Ingemar Petersson | Lund University (original) (raw)

Papers by Ingemar Petersson

The Journal of Rheumatology, Jul 1, 2005

To investigate the risk of cardiovascular disease (CVD) in patients with rheumatoid arthritis (RA... more To investigate the risk of cardiovascular disease (CVD) in patients with rheumatoid arthritis (RA) treated with tumor necrosis factor (TNF) inhibitors, compared to a standard RA population. Patients were recruited from a regional register, which includes over 90% of patients with RA started on TNF blockers in 1999 or later, and a local community based cohort of RA patients, established in 1997. Of a total of 983 patients in the combined cohort, 531 received treatment with etanercept or infliximab during the study period. The total cohort (n = 983) was linked with national registers for inpatient care and cause of death through December 31, 2001. CVD was defined as the first inpatient care or death from CVD without inpatient care for CVD prior to study entry. First CVD events in those treated versus not treated with TNF blockers were estimated, using age and sex adjusted incidence density computations with treatment and disease severity markers as time-dependent covariates. In the anti-TNF-treated patients, the age-sex adjusted incidence rate of first CVD event was 14.0/1000 person-years at risk (95% CI 5.7-22.4), compared with 35.4/1000 person-years (95% CI 16.5-54.4) in those not treated. Controlling for disability, the age-sex adjusted rate ratio was 0.46 (95% CI 0.25-0.85, p = 0.013) in anti-TNF-treated versus not treated. These findings suggest that the risk of developing CVD is lower in patients with RA treated with TNF blockers. This is compatible with the hypothesis that inflammation contributes to the development of cardiovascular events.

Annals of the Rheumatic Diseases, 2013

To study 21st century trends in healthcare utilisation by patients with rheumatoid arthritis (RA)... more To study 21st century trends in healthcare utilisation by patients with rheumatoid arthritis (RA) compared with the general population. Observational cohort study. Using Swedish healthcare register data, we identified 3977 Region Skåne residents (mean age in 2001, 62.7 years; 73% women) presenting with RA (International Classification of Diseases-10 codes M05 or M06) in 1998-2001. We randomly sampled two referents from the general population per RA patient matched for age, sex and area of residence. We calculated the year 2001-2010 trends for the annual ratio (RA cohort/referents) of the mean number of hospitalisations and outpatient clinic visits. By the end of the 10-year period, 62% of patients and 74% of referents were still alive and resident in the region. From 2001 to 2010, the ratio (RA cohort/referents) of the mean number of hospitalisations for men and women decreased by 27% (p=0.01) and 28% (p=0.004), respectively. The corresponding decrease was 29% (p=0.005) and 16% (p=0.004) for outpatient physician care, 34% (p=0.009) and 18% (p=0.01) for nurse visits, and 34% (p=0.01) and 28% (p=0.004) for physiotherapy. The absolute reduction in number of hospitalisations was from an annual mean of 0.79 to 0.69 in male patients and from 0.71 to 0.59 in female patients. The corresponding annual mean number of consultations in outpatient physician care by male and female RA patients changed from 9.2 to 7.7 and from 9.9 to 8.7, respectively. During the first decade of the 21st century, coinciding with increasing use of earlier and more active RA treatment including biological treatment, overall inpatient and outpatient healthcare utilisation by a cohort of patients with RA decreased relative to the general population.

Rheumatology International, 2014

Socioeconomic status could potentially impact on which type of rheumatic diagnosis a patient rece... more Socioeconomic status could potentially impact on which type of rheumatic diagnosis a patient receives. We determined whether different socioeconomic status is a risk factor for being diagnosed with spondyloarthritis (SpA) or chronic pain. In a nested case-control study, we identified two sets of adult cases diagnosed with (i) SpA (n = 1,194) and (ii) chronic pain (n = 3,730) during 2010-2012 in Skåne region, Sweden. We randomly sampled controls matched for age and sex. Level of education, marital status, and income were identified in national registers 4 years before inclusion. We also studied health-care utilization, prescribed pharmaceuticals, and work status. We used conditional logistic regressions and included socioeconomic variables and geographic area in the models. Low (odds ratio [OR] 1.69 95 % CI 1.50-1.91) or moderate education (OR 1.43 95 % CI 1.30-1.57), and low (OR 1.40 95 % CI 1.25-1.57) or moderate income (OR 1.24 95 % CI 1.10-1.38) were associated with a chronic pain diagnosis. For a SpA diagnosis, moderate income (OR 1.25 95 % CI 1.04-1.50) was the only significant factor identified. Both case groups had a larger proportion that did not work (P < 0.001), used more health care (P < 0.001), and were more frequently prescribed NSAIDs (P < 0.001) 4 years before diagnosis than controls. We confirmed that lower levels of education and income are associated with a chronic pain diagnosis. This association may reflect a true higher incidence of chronic pain and/or increased consultation propensity for such pain in people with socioeconomic status. We found no such association for SpA.

Annals of the Rheumatic Diseases, 2005

Scandinavian Journal of Rheumatology

The aim of this study was to ascertain the prevalence of rheumatoid arthritis (RA) in a Swedish g... more The aim of this study was to ascertain the prevalence of rheumatoid arthritis (RA) in a Swedish general adult population. A questionnaire about chronic pain was mailed to a total of 3928 subjects who were chosen as a random sample of the population in two communities in the county of Halland. All persons answering affirmatively to questions intended to identify patients with RA were invited to a clinical examination. X-rays of hands and feet, and analyses of rheumatoid factor and C reactive protein were performed provided that the patients fulfilled two or more of the five clinical items of the 1987 ARA criteria. Furthermore, non-participants were searched for in a patient register and in medical records from the local rheumatology unit in an attempt to identify further cases. Using the modified 1987 ARA criteria for population studies the prevalence rate of RA was calculated to 0.51% (95%, CI = 0.31-0.79).

Annals of the Rheumatic Diseases, 2013

ABSTRACT Background Extra-articular rheumatoid arthritis (ExRA) manifestations are associated wit... more ABSTRACT Background Extra-articular rheumatoid arthritis (ExRA) manifestations are associated with increased comorbidity and premature mortality. While tumour necrosis factor (TNF)-inhibitors efficiently reduce arthritis, their impact on the risk of ExRA is still uncertain. Objectives To evaluate whether treatment with TNF-inhibitors has any effect on the risk of developing severe ExRA, and to investigate potential predictors of ExRA in baseline questionnaire data obtained at the beginning of the study period. Methods A community based sample of patients with rheumatoid arthritis (RA) (n=1016), established in 1997, was studied. Clinical records were reviewed from 1 January 2005 to 31 December 2011 and cases with new onset of severe ExRA (i.e. pericarditis, pleuritis, vasculitis, interstitial lung disease, neuropathy, episcleritis/scleritis, Felty’s syndrome and glomerulonephritis), classified according to predefined criteria, were added to cases found in a previous survey 1. Information on exposure to TNF-inhibitors during the study period was obtained from the South Swedish Arthritis Treatment Group (SSATG) register. Exposure to TNF-inhibitors was treated in a time dependent fashion, and person-years at risk (pyr) were appointed to the appropriate category of exposed or unexposed time. The incidence of ExRA in exposed patients was compared to incidence in unexposed patients. In addition, in 1997 all patients received a questionnaire including the Health Assessment Questionnaire (HAQ), visual analogue scales (VAS) for current pain and global health and questions on current and previous pharmacologic treatment. Cox regression analysis models were used to assess the impact of baseline characteristics and baseline disease severity measures on the risk of ExRA. Results During treatment with TNF-inhibitors there were 9 patients with new onset of ExRA in 1226 pyr [0.73/100 pyr, 95% confidence interval (CI) 0.34-1.4] compared to 72 in 8320 pyr [0.87/100 pyr, 95% CI 0.68-1.1] in patients without TNF-inhibitors. The relative risk comparing those treated to those not treated was 0.85 (95% CI 0.37-1.7). Male gender [age adjusted hazard ratio (HR) 1.88, 95% CI 1.20-2.93], long duration of disease [age and sex adjusted HR (per year) 1.03, 95% CI 1.01-1.05] and greater disability, measured by HAQ [age and sex adjusted HR (per unit) 1.38, 95% CI 1.00-1.90] at baseline were predictors for ExRA. Conclusions TNF-inhibitors did not have any major effect on the incidence of severe ExRA in this sample. However, the assessment of the impact of treatment on ExRA may be influenced by the association between ExRA and severe, longstanding disease. References Disclosure of Interest None Declared

of cartilage oligomeric matrix protein (COMP) into joint tluid after knee injury and in osteoarth... more of cartilage oligomeric matrix protein (COMP) into joint tluid after knee injury and in osteoarthritis. Ann Rheum Dis 1994; 53: 8-13. Morgeh M, Heineglrd D, Engel J, Paulsson zyxwvut M. Electron microcopy of native cartilage oligomeric matrix protein purified from the Swarm Rat Chondrosarcoma reveals a five-armed structure. J Biol Chem 1992; 267: 613741. Paulsson M, Heinegdrd D. Radioimmunoassay of the 148kilodalton cartilage protein. Distribution of the protein among bovine tissue. Biochem J 1982; 207: 207-13. Saxne T, Heinegird D. Cartilage oligomeric matrix protein: a novel marker of cartilage turnover detectable in synovi-a1 fluid and blood. Br J Rheumatol 1992; 3 1 : 583-91.

The Journal of Rheumatology

To investigate the risk of cardiovascular disease (CVD) in patients with rheumatoid arthritis (RA... more To investigate the risk of cardiovascular disease (CVD) in patients with rheumatoid arthritis (RA) treated with tumor necrosis factor (TNF) inhibitors, compared to a standard RA population. Patients were recruited from a regional register, which includes over 90% of patients with RA started on TNF blockers in 1999 or later, and a local community based cohort of RA patients, established in 1997. Of a total of 983 patients in the combined cohort, 531 received treatment with etanercept or infliximab during the study period. The total cohort (n = 983) was linked with national registers for inpatient care and cause of death through December 31, 2001. CVD was defined as the first inpatient care or death from CVD without inpatient care for CVD prior to study entry. First CVD events in those treated versus not treated with TNF blockers were estimated, using age and sex adjusted incidence density computations with treatment and disease severity markers as time-dependent covariates. In the an...

BMC Musculoskeletal Disorders

Annals of the Rheumatic Diseases, 2013

ABSTRACT Background Adding infliximab (IFX) or sulfasalazine+hydroxychloroquine (SSZ+HCQ) to meth... more ABSTRACT Background Adding infliximab (IFX) or sulfasalazine+hydroxychloroquine (SSZ+HCQ) to methotrexate (MTX) in patients with active, early rheumatoid arthritis (RA), resulted in superior radiographic outcome in the IFX group,[1] while disease-activity, utility and work loss improved in both arms, without detectable between-group differences at 21 months[1-3]. Objectives To evaluate the cost-effectiveness of biologic vs. conventional combination treatment in early RA-patients responding insufficiently to MTX. Methods This multicenter, randomised, controlled, open-label trial enrolled RA-patients (symptoms<1y) in Sweden between 2002 and 2005. After 3-4 months of MTX monotherapy, patients with a remaining DAS28>3.2 were randomised to addition of IFX or SSZ+HCQ. The incremental cost-effectiveness ratio (ICER=€/quality-adjusted life-year [QALY]) was assessed during 21 months from randomisation. Costs of RA-related medications, non-primary healthcare utilisation and work loss were retrieved from nationwide registers, while EuroQol 5-Dimensions utility was collected quarterly. Undiscounted analyses including all patients were performed from the societal (human capital method) and healthcare perspectives. Confidence intervals were estimated by non-parametric bootstrapping. Results Of 487 patients initially enrolled, 128 and 130 were randomised to biologic and conventional treatment, respectively. The biologic group had higher drug and healthcare costs (€27,487 vs. 10,364; adjusted mean difference 16,956 [95%CI 14,647;19,162]), while no difference was seen in productivity losses (€33,804 vs. 29,220; 3,961 [-3,986;11,850]), resulting in higher societal cost, as compared to the conventional treatment arm (€61,291 vs. 39,584; 20,916 [12,800;28,660]). Mean accumulated QALYs were 1.10 in the biologic and 1.12 in the conventional treatment group (adjusted mean difference 0.01 [95%CI -0.07;0.08]). The resulting ICER, comparing the biologic to the conventional treatment option, was €2,404,197/QALY from the societal (Figure), and €1,948,919/QALY from the healthcare perspective. Conclusions In early MTX-refractory RA, the addition of IFX, as compared to addition of SSZ+HCQ, was not cost-effective over 21 months at willingness to pay levels generally considered acceptable. References References Disclosure of Interest None Declared

Fatigue is common after stroke and contributes to disability, impaired quality of life, and reduc... more Fatigue is common after stroke and contributes to disability, impaired quality of life, and reduced work ability. Currently, there is no evidence-based intervention for post-stroke fatigue but idiopathic chronic fatigue and burnt-out syndromes may benefit from nature-based rehabilitation. The aim of NASTRU was to examine whether ten weeks of nature-based rehabilitation, as add-on to standard management, could influence post-stroke fatigue (primary outcome), depression, work ability or functional outcome (secondary outcomes), compared to controls. Inclusion criteria were patients with stroke living in the catchment area of the Skåne University Hospital, 50-80 years old, independent in ADL, and reporting fatigue at 3 months (sub-acute subgroup) or > one year (chronic subgroup) after the index stroke. Patients randomized to the intervention underwent a rehabilitation program in groups up to 8 patients in an especially designed garden at the Swedish University of Agricultural Science...

Annals of the Rheumatic Diseases, 2014

ABSTRACT Background The delay of diagnosis after symptom onset for various subgroups of spondyloa... more ABSTRACT Background The delay of diagnosis after symptom onset for various subgroups of spondyloarthritis (SpA) is considerable. Increasing focus on this over the last decades may have decreased this delay (1-2). Objectives To study the duration between symptom onset and date of diagnosis of SpA and its subgroups: ankylosing spondylitis (AS), psoriatic arthritis (PsA), and unspecified spondyloarthritis (USpA). A special focus was to study the change over the past decade. Methods The Swedish SpAScania cohort (N=5,771, = all patients diagnosed with SpA between 2003 and 2007 in primary or secondary care in the Skåne region, total n=1.3 million 2013) was used. We analyzed patients (n=952) identified as having AS (n=173), PsA (n=579) or USpA (n=200) by a rheumatologist or internist at least one time or by any other physician twice during 2003 to 2007 responding to a postal survey in 2009 and 2011. The survey included questions on years for start of symptoms and diagnosis. All patients included had a self-reported diagnosis of SpA between 1997 and 2007 in the survey 2009. The information from 2009 was used to calculate the duration between symptom onset and date of diagnosis and the response from the 2011 survey to investigate the reliability of these answers (647 patients responded to the survey in both 2009 and 2011 and were hence eligible for reliability analysis). The mean duration (years) was calculated (95% CI), both unadjusted and adjusted for sex, age and year of diagnosis. Results The overall mean duration between symptom onset and date of a SpA diagnosis was 6.8 years (95% CI: 6.3-7.3), without any obvious secular change up through 2007. The mean duration for AS was 9.0 (95% CI: 7.8-10.3), for PsA 6.0 (5.4-6.6) and USpA 7.2 (95% CI: 6.1-8.3). There was an overall good consistency between the self-assessed year of symptom start, measured in 2009 and in 2011 (ρ=0.58). However, there was a variation between subgroups, consistency being higher in AS (ρ =0.84) and lower in PsA (ρ =0.53). Conclusions The duration between symptom onset and diagnosis was longest for AS and shortest for PsA with USpA in between. Up to 2007 there was no significant trend for any decrease in such delay for any of the subgroups. References Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.3102

Annals of the Rheumatic Diseases, 2013

Arthritis & Rheumatology, 2015

Objective Rheumatoid arthritis (RA) clinical trials often exclude patients with low C-reactive pr... more Objective Rheumatoid arthritis (RA) clinical trials often exclude patients with low C-reactive protein (CRP), slowing trial enrollment. We evaluated whether RA patients with a high multi-biomarker disease activity (MBDA) score (>44) among those with low CRP (≤10 mg/L) could complement patients with CRP >10mg/L to enhance patient recruitment without affecting clinical trial outcomes. Methods We evaluated patients from the Swedish pharmacotherapy (SWEFOT) trial, which had no CRP selection criteria. Clinical outcomes were assessed after 3 months of methotrexate (MTX) monotherapy for MTX-naïve patients (N=220) and after add-on therapy from Months 3 to 12 for MTX-inadequate responder (IR) patients (N=127). Radiographic outcomes were assessed at 1 year for all patients. Within each cohort, outcomes were compared between patients with CRP ≤10 mg/L and MBDA score >44 at the start of the respective treatment interval versus those with CRP >10 mg/L. Results Patients with baseline CRP ≤10 mg/L and MBDA score >44 at baseline had comparable clinical and radiographic outcomes to those for patients with CRP>10 mg/L. This broadened definition of inclusion criteria identified an additional 24% MTX-naïve and 47% MTX-IR patients. Conclusion Patient recruitment of RA clinical trials may be substantially enhanced by using "CRP >10 mg/L and/or MBDA score >44" as an inclusion criterion, without diminishing clinical or radiographic outcomes. This article is protected by copyright. All rights reserved.

Annals of the Rheumatic Diseases, 2012

Annals of the Rheumatic Diseases

Annals of the Rheumatic Diseases, 2014

The Journal of Rheumatology, Jul 1, 2005

To investigate the risk of cardiovascular disease (CVD) in patients with rheumatoid arthritis (RA... more To investigate the risk of cardiovascular disease (CVD) in patients with rheumatoid arthritis (RA) treated with tumor necrosis factor (TNF) inhibitors, compared to a standard RA population. Patients were recruited from a regional register, which includes over 90% of patients with RA started on TNF blockers in 1999 or later, and a local community based cohort of RA patients, established in 1997. Of a total of 983 patients in the combined cohort, 531 received treatment with etanercept or infliximab during the study period. The total cohort (n = 983) was linked with national registers for inpatient care and cause of death through December 31, 2001. CVD was defined as the first inpatient care or death from CVD without inpatient care for CVD prior to study entry. First CVD events in those treated versus not treated with TNF blockers were estimated, using age and sex adjusted incidence density computations with treatment and disease severity markers as time-dependent covariates. In the anti-TNF-treated patients, the age-sex adjusted incidence rate of first CVD event was 14.0/1000 person-years at risk (95% CI 5.7-22.4), compared with 35.4/1000 person-years (95% CI 16.5-54.4) in those not treated. Controlling for disability, the age-sex adjusted rate ratio was 0.46 (95% CI 0.25-0.85, p = 0.013) in anti-TNF-treated versus not treated. These findings suggest that the risk of developing CVD is lower in patients with RA treated with TNF blockers. This is compatible with the hypothesis that inflammation contributes to the development of cardiovascular events.

Annals of the Rheumatic Diseases, 2013

To study 21st century trends in healthcare utilisation by patients with rheumatoid arthritis (RA)... more To study 21st century trends in healthcare utilisation by patients with rheumatoid arthritis (RA) compared with the general population. Observational cohort study. Using Swedish healthcare register data, we identified 3977 Region Skåne residents (mean age in 2001, 62.7 years; 73% women) presenting with RA (International Classification of Diseases-10 codes M05 or M06) in 1998-2001. We randomly sampled two referents from the general population per RA patient matched for age, sex and area of residence. We calculated the year 2001-2010 trends for the annual ratio (RA cohort/referents) of the mean number of hospitalisations and outpatient clinic visits. By the end of the 10-year period, 62% of patients and 74% of referents were still alive and resident in the region. From 2001 to 2010, the ratio (RA cohort/referents) of the mean number of hospitalisations for men and women decreased by 27% (p=0.01) and 28% (p=0.004), respectively. The corresponding decrease was 29% (p=0.005) and 16% (p=0.004) for outpatient physician care, 34% (p=0.009) and 18% (p=0.01) for nurse visits, and 34% (p=0.01) and 28% (p=0.004) for physiotherapy. The absolute reduction in number of hospitalisations was from an annual mean of 0.79 to 0.69 in male patients and from 0.71 to 0.59 in female patients. The corresponding annual mean number of consultations in outpatient physician care by male and female RA patients changed from 9.2 to 7.7 and from 9.9 to 8.7, respectively. During the first decade of the 21st century, coinciding with increasing use of earlier and more active RA treatment including biological treatment, overall inpatient and outpatient healthcare utilisation by a cohort of patients with RA decreased relative to the general population.

Rheumatology International, 2014

Socioeconomic status could potentially impact on which type of rheumatic diagnosis a patient rece... more Socioeconomic status could potentially impact on which type of rheumatic diagnosis a patient receives. We determined whether different socioeconomic status is a risk factor for being diagnosed with spondyloarthritis (SpA) or chronic pain. In a nested case-control study, we identified two sets of adult cases diagnosed with (i) SpA (n = 1,194) and (ii) chronic pain (n = 3,730) during 2010-2012 in Skåne region, Sweden. We randomly sampled controls matched for age and sex. Level of education, marital status, and income were identified in national registers 4 years before inclusion. We also studied health-care utilization, prescribed pharmaceuticals, and work status. We used conditional logistic regressions and included socioeconomic variables and geographic area in the models. Low (odds ratio [OR] 1.69 95 % CI 1.50-1.91) or moderate education (OR 1.43 95 % CI 1.30-1.57), and low (OR 1.40 95 % CI 1.25-1.57) or moderate income (OR 1.24 95 % CI 1.10-1.38) were associated with a chronic pain diagnosis. For a SpA diagnosis, moderate income (OR 1.25 95 % CI 1.04-1.50) was the only significant factor identified. Both case groups had a larger proportion that did not work (P < 0.001), used more health care (P < 0.001), and were more frequently prescribed NSAIDs (P < 0.001) 4 years before diagnosis than controls. We confirmed that lower levels of education and income are associated with a chronic pain diagnosis. This association may reflect a true higher incidence of chronic pain and/or increased consultation propensity for such pain in people with socioeconomic status. We found no such association for SpA.

Annals of the Rheumatic Diseases, 2005

Scandinavian Journal of Rheumatology

The aim of this study was to ascertain the prevalence of rheumatoid arthritis (RA) in a Swedish g... more The aim of this study was to ascertain the prevalence of rheumatoid arthritis (RA) in a Swedish general adult population. A questionnaire about chronic pain was mailed to a total of 3928 subjects who were chosen as a random sample of the population in two communities in the county of Halland. All persons answering affirmatively to questions intended to identify patients with RA were invited to a clinical examination. X-rays of hands and feet, and analyses of rheumatoid factor and C reactive protein were performed provided that the patients fulfilled two or more of the five clinical items of the 1987 ARA criteria. Furthermore, non-participants were searched for in a patient register and in medical records from the local rheumatology unit in an attempt to identify further cases. Using the modified 1987 ARA criteria for population studies the prevalence rate of RA was calculated to 0.51% (95%, CI = 0.31-0.79).

Annals of the Rheumatic Diseases, 2013

ABSTRACT Background Extra-articular rheumatoid arthritis (ExRA) manifestations are associated wit... more ABSTRACT Background Extra-articular rheumatoid arthritis (ExRA) manifestations are associated with increased comorbidity and premature mortality. While tumour necrosis factor (TNF)-inhibitors efficiently reduce arthritis, their impact on the risk of ExRA is still uncertain. Objectives To evaluate whether treatment with TNF-inhibitors has any effect on the risk of developing severe ExRA, and to investigate potential predictors of ExRA in baseline questionnaire data obtained at the beginning of the study period. Methods A community based sample of patients with rheumatoid arthritis (RA) (n=1016), established in 1997, was studied. Clinical records were reviewed from 1 January 2005 to 31 December 2011 and cases with new onset of severe ExRA (i.e. pericarditis, pleuritis, vasculitis, interstitial lung disease, neuropathy, episcleritis/scleritis, Felty’s syndrome and glomerulonephritis), classified according to predefined criteria, were added to cases found in a previous survey 1. Information on exposure to TNF-inhibitors during the study period was obtained from the South Swedish Arthritis Treatment Group (SSATG) register. Exposure to TNF-inhibitors was treated in a time dependent fashion, and person-years at risk (pyr) were appointed to the appropriate category of exposed or unexposed time. The incidence of ExRA in exposed patients was compared to incidence in unexposed patients. In addition, in 1997 all patients received a questionnaire including the Health Assessment Questionnaire (HAQ), visual analogue scales (VAS) for current pain and global health and questions on current and previous pharmacologic treatment. Cox regression analysis models were used to assess the impact of baseline characteristics and baseline disease severity measures on the risk of ExRA. Results During treatment with TNF-inhibitors there were 9 patients with new onset of ExRA in 1226 pyr [0.73/100 pyr, 95% confidence interval (CI) 0.34-1.4] compared to 72 in 8320 pyr [0.87/100 pyr, 95% CI 0.68-1.1] in patients without TNF-inhibitors. The relative risk comparing those treated to those not treated was 0.85 (95% CI 0.37-1.7). Male gender [age adjusted hazard ratio (HR) 1.88, 95% CI 1.20-2.93], long duration of disease [age and sex adjusted HR (per year) 1.03, 95% CI 1.01-1.05] and greater disability, measured by HAQ [age and sex adjusted HR (per unit) 1.38, 95% CI 1.00-1.90] at baseline were predictors for ExRA. Conclusions TNF-inhibitors did not have any major effect on the incidence of severe ExRA in this sample. However, the assessment of the impact of treatment on ExRA may be influenced by the association between ExRA and severe, longstanding disease. References Disclosure of Interest None Declared

of cartilage oligomeric matrix protein (COMP) into joint tluid after knee injury and in osteoarth... more of cartilage oligomeric matrix protein (COMP) into joint tluid after knee injury and in osteoarthritis. Ann Rheum Dis 1994; 53: 8-13. Morgeh M, Heineglrd D, Engel J, Paulsson zyxwvut M. Electron microcopy of native cartilage oligomeric matrix protein purified from the Swarm Rat Chondrosarcoma reveals a five-armed structure. J Biol Chem 1992; 267: 613741. Paulsson M, Heinegdrd D. Radioimmunoassay of the 148kilodalton cartilage protein. Distribution of the protein among bovine tissue. Biochem J 1982; 207: 207-13. Saxne T, Heinegird D. Cartilage oligomeric matrix protein: a novel marker of cartilage turnover detectable in synovi-a1 fluid and blood. Br J Rheumatol 1992; 3 1 : 583-91.

The Journal of Rheumatology

To investigate the risk of cardiovascular disease (CVD) in patients with rheumatoid arthritis (RA... more To investigate the risk of cardiovascular disease (CVD) in patients with rheumatoid arthritis (RA) treated with tumor necrosis factor (TNF) inhibitors, compared to a standard RA population. Patients were recruited from a regional register, which includes over 90% of patients with RA started on TNF blockers in 1999 or later, and a local community based cohort of RA patients, established in 1997. Of a total of 983 patients in the combined cohort, 531 received treatment with etanercept or infliximab during the study period. The total cohort (n = 983) was linked with national registers for inpatient care and cause of death through December 31, 2001. CVD was defined as the first inpatient care or death from CVD without inpatient care for CVD prior to study entry. First CVD events in those treated versus not treated with TNF blockers were estimated, using age and sex adjusted incidence density computations with treatment and disease severity markers as time-dependent covariates. In the an...

BMC Musculoskeletal Disorders

Annals of the Rheumatic Diseases, 2013

ABSTRACT Background Adding infliximab (IFX) or sulfasalazine+hydroxychloroquine (SSZ+HCQ) to meth... more ABSTRACT Background Adding infliximab (IFX) or sulfasalazine+hydroxychloroquine (SSZ+HCQ) to methotrexate (MTX) in patients with active, early rheumatoid arthritis (RA), resulted in superior radiographic outcome in the IFX group,[1] while disease-activity, utility and work loss improved in both arms, without detectable between-group differences at 21 months[1-3]. Objectives To evaluate the cost-effectiveness of biologic vs. conventional combination treatment in early RA-patients responding insufficiently to MTX. Methods This multicenter, randomised, controlled, open-label trial enrolled RA-patients (symptoms<1y) in Sweden between 2002 and 2005. After 3-4 months of MTX monotherapy, patients with a remaining DAS28>3.2 were randomised to addition of IFX or SSZ+HCQ. The incremental cost-effectiveness ratio (ICER=€/quality-adjusted life-year [QALY]) was assessed during 21 months from randomisation. Costs of RA-related medications, non-primary healthcare utilisation and work loss were retrieved from nationwide registers, while EuroQol 5-Dimensions utility was collected quarterly. Undiscounted analyses including all patients were performed from the societal (human capital method) and healthcare perspectives. Confidence intervals were estimated by non-parametric bootstrapping. Results Of 487 patients initially enrolled, 128 and 130 were randomised to biologic and conventional treatment, respectively. The biologic group had higher drug and healthcare costs (€27,487 vs. 10,364; adjusted mean difference 16,956 [95%CI 14,647;19,162]), while no difference was seen in productivity losses (€33,804 vs. 29,220; 3,961 [-3,986;11,850]), resulting in higher societal cost, as compared to the conventional treatment arm (€61,291 vs. 39,584; 20,916 [12,800;28,660]). Mean accumulated QALYs were 1.10 in the biologic and 1.12 in the conventional treatment group (adjusted mean difference 0.01 [95%CI -0.07;0.08]). The resulting ICER, comparing the biologic to the conventional treatment option, was €2,404,197/QALY from the societal (Figure), and €1,948,919/QALY from the healthcare perspective. Conclusions In early MTX-refractory RA, the addition of IFX, as compared to addition of SSZ+HCQ, was not cost-effective over 21 months at willingness to pay levels generally considered acceptable. References References Disclosure of Interest None Declared

Fatigue is common after stroke and contributes to disability, impaired quality of life, and reduc... more Fatigue is common after stroke and contributes to disability, impaired quality of life, and reduced work ability. Currently, there is no evidence-based intervention for post-stroke fatigue but idiopathic chronic fatigue and burnt-out syndromes may benefit from nature-based rehabilitation. The aim of NASTRU was to examine whether ten weeks of nature-based rehabilitation, as add-on to standard management, could influence post-stroke fatigue (primary outcome), depression, work ability or functional outcome (secondary outcomes), compared to controls. Inclusion criteria were patients with stroke living in the catchment area of the Skåne University Hospital, 50-80 years old, independent in ADL, and reporting fatigue at 3 months (sub-acute subgroup) or > one year (chronic subgroup) after the index stroke. Patients randomized to the intervention underwent a rehabilitation program in groups up to 8 patients in an especially designed garden at the Swedish University of Agricultural Science...

Annals of the Rheumatic Diseases, 2014

ABSTRACT Background The delay of diagnosis after symptom onset for various subgroups of spondyloa... more ABSTRACT Background The delay of diagnosis after symptom onset for various subgroups of spondyloarthritis (SpA) is considerable. Increasing focus on this over the last decades may have decreased this delay (1-2). Objectives To study the duration between symptom onset and date of diagnosis of SpA and its subgroups: ankylosing spondylitis (AS), psoriatic arthritis (PsA), and unspecified spondyloarthritis (USpA). A special focus was to study the change over the past decade. Methods The Swedish SpAScania cohort (N=5,771, = all patients diagnosed with SpA between 2003 and 2007 in primary or secondary care in the Skåne region, total n=1.3 million 2013) was used. We analyzed patients (n=952) identified as having AS (n=173), PsA (n=579) or USpA (n=200) by a rheumatologist or internist at least one time or by any other physician twice during 2003 to 2007 responding to a postal survey in 2009 and 2011. The survey included questions on years for start of symptoms and diagnosis. All patients included had a self-reported diagnosis of SpA between 1997 and 2007 in the survey 2009. The information from 2009 was used to calculate the duration between symptom onset and date of diagnosis and the response from the 2011 survey to investigate the reliability of these answers (647 patients responded to the survey in both 2009 and 2011 and were hence eligible for reliability analysis). The mean duration (years) was calculated (95% CI), both unadjusted and adjusted for sex, age and year of diagnosis. Results The overall mean duration between symptom onset and date of a SpA diagnosis was 6.8 years (95% CI: 6.3-7.3), without any obvious secular change up through 2007. The mean duration for AS was 9.0 (95% CI: 7.8-10.3), for PsA 6.0 (5.4-6.6) and USpA 7.2 (95% CI: 6.1-8.3). There was an overall good consistency between the self-assessed year of symptom start, measured in 2009 and in 2011 (ρ=0.58). However, there was a variation between subgroups, consistency being higher in AS (ρ =0.84) and lower in PsA (ρ =0.53). Conclusions The duration between symptom onset and diagnosis was longest for AS and shortest for PsA with USpA in between. Up to 2007 there was no significant trend for any decrease in such delay for any of the subgroups. References Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.3102

Annals of the Rheumatic Diseases, 2013

Arthritis & Rheumatology, 2015

Objective Rheumatoid arthritis (RA) clinical trials often exclude patients with low C-reactive pr... more Objective Rheumatoid arthritis (RA) clinical trials often exclude patients with low C-reactive protein (CRP), slowing trial enrollment. We evaluated whether RA patients with a high multi-biomarker disease activity (MBDA) score (>44) among those with low CRP (≤10 mg/L) could complement patients with CRP >10mg/L to enhance patient recruitment without affecting clinical trial outcomes. Methods We evaluated patients from the Swedish pharmacotherapy (SWEFOT) trial, which had no CRP selection criteria. Clinical outcomes were assessed after 3 months of methotrexate (MTX) monotherapy for MTX-naïve patients (N=220) and after add-on therapy from Months 3 to 12 for MTX-inadequate responder (IR) patients (N=127). Radiographic outcomes were assessed at 1 year for all patients. Within each cohort, outcomes were compared between patients with CRP ≤10 mg/L and MBDA score >44 at the start of the respective treatment interval versus those with CRP >10 mg/L. Results Patients with baseline CRP ≤10 mg/L and MBDA score >44 at baseline had comparable clinical and radiographic outcomes to those for patients with CRP>10 mg/L. This broadened definition of inclusion criteria identified an additional 24% MTX-naïve and 47% MTX-IR patients. Conclusion Patient recruitment of RA clinical trials may be substantially enhanced by using "CRP >10 mg/L and/or MBDA score >44" as an inclusion criterion, without diminishing clinical or radiographic outcomes. This article is protected by copyright. All rights reserved.

Annals of the Rheumatic Diseases, 2012

Annals of the Rheumatic Diseases

Annals of the Rheumatic Diseases, 2014