The Assessment of SpondyloArthritis International Society classification criteria for peripheral spondyloarthritis and for spondyloarthritis in general

OBJECTIVE

To evaluate new classification criteria for peripheral spondyloarthritis (SpA) in patients with SpA with peripheral manifestations only.

METHODS

In this Assessment of SpondyloArthritis international Society (ASAS) study, two prespecified sets of criteria were compared against the European Spondylarthropathy Study Group (ESSG) and Amor criteria in newly referred consecutive patients with undiagnosed peripheral arthritis, and/or enthesitis, and/or dactylitis that usually began before 45 years of age. The clinical diagnosis (SpA vs no SpA) made by the ASAS rheumatologist served as reference standard.

RESULTS

In all, 24 ASAS centres included 266 patients, with a final diagnosis of SpA being made in 66.2%. After adjustments a final set of criteria showed the best balance between sensitivity (77.8%) and specificity (82.9%): arthritis and/or enthesitis and/or dactylitis plus (A) one or more of the following parameters: psoriasis, inflammatory bowel disease, preceding infection, human leucocyte antigen B27, uveitis, sacroiliitis on imaging, or (B) two or more other parameters: arthritis, enthesitis, dactylitis, inflammatory back pain in the past, family history of SpA. The new criteria performed better than modified versions of the ESSG (sensitivity 62.5%, specificity 81.1%) and the Amor criteria (sensitivity 39.8%, specificity 97.8%), particularly regarding sensitivity. In the entire ASAS population of 975 patients the combined use of ASAS criteria for axial SpA and ASAS criteria for peripheral SpA also had a better balance (sensitivity 79.5%, specificity 83.3%) than the modified ESSG (sensitivity 79.1%, specificity 68.8%) and Amor criteria (sensitivity 67.5%, specificity 86.7%), respectively.

CONCLUSIONS

The new ASAS classification criteria for peripheral SpA performed well in patients presenting with peripheral arthritis, enthesitis and/or dactylitis.

[Exsudative AMD: Regression analysis of transpupillary thermotherapy with and without intravitreal injection of triamcinolone, bevacizumab and ranibizumab]

PURPOSE

The aim of this study was to evaluate therapies for exsudative age-related macular degeneration (AMD) in a regression analysis. Transpupillary thermotherapy (TTT) with and without intravitreal injection (IVI) of triamcinolone, IVI of bevacizumab, and ranibizumab was investigated.

MATERIAL AND METHODS

413 patients with an at least 6-month control were included in this retrospective single-centre study. 209 patients were treated with TTT, 36 received TTT with IVI of triamcinolone, and 70 avastin. All subjects underwent a full ophthalmological examination including fluorescein angiography (FA) at baseline and after 1, 3 and every 6 months. All patients were re-treated immediately after FA if necessary using the same method with ophthalmological controls starting again one month after therapy. 98 patients were treated with IVI of Lucentis. Lucentis patients received an upload with three injections and entered the examination protocol thereafter. Taking into account the natural course of exsudative AMD, therapies started at an advanced stage of the disease. Main outcome measures were best corrected visual acuity (log MAR), mean defect (MD), and pattern standard deviation (PSD) in a 10° visual field threshold test. The time-dependent course was estimated by linear regression analysis and tested for significant differences by pairs. A two-tailed α = 0.05 was considered significant.

RESULTS

Linear regression analysis demonstrated a moderate loss of visual functions in each therapy. Linear regressions did not show significant differences between the therapies with regard to log MAR, MD, and PSD. Taking into account the natural course of exsudative AMD, the contemporary therapy with ranibizumab is initiated earlier than the previous therapies.

CONCLUSIONS

Linear regression analysis of an advanced stage of exsudative AMD did not reveal any significant differences between TTT with and without IVI of triamcinolone, IVI of bevacizumab, and ranibizumab in a clinical setting. As therapies are expected to be more efficious in an early stage of disease, a macula screening is recommended.

The development of Assessment of SpondyloArthritis international Society classification criteria for axial spondyloarthritis (part II): validation and final selection

OBJECTIVE

To validate and refine two sets of candidate criteria for the classification/diagnosis of axial spondyloarthritis (SpA).

METHODS

All Assessment of SpondyloArthritis international Society (ASAS) members were invited to include consecutively new patients with chronic (> or =3 months) back pain of unknown origin that began before 45 years of age. The candidate criteria were first tested in the entire cohort of 649 patients from 25 centres, and then refined in a random selection of 40% of cases and thereafter validated in the remaining 60%.

RESULTS

Upon diagnostic work-up, axial SpA was diagnosed in 60.2% of the cohort. Of these, 70% did not fulfil modified New York criteria and, therefore, were classified as having "non-radiographic" axial SpA. Refinement of the candidate criteria resulted in new ASAS classification criteria that are defined as: the presence of sacroiliitis by radiography or by magnetic resonance imaging (MRI) plus at least one SpA feature ("imaging arm") or the presence of HLA-B27 plus at least two SpA features ("clinical arm"). The sensitivity and specificity of the entire set of the new criteria were 82.9% and 84.4%, and for the imaging arm alone 66.2% and 97.3%, respectively. The specificity of the new criteria was much better than that of the European Spondylarthropathy Study Group criteria modified for MRI (sensitivity 85.1%, specificity 65.1%) and slightly better than that of the modified Amor criteria (sensitivity 82.9, specificity 77.5%).

CONCLUSION

The new ASAS classification criteria for axial SpA can reliably classify patients for clinical studies and may help rheumatologists in clinical practice in diagnosing axial SpA in those with chronic back pain.

TRIAL REGISTRATION NUMBER

NCT00328068.

Data quality of animal health records on Swiss dairy farms

High-quality data are essential for veterinary surveillance systems, and their quality can be affected by the source and the method of collection. Data recorded on farms could provide detailed information about the health of a population of animals, but the accuracy of the data recorded by farmers is uncertain. The aims of this study were to evaluate the quality of the data on animal health recorded on 97 Swiss dairy farms, to compare the quality of the data obtained by different recording systems, and to obtain baseline data on the health of the animals on the 97 farms. Data on animal health were collected from the farms for a year. Their quality was evaluated by assessing the completeness and accuracy of the recorded information, and by comparing farmers' and veterinarians' records. The quality of the data provided by the farmers was satisfactory, although electronic recording systems made it easier to trace the animals treated. The farmers tended to record more health-related events than the veterinarians, although this varied with the event considered, and some events were recorded only by the veterinarians. The farmers' attitude towards data collection was positive. Factors such as motivation, feedback, training, and simplicity and standardisation of data collection were important because they influenced the quality of the data.

[Secondary vascular disease in spondylolisthesis]

The topographic relation of the spine to the great vessels let to the expectation that spondylolisthesis may lead to mechanical irritation of the cauda equina as well as of the great vessels. The angiological examination of 223 patients with spondylolisthesis of the lumbar spine shows that the changes in the anatomy of the great vessels are less significant than expected after experiments involving artificial dislocations of the spine in cadavers. In vivo arterial function is not altered even in true spondyloptosis. Pelvic veins on the other hand show considerable compression and diminished flow in third and fourth degree spondylolisthesis of L5 over S1 as well as in second degree spondylolishtesis of L4 over L5. These patients seem to be disposed to venous disorders involving varices and thrombosis. If therefore a high venous pressure is found and a ventral fusion proposed it should be discussed to combine the procedure with a decompression of the veins.

Conversion of a CHO cell culture process from perfusion to fed-batch technology without altering product quality

During the development of a new drug product, it is a common strategy to develop a first-generation process with the aim to rapidly produce material for pre-clinical and early stage clinical trials. At a later stage of the development, a second-generation process is then introduced with the aim to supply late-stage clinical trials as well as market needs. This work was aimed at comparing the performance of two different CHO cell culture processes (perfusion and fed-batch) used for the production of a therapeutically active recombinant glycoprotein at industrial pilot-scale. The first-generation process was based on the Fibra-Cel packed-bed perfusion technology. It appeared during the development of the candidate drug that high therapeutic doses were required (>100mg per dose), and that future market demand would exceed 100 kg per year. This exceeded by far the production capacity of the first-generation process, and triggered a change of technology from a packed-bed perfusion process with limited scale-up capabilities to a fed-batch process with scale-up potential to typical bioreactor sizes of 15m(3) or more. The productivity per bioreactor unit volume (in product m(-3)year(-1)) of the fed-batch process was about 70% of the level reached with the first-generation perfusion process. However, since the packed-bed perfusion system was limited in scale (0.6m(3) maximum) compared to the volumes reached in suspension cultures (15m(3)), the fed-batch was selected as second-generation process. In fact, the overall process performance (in product year(-1)) was about 18-fold higher for the fed-batch compared to the perfusion mode. Data from perfusion and fed-batch harvests samples indicated that comparable product quality (relative abundance of monomers dimers and aggregates; N-glycan sialylation level; isoforms distribution) was obtained in both processes. To further confirm this observation, purification to homogeneity of the harvest material from both processes, followed by a complementary set of studies (e.g. full physico-chemical characterization, assessment of in vitro and in vivo bioactivity, comparative pharmacokinetics and pharmacodynamics studies in relevant species, etc.) would be required. Finally, this illustrates the need to fix the production process early during the development of a new drug product in order to minimize process conversion efforts and to shorten product development time lines.

Verletzungen des kraniozervikalen Übergangs

Injuries to the upper cervical spine (C0-C2) play a major role in surgical treatment of traumatic sequelae in the entire cervical spine. Even though the number of such operations has increased in recent years, there are no clear treatment recommendations for most types of cervical spine injuries. In view of the wide range of injury types and the correspondingly large number of treatment options, this review focuses mainly on the following types of injuries: C0 fractures, occipital condyle fractures (OCF), atlanto-occipital dislocation (AOD), atlas fractures, atlantoaxial dislocation (AAD), and axis fractures. Important aspects of the mechanisms of injury, clinical signs and symptoms, diagnostic procedures, and treatment options are discussed. Special emphasis is placed on comparatively reviewing the different treatment options discussed in the literature. A summary in table form is presented at the end of each chapter for quick reference.

Die rheumatisch bedingte Instabilität der oberen Halswirbelsäule

Rheumatic manifestation at the cervical spine occurs in more than 50% of all cases in the natural course of this disease. The first cervical manifestation takes place in the upper cervical spine. The initial involvement of the C1/C2 segment leads to atlantodental subluxation. Progressive destruction can result in vertical instability, which is characterized by cranial subluxation of the odontoid process with the danger of resulting stenosis and cervical myelopathy. The goal of diagnosis has to be the early recognition of these changes to establish an effective treatment protocol. Persistent pain, neurological deficits, and progressive radiological signs for instability are indications for operative stabilizing procedures. These procedures avoid progressive destruction and improve the prognosis regarding pain decrease, regression of neurological deficits, and life expectancy.

Fulminanter Myokardinfarkt bei einem ASA-I-Patienten nach Knieoperation in Allgemeinanästhesie

Myocardial ischemia is a major complication in the perioperative period, mostly in patients with high cardiac risks. After non-cardiac surgery myocardial infarction was observed in 5.6% of patients with coronary heart disease, the rate in patients with no cardiac diseases was 0.1-0.7%. We present the case of a 21-year-old ASA I male patient who underwent surgery to reconstruct the cruciate ligament of the knee. General anaesthesia was performed in combination with a femoral nerve block. After surgery the patient suffered from myocardial infarctions on the day of surgery and the 6th day after surgery. After resuscitation, thrombolysis and percutaneous transluminal coronary angioplasty (PTCA), an intraaortic balloon pump had to be temporarily implanted due to persistent cardiogenic shock.

[Rare pathological alterations of the upper cervical spine requiring surgical treatment]

Because of its unique anatomy, specific diseases and lesions arise in the upper cervical spine, which differ widely from the rest of the spine. During the last two decades standardised diagnostic and therapeutic algorithms have been defined for most of the craniocervical pathologies often occurring in combination with an underlying disease requiring surgical intervention as well. On the other hand there are some very rare phathological alterations: about 20% of the patients suffering from neurofibromatosis type I develop spinal deformities. These are mostly found in the thoracic and lumbar spine (dystrophic/non-dystrophic type). In rare cases the dystrophic neurofibromatosis type I involves the upper cervical spine leading to bizarre deformities endangering the spinal cord. An aggressive, timely and combined operative therapy is necessary. Patients with Down syndrome should be investigated regularly for affections of the upper cervical spine. Though only in about 1% of all patients with Down syndrome do instabilities require surgical intervention, the upper cervical spine should be screened on a regular basis, since neurological changes due to the pathognomy of the underlying disease often remain undetected for a long time. The operative therapy of the instable os odontoideum in Down syndrome follows the general principles of this pathoanatomical variation. Even though the Klippel-Feil syndrome is generally not linked with neuropathological findings, rare associated deformities of the upper cervical spine should be excluded by proper diagnostic procedures.

Ultrasonically implanted PLA suture anchors are stable in osteopenic bone

We compared the in vitro pullout strengths of a metallic screw-type suture anchor (5-mm Corkscrew) and a new ultrasonically implanted absorbable pin from cadaveric humeral heads with different bone densities. They were assessed quantitatively using microcomputed tomography. Pullout tests were done at four standardized sites and then correlated with the local bone density. The mean pullout strengths for the 5-mm Corkscrew and the 3.5-mm polylactic pin were similar in weak bone (76 +/- 24 N versus 104 +/- 46 N), intermediate quality bone (194 +/- 81 N versus 218 +/- 76 N), and strong bone (349 +/- 127 N versus 325 +/- 100 N). Pullout strength correlated with bone density for both implants (r = 0.76 and r = 0.86 for the Corkscrew and polylactic pin, respectively). The ultrasonically implanted absorbable 3.5-mm polylactic pin achieved equal pullout strength in weak bone as the larger 5-mm titanium Corkscrew. Bone density is highly variable in humeral heads and influenced the pullout strength of both implants.