Biomedical subjects

M E Suarez-Almazor

Publications and source records attributed to M E Suarez-Almazor.

At least 37 records · Page 2Linked to original sources

PubMed2000

Penicillamine for rheumatoid arthritis.

OBJECTIVES: To estimate the short-term effects of D-penicillamine for the treatment of rheumatoid arthritis (RA). SEARCH STRATEGY: We searched the Cochrane Musculoskeletal Group's trials register, the Cochrane Controlled Trials Register, Medline up to and including December 1998 and Embase from 1988-1998. We also carried out a handsearch of the reference lists of the trials retrieved from the electronic search. SELECTION CRITERIA: All randomized controlled trials and controlled clinical trials comparing D-penicillamine against placebo in patients with rheumatoid arthritis. DATA COLLECTION AND ANALYSIS: The methodological quality of the trials was assessed independently by two reviewers (CS, EB) and checked by a third (MS) using a validated quality assessment tool. Rheumatoid arthritis outcome measures were extracted from the publications for the six-month endpoint and stratified according to D-penicillamine dosages: low (<500mg/day), moderate (500 to <1000mg/day) and high (1000 mg/day or greater). Data was abstracted by one reviewer and checked by a second (CS, MS). The pooled analysis was performed using the standardized mean difference for joint counts, pain and global assessments. The weighted mean difference was used for erythrocyte sedimentation rate (ESR). Toxicity was evaluated with pooled odds ratios for withdrawals and adverse reactions. A chi-square test was used to assess heterogeneity among trials. Fixed effects models were used throughout, since no statistical heterogeneity was found. MAIN RESULTS: Six trials were identified, with 425 patients randomized to D-penacillamine and 258 to placebo. A statistically significant benefit was observed for D-penicillamine when compared to placebo for all three-dose ranges and for most outcome measures including: tender joint counts, pain, physician's global assessments and ESR. The standardized weighted mean differences between treatment and placebo in moderate doses were -0. 51 [95% CI -0.88, -0.14] for tender joint counts, -0.56 (95% CI -0. 87, -0.26) for pain and -0.97 (95% CI -1.25, -0.70) for global assessment. The difference for ESR was -10.6 mm/hr. Similar results were observed for the higher dose group. Total withdrawals were significantly higher in the moderate and high dosage D-penicillamine groups (OR=1.63 and 2.13 respectively), mostly due to increased adverse reactions (OR = 2.60 and 4.95 respectively), including renal and hematological abnormalities. REVIEWER'S CONCLUSIONS: D-penicillamine appears to have a clinically and statistically significant benefit on the disease activity of patients with rheumatoid arthritis. Its efficacy appears to be similar to that of other disease modifying anti-rheumatic drugs (DMARDs), but with a significantly higher toxicity. Its effects on long-term functional status and radiological progression are not clear from this review.

Antirheumatic Agents↗

PubMed2000

Azathioprine for rheumatoid arthritis.

OBJECTIVES: To assess the short-term effects of azathioprine for the treatment of rheumatoid arthritis (RA). SEARCH STRATEGY: We searched the Cochrane Musculoskeletal Group's trials register, the Cochrane Controlled Trials Register, Medline up to and including July 1998 and Embase from 1988-1998. We also carried out a handsearch of the reference lists of the trials retrieved from the electronic search. SELECTION CRITERIA: All randomized controlled trials and controlled clinical trials comparing azathioprine against placebo in patients with rheumatoid arthritis. DATA COLLECTION AND ANALYSIS: Data was extracted independently by two reviewers (CS, EB); disagreements were resolved by discussion or third party adjudication (MS). The same reviewers (CS, EB) assessed the methodological quality of the trials using a validated quality assessment tool. Rheumatoid arthritis outcome measures were extracted from the publications for the six-month endpoint. The pooled analysis was performed using standardized mean differences for joint counts, pain and functional status assessments. Weighted mean differences were used for erythrocyte sedimentation rate (ESR). Toxicity was evaluated with pooled odds ratios for withdrawals and for adverse reactions. The 95% confidence intervals (95% CI) are presented. A chi-square test was used to assess heterogeneity among trials. Fixed effects models were used throughout, since no statistical heterogeneity was found. MAIN RESULTS: Three trials with a total of 81 patients were included in the analysis. Forty patients were randomized to azathioprine and forty-one to placebo. A pooled estimate was calculated for two outcomes. A statistically significant benefit was observed for azathioprine when compared to placebo for tender joint scores. The standardized weighted mean difference between treatment and placebo was -0.98 (95% CI -1.45, -0.50). Withdrawals from adverse reactions were significantly higher in the azathioprine group OR=4.56 (95% CI 1.16, 17.85). REVIEWER'S CONCLUSIONS: Azathioprine appears to have a statistically significant benefit on the disease activity in joints of patients with RA. This evidence however is based on a small number of patients, included in older trials. Its effects on long-term functional status and radiological progression were not assessed due to lack of data. Toxicity is shown to be higher and more serious than that observed with other disease-modifying anti-rheumatic drugs (DMARDs). Given this high risk to benefit ratio, there is no evidence to recommend the use of azathioprine over other DMARDs.

Antirheumatic Agents↗

PubMed2000

Calcitonin for the treatment and prevention of corticosteroid-induced osteoporosis.

BACKGROUND: Corticosteroid-induced osteoporosis is a cause of morbidity in patients with chronic obstructive lung disease, asthma, and rheumatologic disorders. Corticosteroid treatment causes bone loss by a variety of complex mechanisms. It has been shown that bone mineral loss at the hip averages 14% in the first year after starting corticosteroid therapy. OBJECTIVES: To review the efficacy of calcitonin (subcutaneous or nasal) for the treatment and prevention of corticosteroid-induced osteoporosis. SEARCH STRATEGY: We conducted a search of Medline, the Cochrane Controlled Trials Register and Embase using the Cochrane Musculoskeletal Group search strategy for randomized controlled trials (RCTs) up to May 1998. We also searched bibliographic references and consulted content experts. SELECTION CRITERIA: Two independent reviewers selected RCTs which met predetermined inclusion criteria. DATA COLLECTION AND ANALYSIS: Two reviewers independently extracted data using predetermined forms and assessed methodological quality of randomization, blinding and dropouts. For dichotomous outcomes, relative risks (RR) were calculated. For continuous data, weighted mean differences (WMD) of the percent change from baseline were calculated. We decided a priori to use random effects models for all outcomes, because of uncertainty about whether a consistent true effect exists in such different populations. MAIN RESULTS: Nine trials met the inclusion criteria, including 221 patients randomized to calcitonin and 220 to placebo. The median methodologic quality was two out of a maximum of five points. Calcitonin was more effective than placebo at preserving bone mass at the lumbar spine after six and 12 months of therapy with a WMD of 2.8% (95% CI: 1.4 to 4.3) and 3.2% (95% CI: 0.3 to 6.1). At 24 months, lumbar spine BMD was not statistically different between groups: WMD 4.5% (95% CI: -0.6 to 9.5)]. Bone density at the distal radius was also higher with calcitonin after six months of therapy, but bone density at the femoral neck was not different between placebo and calcitonin treated groups. The relative risk of fractures was not significantly different between calcitonin and placebo with a relative risk (RR) of 0.71 (95% CI: 0.26 to 1.89) for vertebral and 0.52 (95% CI: 0.14 to 1.96) for nonvertebral fractures. The subgroup analyses of methodological quality and duration of corticosteroid therapy were confounded. Trials of patients who had been taking steroids for greater than three months (which were of low methodologic quality) demonstrated a larger effect of calcitonin on spine bone density (about 6%) than prevention trials (about 1%). There was no consistent effect of different dosages (50-100 IU compared to 200-400 IU). However, subcutaneous calcitonin showed substantially greater prevention of bone loss. Withdrawals due to side effects were higher in the calcitonin-treated groups: RR 3.19 (95%CI: 0.66 to 15.47). Important side effects included nausea and facial flushing. REVIEWER'S CONCLUSIONS: Calcitonin appears to preserve bone mass in the first year of glucocorticoid therapy at the lumbar spine by about 3% compared to placebo, but not at the femoral neck. Our analysis suggests that the protective effect on bone mass may be greater for the treatment of patients who have been taking corticosteroids for more than three months. Efficacy of calcitonin for fracture prevention in steroid-induced osteoporosis remains to be established.

Calcitonin↗

PubMed2000

Auranofin versus placebo in rheumatoid arthritis.

BACKGROUND: Auranofin is an oral gold compound used for the treatment of rheumatoid arthritis RA. The use of auranofin has declined in the past few years, perhaps due in part to conflicting results from different studies. OBJECTIVES: To estimate the short-term efficacy and toxicity of auranofin for the treatment of (RA) SEARCH STRATEGY: We searched MEDLINE and EMBASE up to December 1998, the Cochrane Controlled Trials Register (CCTR) version 4, 1998, and the Cochrane Musculoskeletal Group Specialized Register. A hand search was also done of the reference lists of the trials retrieved from the electronic search. SELECTION CRITERIA: All randomized controlled trials (RCTs) and controlled clinical trials (CCTs) comparing auranofin against placebo in patients with RA DATA COLLECTION AND ANALYSIS: The methodological quality of the trials was assessed using a validated assessment tool (Jadad 1996). Rheumatoid arthritis outcome measures were extracted from the publications for the 6-month endpoint. The pooled analysis was performed using standardized mean differences (SMDs) for joint counts, pain and global assessments. The weighted mean difference (WMD) was used for ESR. Toxicity was evaluated with pooled odds ratios for withdrawals and adverse reactions. A chi-square test was used to assess heterogeneity among trials. In the presence of heterogeneity, random effects models were used. Otherwise, the data was pooled assuming fixed effects. MAIN RESULTS: A statistically significant benefit was observed for auranofin when compared to placebo for tender joint scores, pain, patient and physician global assessments and ESR. The SMD between treatment and placebo was -0.39 (95% CI -0.54, -0.25) for tender joint scores, -0.08 (95% CI -0.22, -0.07) for swollen joint scores, and the WMD was -4.68 (95% CI -6.59, -2.77) for pain scores and -9.85mm (95% CI -16.46, -3.25) for ESR. Withdrawals from adverse reactions were 1.5 times higher in the auranofin group OR = 1.52 (95% CI 0.94, 2.46) but this result was not statistically significant. Patients receiving placebo were three times more likely to discontinue treatment because of lack of efficacy than patients receiving auranofin: OR=0.31 (95% CI: 0.21, 0.44). REVIEWER'S CONCLUSIONS: Auranofin appears to have a small clinically and statistically significant benefit on the disease activity of patients with RA. The beneficial effects appear to be modest compared to drugs such as methotrexate or parenteral gold. Its effects on long term health status and radiological progression are not clear at this time.

Antirheumatic Agents↗

PubMed2000

Identifying clinical trials in the medical literature with electronic databases: MEDLINE alone is not enough.

The objective of this study was to compare the performance of MEDLINE and EMBASE for the identification of articles regarding controlled clinical trials (CCTs) published in English and related to selected topics: rheumatoid arthritis (RA), osteoporosis (OP), and low back pain (LBP). MEDLINE and EMBASE were searched for literature published in 1988 and 1994. The initial selection of papers was then reviewed to confirm that the articles were about CCTs and to assess the quality of the studies. Selected journals were also hand searched to identify CCTs not retrieved by either database. Overall, 4111 different references were retrieved (2253 for RA, 978 for OP, and 880 for LBP); 3418 (83%) of the papers were in English. EMBASE retrieved 78% more references than MEDLINE (2895 versus 1625). Overall, 1217 (30%) of the papers were retrieved by both databases. Two hundred forty-three papers were about CCTs. Two-thirds of these were retrieved by both databases, and one-third by only one. An additional 16 CCTs not retrieved by either database were identified through hand searching. Taking these into account, EMBASE retrieved 16% more CCTs than MEDLINE (220 versus 188); the EMBASE search identified 85% of the CCTs compared to 73% by MEDLINE. No significant differences were observed in the mean quality scores and sample size of the CCTs missed by MEDLINE compared to those missed by EMBASE. Our findings suggest that the use of MEDLINE alone to identify CCTs is inadequate. The use of two or more databases and hand searching of selected journals are needed to perform a comprehensive search.

Controlled Clinical Trials as Topic↗

PubMed2000

Clinical guidelines: a must for rheumatology?

Clinical guidelines are sets of recommendations, backed by medical evidence, to aid physicians in patient-care decisions. There has been a proliferation of practice guideline development in all fields of medicine, including rheumatology. This chapter will discuss the need for guidelines in rheumatology, the methodology of guideline development, validation and implementation, the various guidelines published in rheumatology, and the role of the rheumatologist in guideline development. Clinical guidelines can serve to inform practitioners of the latest medical evidence and minimize harmful practice variation. Guidelines must rely on good evidence to be credible to the medical community, yet there are still many barriers to guideline acceptance by practitioners. The theories behind guideline development and validation are well described, although not always practised. Guideline dissemination and implementation methods are still being explored. It remains unclear how best to implement guidelines and convince physicians to accept and incorporate evidence-based recommendations into their practice.

Evidence-Based Medicine↗

PubMed2000

The impact of health status on waiting time for major joint arthroplasty.

This study was conducted to determine the impact of health status on waiting time for major joint arthroplasty in a universal publicly funded health system. Data were collected prospectively from a cohort of 553 patients waiting for total hip or total knee arthroplasty. The WOMAC and SF-36 health status instruments were administered at the time the patient was placed on the waiting list. The outcome measure was length of waiting time. Multivariate analyses found increased body mass index and decreased social function as the only determinants of waiting time. This model explained only 4% of the variance in waiting time. The association between health status and waiting time for arthroplasties appears to be small. These findings suggest that major joint arthroplasty is not prioritized on the basis of burden of illness.

Adult↗

PubMed2000

Use of health status measures in patients with low back pain in clinical settings. Comparison of specific, generic and preference-based instruments.

OBJECTIVE: To evaluate the discriminative performance over time of specific, generic and preference-based instruments in patients with low back pain (LBP) in clinical settings. METHODS: Forty-six consecutive patients with LBP participated in the study. Self-response questionnaires were administered at baseline and 3 and 6 months, including the following instruments: Oswestry (specific for LBP), SF-36 (generic), EuroQol (EQ-5D) and Health Utilities Index (HUI) (preference-based). EQ-5D and HUI weights were derived from previously published evaluations in the general population. Patients were asked to compare their health status with their baseline health and were categorized on the basis of an ordinal scale as: (a) improved; (b) stable; or (c) worse. Changes in the instruments were evaluated by rescaling the instruments over the same scale interval and by estimating standardized effect sizes between two time points for the three categories of change. RESULTS: Thirty-seven patients (80%) completed both the baseline and the 3-month questionnaire and 34 the baseline and 6-month questionnaires (74%). Overall, at both time points, approximately half of the patients reported no changes in their health status. Correlations between instruments were generally low, suggesting that they measure different health domains. The scales which discriminated best between patients who improved and those who deteriorated at 3 months were the Oswestry, the HUI, the EQ-5D and the SF-36 bodily pain and emotional role subscales. The SF-36 subscales appeared to have a floor effect for those patients who had deteriorated. CONCLUSIONS: Most SF-36 subscales did not adequately reflect changes in the health status of patients with LBP, mostly for those who reported deterioration. Preference-derived quality-of-life scores appeared to discriminate among patients who improved and those who deteriorated, although not as consistently as the disease-specific measure (Oswestry). Additional research is needed to evaluate the role of generic measures of quality of life in the assessment of patients with LBP before they can be widely implemented in clinical settings or outcomes research.

Data Collection↗

PubMed2000

Survival prediction in terminal cancer patients: a systematic review of the medical literature.

The clinical significance of studies on survival predictors in terminal cancer patients is hindered by both methodological limitations and the difficulty of finding common predictors for all final events in cancer related deaths. To evaluate the published medical literature concerned with the survival of patients with terminal cancer and identify potential prognostic factors, major electronic databases including MEDLINE (1966-), CANCERLIT (1983-) and EMBASE (1988-) were searched up to September 1999. Studies were included in our review if published in English, were cohort studies, addressed the identification of clinical prognostic factors for survival and looked at samples with median survival of < or = 3 months. Data extracted from selected papers included: sample size, median survival, type of study, sampling frame, cohort type, type of statistical analysis (univariate or multivariate), choice of models and underlying assumptions, predictors examined and their reported level of statistical significance. A total of 24 studies were found and reviewed. On the basis of these studies, performance status and the presence of cognitive failure, weight loss, dysphagia, anorexia and dyspnoea appear to be independent survival predictors in this population. Clinical estimation of survival by the treating physician appeared independently associated with survival but the magnitude of the association generally appeared small. Clinical predictions should be considered as one of many criteria, rather than as a unique criterion by which to choose therapeutic interventions or health care programmes for terminally ill cancer patients. The use of convenient samples as opposed to more representative inception cohorts, the inclusion of different variables in the statistical analyses and inappropriate statistical methods appear to be major limitations of the reviewed literature. Methodological improvements in the design and conduction of future studies may reduce the prognostic uncertainty in this population.

Data Collection↗

PubMed2000

Decreased progression to rheumatoid arthritis or other connective tissue diseases in patients with palindromic rheumatism treated with antimalarials.

OBJECTIVE: To determine whether the use of antimalarials is associated with a reduction in the risk of developing rheumatoid arthritis (RA) or other connective tissue diseases in patients with palindromic rheumatism. METHODS: We conducted a retrospective cohort study based on a review of medical records to evaluate the outcome of patients with palindromic rheumatism referred to an academic center from 1986 to 1996: 113 patients complied with the selection criteria, including diagnostic criteria for palindromic rheumatism and onset of disease since 1980. After adjusting for potential confounders, Kaplan-Meier methods and Cox regression models were used to estimate the risk of developing RA or other connective tissue disease in patients who had received antimalarials compared to those who had not. RESULTS: Age of disease onset was 40+/-12 yrs, and mean disease duration 4.8+/-4 yrs; two-thirds of the patients were female. Sixty-two (55%) patients received antimalarials, for a mean duration of therapy of 28 mo. Thirty-three (29%) patients developed RA, 3 developed systemic lupus, and 4 developed other connective tissue diseases. Twenty (32%) patients in the antimalarial group developed a secondary disease, compared to 20 (39%) who did not receive therapy. Statistically significant differences were observed comparing time to event in both groups. The estimated median time to development of a chronic disease was 162 months in treated and 56 months in untreated patients. After adjusting for other variables in the Cox regression models, significant risk reduction in the development of a secondary disease was observed for antimalarial use (hazard ratio = 0.24; 95% CI 0.09-0.61). For RA, the risk reduction was 0.19 (95% CI 0.07-0.57). We conducted a sensitivity analysis around our censoring estimates. The risk reduction remained statistically significant, with 0.36 for RA and 0.41 for RA or other connective tissue disease. CONCLUSION: Use of antimalarials in patients with palindromic rheumatism is associated with a reduction in the risk of developing subsequent RA or other connective tissue disease.

Adult↗

PubMed2000

Health related quality of life outcomes after total hip and knee arthroplasties in a community based population.

OBJECTIVE: To quantify the magnitude of change seen with pain, function, and quality of life outcomes 6 months after total hip and knee arthroplasties (THA, TKA) within a community based cohort of a regional health district. METHODS: An inception cohort of 504 patients who received primary THA (228) or TKA (276) was prospectively followed. All patients resided in the community and were assessed within one month prior to surgery and 6 months postoperatively. Health related quality of life measures were evaluated with the Western Ontario and McMaster Universities (WOMAC) Osteoarthritis Index and the Medical Outcome Survey Short Form SF-36. Perioperative factors were extracted from medical charts. Health services utilization data were collected from regional health databases. RESULTS: Over 75% of patients reported improvement in joint-specific pain and function, regardless of the type of joint replaced. Other health dimensions such as social function, bodily pain, physical function, vitality, and general health showed significant improvement after surgery. Those psychosocial dimensions with modest changes had baseline values comparable to age and sex adjusted normal values; whereas, bodily pain and physical function, which had large changes, had values lower than the normal values. Ninety-one percent of patients receiving THA were satisfied with their surgery, whereas 77% were satisfied with their TKA. The average length of stay was 7 days and the in-hospital complication rate was 0.34 per patient. CONCLUSION: Large improvements were reported for pain and function after joint arthroplasties, while small to moderate changes were seen in other areas related to quality of life. Patients with hip arthroplasties showed greater improvement in pain and function and were more satisfied with their outcomes than patients with knee arthroplasties. Although pain and function show large improvements, bodily pain and physical function were less than the values reported in the general population.

Aged↗

PubMed1999

The relative accuracy of the clinical estimation of the duration of life for patients with end of life cancer.

BACKGROUND: Although the prediction of the duration of life of patients with end of life cancer most often relies on the clinical estimation of survival (CES) made by the treating physician, the accuracy and practical value of CES remains controversial. METHODS: The authors prospectively evaluated the accuracy of CES in an inception and population-based cohort of 233 cancer patients who were seen at the onset of their terminal phase. They also systematically reviewed the literature on CES in advanced or end-stage cancer patients in MEDLINE, CANCERLIT, and EMBASE data bases, using two search strategies developed by a research librarian. RESULTS: CES had low sensitivity in detecting patients who died within shorter time frames (< or =2 months), and a tendency to overestimate survival was noted. A moderate correlation was observed between actual survival (AS) and CES (Pearson correlation coefficient = 0.47, intraclass correlation coefficient = 0.46, weighted kappa coefficient = 0.42). CONCLUSIONS: Treating physicians appear to overestimate the duration of life of end of life ill cancer patients, particularly those patients who die early in the terminal phase and who may potentially benefit from earlier participation in palliative care programs. CES should be considered one of many criteria, rather than a unique criterion, by which to choose therapeutic intervention or health care programs for patients in the end of life cancer phase.

Adult↗

PubMed1999

Health services research.

In the past year, several publications have reported on aspects of health services research in regard to musculoskeletal disorders. Utilization studies in the elderly have shown that an effective procedure such as hip arthroplasty may be underused in this population. As well, surgical complications in these patients appear to vary according to the number of procedures performed in a hospital, with high-volume hospitals showing better outcomes. Studies of practice patterns show variations among rheumatologists in the treatment of various rheumatic diseases. Practice variations between physician groups, in particular, rheumatologists versus primary care providers, have also been reported. Several studies show that primary care physicians may have some difficulties in diagnosing common rheumatic disorders. There is some evidence as well that rheumatologists may provide better care for some conditions, such as rheumatoid arthritis. These findings have major implications for restrictions to patient access to specialist care by health organizations. A variety of clinical practice guidelines have been developed and tested, most aimed at general practitioners. Physician compliance with guidelines continues to be low for most implementation strategies. Multidisciplinary programs for the treatment of rheumatoid arthritis appear to have a somewhat beneficial effect. Programs based only on patient education appear to have short-term gains, and longer-term effects are diluted because of noncompliant behaviors.

Health Services Research↗

PubMed1999

Improving the appropriateness of carotid endarterectomy: results of a prospective city-wide study.

BACKGROUND AND PURPOSE: In light of previously reported concerns regarding carotid endarterectomy (CEA) use in our city, our goal was to determine the influence of a prospective audit and educational campaign on the performance of CEA with respect to surgical appropriateness and complication frequency. METHODS: Results of our previous audit of 291 CEAs, along with CEA practice guidelines and notification of prospective surveillance, were supplied to surgeons performing CEA in our city. After this, 184 consecutive patients undergoing CEA from September 1996 to August 1997 were followed prospectively. On the basis of blinded standardized remeasurements of angiographic carotid stenoses, CEA was classified as appropriate for patients with symptomatic carotid stenoses >/=70%, uncertain for those with symptomatic stenoses <70% or asymptomatic stenoses >/=60%, and inappropriate for patients with asymptomatic carotid stenoses <60% or preoperative neurological or medical instability. RESULTS: Forty percent of patients were asymptomatic. Compared with our prior audit, the rate of appropriate CEAs improved from 33% previously to 49% of cases in the present study (P=0.0005), uncertain indications did not change significantly (49% versus 47%; P=0.61), and inappropriate indications dropped from 18% to 4% (P=0. 00002). Perioperative stroke or death occurred in 6.4% of symptomatic patients but developed in only 2.7% of asymptomatic patients, which was improved from the 5.1% rate previously found. CONCLUSIONS: In our city, the use of a surgical audit identified areas of concern regarding CEA, and subsequent education and ongoing surveillance significantly improved the use and performance of this procedure.

Carotid Stenosis↗

PubMed1999

Prognostic factors for the development of rheumatoid arthritis and other connective tissue diseases in patients with palindromic rheumatism.

OBJECTIVE: Palindromic rheumatism is characterized by attacks of acute arthritis of short duration. In the long term, a substantial proportion of patients will develop rheumatoid arthritis (RA) or other connective tissue diseases, but the determinants of subsequent chronic disease have not been adequately established. We identify clinical prognostic factors for the development of RA and other connective tissue diseases in patients with palindromic rheumatism in a retrospective cohort study. METHODS: The medical records of 4900 patients with arthritis referred from 1986 to 1996 to 3 rheumatologists at an academic center were reviewed. One hundred sixty patients were diagnosed as having palindromic rheumatism. After review, 127 complied with diagnostic criteria for palindromic rheumatism. Disease duration was estimated as time of first attack until the last consultation, or the development of RA or other connective tissue disease. Survival analysis including Cox regression was used to identify clinical variables associated with the risk of developing RA or other connective tissue disease, adjusting for varying disease duration. RESULTS: Sixty-five percent of the patients were female. Age at onset was 40+/-12 years. Mean disease duration was 6+/-6 years, and mean followup by the rheumatologists was 40+/-45 months. Joints more frequently affected were wrist, knee, and metacarpophalangeal. Forty-three patients (34%) subsequently developed a connective tissue disease including 36 (28%) RA, 3 (2%) systemic lupus erythematosus, and 4 (3%) other connective tissue diseases. In the final Cox regression model the hazard ratio for development of a connective tissue disease in the presence of a positive rheumatoid factor (RF) was 2.9 (p = 0.002), for proximal interphalangeal (PIP) joint involvement 2.4 (p = 0.02), for wrist involvement 2.5 (p = 0.05), for female sex 2.2 (p = 0.05), and for age at onset 1.03 (per year) (p = 0.001). Female patients with positive RF and involvement of the hands had an 8-fold risk of developing disease, compared with patients with one or fewer of these features. CONCLUSION: Positive RF and early involvement of the wrist and PIP joints predict the subsequent development of RA or other connective tissue disease in patients with palindromic rheumatism, and identify a group of patients at increased risk.

Adult↗

PubMed1999

Magnetic resonance imaging and clinical assessment of temporomandibular joint pathology in ankylosing spondylitis.

OBJECTIVE: To evaluate temporomandibular joint (TMJ) articular disc position and osseous degenerative changes using magnetic resonance imaging (MRI) as well as clinical symptoms of temporomandibular disorders in patients with ankylosing spondylitis (AS). METHODS: A sample of 43 patients with AS (38 males, age 45.9+/-10.7 years) and 16 controls (all male, age 41.3+/-6.3 years) were studied. All subjects completed a self-administered questionnaire and underwent clinical examination and MRI survey. Recorded variables included disease characteristics, subjective neck and TMJ disorder symptoms, and axial mobility measurements. MRI variables included TMJ disc position and severity of osseous degenerative change. RESULTS: TMJ disorder symptoms of headache duration and frequency, TMJ pain duration and frequency, and painful jaw movement were more frequent in patients with AS (p < 0.05). Significant differences were also observed in MRI indices for disc displacement (AS, 0.89; controls, 0.36; p = 0.005) and degenerative changes (AS, 0.55; controls, 0.06; p = 0.01). A total of 50 (62%) joints in the AS group had disc displacement compared to 11 (34%) joints in the controls. A total of 16 (20%) joints in the AS group had degenerative change compared to 2 (6%) joints in the controls. CONCLUSION: TMJ internal derangement, degenerative changes, and subjective pain complaints are frequent in patients with AS. Physicians should be aware of potential TMJ involvement in these patients, which may require specific assessment and therapy.

Facial Pain↗

PubMed1999

A metaanalysis on the use of bisphosphonates in corticosteroid induced osteoporosis.

OBJECTIVE: To conduct a metaanalysis on the use of bisphosphonates in corticosteroid induced osteoporosis. METHODS: A Cochrane systematic review including electronic database searching (MEDLINE and EMBASE), and selected hand searching of reference lists and scientific abstracts was conducted. Metaanalysis using random and fixed effects modeling was used on the selected trials to calculate summary effect measures. All controlled clinical trials dealing with prevention or treatment of corticosteroid induced osteoporosis with bisphosphonates of any type and reporting the outcome of interest were assessed. Trials had to involve adults only, and subjects had to be taking a mean steroid dose of 7.5 mg/day or more. Outcomes of interest were change in bone mineral density (BMD) at the lumbar spine and femoral neck at 6 and 12 months. If present, data on number of new fractures and adverse effects were also extracted. The extraction was performed by 2 independent reviewers. RESULTS: Results are reported as a weighted mean difference in the percentage change in BMD between the treatment and placebo groups, with trials being weighted by the inverse of their variance. At the lumbar spine the weighted mean difference between the treatment and placebo groups was 4.0% (95% CI 2.5, 5.5). At the femoral neck the weighted mean difference was 2.1% (95% CI 0.2, 4.0). Although there was a 24% reduction in spinal fractures, this result did not reach statistical significance. CONCLUSION: Bisphosphonates are effective at preventing and treating corticosteroid induced bone loss at the lumbar spine. Efficacy regarding fracture prevention cannot be concluded from this analysis, although bone density changes are correlated with fracture risk. Bisphosphonates are less efficacious at preventing or treating corticosteroid induced osteoporosis at the femoral neck.

Adrenal Cortex Hormones↗

PubMed1999

Incidence and risk factors for delirium and other adverse outcomes in older adults after coronary artery bypass graft surgery.

OBJECTIVE: To determine the incidence and risk factors for delirium after coronary artery bypass graft (CABG) surgery. DESIGN: Prospective cohort. SETTING: Cardiac surgery units of a tertiary care hospital. PARTICIPANTS: Consecutive patients over age 65 years undergoing elective CABG surgery. Exclusion criteria included preoperative sensory or language barriers. INTERVENTIONS: Each patient was assessed within 24 h before surgery for baseline demographic, medical and functional data. Incident delirium (within four postoperative days) was diagnosed by a study physician. Nine potential risk factors for delirium were subjected to univariate and multivariate analysis. MAIN RESULTS: Of 75 consenting patients, three died during or soon after surgery and one was still comatose at follow-up. Of the remaining 71 participants, 23 (32%) experienced delirium. Those with delirium were more likely than those without delirium to have a history of a stroke (21% versus 4%, respectively, P=0.032) and to have had a longer duration of cardiopulmonary bypass (CPB) (113 mins versus 95 mins, respectively, P=0.025). A tendency to have experienced low cardiac output (83% versus 58%, respectively, P=0.061) postoperatively was also noted. Multivariate analysis confirmed past stroke and duration of cardiopulmonary bypass as risk factors. CONCLUSIONS: Delirium in the elderly after CABG surgery is common. Its occurrence may be predisposed by a history of a stroke and precipitated by a longer duration of CPB.

Age Factors↗