Prevalence of pulmonary hypertension in an unselected, mixed connective tissue disease cohort: results of a nationwide, Norwegian cross-sectional multicentre study and review of current literature.

OBJECTIVES: The aim of this study was to assess the overall prevalence of pulmonary hypertension (PH) in an unselected MCTD cohort and review the current knowledge with a systematic database search. METHODS: A nationwide multicentre cohort of 147 adult MCTD patients were initially screened for PH by echocardiography, high-resolution computed tomography (HRCT), pulmonary function tests and N-terminal pro-brain natriuretic peptide (NT-proBNP) and then followed up for a mean of 5.6 years. Right-sided heart catheterization was performed when estimated pulmonary artery systolic pressure was >40 mmHg on echocardiography. PH was diagnosed according to the 2009 European Society of Cardiology and European Respiratory Society guidelines. RESULTS: At inclusion, 2.0% (3/147) had established PH. Two additional PH patients were identified during follow-up, giving a total PH frequency in the cohort of 3.4% (5/147). All five had elevated serum NT-proBNP. Two had isolated pulmonary arterial hypertension (PAH) and three PH associated with interstitial lung disease (PH-ILD). Three PH patients died during follow-up. Nine other patients in the cohort also died, but none of them had echocardiographic signs of PH prior to death. CONCLUSION: The data from the current unselected MCTD cohort suggest that the prevalence of PH is much lower than expected from previous studies but confirm the seriousness of the disease complication.

Prevalence and severity of interstitial lung disease in mixed connective tissue disease: a nationwide, cross-sectional study.

BACKGROUND: Mixed connective tissue disease (MCTD) is an immune-mediated, systemic disorder of unknown cause. OBJECTIVE: To assess the prevalence, pattern and severity of interstitial lung disease (ILD) in a cross-sectional study of the nationwide, Norwegian MCTD cohort. METHODS: 126 patients with MCTD were systematically examined for ILD by high-resolution CT (HRCT), pulmonary function tests (PFT), 6 min walk test (6MWT) and by the New York Heart Association (NYHA) functional classification of dyspnoea. The extent and type of HRCT lung abnormalities were scored according to the CT criteria of ILD recommended by the Fleischner Society. RESULTS: All 126 patients were Caucasian, 75% women. At the time of the cross-sectional ILD study, the patients had a mean disease duration of 9.0 years. 52% of the patients had abnormal HRCT findings, most commonly reticular patterns consistent with lung fibrosis (35%). Lung fibrosis was quantified as minor in 7%, moderate in 9% and severe in 19% of the patients. Fibrosis was uniformly concentrated in the lower parts of the lungs and was not associated with smoking. Patients with severe lung fibrosis had lower PFT values, shorter 6MWT and a higher mean NYHA functional class. After a mean 4.2 years' follow-up, overall mortality was 7.9%. Mortality in patients with normal HRCT was 3.3%, as compared with 20.8% in patients with severe lung fibrosis (p<0.01). CONCLUSIONS: Severe lung fibrosis is common in MCTD, has an impact on pulmonary function and overall physical capacity and is associated with increased mortality.

Incidence rates of fragility hip fracture in middle-aged and elderly men and women in southern Norway.

BACKGROUND: Hip fracture contributes to increased morbidity and mortality in the elderly population. As the average age of the population is increasing, the burden of hip fracture on the health-care system is a growing challenge. The highest incidence of hip fracture worldwide has been reported from Scandinavia in fact from Oslo the capital of Norway. During the last decades, efforts have been undertaken to reduce hip fracture risk. OBJECTIVE: To study the incidence of fragility hip fracture in southern Norway. DESIGN: A validated retrospective epidemiological study. SETTING: Population-based study. SUBJECTS: All patients with fragility hip fractures aged 50 years or older in 2004 and 2005 in southern Norway. METHODS: The hip fracture patients were identified from the four hospitals (Kristiansand, Arendal, Flekkefjord and Mandal) located in the two most southern counties in Norway, Vest-Agder and Aust-Agder County. Age-adjusted and age-specific incidence rates for men and women were calculated. We also explored for seasonal variations and differences between rural and urban areas. RESULTS: A total of 951 (271 men, 680 women) individuals aged ≥50 years with hip fracture were identified. The age-adjusted incidence rate was 34.6 for men and 75.8 for women per 10,000 person-years. Age specific incidence rates were significantly higher in women than in men but only for age groups between 70 and 90 years. CONCLUSION: Age-adjusted incidence of hip fracture in men and women in southern Norway is the lowest reported from Norway and among the lowest in Scandinavia. No differences were seen between rural and urban areas. The number of fragility hip fractures was statistically significant higher in winter compared with the other seasons.

Low bone mineral density is a significant risk factor for low-energy distal radius fractures in middle-aged and elderly men: a case-control study.

BACKGROUND: In general there is a lack of data on osteoporosis and fracture in men; this also includes low-energy distal radius fractures. The objectives of this study were to examine BMD and identify factors associated with distal radius fractures in male patients compared with controls recruited from the background population. METHODS: In a 2-year period, 44 men 50 years or older were diagnosed with low-energy distal radius fractures, all recruited from one hospital. The 31 men who attended for osteoporosis assessment were age-matched with 35 controls. Demographic and clinical data were collected and BMD at femoral neck, total hip and spine L2-4 was assessed by dual energy X-ray absorptiometry. RESULTS: Apart from weight and living alone, no significant differences were found between patient and controls for demographic variables (e.g. height, smoking) and clinical variables (e.g. co-morbidity, use of glucocorticoids, osteoporosis treatment, falls and previous history of fracture). However, BMD expressed as T-score was significant lower in patients than in controls at all measurement sites (femoral neck: -2.24 vs. -1.15, p < 0.001; Total hip: -1.65 vs. -0.64, p < 0.001; Spine L2-4: -1.26 vs. 0.25, p = 0.002). Among the potential risk factors for fracture evaluated, only reduced BMD was found to be significantly associated with increased risk for low-energy distal radius fractures in men. CONCLUSION: The results from our study indicate that reduced BMD is an important risk factor for low-energy distal radius fracture in men. This suggests that improvement of BMD by both pharmacological and non-pharmacological initiatives may be a strategy to reduce fracture risk in men.

The ability of hand digital X-ray radiogrammetry to identify middle-aged and elderly women with reduced bone density, as assessed by femoral neck dual-energy X-ray absorptiometry.

In this study, we evaluate the ability of digitized digital X-ray radiogrammetry (DXR) bone mineral density (BMD) to identify women with reduced BMD at femoral neck, assessed by dual-energy X-ray absorptiometry (DXA). The study population contained women with recent low-energy distal radius fracture and women recruited from the general population, all aged 50 yr or older. The correlation between hand BMD and femoral neck BMD was r=0.65 (p<0.001). We used a triage approach where 2 cutoffs for DXR T-score were defined at which patients with 90% sensitivity and 90% specificity could be identified to have or not have reduced BMD at femoral neck, defined as T-score ≤-2.5 standard deviation (SD). The upper and lower DXR T-score cutoffs were -1.2 and -2.7, respectively. Applying the triage approach in the whole cohort, 32% would require a central DXA assessment to determine the presence or absence of femoral neck T-score ≤-2.5 SD. Our data suggest that DXR can be used to reduce the numbers of patients in need of DXA femoral neck and may, thus, be of clinical value where access to DXA is limited.

[Clinical use of COX inhibitors--a consensus]. / Klinisk bruk av COX-hemmere--en konsensus.

BACKGROUND: Many physicians have been uncertain about treatment options following reports that linked cyclooxygenase (COX) inhibitors to serious cardiovascular events and the subsequent withdrawal of two selective COX-2 inhibitors. Therefore, on June 14, 2005, the Norwegian Medicines Agency and the Department of Pharmacotherapeutics, University of Oslo, held an expert meeting on COX inhibitors. METHODS: Presentations and discussions based on existing literature and statements from European (EMEA) and American (FDA) medicine authorities. This constitutes the basis for the current recommendations. RESULTS AND INTERPRETATION: COX inhibitors have solely symptomatic effects, and there are no differences in analgesic and anti-inflammatory efficacy between the various COX-inhibitors. These drugs should, if possible, be used at the lowest effective dose and for as short a time as possible. Some of the COX-2 selective inhibitors show a lower incidence of gastrointestinal side effects than unselective COX inhibitors, but this advantage can be outweighed by increased occurrence of cardiovascular side effects. Generally, the cardiovascular adverse effects are more serious, and more often irreversible, than the gastrointestinal adverse effects. Patients with established or increased risk of cardiovascular disease should not use COX-2-selective inhibitors. In general, COX inhibitors should, if possible, not be administered to individuals with previous peptic ulcer disease, hypertension, heart failure, or kidney disease. There is a need for more data on the effect and safety of COX inhibitors.

[Medical prophylaxis and treatment of steroid induced osteoporosis]. / Medikamentell profylakse og behandling av steroidindusert osteoporose.

BACKGROUND: Glucocorticoid steroids are widely used as antiinflammatory and immunosuppressive medications and are well known to induce osteoporosis. MATERIAL AND METHODS: Randomised clinical trials and Cochrane reports on the use of calcium, vitamin D, bisphosphonates and hormones were reviewed and the results summarised. Additionally, national and some international recommendations were reviewed in order to propose recommendations for prophylaxis and treatment. The literature was identified by Medline searches. RESULTS AND INTERPRETATION: Calcium and vitamin D prevent bone loss in low-to-medium-dose glucocorticoid steroid therapy. Bisphosphonates maintain or modestly increase lumbar and hip bone mass. The fracture risk was not significantly reduced in the spine and the hip. The clinical randomised trials and Cochrane reports conclude that bisphosphonates as well as calcium and vitamin D taken together are effective and the drugs of choice in prevention and treatment.

[Combination therapy in rheumatoid arthritis]. / Kombinasjonsterapi ved revmatoid artritt.

BACKGROUND: During the last decade patients with active rheumatoid arthritis have been offered early and aggressive drug therapy in order to decrease the damaging effect of inflammation on cartilage and bone. Combination of two or more disease-modifying antirheumatic drugs has been used more frequently to achieve better efficacy than with monotherapy without increasing drug side effects. MATERIALS AND METHODS: We have studied available rheumatological literature to find the best documented drug combinations. RESULTS: The combination of methotrexate, sulfasalazine and hydroxychloroquine seems to be a well documented alternative, and so is the combination of methotrexate and cyclosporine. Modern biologic drugs like etanercept, infliximab and anakinra work best in combination with methotrexate. INTERPRETATION: The combination of two or more disease-modifying antirheumatic drugs can be a good alternative to monotherapy in the treatment of patients with active rheumatoid arthritis, either when monotherapy has failed or unacceptable side effects have occurred, or as a first choice in patients who need very early and aggressive therapy. Combination therapy should only be initiated by a rheumatologist, after informed consent. A safe clinical and chemical monitoring must be organized in cooperation with the patient and the primary physician.