On the organization of an early arthritis clinic

Early active treatment with disease-modifying anti-rheumatic drugs has become standard management for patients with recent-onset rheumatoid arthritis. A number of questions, however, remain unresolved for practising clinicians, for example how early and how actively to treat and what the treatment goals should be. This chapter summarizes some recent data that have added important empirical evidence on these issues. It has thus been demonstrated that the formal organization of an early arthritis clinic shortens the referral time from primary care, that a delay in the institution of disease-modifying drug treatment leads to decreased long-term function and that early active treatment with pharmacotherapy as well as team-based care may increase occupational capacity. It is argued that adopting a day care approach in the initial encounter with specialist care may increase the possibility for patients actively to understand the disease and their own potentials to diminish and cope with its effects. The further development of care for early arthritis patients with new, potentially efficient but also expensive drugs will increase the requirement for a structured documentation of outcomes, systems for such documentation being discussed in the chapter.     

The development of sleep in persons undergoing cataract surgery

This study was undertaken in order to analyse sleep in a group of patients who were operated on for cataract. All patients (n=328) undergoing cataract surgery at the Department of Ophthalmology, Sundsvall Hospital during a 4-month period were asked to complete a questionnaire on the state and change of sleep and sleepiness 1 month after the operation. Twelve persons were unable or declined to participate. The response rate was 97.2%. The mean ages of the participating men and women were 74.5 and 76.3 years, respectively. Pre-operative visual acuity in the operated eye was 0.16 in men and 0.18 in women. After cataract extraction sleep was improved in 12.0% of the men and in 26.3% of the women. Nevertheless poor sleep 1 month post-operatively was reported by 29.3% of the men and 42.6% of the women (P<0.05). There was no age-related increase in sleep complaints. The results indicate that in elderly persons with cataract sleep is impaired, and that 1 month after cataract extraction improved sleep may be experienced.     

Association between a variant in the 11 beta-hydroxysteroid dehydrogenase type 2 gene and primary hypertension

The enzyme 11 beta-hydroxysteroid dehydrogenase type 2 (11BHSD2) converts cortisol to cortisone in the kidney, thereby protecting the mineralocorticoid receptor from the mineralocorticoid actions of cortisol. The syndrome of Apparent Mineralocorticoid Excess (AME), a rare monogenic form of early onset hypertension with autosomal recessive inheritance, is caused by homozygous or compound heterozygous loss of function mutations in the 11BHSD2 gene. Association has been reported between a microsatellite marker flanking the 11BHSD2 gene (D16S496) and primary hypertension. The aim of this study was to identify variants in the 11BHSD2 gene and to test if such variants or the D16S496 are associated with primary hypertension, in Swedes. To address this, the coding sequences of the 11BHSD2 gene was screened for mutations in 20 patients with primary hypertension with single strand conformation polymorphism and direct DNA sequencing techniques. A polymorphism was identified in exon 3; G534A (Glu178Glu). This polymorphism and the D16S496 microsatellite were tested for association with primary hypertension in a population consisting of 292 patients with primary hypertension and 263 normotensive control subjects. The frequency of G534G homozygotes was higher in patients with primary hypertension than in normotensive control subjects (92.8% vs 87.8%; P < 0.05). The allele frequencies of the D16S496 microsatellite did not differ between the two groups (chi(2) = 11.0, df = 10; P = 0.36). In conclusion, over-representation of individuals homozygous for the G534 allele in hypertensive patients compared with control subjects suggests that a mutation in linkage disequilibrium with the G534A polymorphism could increase susceptibility to primary hypertension. Journal of Human Hypertension (2000) 14, 819-823     

Peroxisome proliferator-activated receptor-gammaPro12Ala polymorphism and the association with blood pressure in type 2 diabetes: skaraborg hypertension and diabetes project

OBJECTIVE: This study explored whether the Pro12Ala polymorphism in the peroxisome proliferator-activated receptor-gamma (PPARgamma) is associated with blood pressure in subjects with type 2 diabetes. DESIGN: A community-based, cross-sectional observation study. SETTING: Primary care. PATIENTS: One hundred and ninety-two men and 192 women with type 2 diabetes who consecutively underwent annual follow-up. MAIN OUTCOME MEASURE: The PPARgammaPro12Ala genotype was determined by polymerase chain reaction-based techniques. Associations between genotype and blood pressure were analysed by linear regression and expressed as differences in blood pressure (delta) with 95% confidence interval (CI). RESULTS: The mean systolic blood pressure and the diastolic blood pressure were 160 mmHg (standard deviation = 22.8) and 84 mmHg (standard deviation = 9.6), respectively. Subjects with Pro/Ala (24%) or Ala/Ala (2%) had lower diastolic blood pressure (delta = 2.8; 95% CI, 0.6-5.0) when adjusted for age and gender compared with Pro/Pro subjects (74%). This association was restricted to men (delta = 4.4; 95% CI, 1.3-7.4), who also had a borderline significant difference in systolic blood pressure (delta = 6.9; 95% CI, -0.8 to 13.8). In men the difference in diastolic blood pressure remained after adjustment for age, body mass index, serum triglycerides, serum insulin and haemoglobin A(1c) (delta = 4.6; 95% CI, 1.1-8.1). A subanalysis of normotensive men (n = 100) confirmed the difference associated with the Pro12Ala polymorphism in diastolic blood pressure (delta = 5.2; 95% CI, 0.6-10.0). CONCLUSIONS: The common Pro12Ala polymorphism in PPARgamma is associated with lower diastolic blood pressure in male subjects with type 2 diabetes.     

Sleep and sleepiness 1 and 9 months after cataract surgery

This study was undertaken to analyze sleep development in a group of patients during the first 9 months after cataract extraction. Men and women (n=407) undergoing cataract surgery at the Department of Ophthalmology, Sundsvall Hospital during two periods in 2000-2002 were asked to complete a questionnaire on the state and change of sleep and sleepiness 1 and 9 months after the operation. The response rate was 90.8%. The mean ages of the participating men and women were 74.5 and 75.6 years, respectively. One week after cataract extraction the visual acuity in the treated eye was 0.67 (+/-0.31) in men and 0.69 (+/-0.28) in women (NS), and showed an inverse relationship to age in both men (P<0.01) and women (P<0.0001). One month after cataract extraction 28.3% of the men and 37.5% of the women experienced poor sleep, and after 9 months the figures were 15.8 and 31.4%, respectively. Frequent awakenings and difficulty in falling asleep after nocturnal awakenings improved correspondingly. Being well rested in the morning increased and daytime sleepiness decreased. The results indicate that in elderly persons with cataract sleep is improved 1 month after cataract extraction and further improvement during the first 9 months may be experienced.     

predictors for failure of stent treatment for benign esophageal perforations- a single center 10-year experience

AIM:To investigate possible predictors for failed selfexpandable metallic stent(SEMS)therapy in consecutive patients with benign esophageal perforationrupture(EPR).METHODS:All patients between 2003-2013 treated for EPR at the Karolinska University Hospital,a tertiary referral center,were studied with regard to initial management with SEMS.Patients with malignancy as an underlying cause and those with anastomotic leakages were excluded.Sealing of the perforation with a covered SEMS was the primary strategy whenever feasible.Stent therapy failure was defined as a radical change of treatment strategy due to uncontrolled mediastinitis,which in this setting consisted of emergency esophagectomy with end-esophagostomy or death as a consequence of the perforation and subsequent uncontrolled sepsis.Patient and lesion characteristics were analyzed and are presented as median and interquartile range.Possible predictors for failed stent therapy were analyzed with uni-variate logistic regression,while variables with P<0.2 were further analyzed with multi-variate logistic regression.RESULTS:Of the total number of 48 patients presenting with EPR,40 patients(83.3%)were treated with SEMS at the time of admission,with an intention to heal the perforation.Twenty-three patients had Boerhaave’s syndrome(58%),16 had an iatrogenic perforation(40%)and 1 had external trauma to the esophagus(3%).The total in-hospital mortality,including the cases that had other initial treatments(n=8),was10.4%and 7.5%among those who were subjected to the SEMS-based strategy.In 33 of the 40 patients(82.5%)who were treated with stent,the EPR healed without further change in treatment strategy.Patients classified as treatment success received a SEMS at a median time of 1(1-1)d after the actual EPR,compared to 3(1-10)d among those where the initial treatment failed,P=0.039 in uni-variate analysis and P=0.052 in multi-variate analysis.No other significant factors emerged,indicating an increased risk for failure.Six of 7 patients,where stent treatment of the defect failed,underwent an emergency esophagectomy with end esophagostomy and one patient died.CONCLUSION:SEMS as an upfront therapeutic strategy seems to be a successful concept,when applied to an unselected group of patients with EPR.     

Salivary cortisol levels and dental anxiety in children with attention deficit hyperactivity disorder

Attention deficit hyperactivity disorder (ADHD) is a common developmental disorder. The present study tested the hypotheses that children with ADHD, particularly those exhibiting severe hyperactivity and impulsivity, have a different stress reaction (measured by salivary cortisol) during a dental recall visit and are more dentally anxious than children in a control group. Eighteen children with ADHD and a control group of 71 children, all 13 yr of age, underwent a clinical dental examination and completed the Corah Dental Anxiety Scale (CDAS). Four saliva samples were gathered for analysis of cortisol: one prior to dental examination, one after, and two the following morning. The subgroup ADHD with hyperactivity/impulsivity had statistically significantly lower cortisol levels than the control group 30 min after awakening. When cortisol values were plotted on a timeline, this subgroup always had lower cortisol concentrations than children in the control group. There was a significant correlation between CDAS scores and cortisol concentrations prior to the dental examination in both the ADHD and the control group. Behavioral expressions of anxiety in children with ADHD may be different from those in other children, not only due to the characteristics of their disorder, but also because of lower stress reactivity.