Identical and Nonidentical Twins: Risk and Factors Involved in Development of Islet Autoimmunity and Type 1 Diabetes

OBJECTIVE

There are variable reports of risk of concordance for progression to islet autoantibodies and type 1 diabetes in identical twins after one twin is diagnosed. We examined development of positive autoantibodies and type 1 diabetes and the effects of genetic factors and common environment on autoantibody positivity in identical twins, nonidentical twins, and full siblings.

RESEARCH DESIGN AND METHODS

Subjects from the TrialNet Pathway to Prevention Study (N = 48,026) were screened from 2004 to 2015 for islet autoantibodies (GAD antibody [GADA], insulinoma-associated antigen 2 [IA-2A], and autoantibodies against insulin [IAA]). Of these subjects, 17,226 (157 identical twins, 283 nonidentical twins, and 16,786 full siblings) were followed for autoantibody positivity or type 1 diabetes for a median of 2.1 years.

RESULTS

At screening, identical twins were more likely to have positive GADA, IA-2A, and IAA than nonidentical twins or full siblings (all P < 0.0001). Younger age, male sex, and genetic factors were significant factors for expression of IA-2A, IAA, one or more positive autoantibodies, and two or more positive autoantibodies (all P ≤ 0.03). Initially autoantibody-positive identical twins had a 69% risk of diabetes by 3 years compared with 1.5% for initially autoantibody-negative identical twins. In nonidentical twins, type 1 diabetes risk by 3 years was 72% for initially multiple autoantibody-positive, 13% for single autoantibody-positive, and 0% for initially autoantibody-negative nonidentical twins. Full siblings had a 3-year type 1 diabetes risk of 47% for multiple autoantibody-positive, 12% for single autoantibody-positive, and 0.5% for initially autoantibody-negative subjects.

CONCLUSIONS

Risk of type 1 diabetes at 3 years is high for initially multiple and single autoantibody-positive identical twins and multiple autoantibody-positive nonidentical twins. Genetic predisposition, age, and male sex are significant risk factors for development of positive autoantibodies in twins.

A Type 1 Diabetes Genetic Risk Score Predicts Progression of Islet Autoimmunity and Development of Type 1 Diabetes in Individuals at Risk

OBJECTIVE

We tested the ability of a type 1 diabetes (T1D) genetic risk score (GRS) to predict progression of islet autoimmunity and T1D in at-risk individuals.

RESEARCH DESIGN AND METHODS

We studied the 1,244 TrialNet Pathway to Prevention study participants (T1D patients' relatives without diabetes and with one or more positive autoantibodies) who were genotyped with Illumina ImmunoChip (median [range] age at initial autoantibody determination 11.1 years [1.2-51.8], 48% male, 80.5% non-Hispanic white, median follow-up 5.4 years). Of 291 participants with a single positive autoantibody at screening, 157 converted to multiple autoantibody positivity and 55 developed diabetes. Of 953 participants with multiple positive autoantibodies at screening, 419 developed diabetes. We calculated the T1D GRS from 30 T1D-associated single nucleotide polymorphisms. We used multivariable Cox regression models, time-dependent receiver operating characteristic curves, and area under the curve (AUC) measures to evaluate prognostic utility of T1D GRS, age, sex, Diabetes Prevention Trial-Type 1 (DPT-1) Risk Score, positive autoantibody number or type, HLA DR3/DR4-DQ8 status, and race/ethnicity. We used recursive partitioning analyses to identify cut points in continuous variables.

RESULTS

Higher T1D GRS significantly increased the rate of progression to T1D adjusting for DPT-1 Risk Score, age, number of positive autoantibodies, sex, and ethnicity (hazard ratio [HR] 1.29 for a 0.05 increase, 95% CI 1.06-1.6; P = 0.011). Progression to T1D was best predicted by a combined model with GRS, number of positive autoantibodies, DPT-1 Risk Score, and age (7-year time-integrated AUC = 0.79, 5-year AUC = 0.73). Higher GRS was significantly associated with increased progression rate from single to multiple positive autoantibodies after adjusting for age, autoantibody type, ethnicity, and sex (HR 2.27 for GRS >0.295, 95% CI 1.47-3.51; P = 0.0002).

CONCLUSIONS

The T1D GRS independently predicts progression to T1D and improves prediction along T1D stages in autoantibody-positive relatives.

Gender differences in tuberculosis diagnosis, treatment and outcomes in Victoria, Australia, 2002–2015

BACKGROUND: Gender has a significant impact on tuberculosis (TB) diagnosis and outcomes in many settings worldwide. We explored gender differences in Victoria, Australia, a low-incidence setting.METHODS: Retrospective cohort study: 2002–2015. Gender was included as an independent variable in multivariate statistical analyses assessing TB management.RESULTS: There were 2655 (54.5%) males and 2212 (45.5%) females notified (male:female ratio = 1.2:1). Among cases with pulmonary involvement, males underwent a chest X-ray or CT scan (CXR) sooner (hazard ratio [HR] 1.2, 95%CI 1.04–1.31, P = 0.010), began treatment sooner after presentation (HR 1.2, 95%CI 1.08–1.34, P = 0.001) and were more likely to have a sputum smear sample performed (OR 1.3, 95%CI 1.01–1.55, P = 0.037). Male cases with extra-pulmonary TB sought health care sooner after symptom onset (HR 1.3, 95%CI 1.03–1.58, P = 0.024) and were more likely to have an abnormal CXR (OR 1.9, 95%CI 1.54–2.32, P < 0.001). Males were more likely to die before or during treatment (OR 1.5, 95%CI 1.06–2.11, P = 0.024).CONCLUSIONS: Women experienced small delays in management compared with men, with no obvious detriment to assessment results or treatment outcomes. Differences were consistent with the hypothesis that males manifest more severe disease at presentation, which could be related to a range of biological and social factors.

Mortality among tuberculosis cases in Victoria, 2002-2013: case fatality and factors associated with death

SETTING

The state of Victoria, Australia, is an industrialised setting with low tuberculosis (TB) incidence, universal health care and high levels of migration.

OBJECTIVE

To assess case fatality rates (CFRs) and factors associated with death in a cohort of TB cases notified between 2002 and 2013.

DESIGN

Retrospective cohort study. Cases who died untreated or during treatment were reviewed to determine whether TB was a primary cause of, contributed to or was unrelated to death. Descriptive and multivariate analyses were used to compare demographic, clinical and pathological characteristics.

RESULTS

Of 3956 cases, 198 (5.0%) died of any cause. TB was the primary cause of death in 99 cases (50.3%) and contributed to death in a further 34 cases, giving a TB-related CFR of 3.4%. In multivariate analysis, TB-related mortality reduced over time, and was positively associated with male sex, older age, history of substance use and disseminated or meningeal TB. Factors associated with survival included having a history of past travel to or residence in a high TB risk country, lymph node TB or extra-pulmonary TB manifestations, excluding meningeal, genitourinary, pleural and lymphnode TB.

CONCLUSIONS

TB CFRs in this setting are among the lowest reported globally. TB mortality steadily decreased from 2002 to 2013.

Quantitative Radio-Isotope Scanning of the Sacroiliac Joints in Ankylosing Spondylitis

A method for applying 99mTc-MDP for dynamic and static quantitative radioisotope scanning (QRS) of the sacroiliac joints (SI) in early progressive sacroiliitis in ankylosing spondylitis (AS) is described. In a prospective study, 2 groups of male AS patients were investigated, one with increased elevated erythrocytic sedimentation rate (ESR) (group A, n = 7) and one with normal ESR (group B, n = 8). In both groups an increased uptake of the radiotracer was found in the static part of the study versus a control group C (n = 9). An increased uptake versus group C was also found for group A in the dynamic part of the study (p = 0.01) while there was no significant difference dynamically between groups B and C. The results of the dynamic study in group A indicate ESR to be a parameter of inflammatory activity in the SI joints. The study also seems to indicate QRS to be a valuable diagnostic method in early AS without definite radiographic changes in the SI joints.

Interobserver Variability in the Radiographic Diagnosis of Adult Outpatient Pneumonia

Acute chest radiographs were obtained from 319 adult patients with acute respiratory infections. Where a lower respiratory infection was diagnosed, follow-up chest radiographs were obtained in most patients. A radiologic panel diagnosed pneumonia in 21 patients. The agreements between the panel and 3 independent interpreters, 2 residents in radiology, and one senior chest physician, were assessed. Also the reports given by the specialist in radiology at the Department of Radiology were compared with the panel's evaluation. While the kappa-agreements between the panel's interpretations and those by the Department of Radiology and the consultant in chest medicine was 0.71 and 0.72, respectively, the corresponding kappa-values between the residents and the panel was only 0.50. The proportion of agreement when pneumonia was diagnosed was 0.56 between the panel and the Department of Radiology, and 0.59 between the panel and the chest consultant, compared to 0.36 between the panel and the residents. The study demonstrates the difficulty of diagnosing outpatient pneumonia and the importance of experience.

Contrast-enhanced dynamic magnetic resonance imaging of finger joints in osteoarthritis and rheumatoid arthritis: an analysis based on pharmacokinetic modeling

PURPOSE

To investigate a two-compartment kinetic model applied to the dynamic time course of contrast enhancement as a method to differentiate between finger-joint synovitis in established osteoarthritis (OA) and rheumatoid arthritis (RA).

MATERIAL AND METHODS

Dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) of one hand in 19 patients and six healthy volunteers was undertaken. Eight patients had OA of the hand and eleven patients had RA. From the signal intensity curves, the three parameters Kps (endothelial transfer constant), Kep (elimination rate constant from extracellular space back to plasma) and Kel (elimination rate constant from plasma by renal excretion) were calculated.

RESULTS

The rate constant Kps showed the best separation between the groups with significantly higher values in the RA group compared to the OA group (P<0.005) and in the OA group compared to the control group (P<0.005). Significantly higher values of Kep were also found in the RA group compared with the OA group (P<0.005).

CONCLUSION

DCE-MRI may provide useful information that can help differentiate synovitis in OA from synovitis in RA.

Using artificial evolution and selection to model insect navigation

BACKGROUND

An animal's behavioral strategies are often constrained by its evolutionary history and the resources available to it. Artificial evolution allows one to manipulate such constraints and explore how they influence evolved strategies. Here we compare the navigational strategies of flying insects with those of artificially evolved "animats" endowed with various motor architectures. Using evolutionary algorithms, we generated artificial neural networks that controlled a virtual animat's navigation within a 2D, simulated world. Like a flying insect, the animat possessed motors that generated thrust and torque, a compass, and visual sensors. Some animats were limited to forward motion, while others could also move sideways. Animats were selected for the precision with which they reached a target specified by a visual landmark.

RESULTS

Animats given sideways motors could alter flight direction without changing body orientation and evolved strategies similar to those of flying bees or wasps performing the same task. Both animats and insects first aimed at the landmark. In the last phase, both adopted a fixed body orientation and adjusted their position to keep the landmark at a fixed retinal location. Animats unable to uncouple flight direction and body orientation evolved subtly different strategies and performed less robustly.

CONCLUSIONS

This convergence between the navigational strategies of animals and animats suggests that the insect's strategies are primarily an adaptation to the demands of using visual information and compass direction to reach a position in space and that they are not significantly compromised by the insect's evolutionary history.

Dynamic MR-imaging in the diagnosis of pigmented villonodular synovitis of the knee

The aim of this report was to study the rate of contrast enhancement at MRI in pigmented villonodular synovitis (PVNS). Dynamic MRI was performed in a patient with PVNS just before and 1 week and 3 years following synovectomy of the knee. As opposed to patients with rheumatic disease the patient with PVNS showed a slower enhancement rate before synovectomy than 1 week after. At 3 years follow-up the patient with PVNS showed an enhancement rate just above that of the normal controls. The results indicate that PVNS has features more common to hyperplastic or neoplastic lesions than to inflammatory ones. The results at 3 years follow-up also suggest that dynamic MRI may indicate the efficacy of arthroscopic synovectomy.

Oscillating expression of c-Hey2 in the presomitic mesoderm suggests that the segmentation clock may use combinatorial signaling through multiple interacting bHLH factors

Vertebrate somitogenesis comprises the generation of a temporal periodicity, the establishment of anteroposterior compartment identity, and the translation of the temporal periodicity into the metameric pattern of somites. Molecular players at each of these steps are beginning to be identified. Especially, members of the Notch signaling cascade appear to be involved in setting up the somitogenesis clock and subsequent events. We had previously demonstrated specific expression of the mHey1 and mHey2 basic helix-loop-helix (bHLH) factors during somitogenesis. Here we show that perturbed Notch signaling in Dll1 and Notch1 knockout mutants affects this expression in the presomitic mesoderm (PSM) and the somites. In the caudal PSM, however, mHey2 expression is maintained and thus is likely to be independent of Notch signaling. Furthermore, we analysed the dynamic expression of the respective chicken c-Hey1 and c-Hey2 genes during somitogenesis. Not only is c-Hey2 rhythmically expressed across the chicken presomitic mesoderm like c-hairy1, but its transcription is similarly independent of de novo protein synthesis. In contrast, the dynamic expression of c-Hey1 is restricted to the anterior segmental plate. Both c-Hey genes are coexpressed with c-hairy1 in the posterior somite half. Further in vitro and in vivo interaction assays demonstrated direct homo- and heterodimerisation between these hairy-related bHLH proteins, suggesting a combinatorial action in both the generation of a temporal periodicity and the anterior-posterior somite compartmentalisation.

Differential patterning of ventral midline cells by axial mesoderm is regulated by BMP7 and chordin

Ventral midline cells in the neural tube have distinct properties at different rostrocaudal levels, apparently in response to differential signalling by axial mesoderm. Floor plate cells are induced by sonic hedgehog (SHH) secreted from the notochord whereas ventral midline cells of the rostral diencephalon (RDVM cells) appear to be induced by the dual actions of SHH and bone morphogenetic protein 7 (BMP7) from prechordal mesoderm. We have examined the cellular and molecular events that govern the program of differentiation of RDVM cells under the influence of the axial mesoderm. By fate mapping, we show that prospective RDVM cells migrate rostrally within the neural plate, passing over rostral notochord before establishing register with prechordal mesoderm at stage 7. Despite the co-expression of SHH and BMP7 by rostral notochord, prospective RDVM cells appear to be specified initially as caudal ventral midline neurectodermal cells and to acquire RDVM properties only at stage 7. We provide evidence that the signalling properties of axial mesoderm over this period are regulated by the BMP antagonist, chordin. Chordin is expressed throughout the axial mesoderm as it extends, but is downregulated in prechordal mesoderm coincident with the onset of RDVM cell differentiation. Addition of chordin to conjugate explant cultures of prechordal mesoderm and neural tissue prevents the rostralization of ventral midline cells by prechordal mesoderm. Chordin may thus act to refine the patterning of the ventral midline along the rostrocaudal axis.

[The chemical working environment among car painters in Bergen]

Official guidelines have been prepared for the working environment in Norwegian spraylacquering garages, in order to reduce the incidence of symptoms and diseases related to exposure to organic solvents. 11 garages were visited to see if the guidelines were being followed. All the sprayers (n = 28) were examined by questionnaire about the occurrence of acute symptoms connected to the central nervous system, the skin, the eyes and the airways during work, and about their use of personal protective equipment. All the garages had specially ventilated rooms for the lacquering procedure, and all the workers used personal respiratory protective equipment. The sprayers did not report more acute symptoms than a control group of office workers employed in the same companies.

The prevalence of ankylosing spondylitis among Norwegian Samis (Lapps)

A population survey of the Sami (Lapp) population of the municipalities Karasjok and Kautokeino in north Norway revealed a prevalence of ankylosing spondylitis (AS) according to the New York criteria of 1.8%. Eleven cases of AS were found, 7 men and 4 women. Only 4 of the 11 observed cases of AS were aware of the diagnosis of AS prior to the survey. Ten of 11 patients with AS possessed HLA-B27 (91%) which is found in 24% of the general Sami population in this area. It was calculated that 6.8% of B27 positive persons had AS.

Diagnosis of pneumonia in adults in general practice. Relative importance of typical symptoms and abnormal chest signs evaluated against a radiographic reference standard

The diagnostic value of typical symptoms and abnormal chest signs for pneumonia have been evaluated against a radiographic reference standard in 402 adult patients with respiratory tract infection in general practice. Pneumonia was diagnosed in 20 patients by a positive chest radiograph. The doctors diagnosed pneumonia in seven of these on the basis of history and physical examination alone, and in addition in 22 patients with normal radiographs. The diagnostic value of the typical symptoms cough, chest pain, and dyspnoea, reported by the patients on a questionnaire, increased with increasing intensity of the symptoms, and both "very annoying lateral chest pain" and "very annoying dyspnoea" had likelihood ratios (LR) between 4 and 5. The LR of crackles was 3.7. When evaluated against the doctor's clinical diagnosis of pneumonia as reference standard, crackles achieved an LR of 14.8, while the typical symptoms achieved lower LRs than when evaluated against the radiographic reference standard. These discrepancies, which were confirmed by logistic regression, indicate that crackles and other abnormal chest findings are interpreted too frequently as features of pneumonia and that the importance of typical symptoms is underestimated in the diagnosis of pneumonia.

Quantitative radio-isotope scanning of the sacroiliac joints in ankylosing spondylitis

A method for applying 99mTc-MDP for dynamic and static quantitative radioisotope scanning (QRS) of the sacroiliac joints (SI) in early progressive sacroiliitis in ankylosing spondylitis (AS) is described. In a prospective study, 2 groups of male AS patients were investigated, one with increased elevated erythrocytic sedimentation rate (ESR) (group A, n = 7) and one with normal ESR (group B, n = 8). In both groups an increased uptake of the radiotracer was found in the static part of the study versus a control group C (n = 9). An increased uptake versus group C was also found for group A in the dynamic part of the study (p = 0.01) while there was no significant difference dynamically between groups B and C. The results of the dynamic study in group A indicate ESR to be a parameter of inflammatory activity in the SI joints. The study also seems to indicate QRS to be a valuable diagnostic method in early AS without definite radiographic changes in the SI joints.

Interobserver variability in the radiographic diagnosis of adult outpatient pneumonia

Acute chest radiographs were obtained from 319 adult patients with acute respiratory infections. Where a lower respiratory infection was diagnosed, follow-up chest radiographs were obtained in most patients. A radiologic panel diagnosed pneumonia in 21 patients. The agreements between the panel and 3 independent interpreters, 2 residents in radiology, and one senior chest physician, were assessed. Also the reports given by the specialist in radiology at the Department of Radiology were compared with the panel's evaluation. While the kappa-agreements between the panel's interpretations and those by the Department of Radiology and the consultant in chest medicine was 0.71 and 0.72, respectively, the corresponding kappa-values between the residents and the panel was only 0.50. The proportion of agreement when pneumonia was diagnosed was 0.56 between the panel and the Department of Radiology, and 0.59 between the panel and the chest consultant, compared to 0.36 between the panel and the residents. The study demonstrates the difficulty of diagnosing outpatient pneumonia and the importance of experience.

[Osteitis fibrosa cystica von Recklinghausen]

We present the case of a woman with classical osteitis fibrosa cystica generalisata von Recklinghausen, caused by a single adenoma of the left inferior parathyroid gland. After six months with increasing bone pain, pathological fractures and cystic lesions radiologically, hyperparathyroidism was diagnosed by persistent elevated levels of serum calcium, and elevated levels of PTH. Surgical extirpation of the parathyroid adenoma caused a period with severe hypocalcemia followed by complete clinical restitution. The diagnosis should be considered in any case of persistent bone pain and uncharacteristic fatigue.

Low osmolality contrast media and metabolic changes in the myocardium during free and reduced coronary flow in the dog

The authors assessed whether intracoronary injection of low osmolality contrast media induces metabolic and electrocardiographic changes consistent with myocardial ischemia in anesthetized dogs. Ioxaglate and iohexol were injected into the left main coronary artery (eight dogs) and into a carotid-coronary artery shunt (eight dogs), during free coronary flow and during 50% flow reduction. Blood samples were obtained simultaneously from a femoral artery and from a small cardiac vein draining the contrast perfused area. Contrast media had no immediate or late effects on lactate balance during free or reduced flow. Early depression of the ST segment in epicardial ECG did not reflect ischemia. The authors conclude that the two low-osmolality contrast media, iohexol and ioxaglate, did not induce ischemic changes in the myocardium.

Effects of contrast media on myocardial function during acute left ventricular failure in the dog

We studied the hemodynamic side effects of intracoronary injection of contrast media during acute ischemic heart failure by using anesthetized dogs. Induction of failure was performed by microembolization of the area supplied by the left main coronary artery. Six ml of iohexol (Omnipaque) increased contractility during the normal state, while this contrast medium induced no alterations in any of the recorded hemodynamic variables during left ventricular failure. Ioxaglate (Hexabrix) was also well tolerated during the normal state, while sodium-meglumine diatrizoate (Renografin) markedly decreased systolic variables. However, in the failing heart both ioxaglate and diatrizoate resulted in greater reduction in all systolic variables than in the normal heart. We conclude that both ionic contrast media may be harmful in acute ischemic heart failure. Non-ionic iohexol appears safer in this condition.

Radiography of the spine and sacro-iliac joints in ankylosing spondylitis and psoriasis

A grading system involving six stages of arthritis from grade 0 = normal joints to grade V = extensive bony ankylosis in the sacro-iliac joints and a scheme applicable for quantitative registration of the radiographic findings of the spine in ankylosing spondylitis (AS) are detailed. These radiographic grading systems were used in a study comprising 48 patients with psoriasis (group A), 19 patients with AS and psoriasis (group B), 103 patients with AS (group C) and 231 first-degree relatives of the patients belonging to groups B and C (group D). Radiographic abnormalities of the spine were found totally in 80 per cent of the patients belonging to groups B and C. In these groups sclerotic anterior borders of vertebrae (SABS) and/or straightened anterior surfaces of vertebrae were seen totally in 66 per cent. SABS were earlier findings than syndesmophyte formation which was found in 60 per cent of the patients belonging to groups B and C. Except for ankylosis of the apophyseal joints and ossified interspinous ligament most frequently found in the lower lumbar region in patients with duration of disease more than 20 years, all abnormalities of the spine were most frequent in the dorsolumbar junction. Grade V sacro-iliitis was associated with ankylosis of two or more segments of the spine. Such spinal changes were infrequently seen in patients with grade IV sacro-iliitis. This finding supports the previous notion that among patients fulfilling the criteria for AS, there is a group with a non-ankylosing disease. Thus two different subgroups of AS could be identified. Except for frequent unilateral sacro-iliitis and slight changes of the spine in group A no radiographic differences were found between the groups A, B and C. Sacro-iliitis was found in 22 (9%) in group D, and 11 of those with sacro-iliitis had abnormalities of the spine compatible with AS.

Radiographic evaluation of patients with Bechterew's syndrome (ankylosing spondylitis) and their first-degree relatives. Findings in the spine and sacro-iliac joints and relations to non-radiographic findings

One hundred and twenty-two hospitalized patients, 35 years or more of age with confirmed bilateral sacro-iliitis and 239 first-degree relatives, 25 years or more of age, were examined. All but 3 of the patients had confirmed ankylosing spondylitis (AS) in accordance with established criteria. The sacro-iliac joints were scored by a recently developed grading system. The prevalence of grade V sacro-iliits--extensive ankylosis--was greater in HLA B27-positive than in HLA B27-negative patients, and ankylosis of apophyseal joints, ossification of the interspinous ligament, or block vertebrae were not seen in HLA B27-negative patients. Shining corners and/or squared vertebrae were the most frequent findings of the dorsolumbar spine in patients with a disease course of less than 10 years. Mixed osteophytes were rare in patients below 40 years of age. All radiographic inflammatory changes scored in the spine-except for shining corners--were most often seen in patients with a disease history exceeding 20 years. Syndesmophytes and/or ankylosed apophyseal joints were less extensive in female than in male patients. No differences in the severity of radiographic changes in sacro-iliac joints or in frequency, severity or localization of different radiographic changes of the dorsolumbar spine were observed between HLA B27-positive patients with and those without psoriasis or acute anterior uveitis. Definite sacro-iliitis was restricted to HLA B27-positive relatives of HLA B27-positive probands and demonstrated in one-fifth of them. Shining corners and/or squared vertebrae were frequent findings in relatives with sacro-iliitis (45%), whereas apophyseal joint ankylosis, ossification of the interspinous ligament, block vertebrae and bridging syndesmophytes were not seen. Our results support the view that AS is not a defined disease entity and should be regarded as a syndrome. AS is an improper name for all patients fulfilling the Rome and/or New York criteria for definite AS, since many of them will probably never develop ankylosis of the spine or sacro-iliac joints.

Juvenile ankylosing spondylitis and HLA B27 homozygosity

Ten consecutive patients with juvenile ankylosing spondylitis were investigated in a prospective study. At least one of the parents of each patient had a positive history of probable or definite ankylosing spondylitis, Reiter's syndrome, or acute anterior uveitis. The patients and their parents were examined clinically and were HLA-typed. Nine of the 10 patients exhibited the genetic marker HLA B27, but only one patient was homozygous for HLA B27. This prevalence of homozygosity among HLA B27 positive persons could be expected to occur by chance alone. Based on the limited material studied, we cautiously conclude that HLA B27 homozygosity is probably not responsible for disease onset in childhood.

Bechterew's syndrome (ankylosing spondylitis). A syndrome with distinct subgroups

The results of tests for associations among radiographic findings of the dorsolumbar spine, peripheral joints, tendon insertions and the pubic symphysis are presented. Ankylosis of sacro-iliac joints, ankylosis of apophyseal joints, bridging syndesmophytes, ossified interspinous ligament, block vertebrae, arthritis of the pubic symphysis and new bone formation of the ischium were strongly mutually associated. They probably belong to the same subgroup of disease. Such findings were negatively associated with distal peripheral joint arthritis. Mixed osteophytes, parasyndesmophytes or shining corners (anterior spondylitis) showed associations suggesting that the etiology may be mixed. A late stage of sacro-iliitis, regressive changes, characterized by narrow joint spaces without extensive ankylosis and with minimal sclerosis (grade IV sacro-iliitis) was associated with distal peripheral joints arthritis, but negatively associated with signs of ankylosing processes of the dorsolumbar spine. On the basis of the radiographic findings, distinct subgroups of AS could be identified. These results confirm our previous results of an association pattern between clinical findings. We would also recommend that the grading system of sacro-iliitis put forward by Dale be adopted, since it turned out that this grading system often distinguished between distinct subgroups of this heterogeneous condition(s).

Radiographic evaluation of patients with Bechterew's syndrome (ankylosing spondylitis). Findings in peripheral joints, tendon insertions and the pubic symphysis and relations to non-radiographic findings

One hundred and twenty-two consecutive hospitalized patients aged 35 years or more, and with definite radiographic bilateral sacro-iliitis were re-examined. All but 3 met established criteria for definite ankylosing spondylitis (AS). All peripheral joints from 114 of these patients were radiographed, and definite arthritis in one or several joints was demonstrated in 47 (41%) of them. The distribution pattern of arthritis was generally symmetric or slightly asymmetric. Articular new bone formation was a common finding in arthritic joints. The frequency of patients with hip arthritis was low (24% including patients with hip joint replacements); possible explanations include the selection of patients examined and difficulties in distinguishing between a primary osteoarthritis and osteoarthritis secondary to arthritis in a single radiographic examination in such patients. Although the hip joints were often severely affected, with extensive new bone formation, the erosions were generally small and protrusion of the acetabulum was not seen. Arthritis of the shoulder or of the hip was associated with an early onset of AS. Arthritis in the finger joints was associated with clinical psoriasis but was also a frequent finding in HLA B27-positive patients free from this condition (23%). Arthritic changes of small joints with extensive new bone formation ('egg in shell', 'pencil in cup' or 'gull wing' appearance) were seen in patients without clinical psoriasis. New bone formation of the ischium was frequent in HLA B27-positive patients (36%), but was not seen in HLA B27-negative patients. No differences concerning the frequency or severity of different radiographic pathologic changes recorded were observed between the sexes.

Family studies in Bechterew's syndrome (ankylosing spondylitis). I. Prevalences of symptoms and signs in relatives of HLAB27 positive probands

All available adult first-degree relatives of 66 patients with HLAB27 positive ankylosing spondylitis were examined clinically and radiographically and their white blood cells were HLA typed. Ten per cent of all relatives and 20% of HLAB27 positive relatives had Bechterew's syndrome. An additional 10% had minimal radiographical changes in the sacro-iliac joints, or peripheral arthropathy. Sixteen out of 19 persons who had minimal radiographical changes in the sacro-iliac joints were HLAB27 positive. Backache was common (25% or more) in any group of relatives, and did not discriminate well between relatives with or without Bechterew's syndrome. Spine or chest stiffness should prompt examination for Bechterew's syndrome, but is an inadequate diagnostic criterion for the syndrome. Typing for HLAB27 is probably the best prognostic test, although most HLAB27 positive persons did not exhibit any objective sign of disease. Repeated radiographical examination of HLAB27 negative persons should be avoided.

Family studies in Bechterew's syndrome (ankylosing spondylitis). II. Prevalences of symptoms and signs in relatives of HLAB27 negative probands

All available adult first-degree relatives of 9 probands with HLAB27 negative ankylosing spondylitis were examined. Completion rate was 90%. Prevalences of symptoms and signs and distributions of chest and spinal mobility are presented. No secondary case of Bechterew's syndrome was found among the relatives, compared with 10% among the relatives of HLAB27 positive probands (p = 0.05). We conclude from this study and that of relatives of HLAB27 positive probands, that a HLAB27 negative relative runs a low risk of contracting Bechterew's syndrome, irrespective of the HLAB27 status of the proband.

Radiographic changes, HLA B27 and back pain in patients with psoriasis or acute anterior uveitis

Twenty-five female and 23 male consecutive patients hospitalized because of severe psoriasis, and 34 consecutive patients hospitalized because of acute anterior uveitis (AAU) were examined. Twelve of the patients with AAU (35%) and 11 of the patients with psoriasis (23%) had definite sacro-iliitis, which was unilateral in 6 (55%) of the former and in 2 (17%) of the latter. No definite radiographic differences in sacro-iliitis between HLA B27-positive and -negative patients could be detected. The radiographic changes of the dorso-lumbar junction (Th9-L2) related to the diseases, were seen only in HLA B27 positive patients with sacro-iliitis. Scattered lateral syndesmophytes were the commonest paravertebral ossifications in patients with psoriasis, whereas more diffuse and more numerous lateral mixed osteophytes appeared most frequently in AAU patients. Parasyndesmophytes were seen both in patients with psoriasis and in those with AAU. Asymptomatic sacro-iliitis was frequently found in unilateral, psoriatic sacro-iliitis (4 out of 6 patients) but was not restricted to this group. No radiographic indications of aortic valve insufficiency or apical lung fibrosis were found.

Temporomandibular joint abnormalities in rheumatoid arthritis: comparison of different radiographic methods

Transantral (infraorbital, transmaxillary) examination of the temporomandibular joint was compared with conventional transcranial examination and lateral tomography of patients with rheumatoid arthritis aged 23 to 83. Abnormalities were most frequently found at tomography, and equally frequent at transantral and transcranial examinations. The various examinations appeared to be rather supplementary. Bone erosion was frequently observed at transantral examination, which appeared to be the preferable radiographic method for detecting arthritis of this joint. Combined with transcranial examination, the method is recommended for the evaluation of temporomandibular joint abnormalities in rheumatoid arthritis if tomographic equipment is not available.

Radiographic temporomandibular joint abnormality in adults with micrognathia and juvenile rheumatoid arthritis

Radiographic findings of the upper and lower jaw bone of 20 adult patients with micrognathia, bird face, and juvenile rheumatoid arthritis are reported. In all patients a symmetrically underdeveloped mandible with the chin posteriorly positioned was found at cephalometry. Arthritic lesion of the temporomandibular joint, mostly symmetric, with limitation of movement and secondary arthrosis, was observed in all patients. Complete absence of the tubercle. Abnormal anterior position of the mandibular head occurred in almost half of the patients. The degree of mandibular growth disturbance seemed to be correlated to the severity of the arthritis, indicating the arthritis to be a causal mechanism of micrognathia.

Radiographic abnormalities of the temporomandibular joint in children with juvenile rheumatoid arthritis

Radiographic lesion of the temporomandibular joint was found in 41 of 100 children with juvenile rheumatoid arthritis using a combination of radiographic techniques. In patients with abnormality, unilateral lesion occurred in 41 per cent. In patients with definite affection, a varying degree of destructions was observed in 93 per cent, restricted translatory movement of the mandibular head in 83 per cent. In many cases dystrophic or dysplasia-like changes occurred, with stump and thick, anteriorly positioned mandibular head and flat fossa. The lesions seemed to be most frequently associated with the polyarticular type, early onset and long duration of the disease.

Radiographic evaluation of rheumatoid arthritis and related conditions by standard reference films

A review of radiographic evaluation of rheumatoid arthritis is given. Standard reference films are introduced for evaluation of rheumatoid arthritis and related conditions in the extremity joints. In this system, numerical evaluation of arthritis is given for individual joints in a patient.