Low-energy distal radius fractures in middle-aged and elderly women-seasonal variations, prevalence of osteoporosis, and associates with fractures

There is a lack of data on the prevalence of osteoporosis in patients with distal radius fractures occurring at the various seasons. The prevalence of osteoporosis is high, both in patients with indoor and outdoor fractures and higher than in controls. All female distal radius fracture patients >or=50 years should be referred for osteoporosis assessment.

INTRODUCTION

The objectives of this study in female distal radius fracture patients were to investigate seasonal differences, estimate the prevalence of osteoporosis, and identify factors associated with distal radius fractures compared with controls.

METHODS

In a 2-year period, 263 women >/=50 years suffered a low-energy distal radius fracture in the geographic catchment area. The 214 women who met for osteoporosis assessment were age-matched with 191 controls. Bone mineral density was assessed by dual energy X-ray absorptiometry at femoral neck, total hip, and lumbar spine. Demographic and clinical data were collected.

RESULTS

The prevalence of indoor fractures showed no seasonal variance. For outdoor fractures, the prevalence was highest in the winter months. The prevalence of osteoporosis among patients with indoor fractures was higher (58.5%) than outdoor fractures without (38.6%) and with snow/ice (36.0%; p < 0.001). The prevalence of osteoporosis was higher in fracture patients (42.5%) than controls (24.1%; p < 0.001), this was also found in the youngest age group 50-59 years (22.2% vs 1.8%; p < 0.001). In conditional logistic regression analyses osteoporosis, current use of glucocorticoids, and living alone were independently associated with distal radius fractures.

CONCLUSIONS

Our study highlights that environmental factor, as well as osteoporosis are associated with distal radius fractures in middle-aged and elderly women. Osteoporosis is also frequently found in outdoor patients, thus, all female distal radius fracture patients >or=50 years should be referred for osteoporosis assessment.

The effect of clofibrate on glucose tolerance, insulin secretion, triglycerides and fibrinogen in patients with coronary heart disease

The effects of clofibrate treatment have been monitored in a double-blind cross-over study conducted in 16 male patients with coronary heart disease. Most had latent diabetes mellitus with elevated and delayed insulin release after i.v. glucose administration. Blood glucose and insulin levels were measured during repeated i.v. glucose tolerance tests in each patient and serum triglyceride and plasma fibrinogen were estimated at intervals. Clofibrate treatment significantly lowered fasting blood glucose levels (p less than 0.01) and improved the glucose tolerance (p less than 0.01). Fasting plasma insulin levels and those at 30 min after glucose loading were reduced (p less than 0.05). Serum triglycerides (p less than 0.01) and plasma fibrinogen levels (p less than 0.05) were lowered during the treatment period. The change in k-value (glucose utilization) did not correlate to changes in triglyceride or fibrinogen. This study confirms the beneficial effect of clofibrate therapy on abnormal glucose tolerance observed by other workers. It is suggested that clofibrate acts by reducing peripheral insulin resistance.

[Leflunomide--a new disease modifying anti-rheumatic agent]

BACKGROUND

Leflunomide is a novel disease-modifying antirheumatic drug (DMARD) for treatment of rheumatoid arthritis. The agent has been developed for the treatment of rheumatoid arthritis, but its multiple immunomodulatory properties may in the future be of interest in the treatment of other rheumatic and immunological diseases.

MATERIAL AND METHODS

Review of the literature in order to present the current relevant clinical documentation of the drug.

RESULTS

The clinical documentation is mainly based on three large, prospective, randomized trials of six months "to two years" duration comparing leflunomide with placebo, sulphasalazine or methotrexate. The efficacy of leflunomide in all trials was superior to placebo and comparable to sulphasalazine and methotrexate. The frequency of adverse events was also comparable to the comparators.

INTERPRETATION

Leflunomide is a safe and efficacious addition to the roster of antirheumatic drugs, but further clinical trials and experience from clinical practice are needed in the evaluation of its place as a disease-modifying agent.

[Voiding problems and urinary tract complications in adolescents and adults with myelomeningocele]

BACKGROUND

The aim of this study was to describe voiding dysfunction and urinary tract complications in a population above 16 years of age with myelomeningocele.

MATERIAL AND METHODS

51 persons were included in the study. Data were obtained by questionnaires, ultrasound and glomerular filtration rate; in those with intact urinary bladder, by cystometry and videocystography.

RESULTS

30 out of 33 persons with intact urinary bladder were incontinent. Those with daily incontinence described this as a major problem. Cystometry concluded with normal detrusor contractions in three, detrusor hyperreflexia in five, and a detrusor hyporeflexia in 25 persons. Three out of 30 had vesicoureteral reflux. Ultrasound showed mild hydronephrosis and/or scarring in three persons. Average glomerular filtration rate was 86% (50-131%). 11 had Bricker diversion and seven continent reservoirs. 15 out of 18 persons with urinary diversion were satisfied with this solution. In persons with urinary diversion, the average glomerular filtration rate was 78% (44-109%). Ultrasound showed hydronephrosis and/or scarring in seven out of 16. Overall, urinary tract infections last year were reported by 56%, and pyelonephritis was more common in those with urinary diversion.

INTERPRETATION

Incontinence is a common problem in adults with myelomeningocele. About one third had upper urinary tract changes, but none had renal failure.

[Myalgia and high sedimentation rate in adults]

The polymyalgic syndrome may be the presenting clinical feature for several diseases such as polymyalgia rheumatica, temporal arteritis, malignancy, rheumatoid arthritis, virus infections, connective tissue diseases, and myositis. In this review we present the various diagnostic options seen from a rheumatological point of view, with emphasis on polymyalgia rheumatica, temporal arteritis and the paraneoplastic syndrome. We are of the opinion that polymyalgia rheumatica is overdiagnosed in general practice, and steroid treatment may delay diagnosis and treatment of other differential diagnosis presenting as the polymyalgic syndrome. Several recently published Norwegian epidemiological studies offer new information on various aspects of the polymyalgic syndrome, which will be discussed.

Primary vasculitis in a Norwegian community hospital: a retrospective study

Primary systemic vasculitic diseases are relatively rare. Untreated, they have a high morbidity and mortality. The introduction of steroids and cytotoxic drugs has dramatically reduced the mortality. In a retrospective study in a Norwegian community hospital, which serves a county with a population of 150,426 in 1996, 68 patients were found to have a primary vasculitis, 63 of whom fulfilled the ACR 1990 criteria. Patients with Henoch-Schönlein purpura aged less than 16 years and patients with Kawasaki's disease were excluded. The overall prevalence was 43.9 per 100,000 inhabitants (Churg-Strauss syndrome 1.3, hypersensitivity vasculitis 2.7, Henoch-Schönlein purpura 3.3, polyarteritis nodosa 3.3, Wegener's granulomatosis 5.3 and temporal arteritis 27.9). In most cases, disease control was achieved with corticosteroids alone, or with the addition of cytotoxic drugs. Two patients had died in the latest 5-year period but of unrelated disorders. Biopsy plays a major role in diagnosing vasculitic diseases. In our study, 62 patients had a positive biopsy supporting the diagnosis.

Vasculitic changes in the temporal artery in polyarteritis nodosa

In a retrospective study of primary vasculitis in a Norwegian community hospital 6 patients were found to have polyarteritis nodosa (PAN). Five of them had taken a temporal artery biopsy and in all biopsies vasculitic changes were found, but no giant cells. Muscle biopsies from each of the patients showed the same major vasculitic changes as in the temporal artery. The histopathological findings could not exclude temporal arteritis (TA). None of the 5 polyarteritis patients who all fulfilled the ACR 1990 criteria had a case history typical for TA. Our results give the impression that vasculitic changes in the temporal artery may be a frequent finding in PAN. An atypical case history of TA with vasculitis in the temporal artery without giant cells and atypical histopathological findings should lead to the suspicion of PAN or another primary vasculitis. We also recommend a temporal artery biopsy in all cases of suspected PAN.

The impact of physician order entry on nursing roles

This study examines the impact of physician order entry (POE) on nurses perceptions of work, quality of care, and nurse/physician communication. Four hospitals that have implemented a computerized order-entry system with POE were compared with four similar hospitals using the same computerized system with clerk order entry only. Three factors were extracted from the 29 item survey using principal component extraction with varimax rotation that accounted for 16.5%, 12.4% and 8.7% of the variance respectively. Three scales were constructed from these factors measuring perceptions of impact of the information system on the quality of care, job, control, and nurse/physician communication. Nurses working in the POE environment rated their computer system as having greater impact on the quality of care and lower ratings of perceived control than those working in non-POE environments. No differences were found between nurses working in POE environments and those working in POE in terms of their ratings of frequency of contact and ease of access to physicians.

[Systemic sclerosis. A rare connective tissue disease with manifestations in many organs]

Systemic sclerosis (scleroderma) is a rare connective tissue disease which can affect most human organs. Systemic sclerosis is divided into two groups: one diffuse scleroderma form, which is often more serious, with extensive organ involvement, and a limited scleroderma form with good prognosis. During a period of 20 years from 1974 to 1994, 14 patients were diagnosed as having systemic sclerosis in a population of approximately 150,000. Five were classified as having the diffuse form, and nine as having the limited form. Ten patients were found to have antinuclear antibodies. All patients had Raynaud's phenomena and scleroderma. Involvement of the gastrointestinal tract/lungs and joint-tendon sheets were found in six and eight patients respectively. Muscles, heart and kidneys were involved in three of the patients. Our results correspond with those described in the literature.

The variable clinical picture of arthritis induced by human parvovirus B19. Report of seven adult cases and review of the literature

Seven patients with arthritis due to infection with human parvovirus B19 are reported, and the literature association reviewed. B19 virus arthritis most frequently affects young to middle aged women and occurs predominantly during the first six months of the year. The majority of cases have oligoarthritis or polyarthritis, and the joints most often involved are the proximal interphalangeal joints and knees. Of the seven patients reported, one case developed systemic lupus erythematosus, one case evolved into erosive, seropositive rheumatoid arthritis while one case was subsequently diagnosed as undifferentiated connective tissue disease.

Low energy laser therapy in rheumatoid arthritis

Low energy laser (LEL) is a widely used treatment for a variety of musculoskeletal disorders although convincing documentation of the effect is missing. We have examined the LEL effect on Rheumatoid Arthritis (RA) in a double blind placebo controlled study. Twenty-two patients completed the study (10 receiving LEL treatment) according to the protocol. A significant effect on pain score was found due to LEL treatment, but when data were corrected for disease variation the effect disappeared. No effect of LEL could be demonstrated on the other assessed variables: grip strength, morning stiffness, flexibility, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP). In conclusion, we did not find that LEL had any clinically relevant effects on RA.

Morning stiffness and nightime pain in ankylosing spondylitis. A comparison between enteric-coated and plain naproxen tablets

Thirty-nine patients with ankylosing spondylitis participated in a randomized, double-blind, double-dummy, multi-cross-over study with enteric-coated (ECT) and plain (PT) naproxen tablets. The duration of the study was 24 days with 6 treatment periods of 4 days. The majority of the patients were taking 750 mg naproxen daily. The mean plasma concentration of naproxen in the morning was 36% higher with ECT (p < 0.001). No significant differences regarding duration of morning stiffness and night time pain were found in this patient category. The mean duration of morning stiffness was 116 minutes (ECT) and 125 minutes (PT). We were not able to show correlation between plasma concentration of naproxen and duration of morning stiffness.

Auranofin (SK&F) in early rheumatoid arthritis: results from a 24-month double-blind, placebo-controlled study. Effect on clinical and biochemical assessments

In a 2-year, randomized, double-blind Nordic multicentre trial, auranofin was compared with placebo in early (disease duration less than or equal to 2 years), active rheumatoid arthritis (RA). Efficacy and safety were analysed in 67 patients receiving auranofin and 65 receiving placebo. Life table analysis demonstrated a significantly higher withdrawal rate due to insufficient therapeutic effect in the placebo group, whereas more patients dropped out due to side effects in the auranofin group. More auranofin than placebo patients (35 vs. 24) completed the 2 years. Clinical and inflammatory activity improved in both groups, but consistently more so in the auranofin group, in spite of the greater consumption of local steroids and NSAIDs in the placebo group. The most frequent side effects leading to withdrawal in the auranofin group were cutaneous and gastrointestinal reactions. The study demonstrated that most patients exhibit improvement in clinical signs and symptoms and about half of all patients with early RA continue to take auranofin for at least 2 years.

Duration of morning stiffness in rheumatic patients after medication with enteric-coated and plain naproxen tablets

Twenty-nine adult rheumatic patients who were taking 500 mg naproxen at bedtime and had a certain degree of morning stiffness despite this medication took part in a randomized double-blind cross-over study in which the duration of morning stiffness after evening doses of 500 mg enteric-coated naproxen tablets was compared with that after identical doses of plain naproxen tablets. The duration of morning stiffness was significantly shorter after taking enteric-coated tablets (p less than 0.01), and the mean plasma naproxen morning concentration was 34% higher (p = 0.01). Since the results were unambiguous in such a small group of patients, they are judged to be of considerable clinical value.

Complexed autoantibodies in patients with juvenile connective tissue diseases, isolated by rate-zonal ultracentrifugation

Selected sera from one patient with systemic lupus erythematosus, two with mixed connective tissue disease, one with dermatomyositis, one with progressive systemic sclerosis and one with juvenile rheumatoid arthritis were investigated for autoantibodies after fractionation by computerized rate-zonal ultracentrifugation. Anti-Smith antibodies sedimented in an area from 6-11 S and anti-ribonucleoprotein from 6-13 S. IgG anti-IgG and IgG antinuclear antibodies (ANA) were present in free or complexed form in the 6-13 S area. IgM ANA occurred as 7 S IgM in patients with systemic lupus erythematosus and mixed connective tissue disease, whereas IgM ANA sedimented in the 19 S area in patients with dermatomyositis and progressive systemic sclerosis. Complexes containing IgG anti-IgG and ANA, positioned in the 6-13 S area are likely to play a significant role in the pathogenesis of systemic lupus erythematosus and mixed connective tissue disease.