective: To study the sleep pattern in ankylosing spondylitis, and to investigate gender differences in sleep, pain, and fatigue. Methods: Forty-three male and 27 female patients with ankylosing spondylitis completed a sleep questionnaire and the results were compared with earlier findings in 3,558 persons randomly selected from the general population. Results: Too little sleep was reported by 80.8% of the female and 50.0% of the male patients, compared to 28.8% and 21.8% respectively in the reference group (p<0.0001). The main reason was pain in the pre-sleep and sleep-periods (p<0.0001). Daytime fatigue was a major problem (p<0.0001). Higher correlation was found between pain and daytime fatigue than between sleep disturbance and daytime fatigue. Conclusion: Sleep disturbance is a significant problem in ankylosing spondylitis. The disturbance is closely related to pain at bedtime and during the night. Gender differences exist in the subjective sleep disturbance, fatigue, and pain.

Serum hyaluronan and aminoterminal propeptide of type III procollagen: Variation with age

The serum levels of hyaluronan and the aminoterminal propeptide of Type III procollagen (PIIINP) were compared in 585 healthy individuals as a function of age. Newborn children displayed high hyaluronan (695 +/- 634 micrograms l-1, mean +/- SD) and PIIINP (295 +/- 152 micrograms l-1) values. The values were not correlated to the gestational week in which the children were born or to the birth weight but there was a significant correlation (p < 0.05) between the hyaluronan and PIIINP levels. During the first year the levels dropped and in childhood (1-16 years of age) both hyaluronan and PIIINP levels were fairly constant at 27 +/- 16 and 22 +/- 8.4 micrograms l-1, respectively. The PIIINP level showed a marked drop in adults compared to children. The drop continued to about 50 years of age (6.5 +/- 2.2 micrograms l-1) and then there was a slight increase in elderly people. The hyaluronan showed a continued increase with age from the level at 16 years of 29 +/- 17 micrograms l-1 to a mean value of 177 +/- 133 micrograms l-1 in people over 75 years. There was no increase in serum hyaluronan in women during pregnancy but the PIINP level increased in the later part of the gestational period. There was no correlation between the serum values of hyaluronan and PIIINP when compared throughout the life span which indicates that the blood levels of the two markers are regulated by independent factors.

Hyaluronan in pleural effusions and in serum

It has been suggested that a high level of hyaluronan (hyaluronic acid, HYA) in pleural fluid is an indicator of malignant mesothelioma. In 78 consecutive patients with pleural effusion of various causes the HYA concentration was measured in pleural fluid samples and in serum. Nine patients had malignant pleural mesothelioma, and in three of them the HYA level in pleural fluid was 100 mg/l or more. In 42 patients with effusions due to metastatic malignancy, the mean HYA in the pleural fluid was 75 mg/l, and in five the HYA level was above 100 mg/l. Cardiac insufficiency caused the effusion in 11 patients, of whom two had a level above 100 mg/l in pleural fluid. Four patients had a serologically confirmed viral infection and had HYA levels in pleural fluid of 8, 157, 335, and 554 mg/l, respectively. One patient had postinfectious effusion with an HYA level in pleural exudate of 748 mg/l, the highest in this investigation. Two patients had benign asbestos pleural effusions, and both had high pleural HYA levels (256 and 490 mg/l, respectively). The serum HYA values were much lower than in the pleural fluid, namely from 15 to 480 μg/l; the levels were independent of the levels in the pleural fluid. Thus, a high level of HYA in pleural fluid is not specific for mesothelioma but can occur in other malignant or benign diseases, and a low level does not exclude mesothelioma.

The diurnal variation of serum hyaluronan in health and disease

The variation of the serum concentration of hyaluronan during the day and between days has been investigated. In a group of healthy volunteers, the mean hyaluronan level was very stable over time except for a moderate but significant elevation after rising from bed in the morning. Patients with rheumatoid arthritis showed markedly increased hyaluronan concentrations 0.5-2 h after leaving bed. Patients with primary biliary cirrhosis exhibited high and rather constant levels during the day. A reference group of hospitalized patients with other diseases did not show any diurnal variation. The best reproducibility in hyaluronan determinations is obtained if specimens are taken before the subjects rise from bed or a few hours later, i.e. after the morning elevation of serum hyaluronan has subsided. In rheumatoid arthritis valuable information can be obtained by repeated sampling during the morning hours.

Serum hyaluronan and aminoterminal propeptide of type III procollagen in primary biliary cirrhosis : relation to clinical symptoms, liver histopathology and outcome

Abstract. Hyaluronan (HA) and aminoterminal propeptide of type III procollagen (PIIINP), two biochemical connective tissue markers, were determined in 76 patients with primary biliary cirrhosis (PBC). The HA and PIIINP concentrations were significantly increased compared with controls (P < 0.001). Both HA and PIIINP levels correlated significantly with conventional liver‐function tests. All patients with stage IV PBC showed increased concentrations of both these variables. However, HA was a better marker with regard to prediction of development of cirrhosis as well as prediction of symptoms. Furthermore, HA also showed a negative correlation with time of survival (P < 0.05). The present data indicate that HA is a more sensitive marker of liver damage in PBC than PIIINP.

Is serum hyaluronan a helpful tool in the management of patients with liver diseases

Lindqvist U (University Hospital, Uppsala, Sweden). Is serum hyaluronan a helpful tool in the management of patients with liver diseases? (Minisymposium: Hyaluronan). J Intern Med 1997; 242: 67–71.

Down regulation of Fc and complement receptors on B cells in rheumatoid arthritis

B cell tolerance is regulated by receptors that modulate B cell receptor signaling, such as Fc gamma receptor IIb (FcγRIIb; CD32b) and complement receptors (CR) 1 and 2. Deficiency in these receptors may contribute to autoimmunity. To address this we have investigated the receptor expression in healthy individuals in comparison with rheumatoid arthritis (RA) patients. In healthy subjects we found that women had overall lower FcγRIIb expression on B cells than men that significantly decreased with age. RA patients had fewer FcγRIIb, CR1 and CR2 positive B cells and decreased receptor expressions compared to healthy subjects. Further, the RA B cells displayed a significantly increased proliferative response when cultured with interleukin-2 in vitro. In summary, the dysregulated B cells in RA are associated with lower FcγRIIb, CR1 and CR2 levels. The reduced FcγRIIb expression on B cells in women may influence the increased frequency of autoimmunity in women.