Low-molecular-weight heparin added to aspirin in the prevention of recurrent early-onset pre-eclampsia in women with inheritable thrombophilia: the FRUIT-RCT.

BACKGROUND: Early-onset hypertensive disorders (HD) of pregnancy and small-for-gestational age infants (SGA) are associated with placental vascular thrombosis, these often recur and are also associated with inheritable thrombophilia. Aspirin reduces the recurrence risk. OBJECTIVES: Adding low-molecular-weight heparin (LMWH) to aspirin at < 12 weeks gestation reduces the recurrence of HD in women with previous early-onset HD (pre-eclampsia, hemolysis, elevated liver enzymes and low platelets [HELLP] syndrome and eclampsia) and/or SGA, in the context of inheritable thrombophilia without antiphospholipid antibodies. PATIENTS/METHODS: In a multicenter randomized control trial (RCT), 139 women included were< 12 weeks gestation. INCLUSION CRITERIA: previous delivery< 34 weeks gestation with HD and/or SGA; inheritable thrombophilia (protein C deficiency, protein S deficiency, activated protein C resistance, factor V Leiden heterozygosity and prothrombin gene G20210A mutation heterozygosity); and no antiphospholipid antibodies detected. INTERVENTION: either daily LMWH (dalteparin, 5000 IU weight-adjusted dosage) with aspirin 80 mg or aspirin 80 mg alone. PRIMARY OUTCOMES: recurrent HD onset (i) < 34 weeks gestation and (ii) irrespective of gestational age. SECONDARY OUTCOMES: recurrent SGA, preterm birth, maternal/neonatal hospitalization, spontaneous abortion and individual HD. Analysis by intention-to-treat. RESULTS: Low-molecular-weight heparin with aspirin reduced recurrent HD onset < 34 weeks gestation (risk difference [RD] 8.7%: confidence interval [CI] of RD 1.9­15.5%; P = 0.012; number needed to treat [NNT] 12). Recurrent HD irrespective of gestational age was not different between the arms. No women withdrew as a result of adverse effects. TRIAL REGISTRATION: http://www.isrctn.org) (isrctn87325378). CONCLUSIONS: Adding LMWH to aspirin at < 12 weeks gestation reduces recurrent HD onset < 34 weeks gestation in women with inheritable thrombophilia and prior delivery for HD/SGA <34 weeks. However, close monitoring of the mother and fetus remains important throughout pregnancy.

Guideline-based care of common mental disorders by occupational physicians (CO-OP study): a randomized controlled trial.

OBJECTIVE: To evaluate the effectiveness of guideline-based care (GBC) of workers with mental health problems, which promotes counseling by the occupational physician (OP) facilitating return to work (RTW). METHODS: In a randomized controlled trial with police workers on sick leave due to mental health problems (n = 240), trained OPs delivered GBC in the intervention group. Time to RTW and recurrences during 1-year follow-up, analyzed using Cox proportional hazards models, were compared with usual care (UC) with easy access to a psychologist. RESULTS: GBC by OPs did not result in earlier RTW than UC. Subgroup analysis showed a small effect in favor of GBC for workers with administrative functions and/or "minor" stress-related symptoms. CONCLUSIONS: GBC did not differ in RTW compared with UC, but may be beneficial for the majority of workers with minor stress-related disorders.

Behavioural functioning of retinoblastoma survivors.

OBJECTIVE: To assess behavioural problems in retinoblastoma (RB) survivors. METHODS: This population-based cross-sectional study included 148 RB survivors (8-35 years), registered in the Dutch national RB register. Survivors and parents were asked to fill in behavioural questionnaires. Prevalence rates were computed, based on both self-reports and proxy reports. One-sample T-tests were applied to analyse differences compared with healthy reference samples. Multiple regression analyses were performed to identify predictors for behavioural problems within the RB sample. RESULTS: Between-group differences varied across informants and across age groups. Parents reported significantly elevated total problem behaviour in 30% of their offspring (aged 8-17 years); this against 9% in adolescents (12-17 years) and 12% in adults (18-35 years) based on self-report. Parental reports showed significantly elevated rates of (1) internalising problems in boys and (2) somatic complaints in both girls and boys. Self-reports indicate significantly lowered levels of (1) externalising problems in adolescent and adult women and (2) thought problems in female adolescents and in adult men. Especially survivors who suffered hereditary RB, who had undergone more intensive treatment, and who came from a single-parent family were identified to be at most behavioural risk. CONCLUSION: Perception of severity and the nature of behavioural problems seem to differ between beholder, and to vary between age groups, if not between life stages. Health professionals should be aware that especially those who are confronted with hereditary RB and who subsequently undergo intensive treatment, and who grow up in broken families, run the risk of developing behavioural difficulties.

[Determining factors for deciding whether or not to treat refractive errors and cataract in people with a learning disability]. / Determinanten van het al dan niet behandelen van refractieafwijkingen en cataract bij mensen met een verstandelijke beperking.

OBJECTIVE: A study into the treatment of refractive errors and cataract in a selected population with learning disabilities. Design. Retrospective. METHOD: In the years 1993-2003, 5205 people (mean age: 39 years) were referred to the visual advisory centre of Bartiméus (one of three institutes for the visually impaired in the Netherlands) by learning disability physicians and were assessed ophthalmologically. This assessment consisted of a measurement of visual acuity and refractive error, slitlamp examination and retinoscopy, and was performed at the client's accommodation. Advised treatment for spectacle prescriptions and referral for cataract surgery were registered. RESULTS: Refractive errors were found in 35% (1845/5205) of the patients with learning disabilities; 49% (905/1845) already wore spectacles; another 14% (265/1845) were prescribed spectacles for the first time. Of those with presbyopia, 12% (232/1865) had reading glasses and 10% (181/1865) were given a first prescription for spectacles. The most important determinant for not prescribing spectacles was: presence of severe learning disability (odds ratio (OR): 3.7). Cataract was present in 10% (497/5205) of the population; 399 patients were advised to be referred for surgery, 55% (219/399) were referred ofwhom 26% (57/219) had surgery. Moderately severe bilateral cataract was the only determinant of cataract surgery (OR: 7.8). CONCLUSION: Refractive errors and cataract were not always treated in this group. One of the reasons for non-treatment of refractive errors was a severe learning disability. The reason for treatment or non-treatment in patients with cataract was less clear.

Should medical students learn to develop a personal formulary? An international, multicentre, randomised controlled study.

OBJECTIVE: This study was performed to determine whether students who are trained in developing a personal formulary become more competent in rational prescribing than students who have only learned to use existing formularies. METHODS: This was a multicentre, randomised, controlled study conducted in eight universities in India, Indonesia, the Netherlands, the Russian Federation, Slovakia, South Africa, Spain and Yemen. Five hundred and eighty-three medical students were randomised into three groups: the personal formulary group (PF; 94), the existing formulary group (EF; 98) and the control group (C; 191). The PF group was taught how to develop and use a personal formulary, whereas e the EF group was taught how to review and use an existing formulary. The C group received no additional training and participated only in the tests. Student's prescribing skills were measured by scoring their treatment plans for written patient cases. RESULTS: The mean PF group score increased by 23% compared with 19% for the EF group (p < 0.05) and 6% for controls (p < 0.05). The positive effect of PF training was only significant in universities that had a mainly classic curriculum. CONCLUSION: Training in development and use of a personal formulary was particularly effective in universities with a classic curriculum and with traditional pharmacology teaching. In universities with a general problem-based curriculum, pharmacotherapy teaching can be based on either existing or personal formularies.

6,220 institutionalised people with intellectual disability referred for visual assessment between 1993 and 2003: overview and trends.

AIMS: To summarise the results of visual performance tests and other data of institutionalised people with intellectual disability referred to a visual advisory centre (VAC) between 1993 and 2003, and to determine trends in these data. METHODS: A retrospective medical record review was undertaken of 6,220 consecutive people examined ophthalmologically according to a standard protocol by one VAC that specialised in visual assessment and treatment of people with intellectual disability, between 1993 and 2003. chi2 test for linear trend was used and linear regression coefficients were calculated. RESULTS: The proportion of people aged > or =50 years increased from 19.3% to 34.2% between 1995 and 2003 (p<0.001); the combined figure of severe or profound intellectual disability decreased from 80.0% to 52.6% (p<0.001); the proportion of mobile people increased from 52.1% to 98.0% (p<0.001); the combined proportion of people with visual impairment or blindness decreased from 70.9% to 22.9% (p<0.001), and that of people with visual disorders decreased from 89.6% to 75.3% (p<0.001). Causes of intellectual disability were identified in 58.4% people; 20.8% had Down's syndrome. CONCLUSION: Many ocular diagnoses were found, indicating the need for ophthalmological monitoring. Specialised centres are helpful, because assessment and treatment of people with intellectual disability is complicated and time consuming. Protocols for efficient referral will have to be developed. A major task lies ahead to improve the treatment rates of refractive errors, cataract and strabismus, and to find specific causes of intellectual disability.

Introduction of sentinel node biopsy and stage migration of breast cancer.

AIM: The purpose of this study was to examine in a large population based group of breast cancer patients treated in a regular care setting whether the introduction of the Sentinel Node Biopsy (SNB) led to detection of a higher percentage of patients with positive regional lymph nodes. METHODS: The study includes 3665 early breast cancer patients, aged 30-85 years, diagnosed in the period 1997-2002 and registered at the Regional Cancer Registry of the Comprehensive Cancer Centre Middle Netherlands. During this period the SNB was introduced. The outcome of staging was compared for groups staged with or without SNB. A logistic regression model was used to adjust for age, calendar period and tumour size. RESULTS: Overall a quarter of all patients over the period 1997-2002 underwent a SNB as method of lymphatic staging. The use of SNB clearly increased over time: from 2% in 1998 to 65% in 2002. The percentage node positive patients also rose significantly; before introduction of the SNB 30% of all patients were diagnosed with positive lymph nodes, and after SNB introduction this percentage was 40%. The increase is largely explained by the increase of patients diagnosed with only micrometastases. Adjustment did not change the results. CONCLUSION: In conclusion, introduction of the SNB in early breast cancer led to significant upstaging of breast cancer patients treated in a regular care setting, due to the detection of more micrometastases. Since the relevance of micrometastases for long term survival is not yet known, this upstaging potentially led to over treatment of patients. On the other side, for some patients axillary lymph node dissection was prevented by the SNB procedure, preventing comorbidity.

Predictive value of symptom level measurements for complex regional pain syndrome type I.

The validity with respect to presence or absence of CRPS I according to Veldman's criteria was assessed for measured pain, temperature, volume differences and limitations in range of motion. Evaluated were 155 assessments of 66 outpatients, initially diagnosed with CRPS I, but many of them not so on follow up visits. Pain was measured with VAS and McGill, temperature by infrared thermometry, volume differences by water displacement volumeters and limitations in range of motion by universal goniometers. Sensitivity, specificity, positive and negative predictive value of the measurement instruments at different cut-off points was calculated. Combined symptom scores were evaluated in a similar fashion. High sensitivity was found for the VAS, McGill, and range of motion. The specificity was overall lower, but highest values were obtained for volume differences. The positive predictive value was good for all measurement instruments. Negative predictive value was lower, especially for measurement of temperature and volume asymmetries. If sensitivity and specificity are equally important, VAS>3 cm, McGill>6 words, temperature difference>or=0.4 degrees C, volume difference>6.5% and ROM limitation>15% provide the best results. Using these cut off values, the highest value of sensitivity and of sensitivity and specificity combined, was found for a combination of VAS, McGill and ROM. The highest value of specificity was found for different combinations of 3, 4 and 5 instruments, all containing the VAS. We conclude that the measured pain, temperature, volume and range of motion can be used as diagnostic indicators for establishing presence or absence of CRPS I.

Recurrence rate of pre-eclampsia in women with thrombophilia influenced by low-molecular-weight heparin treatment?

OBJECTIVES: (1) To assess the recurrence rate of pre-eclampsia in women with this history before 34 weeks of pregnancy and thrombophilia. (2) To evaluate the effects of low-molecular-weight heparin (LMWH) on pregnancy outcome. METHODS: In a multicentre retrospective study subsequent pregnancies of women with a history of pre-eclampsia necessitating birth before 34 weeks and thrombophilia were analysed. Of 58 women, 26 received LMWH and aspirin (ASA) and 32 ASA (22) or no (10) medication in their subsequent pregnancies. RESULTS: In eight women treated with LMWH and ASA and in 16 women receiving ASA or no medication pre-eclampsia recurred in the subsequent pregnancy. (OR 0.55, 95% CI 0.15-1.31) There were no significant differences in birth weight or gestational age between both groups. CONCLUSIONS: The recurrence rate of pre-eclampsia in women with thrombophilic disorders is high in this small retrospective study. No positive effect was found for LMWH treatment. A multicentred randomised study has been started to reach an adequate number of patients to evaluate the influence of LMWH treatment.

Patch-test-induced subjective complaints.

BACKGROUND: Many patients report subjective complaints during epicutaneous patch testing. OBJECTIVE: To demonstrate the possible relationship between the occurrence of subjective complaints and patch testing. METHODS: All consecutive patients who were referred to our clinic for patch testing, during 1 year, were investigated to study a possible association of the patch test procedure and subjective complaints like tiredness, shakiness or feeling unwell. The patients were asked to fill in a form concerning subjective complaints on the days of the investigation. Only those without complaints on the day the patches were applied were included in the study (n=102). RESULTS: Of the 102 patients, 17 had complaints on both days 2 and 3, 14 only on day 2, 6 only on day 3 and 65 did not develop any complaints at all. The number of patients with complaints on both days 2 and 3 (n=17) was larger than was to be expected from chance (n=4.6; p<0.01). There was a significant correlation between the number of positive patch test reactions and the number of complaints on day 2 (r=0.19; p<<0.001) and on day 3 (r=0.15; p<0.001). Positive patch tests were found in 72.2% of the patients who reported the complaint of shakiness; this proportion is significantly higher than expected from chance (p<0.05). CONCLUSION: The results confirm those of our earlier study and demonstrate that patch testing can cause subjective complaints, especially when positive patch tests are present.

Comparison of endocrine tests with respect to their predictive value on the outcome of ovarian hyperstimulation in IVF treatment: results of a prospective randomized study.

BACKGROUND: This study was designed to compare endocrine tests [clomiphene citrate challenge test (CCT), exogenous FSH ovarian reserve test (EFORT) and basal FSH, basal estradiol (E(2)) and basal inhibin B as an integral part of all CCT and EFORT], with respect to their ability to estimate the stimulable cohort of follicles in the ovaries (ovarian capacity) and to analyse which test or combination of tests would give the best prediction of ovarian capacity. METHODS: A total of 110 regularly menstruating patients, aged 18-39 years, participated in this prospective study, randomized by a computer-designed 4-block system study into two groups. Fifty-six patients underwent a CCT, and 54 patients underwent an EFORT. In all patients, the test was followed by an IVF treatment. The result of ovarian hyperstimulation during IVF treatment, expressed by the total number of follicles, was used as gold standard. RESULTS: Univariate linear regression analysis showed that the best correlation with the number of follicles after ovarian hyperstimulation (Y) is found by the inhibin B increment (InhB incr.) in the EFORT (Y = 3.957 + 0.081 x InhB incr. (95% CI 0.061-0.101); r = 0.751; P < 0.001). Multiple linear regression analysis showed a significant contributing value of the variables basal FSH, E(2) increment of the EFORT and inhibin B increment to the basic model with the variable age. The best prediction of ovarian capacity (Y) was seen when E(2) increment and inhibin B increment were used simultaneously in a stepforward multiple regression prediction model [Y = 2.659 + 0.052 x InhB incr. (0.026-0.078) + 0.027 x E(2) incr. (95% CI 0.012-0.054); r = 0.796; P < 0.001]. The CCT could not be used in a prediction model. CONCLUSIONS: The EFORT is the endocrine test which gives the best prediction of ovarian capacity.

[Systematic reviews in practice. X. Searching, selecting and the methodological assessment of diagnostic evaluation research]. / De praktijk van systematische reviews. X. Zoeken, selecteren en methodologisch beoordelen van diagnostisch evaluatieonderzoek.

Literature concerning the value of diagnostic tests is poorly indexed in electronic bibliographical databases. An extensive, sensitive and specific search strategy for evaluation of a diagnostic test in Medline is a combination of key words or text words concerning the diagnostic test with: 'sensitivity and specificity' (exploded), 'mass screening' (exploded), 'reference values', 'false positive reactions', 'false negative reactions', 'specificit$.tw', 'screening.tw', 'false positive$.tw', 'false negative$.tw', 'accuracy.tw', 'predictive value$.tw', 'reference value$.tw', 'roc$.tw' or 'likelihood ratio$.tw'. Inclusion and exclusion criteria select publications which meet certain minimum requirements, such as the presence of an accepted reference standard, a clear definition of 'diseased', and the presence of a suitable outcome measure. The methodological assessment list should contain a number of validity criteria as well as a number of criteria by which to measure the extent to which the study results can be generalised. Important assessment criteria that may affect the diagnostic value of the test are: study design, blinding, use of different reference standards, the absence of details about the diagnostic criteria for the diagnostic test and insufficient information about the study population.

Cost-effectiveness of screening for the possible development of cancer in patients with oral lichen planus.

INTRODUCTION: Several authors have expressed the view that patients with oral lichen planus (OLP) are at increased risk of developing oral cancer. Since OLP cannot be effectively treated, regular screening for the possible development of oral cancer might be considered. OBJECTIVES: (i) To calculate costs and effectiveness of screening for oral cancer in OLP patients with a decision model; (ii) to compare the cost-effectiveness of different screening scenarios; and (iii) to perform a sensitivity analysis of several variables used in this model. METHODS: Costs and effectiveness of a population of 100,000 OLP patients, being either screened or not screened for oral cancer, were calculated for the period of 1 year. Health gain was expressed as quality adjusted live years (QALY's) and equivalent lives saved (ELS). Cost-effectiveness was expressed as extra costs (costs of screening minus costs of no screening) per ELS. Then, the outcome was compared with the cost-effectiveness of a different screening scenario. Finally, the effect of varying the variables: (i) costs of cancer treatment; (ii) annual malignant transformation rate (MTR); (iii) sensitivity and specificity of an oral examination; and (iv) proportion of cancers found in stage I on extra costs per ELS were assessed in a sensitivity analysis. RESULTS: The health gain from screening was 592 QALY's or the equivalent of 23.68 lives saved, costing 1,265,229 dollars, meaning that one ELS costed 53,430 dollars. Increase of cancer-treatment costs will significantly decrease the costs per ELS. When the MTR is lower than 0.4% per year, extra costs per ELS will increase exponentially. The effect of sensitivity and specificity of an oral examination in detecting oral cancer on cost-effectiveness seems to be substantial. When the proportion of cancers found in stage I can be increased from 40% (without screening) up to at least 60% after screening, extra costs per ELS will decrease exponentially. CONCLUSIONS: Screening for oral cancer in OLP patients, based on the presently used model, seems attractive. However, varying the several variables in the decision model has a significant impact on the final costs and effectiveness. Only, when additional information about these variables will become available, a more precise and realistic calculation can be performed.

High-risk human papillomavirus clearance in pregnant women: trends for lower clearance during pregnancy with a catch-up postpartum.

We followed 353 women referred with abnormal cervical cytology in a non-intervention cohort study. In 91 pregnant women we compared high-risk human papilloma virus rates in the subsequent trimesters and postpartum in comparison to 262 non-pregnant women. High-risk human papilloma virus clearance was compared with 179 high-risk human papilloma virus positive non-pregnant women. Our main questions were: (1) do high-risk human papilloma virus rates change during pregnancy?; and (2) is there any difference between high-risk human papilloma virus clearance in pregnant and non-pregnant women? Women were monitored 3-4 monthly by cytology, colposcopy, and high-risk human papilloma virus testing. The median follow-up time was 33 months (range 3-74). Non-pregnant women showed prevalence rates of high-risk human papilloma virus of 64, 57, 53, and 50%, respectively, in four subsequent 3-months periods since the start of the study. These high-risk human papilloma virus rates were higher than in the three trimesters of pregnancy, and during the first 3 months postpartum, i.e. 50, 44, 45, and 31%, respectively. Postpartum only, this difference was statistically significant (P=0.004). Paired comparisons of high-risk human papilloma virus prevalence rates of the different trimesters with the postpartum rate showed (McNemar test) decreased rates: first trimester: 18% (P=0.02), second trimester: 13% (P=0.02) and third trimester: 23% (P<0.005). Such a phenomenon was not found in non-pregnant women. Pregnant women showed a trend for increased high-risk human papilloma virus clearance during the third trimester and postpartum compared to non-pregnant women (hazard ratios 3.3 (0.8-13.7) and 4.6 (1.6-12.8), respectively). These results suggest a lowered immune-response against human papilloma virus during the first two trimesters of pregnancy with a catch-up postpartum.

The clinical relevance of epithelial dysplasia in the surgical margins of tongue and floor of mouth squamous cell carcinoma: an analysis of 37 patients.

BACKGROUND: The clinical relevance of the presence of epithelial dysplasia in the margins of surgically removed oral squamous cell carcinoma is still unclear. METHOD: In a retrospective study, the presence of mild or moderate epithelial dysplasia in the surgical margins of tongue and floor of mouth squamous cell carcinoma was examined histologically. Patients with tumor cells within 0.5 cm of the surgical margins were excluded. Also patients with severe dysplasia were excluded, as this is usually regarded as carcinoma in situ. Patients that received postoperative irradiation were also excluded. Only patients who completed a follow-up period of five years were included. All together, a total number of 37 patients fulfilled the inclusion criteria. RESULTS: Epithelial dysplasia was observed in 7 out of the 37 patients. Five of these patients, and two of the 30 patients with no dysplasia, had a local recurrence (P < 0.01). CONCLUSION: The presence of mild or moderate epithelial dysplasia in the margins of surgically removed oral squamous cell carcinoma carries a significant risk for the development of local recurrence. However, it should be noted that this study was of a retrospective nature and that the group of patients with epithelial dysplasia in the surgical margins was rather small. On the other hand, the inclusion criteria were somewhat strict, by limiting the oral subsite to tongue/floor of mouth, by excluding patients in whom tumors cell were found within 0.5 cm of the surgical margins and by excluding patients who received postoperative radiotherapy, amongst others.

Cytological regression and clearance of high-risk human papillomavirus in women with an abnormal cervical smear.

We studied the natural course of high-risk human papillomavirus (HPV) infection and cytological regression in women referred for colposcopy because of abnormal cervical smears. We found that high-risk HPV clearance preceded regression of cervical lesions by an average of 3 months. The cumulative 1-year rate of cytological regression was similar in women with mild and moderate dyskaryotic cervical smears. Thus, retesting of high-risk HPV after 6 months in women with mild to moderate dyskaryosis predicts cytological regression.

The oedema-protective effect of Lycra support stockings.

BACKGROUND: Oedema may be an early sign of chronic venous insufficiency (CVI), but swelling of the lower legs is a common phenomenon in many people. The distinction between physiological swelling and CVI is not clear. There is a gradual transition between healthy legs and the early stages of CVI. In case of CVI, medical elastic compression stockings are used in order to prevent oedema completely. In case of healthy people without demonstrable CVI, no medical stockings are required in the prevention of oedema but stockings exerting less compression. OBJECTIVE: The aim of this study was to investigate the effect of mild compression on the development of swelling of the legs and the effect on subjective complaints in healthy subjects. METHODS: The diurnal volume change (DVC) of the lower legs during full working days was monitored with an optical leg volume meter in 118 healthy volunteers (60 males, 58 females) without objective symptoms of CVI. The DVCs after wearing two kinds of class I support stockings (X: average pressure at the ankle of almost 14 mm Hg; Y: almost 18 mm Hg) were compared with the DVC after wearing a control stocking (Z: almost 6 mm Hg). Also, the effect on subjective feelings of the legs was noted. RESULTS: It appeared that healthy people have a mean daily volume increase of the legs of 2.3% in females and 1.6% in males. Mild compression stockings reduced this daily increase with 31 and 18% in males and females, respectively, by stocking X and 37 and 32% by stocking Y. Subjective feelings occurred in 57% of all cases. A beneficial effect on subjective feelings, in particular of tired and swollen legs, was found. A difference in this beneficial effect between stocking X and Y was not obvious. CONCLUSIONS: Mild compression stockings reduce diurnal oedema and unpleasant feelings of the legs in healthy individuals.

Predictors of radiographic joint damage in patients with early rheumatoid arthritis.

OBJECTIVE: To determine factors at diagnosis, associated with radiographic damage at diagnosis and after one year, in patients with early rheumatoid arthritis (RA). METHODS: New patients with early RA were followed up for one year. Possible prognostic factors were duration of complaints, morning stiffness, disease activity score (DAS28), functional status (Health Assessment Questionnaire (HAQ) score), rheumatoid factor (IgM RF), and C reactive protein (CRP). Outcome was defined as radiographic damage of the hands and feet (Sharp/van der Heijde score). For the statistical analysis, one way analysis of variance and a forward stepwise logistic regression model was used. RESULTS: 130 patients with RA (68% female; median age 64 years, range 21-86) were included. Despite the fact that the median duration of complaints was short (15 weeks, range 2-106) the radiographic damage at diagnosis was significantly correlated with the duration of complaints (p<0.05). Patients with a duration of complaints of >34 weeks had significantly more radiographic joint damage at diagnosis than patients with a shorter duration of complaints. Radiographic progression at one year was correlated with high radiographic joint damage, high CRP level, and a positive IgM RF at entry. CONCLUSIONS: In early RA, the number of radiographic lesions was correlated with a longer duration of complaints at the first visit. Progression of these lesions was predicted by a high baseline joint damage, high CRP level, and a positive IgM RF. Further reduction of the delay in referral and early treatment may further decrease joint damage in patients with recent onset polyarthritis.

Tobacco usage in relation to the anatomical site of oral leukoplakia.

OBJECTIVE: Tobacco usage is the most important known aetiological factor in the development of oral leukoplakia. The purpose of this study was to investigate the possible relation of tobacco usage to the anatomical site of the leukoplakia. SUBJECTS AND METHODS: Clinical data regarding tobacco usage and localisation of leukoplakia obtained from 166 patients with oral leukoplakia. RESULTS: Leukoplakias in the floor of mouth appeared to be statistically significantly more often present in smokers than in non-smokers, compared to all other oral sites (P < 0.001; OR = 8.47 and 18.13 for men and women, respectively). On the contrary, leukoplakias on the borders of the tongue were statistically significantly more common among non-smokers, than smokers, compared to all other oral sites (P < 0.001; OR = 0.22 and 0.12 for men and women, respectively). CONCLUSION: The present study suggests that the influence of tobacco on the development of leukoplakia varies by anatomical site.