Outcome based definition of the anterior thalamic deep brain stimulation target in refractory epilepsy.

BACKGROUND: Deep brain stimulation of the anterior nucleus of the thalamus (ANT) is an emerging therapy for refractory focal epilepsy. However, the most optimal target for stimulation has not been unambiguously described. OBJECTIVE: In the present study, we investigated the correlation between the stimulation site and outcome in order to define the optimal target for deep brain stimulation in refractory epilepsy. METHODS: The locations of 62 contacts used in 30 treatment attempts in 15 prospectively followed patients during a 5 year period were assessed. Treatment attempts were classified into responding and non-responding trials using seizure reduction and side effect profile as criteria. The locations of active contacts were calculated with respect to mid-commissural point and visible borders of ANT in 3T MRI (ANT-normalized coordinate system) aiming to minimize the confounding effect of individual variation in the location and size of the ANT. RESULTS: Contacts in successful treatment trials were located significantly more anterior and superior both in AC-PC and ANT-normalized coordinate systems. Favourable outcome was observed at 3T MRI based location of ANT but not at location predicted by Schaltenbrandt atlas sagittal data. Contacts used in successful trials were at anterior aspect of the ANT complex evidenced by the ANT-normalized coordinate system. CONCLUSION: The anti-epileptic effect of anterior thalamic DBS may be dependent on stimulation site especially in the anterior to posterior axis. Extensive anatomical variation confounds severely the targeting of ANT. Therefore, direct visualization of the desired target for stimulation is essential for favourable outcome in refractory epilepsy.

Defining the anterior nucleus of the thalamus (ANT) as a deep brain stimulation target in refractory epilepsy: Delineation using 3 T MRI and intraoperative microelectrode recording.

BACKGROUND: Deep brain stimulation (DBS) is a minimally invasive and reversible method to treat an increasing number of neurological and psychiatric disorders, including epilepsy. Targeting poorly defined deep structures is based in large degree on stereotactic atlas information, which may be a major source of inconsistent treatment effects. AIM OF THE STUDY: In the present study, we aimed to study whether a recently approved target for epilepsy (anterior nucleus of thalamus, ANT) is visualized in clinically established 3 T MRI and whether ANT is delineated using intraoperative microelectrode recording (MER). We have especially focused on individual variation in the location of ANT in stereotactic space. We also aimed to demonstrate the role of individual variation in interpretation of MER data by projecting samples onto AC-PC (anterior and posterior commissure) and ANT-normalized coordinate systems. METHODS: Detailed analysis of ANT delineations in 3 T MRI short tau inversion recovery (STIR) images from eight patients undergoing DBS for refractory epilepsy was performed. Coronal and sagittal cross-sectional models of ANT were plotted in the AC-PC coordinate system to study individual variation. A total of 186 MER samples collected from 10 DBS trajectories and 5 patients were analyzed, and the location of each sample was calculated and corrected accordingly to the location of the final DBS electrode and projected to the AC-PC or coordinate system normalized to ANT. RESULTS: Most of the key structures in the anatomic atlas around ANT (mammillothalamic tract and external medullary lamina) were identified in STIR images allowing visual delineation of ANT. We observed a high degree of anatomical variation in the location of ANT, and the cross-sectional areas overlapped by study patients decreased in a linear fashion with an increasing number of patients. MER information from 10 individual trajectories correlated with STIR signal characteristics by demonstrating a spike-negative zone, presumably white matter layer, at the lateral aspect of ANT in ANT-normalized coordinate system as predicted by STIR images. However, MER information projected to the AC-PC coordinate system was not able to delineate ANT. CONCLUSIONS: ANT is delineated in 3 T MRI by visualization of a thin white matter lamina between ANT and other nuclear groups that lack spiking activity. Direct targeting in the anterior thalamic area is superior to indirect targeting due to extensive individual variation in the location of ANT. Without detailed imaging information, however, a single trajectory MER has little localizing value.

A nationwide cross-sectional overview of patients with rheumatoid arthritis followed in outpatient specialty clinics in Finland.

OBJECTIVES: We aimed to conduct a cross-sectional overview of patients with rheumatoid arthritis (RA) in outpatient specialized clinics in Finland. METHOD: Consecutive patients were enrolled in the study. The data collected comprised demographic, disease- and treatment-related variables. RESULTS: Between November 2011 and May 2012, 890 patients with RA (77% female) were enrolled from 14 sites. The median age was 59.8 years and the time from diagnosis 7.2 years. Values for the Disease Activity Score using 28 joint counts (DAS28) ranged from 0.28 to 6.61 (median 2.55) with 52% and 70% of patients reaching remission and low disease activity, respectively. Rheumatoid factor (RF) and anti-cyclic citrullinated peptide (anti-CCP) antibodies were evident in 70% and 63% of patients, respectively. Median Health Assessment Questionnaire (HAQ) scores with and without aids and devices were 0.75 [interquartile range (IQR) 0.13-1.38] and 0.63 (IQR 0.13-1.13), respectively. Conventional disease-modifying anti-rheumatic drugs (DMARDs) were used by 91% of patients. A triple therapy of methotrexate (MTX), hydroxychloroquine (HCQ), and sulfasalazine (SSZ) was used by 15%, other MTX-based combination by 30%, MTX alone by 20%, and other DMARDs alone or in combination by 26% of patients. In addition, glucocorticoids and biologics were taken by 58% and 21% of patients, respectively. Of the 184 biologics users, 18% were not using DMARDs concomitantly. CONCLUSIONS: Our cross-sectional review of patients with RA revealed that > 50% of patients were in remission according to DAS28. Comparison with previous studies revealed a reduction in disease activity of prevalent RA cases, possibly resulting from increased use of aggressive anti-rheumatic treatments.

Reduction in Clostridium difficile infections in Finland, 2008-2010.

BACKGROUND: In January 2008, laboratory-based surveillance of Clostridium difficile was initiated as a part of the Finnish National Infectious Disease Register (NIDR) and enhanced surveillance of hospitalized patients with C. difficile-associated infections (CDI) by the Finnish Hospital Infection Programme (SIRO). AIM: To present data from the first three years. METHODS: All laboratories reported C. difficile findings positive for toxin production from stools to NIDR. Surveillance of hospitalized patients with CDI was conducted using the interim case definitions of the European Centre for Disease Prevention and Control for CDI, origin and severe case of CDI. In all, 16 acute care hospitals from 10 of the 21 healthcare districts (HDs) participated in SIRO during 2008-2010. Clinical microbiology laboratories were asked to send isolates from severe cases and persistent outbreaks to the national reference laboratory for genotyping. FINDINGS: The annual incidence rate of CDIs decreased by 24%, from 119 per 100,000 population in 2008 to 90 per 100,000 in 2010. The decrease occurred in 13/21 (62%) HDs (range of decrease by HD: 2-51%). The nosocomial rate decreased 26%, from 0.31 to 0.23 per 1000 patient-days, and occurred in about half of the hospitals that participated in SIRO. During 2008-2010, 17 HDs sent C. difficile specimens for typing. Ribotype 027 was found in eight HDs, all showing values above the mean or increasing population-based incidence rates of CDIs. CONCLUSIONS: Population-based surveillance of CDIs and enhanced surveillance of nosocomial cases showed reduction in CDIs, but success in controlling the disease varied between regions.

Consistency of assessments and willingness to pay for a reduction in morning symptoms over time in patients with rheumatoid arthritis.

OBJECTIVES: To determine the variation in morning symptoms and in the corresponding monetary equivalents assigned to their reduction. METHODS: The sampled (n = 100) rheumatoid arthritis (RA) patients were interviewed twice by a trained interviewer using the same interview, 2 weeks apart. Patients assessed fatigue, pain, and severity of morning stiffness (MS) on waking up and after maximum improvement on a numeric rating scale (NRS). Patients estimated the duration of MS in minutes and reported the number of tender and swollen joints. Patients were also asked to estimate how much they would be willing to pay on a daily basis if pain, duration of MS, and severity of MS when waking up could be reduced by 25, 50, 75, and 100%. Weighted averages of the monetary assessments for symptom reduction were computed. RESULTS: On average, the NRS values at the first and second assessments were close to each other, except for fatigue and pain, which were significantly lower (p < 0.01) in the second assessment. There was limited within-patient variation, with the majority of symptom assessments within a range of ±10%. Weighted average willingness-to-pay (WTP) estimates were consistent across time points for reduction in pain and MS severity and duration. Changes in symptom assessments were reflected in the WTP estimates. CONCLUSIONS: The duration and severity of MS seemed to be more consistent over time than pain and fatigue. WTP estimates and their changes corresponded closely to changes in symptom assessments.

Anti-citrullinated peptide antibodies and the progression of radiographic joint erosions in patients with early rheumatoid arthritis treated with FIN-RACo combination and single disease-modifying antirheumatic drug strategies.

OBJECTIVES: To evaluate the impact of antibodies to cyclic citrullinated peptide (ACPAs) on radiographic progression in patients with early rheumatoid arthritis (RA) initially treated either with a combination of 3 disease-modifying antirheumatic drugs (DMARDs) or with a single DMARD. METHODS: This study included 129 patients with early active RA initially randomised to treatment either with a combination of methotrexate, sulfasalazine, hydroxychloroquine, and prednisolone (FIN-RACo) (n=69) or with a single DMARD (initially sulfalasalazine) with or without prednisolone (SINGLE) (n=60). After 2 years, the use of DMARDs and prednisolone became unrestricted. Radiographic progression in hands and feet was assessed at baseline and at 1, 2, 3, 4 and 5 years. ACPAs at baseline were determined with enzyme immunoassay. RESULTS: ACPAs were positive in 92 (71%) patients. ACPA-positive vs. negative patients were more frequently rheumatoid factor (RF) positive (83% vs. 22%, p<0.001) and had an erosive disease (54% vs. 22%, p<0.001) at baseline. The presence of ACPA was associated with radiographic progression in FIN-RACo group even when the impact of RF was controlled; the radiographic progression was remarkably slower in ACPA-negative than in ACPA-positive cases (RF adjusted change over time between groups p=0.034). In the SINGLE group, the radiographic changes progressed parallel in ACPA-negative and positive patients. CONCLUSIONS: Most ACPA-positive RA patients have joint erosions already at diagnosis. ACPA positivity in early RA was related to radiographic progression even in patients treated initially with the FIN-RACo regimen. The initial FIN-RACo therapy seems to slow down the progression of joint damage in ACPA-negative patients.

How much is a reduction in morning stiffness worth to patients with rheumatoid arthritis?

OBJECTIVE: The aim of this study was to determine the monetary equivalent of the emotional and functional impact of morning stiffness (MS) in patients with rheumatoid arthritis (RA), using alternative valuing methods. METHODS: Telephone interviews were conducted among 166 patients with RA to assess utility and clinical symptoms, including MS. Three standard economic methods were used: the human capital approach (HCA), marginal value of time (MVT), and willingness-to-pay (WTP). RESULTS: The monetary equivalent of the impact of MS varied with the method used (from EUR 5.74 to EUR 17.87 per patient per day) and severity of MS (5-8-fold higher in patients with severe MS compared with mild MS). Patients placed considerable value on a reduction in duration and severity of MS. Patients with MS lasting an hour or more were willing to pay EUR 21.74/day to stop the symptom and EUR 10.63/day to halve the duration. Patients with severe MS were willing to pay EUR 47.86/day to stop the symptom and EUR 21.68/day to halve the severity. CONCLUSIONS: The observed variation in the monetary equivalent of the impact of MS obtained with the three estimation methods indicates that the findings of studies using different valuing methods should not be compared directly. The study demonstrates that a reduction in MS is worth a considerable amount to patients with RA, particularly those with severe or prolonged MS. These findings suggest that clinical treatment decisions to improve patients' quality of life should also incorporate therapy that reduces MS.

Trends in treatment strategies and the usage of different disease-modifying anti-rheumatic drugs in early rheumatoid arthritis in Finland. Results from a nationwide register in 2000-2007.

OBJECTIVES: To determine which disease-modifying anti-rheumatic drugs (DMARDs) are currently used by Finnish rheumatologists to treat early rheumatoid arthritis (RA). METHODS: Information on sex, date of birth, and date of special medicine reimbursement decision for all new RA patients was collected from a nationwide register maintained by the Social Insurance Institution (SII) during the time period from 1 January 2000 to 31 December 2007. Patient cohorts were registered in 2-year time periods (2000-01, 2002-03, 2004-05, 2006-07) and DMARDs purchased by the patient cohorts during the first year after the date of reimbursement decision for RA were registered. The frequencies of early drug treatment strategies (combination of DMARDs, single DMARD, or no DMARDs) were evaluated. RESULTS: A total of 14 878 (68.0% female, 62.6% rheumatoid factor (RF)-positive) patients were identified. Between 2000 and 2001 the most commonly used treatment strategy for early RA during the first 3 months was single DMARD treatment (56.1%) and the most commonly used DMARD during the first year was sulfasalazine (63.0%), while between 2006 and 2007 the respective treatments were combination DMARDs (55.3%) and methotrexate (69.0%). The change in treatment strategies as well as in DMARDs used was highly significant (p < 0.001 for linearity). At the end of the study period only 4.9% of the patients with early RA were not receiving DMARDs during the first 3 months. CONCLUSIONS: Currently, combination therapy including methotrexate is the most commonly prescribed treatment strategy for early RA in Finland. In recent years, an increasing number of active drug treatments have been taken into practice.

Renal safety of initial combination versus single DMARD therapy in patients with early rheumatoid arthritis: an 11-year experience from the FIN-RACo Trial.

OBJECTIVE: To evaluate the renal safety of traditional disease-modifying antirheumatic drugs (DMARDs) in early rheumatoid arthritis (RA). METHODS: One hundred and ninety-five DMARD-naïve patients with recent-onset RA were randomised to receive combination DMARD therapy (n=97) starting with sulfasalazine, methotrexate, hydroxychloroquine, and prednisolone (COMBI) or monotherapy (n=98), initially with sulfasalazine, with or without prednisolone (SINGLE). After two years, the choice and dosing of DMARDs and prednisolone were not restricted, but the treatment was still targeted to achieve or maintain remission. Urinalysis, serum creatinine and glomerular filtration rate (GFR; estimated according to the Cockcroft-Gault formula [eGFRCG]) were analysed at baseline and at months 6, 9, 12, 18, 24 and thereafter yearly up to 11 years. RESULTS: The cumulative incidence of repeated (>or=3 times) abnormal renal findings during the 11-year follow-up period were as follows (COMBI versus SINGLE; p-values adjusted for age and sex): proteinuria (dipstick positive) 4.8% (95%CI 1.8-12.2) vs. 5.3% (95%CI 2.0-13.7, p=0.93), haematuria (dipstick positive) 14.1% (95%CI 8.0-24.2) vs. 22.1 % (95%CI 14.5-33.0, p=0.14), raised serum creatinine (>or=100 micromol/l in females and >or=115 micromol/l in males) 4.4% (95%CI 1.7-11.4) vs. 6.7% (3.0-14.3, p=0.87) and eGFRGC<60 ml/min/1.73 m2 11.9% (95%CI 6.8-20.5) vs. 10.5% (95%CI 5.8-18.7, p=0.85). CONCLUSION: Initial remission targeted therapy with the FIN-RACo DMARD combination in early RA is safe for kidneys and does not induce more short- or long-term renal complications compared to traditional therapy with a single DMARD.

A mismatch between self-reported physical work load and the HAQ: early identification of rheumatoid arthritis patients at risk for loss of work productivity.

OBJECTIVE: To explore the combination of data on functioning and work load for early identification of patients at risk for diminished work productivity in rheumatoid arthritis (RA). PATIENTS AND METHODS: In the FIN-RACo trial, 162 patients with recent onset RA and available for the workforce were treated with either a combination of disease-modifying antirheumatic drugs (DMARDs) or a single DMARD for 2 years. Otherwise, they received routine care and were followed up for 5 years. Data on their individual income and lost work days came from official registers. Loss of productivity was computed by the human capital approach. Self-reported data on physical work demand (Finnish Institute for Occupational Health Questionnaire) at baseline and on functioning (HAQ) at 6 months were linked according to the International Classification of Functioning, Disability and Health. RESULTS: Data on 112 patients were analyzable at 6 months; 35 (31%) of them had diminished capacity in functions required at paid work. Any mismatch between perceived abilities and requirements predicted future (7 through 60 months) loss of productivity - on average Euro 14,040 (95% confidence interval (CI): 9,143-20,511) per year in patients with the mismatch compared to Euro 3,043 (1,623-5,534) in those without any mismatch - and was associated with RA-related permanent work disability (hazard ratio: 11.6; 95%CI: 4.0-33.4). CONCLUSION: Linking together self-reported data about functioning and work load helps in early identification of the RA patients at risk for loss of working days.

Rituximab therapy in patients with rheumatoid arthritis refractory or with contraindication to anti-tumour necrosis factor drugs: real-life experience in Finnish patients.

OBJECTIVES: To describe the effects of rituximab therapy in patients with rheumatoid arthritis (RA) in routine clinical practice in Finland. METHODS: Data were collected retrospectively from patient records in five rheumatology clinics in Finland. All RA patients treated during 2005-2008 (n = 81) were included. Information on disease-modifying anti-rheumatic drugs (DMARDs), DMARD combinations, and biologics prior to rituximab use was collected as well as treatment responses after initiating rituximab therapy. The Disease Activity Score using 28 joint counts (DAS28) was used to determine disease activity and European League Against Rheumatism (EULAR) responses. RESULTS: Mean disease duration was 14 (range 0-47) years and the median number of prior DMARDs and biologics used were 7 (1-12) and 2 (0-4), respectively. Efficacy analysis was performed on 57 patients with available DAS28 data at treatment onset and follow-up visits. Median DAS28 declined from 6.07 (3.19-7.70) to 3.99 (1.53-6.55) by the first rituximab treatment course. Altogether 77% of the patients achieved a EULAR response, 26% with a good response including 18% with remission. Furthermore, the patients treated concomitantly with DMARDs other than methotrexate (MTX) achieved a EULAR response slightly more often than the patients on MTX (85% vs. 70%) only. A second course of rituximab was given to 48% of the patients on an average of 9 months after initial therapy, with the median DAS28 score declining further to 3.49 (0.1-5.74). Safety and tolerability assessment of the 81 patients indicates rituximab to be well tolerated. CONCLUSIONS: Rituximab can effectively control disease activity in patients with active disease and poor response to previous therapies, in combination with MTX but also with other DMARDs.

Use of the Stanford Health Assessment Questionnaire in estimation of long-term productivity costs in patients with recent-onset rheumatoid arthritis.

OBJECTIVE: To evaluate the utility of the Stanford Health Assessment Questionnaire (HAQ) in the estimation of loss of productivity due to early rheumatoid arthritis (RA) and to develop a simple model for analysis of the cost-benefit of therapies. METHODS: In the Finnish Rheumatoid Arthritis Combination Therapy (FIN-RACo) trial, 162 patients with recent-onset RA who were available for the workforce were randomized to receive either a combination of three disease-modifying anti-rheumatic drugs (DMARDs) or a single DMARD for 2 years and were followed up for 5 years. No biological drugs were used. Data on sick leave and RA-related disability pensions came from official register records. Loss of productivity was computed by both the human capital approach (HCA) and the friction cost approach (FCA). Functional capacity was assessed by the HAQ at baseline and at 6 months. RESULTS: Over 5 years, mean loss of productivity per year was EUR 8344 by the HCA and EUR 1928 by the FCA. The level of the HAQ index at 6 months, but not the change in HAQ from baseline, determined productivity costs. With the HCA, a monotonous association between annual loss of productivity and the 6-month HAQ was found: EUR 2087 [95% confidence interval (CI) 1340-2903] per one step (0.13) on the HAQ scale from 0 to 1.88. With the FCA, the increase in loss of productivity was cut at the HAQ level of 0.5 to 0.75 (EUR 17 740 in 5 years). CONCLUSION: The HAQ index at 6 months may serve as a determinant of long-term RA-related indirect costs in economic analyses in early RA.

Exercise-induced training effects on bone mineral content: a 7-year follow-up study with adolescent female gymnasts and runners.

The objective of this study was to assess differences in the effects of competitive gymnastics and running on bone mineral content (BMC) of the lumbar spine and femoral neck when compared with their non-competing age-matched controls. Caucasian healthy peri-pubertal girls (52 competing gymnasts, 46 competing runners, 44 non-athletic controls) were included. Weight, height, and type and amount of exercise (MET h/week) as well as BMC of the lumbar spine and femoral neck were measured repeatedly. Statistical comparisons between groups were made using ANOVA. Repeated measures were analyzed using generalized linear mixed models. The median MET value of gymnasts was significantly higher when compared with runners and controls at baseline, P=0.001. The weekly median MET hours decreased during the follow-up. The mean (adjusted for height, weight, and years from menarche in the 7-year follow-up) BMC of the lumbar spine and femoral neck was significantly higher among gymnasts when compared with the other two groups. Group-by-time interaction was significant only at the femoral neck (P=0.048). The type of physical activity was a significant factor in BMC of the adolescent women. Gymnasts had greater BMC at lumbar spine and femoral neck during the total 7-year follow-up period when compared with runners and controls.

Healthcare-associated infections in Finnish acute care hospitals: a national prevalence survey, 2005.

The objectives of the first national prevalence survey on healthcare-associated infections (HAIs) in Finland were to assess the extent of HAI, distribution of HAI types, causative organisms, prevalence of predisposing factors and use of antimicrobial agents. The voluntary survey was performed during February-March 2005 in 30 hospitals, including tertiary and secondary care hospitals and 10 (25%) other acute care hospitals in the country. The overall prevalence of HAI was 8.5% (703/8234). Surgical site infection was the most common HAI (29%), followed by urinary tract infection (19%) and primary bloodstream infection or clinical sepsis (17%). HAI prevalence was higher in males, among intensive care and surgical patients, and increased with age and severity of underlying illness. The most common causative organisms, identified in 56% (398/703) of patients with HAIs, were Escherichia coli (13%), Staphylococcus aureus (10%) and Enterococcus faecalis (9%). HAIs caused by multi-resistant microbes were rare (N = 6). A total of 122 patients were treated in contact isolation due to the carriage of multi-resistant microbes. At the time of the survey, 19% of patients had a urinary catheter, 6% central venous line and 1% were ventilated. Antimicrobial treatment was given to 39% of patients. These results can be used for prioritising infection control measures and planning more detailed incidence surveillance of HAI. The survey was a useful tool to increase the awareness of HAI in participating hospitals and to train infection control staff in diagnosing HAIs.

Combination drug strategy in recent-onset rheumatoid arthritis suppresses collagen I degradation and is associated with retardation of radiological progression.

OBJECTIVE: To assess whether serum C-terminal cross-linking telopeptide of type I collagen (ICTP), a marker of type I collagen degradation, has any additional value in the assessment of treatment effect in patients with early rheumatoid arthritis (RA). METHODS: A total of 182 patients were randomized to treatment either with three disease-modifying anti-rheumatic drugs (DMARDs) and low-dose prednisolone (COMBI) or with a single DMARD with or without low-dose prednisolone (SINGLE). We investigated the prognostic value of serum ICTP level for the progression of joint destruction in X-rays (Larsen's score) from baseline to 2 years. RESULTS: There was a statistically significant decrease in serum ICTP levels from baseline to 1 year. At 6 months, the serum ICTP level was lower in the COMBI patients compared to that of the SINGLE cases (p = 0.008, after adjustment for baseline ICTP). When grouping the patients according to serum ICTP tertiles at 6 months, there was a statistically significant trend for increasing median change in Larsen score from baseline to 2 years from lowest to highest ICTP tertile in the SINGLE patients [p = 0.008, after adjustment for 28-joint Disease Activity Score (DAS28) score and RF status at baseline], while in the COMBI, the change remained low in all ICTP tertiles. CONCLUSIONS: The COMBI strategy for recent-onset RA results in early suppression of type I collagen degradation, which is reflected in radiological joint damage at 2 years. Serum ICTP at 6 months may be useful for identifying those RA patients whose treatment should be intensified to prevent further joint damage.

Serum IL-1beta levels are associated with the presence of erosions in recent onset rheumatoid arthritis.

OBJECTIVE: To study interleukin (IL)-1beta levels in recent onset RA patients treated either with combination DMARD therapy (sulfasalazine, methotrexate, hydroxychloroquine) or a single DMARD therapy. METHODS: Serum IL-1beta levels were measured before the treatment and 6 months after the institution of either single or combination DMARD therapy using a high sensitivity ELISA method. Radiographic evaluation of the hands and feet was performed at 0 and 24 months. RESULTS: Significant correlations (r = 0.28, 95% CI 0.10-0.45) were found between IL-1beta levels measured at 0 and 6 months. The IL-1beta levels at 0 months correlated significantly (r = 0.23, 95% CI 0.03-0.4, p= 0.021) with the baseline number of eroded joints at 0 months but not with radiographic joint damage at 24 months. The baseline level of IL-1beta was a better indicator for the presence of eroded joints than the baseline level of serum CRP. No significant changes in IL-1beta levels were observed during the first 6 months of anti-rheumatic treatment in either group. No statistically significant difference between IL-1beta levels in the patients with or without the shared epitope could be observed. CONCLUSIONS: The serum IL-1beta level is significantly associated with the presence of erosions at the onset of RA but its predictive value is attenuated or lost when single or combination DMARD medication is instituted. Measuring IL-1beta at the time of diagnosis in a single patient cannot be used to estimate the erosive nature of the disease or the prognosis.

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.

The reduction of physical activity reflects on the bone mass among young females: a follow-up study of 142 adolescent girls.

UNLABELLED: Maintenance of positive effects of physical activity on growing bone is unknown. Physical activity was associated with increased BMC and BMD in a 7-year follow-up with 142 adolescent girls. Marked reduction in physical activity had an unfavorable effect on bone measurements, which is an important finding when the prevention of osteoporosis is considered. INTRODUCTION: Environmental factors influence quality and durability of bone. Physical activity, with high-impact weight bearing activity during puberty in particular, has been shown to have a beneficial effect on growing bone. Only few studies have been published on the maintenance of these effects. METHODS: At baseline, 142 girls aged 9-15 years participated in the present 7-year follow-up study. Growth and development, physical activity, and intakes of calcium and vitamin-D were recorded at intervals. BMC and BMD measurements were repeated using DXA. Based on the recording of physical activity during the follow-up measurements, the effect of the reduction in physical activity was examined with the bone measurements, and the measurements in the tertiles based on the amount of physical activity during the whole follow-up period were compared. RESULTS: Physical activity was positively associated with the development of BMC and BMD during the follow-up. The mean BMC of the lumbar spine increased 1.69 g (3%) (p = 0.021) more among those girls who maintained the physical activity level as compared with those who reduced it during last 4 years. In the femoral neck, the corresponding difference was 0.14 g (4.6%) (p = 0.015) between the same two groups of girls. The mean increases in BMC at lumbar spine and femoral neck were more substantial among those girls having the highest physical activity levels during the 7-year follow-up (46.7% and 22.6%) as compared with those having the lowest physical activity levels (43.3% and 17.4%, respectively). CONCLUSIONS: The findings of the present study show that regular physical activity is valuable in preserving the peak bone mass acquired at puberty in particular. Many of the girls who markedly reduced their activity levels lost bone in their femoral neck prior to their 25th birthday.

Remission as the treatment goal--the FIN-RACo trial.

The Finnish Rheumatoid Arthritis Combination Therapy (FIN-RACo) trial is the first rheumatoid arthritis (RA) clinical trial in which remission served as the primary outcome measure. This chapter reviews the philosophical background, study design, and results of the FIN-RACo trial. The study showed that a third of patients with active early RA may achieve remission with a combination of methotrexate (MTX), sulfasalazine (SSZ), hydroxychloroquine (HCQ), and prednisolone.

Association of reduced physical activity and quantitative ultrasound measurements: a 6-year follow-up study of adolescent girls.

Sonographic parameters of the heel were recorded in order to investigate the effects of changes in physical activities among 140 healthy growing peripubertal Caucasian girls. Calcaneal quantitative ultrasound measurements (Hologic Sahara) were recorded at baseline and 2- and 6-year follow-up. Broadband ultrasound attenuation, speed of sound (SOS), and T scores were documented. Altogether, 30 girls reduced their physical activity by >50% and 29 girls by 25-50%, whereas 81 girls continued at the present level or increased it. Age and physical activity together accounted for 16.7% of the variation in calcaneal T scores at baseline and for 16.4% at 2-year follow-up, whereas physical activity alone accounted for 11.3% of the variation at 6-year follow-up. The reduction in mean T scores was significant (from 2.0 to 0.8, P < 0.001) among those having discontinued their physical activity by the 6-year measurement. The changes between three groups were statistically significantly different from each other (P = 0.003). The mean SOS values decreased 16.78 meters per second (95% CI -26.9 to -6.7) among those having discontinued their physical activity between the 2- and 6-year follow-up measurements. The SOS value sensitively reacts to changes in physical activity, and consequently, it will help assess changes in bone quality. Because of such an immediate reaction, SOS is a good-quality measure for the physical condition of bone in young people and a suitable tool for detecting changes in calcaneal bone.