Drugs used in incident systemic lupus erythematosus - results from the Finnish nationwide register 2000-2007.

The objectives of the study were to examine the initial, first-year anti-rheumatic outpatient therapy in patients with incident SLE, as well as the concomitant use of drugs for certain comorbidities, compared to the use in the general population. The Finnish nationwide register data on special reimbursements for medication costs was screened to identify the inception cohort of 566 adult SLE patients (87% females, mean age 46.5 ± 15.9 years) over the years 2000-2007. The patients were linked to the national Drug Purchase Register. Of those, 90% had purchased at least once some disease-modifying anti-rheumatic drugs (DMARDs) during the first year. Hydroxychloroquine was the most common (76%), followed by azathioprine (15%) and methotrexate (13%). With the exception of increase in mycophenolate mofetil, the proportions remained stable over the whole study period 2000-2007. Drugs for cardiovascular diseases, dyslipidemia, diabetes mellitus, hypothyroidism and obstructive pulmonary disease were more frequently purchased than in the sex- and age-adjusted population, with rate ratios ranging from 1.6 to 7.8. Over the years 2000-2007, almost all the patients with incident SLE in Finland started with a DMARD. Higher percentages of SLE patients were on medication for several common chronic diseases than in the population as a whole.

Psychiatric and cardiovascular comorbidities as causes of long-term work disability among individuals with recent-onset rheumatoid arthritis.

OBJECTIVES: With the ameliorating prognosis of rheumatoid arthritis (RA), the role of comorbidities as causes of work disability (WD) may increase. The aim of this study was to determine the contribution of psychiatric and cardiovascular (CV) comorbidities as the leading causes of long-term WD among patients with recent-onset RA. METHOD: Between 2000 and 2007, all incident, working-age and non-retired RA patients were identified from a Finnish nationwide register. From other registers, we identified the RA patients who were granted a permanent or temporary disability pension by 31 December 2008. The incidences of disability pensions with CV diseases (ICD-10 codes I00-I99) or psychiatric disorders (F20-F69) as the leading causes were assessed and compared with the general population. RESULTS: We identified a cohort of 7831 patients with RA. During follow-up, 1095 patients were granted a disability pension. After adjusting for competing risks, the 9-year cumulative incidence of WD caused by RA, a psychiatric comorbidity, or a CV disease was 11.9, 1.3, and 0.5%, respectively. Compared to the general population, the age- and sex-specific standardized incidence ratio (SIR) of WD due to psychiatric comorbidities was 0.99 [95% confidence interval (CI) 0.80-1.23] and due to CV disease 1.75 (95% CI 1.23-2.51). CONCLUSIONS: In the study cohort with recent-onset RA, the 9-year cumulative incidence of disability pensions caused by psychiatric or CV comorbidities was only 11% or 4%, respectively, of that caused by RA itself. Compared to the general population, the risk of WD due to CV disease was increased.

Mortality and causes of death among incident cases of systemic lupus erythematosus in Finland 2000-2008.

The objectives of the study were to investigate mortality and causes of death in patients with recent-onset systemic lupus erythematosus (SLE) in Finland. Data for patients with SLE for the study were collected (2000-2007) from the nationwide register on decisions of special reimbursements for drugs, maintained by the Social Insurance Institution (SII) in Finland. Data on deaths of the patients were obtained from the official death certificate statistics of Statistics Finland until the end of 2008. Of the 566 incident SLE patients, median follow-up time was 5.4 (IQR 3.3, 7.1) years, and 30 patients (23 females, seven males) died in the years 2000 through 2008. Mean age at death was 67.8 ± 17.2 years for females and 62.3 ± 15.2 years for males. The 5-year survival rates were 94.8% (95%CI 92.0-96.6%) and 88.2% (95%CI 76.5-94.3%), respectively. The age- and sex-adjusted standardized mortality ratio was 1.48 (95%CI 1.01-2.12). Primary causes of death were cardiovascular diseases, malignancy and SLE itself. In conclusion, survival of the patients with SLE was inferior to that of the general population. Cardiovascular diseases were responsible for 37% of deaths.

Test-retest reliability and comparability of paper and computer questionnaires for the Finnish version of the Tampa Scale of Kinesiophobia.

OBJECTIVES: To estimate the internal consistency, test-retest reliability and comparability of paper and computer versions of the Finnish version of the Tampa Scale of Kinesiophobia (TSK-FIN) among patients with chronic pain. In addition, patients' personal experiences of completing both versions of the TSK-FIN and preferences between these two methods of data collection were studied. DESIGN: Test-retest reliability study. Paper and computer versions of the TSK-FIN were completed twice on two consecutive days. PARTICIPANTS: The sample comprised 94 consecutive patients with chronic musculoskeletal pain participating in a pain management or individual rehabilitation programme. The group rehabilitation design consisted of physical and functional exercises, evaluation of the social situation, psychological assessment of pain-related stress factors, and personal pain management training in order to regain overall function and mitigate the inconvenience of pain and fear-avoidance behaviour. RESULTS: The mean TSK-FIN score was 37.1 [standard deviation (SD) 8.1] for the computer version and 35.3 (SD 7.9) for the paper version. The mean difference between the two versions was 1.9 (95% confidence interval 0.8 to 2.9). Test-retest reliability was 0.89 for the paper version and 0.88 for the computer version. Internal consistency was considered to be good for both versions. The intraclass correlation coefficient for comparability was 0.77 (95% confidence interval 0.66 to 0.85), indicating substantial reliability between the two methods. CONCLUSION: Both versions of the TSK-FIN demonstrated substantial intertest reliability, good test-retest reliability, good internal consistency and acceptable limits of agreement, suggesting their suitability for clinical use. However, subjects tended to score higher when using the computer version. As such, in an ideal situation, data should be collected in a similar manner throughout the course of rehabilitation or clinical research.

Antidepressant use among persons with recent-onset rheumatoid arthritis: a nationwide register-based study in Finland.

OBJECTIVES: The aim of this study was to investigate antidepressant use in a nationwide cohort of persons with incident rheumatoid arthritis (RA) in 2000-2007 in Finland. METHOD: Register data from the Social Insurance Institution of Finland were used to evaluate antidepressant use in ≥ 50-year-old incident RA patients (n = 10,356) and the same-age general population. RESULTS: Of the RA patients, 10.0% (n = 1034) had used antidepressants during the year preceding RA diagnosis. The cumulative incidence of antidepressant initiations after RA diagnosis was 11.4% [95% confidence interval (CI) 10.0-12.9] for men and 16.2% (95% CI 14.9-17.5) for women at the end of follow-up (mean 4.4 years). Female gender [age-adjusted hazard ratio (HR) 1.39, 95% CI 1.21-1.60] and increasing number of comorbidities (p for linearity < 0.001) predicted antidepressant initiations. In the last follow-up year, antidepressant use was at the same level among men with RA [prevalence rate ratio (PRR) 0.93, 95% CI 0.82-1.06] but lower among women (PRR 0.89, 95% CI 0.83-0.95) when compared to the general population. CONCLUSIONS: Antidepressant initiations in early RA were associated with female gender and comorbidity. Although depression is stated to be a sizeable problem in RA, the prevalence of antidepressant use did not exceed the population level.

Acute cold stress in rheumatoid arthritis inadequately activates stress responses and induces an increase of interleukin 6.

OBJECTIVE: Acute stress in patients with rheumatoid arthritis (RA) should stimulate a strong stress response. After cryotherapy, we expected to observe an increase of hormones of the adrenal gland and the sympathetic nervous system. METHODS: A total of 55 patients with RA were recruited for whole-body cryotherapy at -110 degrees C and -60 degrees C, and local cold therapy between -20 degrees C and -30 degrees C for 7 days. We measured plasma levels of steroid hormones, neuropeptide Y (sympathetic marker), and interleukin (IL)6 daily before and after cryotherapy. RESULTS: In both therapy groups with/without glucocorticoids (GC), hormone and IL6 levels at baseline and 5 h after cold stress did not change over 7 days of cryotherapy. In patients without GC, plasma levels of cortisol and androstenedione were highest after -110 degrees C cold stress followed by -60 degrees C or local cold stress. The opposite was found in patients under GC therapy, in whom, unexpectedly, -110 degrees C cold stress elicited the smallest responses. In patients without GC, adrenal cortisol production increased relative to other adrenal steroids, and again the opposite was seen under GC therapy with a loss of cortisol and an increase of dehydroepiandrosterone. Importantly, there was no sympathetic stress response in both groups. Patients without GC and -110 degrees C cold stress demonstrated higher plasma IL6 compared to the other treatment groups (not observed under GC), but they showed the best clinical response. CONCLUSIONS: We detected an inadequate stress response in patients with GC. It is further shown that the sympathetic stress response was inadequate in patients with/without GC. Paradoxically, plasma levels of IL6 increased under strong cold stress in patients without GC. These findings confirm dysfunctional stress axes in RA.

Cost of Finnish statutory inpatient rehabilitation and its impact on functional and work capacity of patients with early rheumatoid arthritis: experience from the FIN-RACo trial.

OBJECTIVE: To explore the cost of the statutory inpatient rehabilitation system in Finland and its impact on the functional and work capacity of patients with early rheumatoid arthritis (RA). METHODS: In the Finnish Rheumatoid Arthritis Combination-Therapy trial (FIN-RACo), 195 patients with recent-onset RA, 162 of them available for the work force, were randomly assigned to two different drug treatment strategies for 2 years. Otherwise, the patients received routine multidisciplinary care and, if their functional or work capacity was endangered, were referred to inpatient rehabilitation. After a 5-year follow-up, data on rehabilitation, sick leave, and RA-related disability pensions were obtained from official registers. RESULTS: Of the 162 patients, 49 (30%) underwent inpatient rehabilitation at an average cost of EURO5400. The rehabilitated patients more often worked in white-collar jobs and had more pain and a worse Health Assessment Questionnaire (HAQ) score (1.0 vs. 0.78; p = 0.01) at baseline. Their HAQ scores remained higher throughout follow-up (p<0.001); no change appeared over inpatient periods [mean 0.01; 95% confidence interval (CI) -0.13 to 0.16]. No independent impact of rehabilitation on the HAQ score emerged in an adjusted generalized estimating equations (GEE) model (p = 0.55). Nor did any improvement in work capacity appear: average lost productivity (human capital approach) per patient-year was EURO10 155 (95% CI 6994-14 196) before and EUR 12 839 (95% CI 8589-19 139) after the start of rehabilitation. CONCLUSION: For patients with recent-onset RA, the Finnish statutory inpatient rehabilitation system had no positive impact on either functional or work capacity during the first few years, despite its considerable cost.

Effectiveness of different cryotherapies on pain and disease activity in active rheumatoid arthritis. A randomised single blinded controlled trial.

OBJECTIVE: Local cryotherapy is used to relieve pain and inflammation in injuries and inflammatory conditions. Whole-body cryotherapy is an extreme method administered at -110 degrees C for 2 to 3 minutes. The aim of the study was to compare the effect of cryotherapies on pain and inflammation in patients with rheumatoid arthritis (RA). METHODS: Sixty patients with active seropositive RA were recruited in a randomised controlled single-blinded study to receive whole-body cryotherapy at -110 degrees C, whole-body cryotherapy at -60 degrees C, application of local cold air at -30 degrees C and the use of cold packs locally. In the final analysis, the last 2 groups were pooled. The patients had 2-3 cryotherapy sessions daily for one week plus conventional physiotherapy. Clinical and laboratory variables and patient's and physician's global assessments were used to assess the outcome. Disease activity was calculated by DAS. RESULTS: Pain decreased in all treatment groups, most markedly in the whole-body cryotherapy (-110 degrees C) group. DAS decreased slightly with no statistically significant differences between the groups. No serious or permanent adverse effects were detected. Six of 40 patients (15%) discontinued the whole-body cryotherapy. CONCLUSION: Pain seemed to decrease more in patients in the whole-body cryotherapy at -110 degrees C than during other cryotherapies, but there were no significant differences in the disease activity between the groups. However, cryotherapy at -110 degrees C is expensive and available only in special centres and may have minor adverse effects. Based on our results, whole-body cryotherapy at -110 degrees C is not superior to local cryotherapy commonly used in RA patients for pain relief and as an adjunct to physiotherapy.

Effects of a 6-month exercise program on patients with multiple sclerosis: a randomized study.

OBJECTIVE: To improve walking and other aspects of physical function with a progressive 6-month exercise program in patients with multiple sclerosis (MS). METHODS: MS patients with mild to moderate disability (Expanded Disability Status Scale scores 1.0 to 5.5) were randomly assigned to an exercise or control group. The intervention consisted of strength and aerobic training initiated during 3-week inpatient rehabilitation and continued for 23 weeks at home. The groups were evaluated at baseline and at 6 months. The primary outcome was walking speed, measured by 7.62 m and 500 m walk tests. Secondary outcomes included lower extremity strength, upper extremity endurance and dexterity, peak oxygen uptake, and static balance. An intention-to-treat analysis was used. RESULTS: Ninety-one (96%) of the 95 patients entering the study completed it. Change between groups was significant in the 7.62 m (p = 0.04) and 500 m walk tests (p = 0.01). In the 7.62 m walk test, 22% of the exercising patients showed clinically meaningful improvements. The exercise group also showed increased upper extremity endurance as compared to controls. No other noteworthy exercise-induced changes were observed. Exercise adherence varied considerably among the exercisers. CONCLUSIONS: Walking speed improved in this randomized study. The results confirm that exercise is safe for multiple sclerosis patients and should be recommended for those with mild to moderate disability.

Manipulation under anesthesia for frozen shoulder with and without steroid injection.

OBJECTIVE: To study the effect of manipulating a shoulder with adhesive capsulitis (frozen shoulder) under anesthesia with and without corticosteroid injection. DESIGN: Randomized trial. SETTING: Hospital. PARTICIPANTS: Twenty-four patients referred for manipulation of a frozen shoulder. INTERVENTION: The patients were randomized into 2 groups. One group received an injection of corticosteroid and manipulation; the other was only administered manipulation during anesthesia. MAIN OUTCOME MEASURES: The degree of shoulder mobility and pain before and after the manipulation. RESULTS: Manipulation under anesthesia increased the mobility of the affected shoulder. Injection with lidocaine and betamethason did not enhance the effect of the manipulation. CONCLUSION: Manipulation under anesthesia without intraarticular corticosteroids is recommended as the therapy for frozen shoulder.

Treatment of acute low back pain with the COX-2-selective anti-inflammatory drug nimesulide: results of a randomized, double-blind comparative trial versus ibuprofen.

STUDY DESIGN: A prospective, randomized double-blind comparative trial. OBJECTIVES: To evaluate the efficacy and tolerability of nimesulide, a cyclooxygenase (COX)-2-selective anti-inflammatory agent versus ibuprofen in patients with acute lumbosacral back pain. SUMMARY OF BACKGROUND DATA: Nonsteroidal anti-inflammatory drugs (NSAIDs) have been more effective than placebo in patients with uncomplicated acute low back pain in previous randomized controlled trials. The efficacy and tolerability of a new COX-2-selective anti-inflammatory drug have not yet been established. METHODS: One hundred four patients aged 18-65 years with acute low back pain were enrolled. The patients were randomly allocated either to oral nimesulide (100 mg twice daily for 10 days) or oral ibuprofen (600 mg three times daily for 10 days). Outcome measures on a visual analog scale were an average of the pain intensity and the pain relief, stiffness in the back, functional status, and the results of physical examinations. All side effects were recorded at each visit. RESULTS: With both study therapies, there was a clear improvement in all measured parameters of the pain and back function parameters measured from the third day of treatment onward. The patients' capacity for daily tasks, showed improvement in both groups (P < 0. 001), but a statistically significant difference was found between the two groups in favor of the nimesulide group (P < 0.05) after 10 days. Nimesulide was more effective than ibuprofen in improved lateral bending measurements (P = 0.026). Nimesulide and ibuprofen provided similar degrees of improvement in the modified Schober tests and in the pain intensity and back stiffness scores. More gastrointestinal side effects were reported with ibuprofen than nimesulide, and the comparison showed a trend (P = 0.067). Ten side effects occurred in the nimesulide group in 7 (13%) patients and 13 in the ibuprofen group in 11 (21%) patients. CONCLUSIONS: The results confirmed that the COX-2-selective inhibitor nimesulide is an effective and well-tolerated agent for use in general practices to treat acute low back pain. The incidence of gastrointestinal side effects seems to be lower with nimesulide than with ibuprofen.

Epidemiology of lower limb amputees in Southern Finland in 1995 and trends since 1984.

The purpose of this study was to look at the current epidemiological trends of lower limb amputees in 1995 and the trends since 1984 in the area of Southern Finland with 1.3 million inhabitants. During the one-year period, the lower limb amputation was performed on 366 patients. The overall amputation rate has been unchanged since 1984 being 28.0 per 100,000 inhabitants in 1995. The mean age was 71.4 years. The overall amputation rate was 28.0 per 100,000 inhabitants. Of the 366 patients in the study 30% had arteriosclerosis without diabetes mellitus and 49% had diabetes. Diabetes mellitus has become the most common cause of amputation since 1985. Tumours were the cause in 2% and trauma in 4%. The most common unilateral amputations were trans-femoral amputations (29%) followed by trans-tibial amputations (28%) and toe amputations (24%). The unilateral trans-tibial/trans-femoral ratio was 0.54 in 1984 and 0.95 in 1995. The one-year mortality rate was 39% in 1984 and 40% in 1995. The rate of amputation has been relatively constant over the last ten years. The age related incidence in the older age groups has also been unchanged over the last ten years. Better control of diabetes and prophylactic foot care of diabetics can have a positive contribution in prevention of lower limb amputations. The current rehabilitation and prosthetic services of the lower limb amputees can be planned in the south of Finland on the basis of the incidence of 28 per 100,000 inhabitants.

Ten-year survival of Finnish lower limb amputees.

Data on mortality for the ten years following lower limb amputation were obtained from all the 16 surgical units in Southern Finland and the National Social Insurance Institution. In Southern Finland during the period 1984-1985, amputations of the lower limb were performed on 705 patients, of whom 382 (54%) were women and 323 (46%) men. The majority of the amputations, 47% were performed for vascular diseases and 41% were performed for diabetes mellitus. The overall survival was 62% at one year after amputation, 49% at two years, 27% at five years and 15% at ten years. The median survival after amputation was 1 yr 5 mth for the women and 2 yr 8 mth for the men. Of the arteriosclerotics, 43% died within one postoperative year while 43% lived longer than two years and 23% longer than five years. The median survival of arteriosclerotics was 1 yr 6 mth. The corresponding figure for patients with diabetes was 1 yr 11 mth. Of the diabetics, 38% died within one postoperative year while 47% lived longer than two years and 20% longer than five years. Of the trauma patients, 86% lived longer than five years and 71% longer than ten years. Of the trans-femoral amputees, 54% lived longer than one year, 36% over two years, 18% over five years and 8% over ten years. The corresponding figures for trans-tibial amputees were 70%, 53%, 21% and 4%. Many elderly vascular and diabetic patients undergoing amputation have a reduced physiological reserve and high mortality. The more proximal the amputation, the greater the risk that the patient will never be able to walk or that the duration of use of the prosthesis will be short. If a prosthesis seems to be a reasonable option for the elderly amputee, any delays in prosthetic fitting should be avoided in older age groups.

Lower limb amputees in Southern Finland.

The purpose of this study was to look at the current epidemiological trends of lower limb amputees in 1992 in the area of Southern Finland with 1.2 million inhabitants. Similar data was collected earlier in 1984-85 and 1989. The amputation incidence was found to be 27.4 per 100,000 inhabitants. The trans-tibial/trans-femoral ratio was 0.78. The percentage of prosthetic fitting among patients undergoing unilateral trans-tibial amputation was 68% and the corresponding figure among the trans-femoral patients was 35%. The epidemiological data showed an improvement on that found 8 years earlier although the overall age structure is shifting upwards.

Subjective benefits of energy storing prostheses.

The energy storing (ES) prosthesis has been used in the Prosthetic Foundation's workshop since 1987. Subjective responses from 168 amputees (141 trans-tibial and 27 trans-femoral) fitted with the ES prosthesis were analysed. Ratings were generally favourable in comparison with those for conventional prostheses. The most pronounced advantages of the new prosthesis as shown by the ratings were in walking uphill or swift walking. The younger amputees had more benefit than the older ones. High body weight decreased the benefit of the ES prosthesis. The ES prosthesis does not seem to provide any major advantage for the less active amputee whose movements are mainly indoors.

Spondylodesis augmented by transpedicular fixation in the treatment of olisthetic and degenerative conditions of the lumbar spine.

Fifty-one patients having lumbar or lumbosacral posterolateral fusion with pedicle screw internal fixation were reviewed retrospectively two years after the fusion by an independent observer. In 44 patients, the underlying condition was lytic or degenerative spondylolisthesis. The internal device was removed one year after the fusion. The fusion rate was 94%. The subjective disability was assessed using the Oswestry disability index. The mean Oswestry score was 38% preoperatively, and 24% two years after the fusion. Preoperatively, only every fifth patient was able to work; two years postoperatively, almost 60% held jobs. Complications due to internal fixation were recorded in 57% of the cases. Most of these, such as screw breakage and screw loosening in the sacrum, were of no clinical importance. The use of internal fixation seems to enhance the fusion rate but is associated with more complications than posterolateral fusion without implants.