Denosumab improves trabecular bone score in relationship with decrease in fracture risk of women exposed to aromatase inhibitors

PURPOSE

Trabecular bone score (TBS) is a gray-level textural metric that has shown to correlate with risk of fractures in several forms of osteoporosis. The value of TBS in predicting fractures and the effects of bone-active drugs on TBS in aromatase inhibitors (AIs)-induced osteoporosis are still largely unknown. The primary objective of this retrospective study was to assess the effects of denosumab and bisphosphonates (BPs) on TBS and vertebral fractures (VFs) in women exposed to AIs.

METHODS

241 consecutive women (median age 58 years) with early breast cancer undergoing treatment with AIs were evaluated for TBS, bone mineral density (BMD) and morphometric VFs at baseline and after 18-24 months of follow-up. During the study period, 139 women (57.7%) received denosumab 60 mg every 6 months, 53 (22.0%) BPs, whereas 49 women (20.3%) were not treated with bone-active drugs.

RESULTS

Denosumab significantly increased TBS values (from 1.270 to 1.323; P < 0.001) accompanied by a significant decrease in risk of VFs (odds ratio 0.282; P = 0.021). During treatment with BPs, TBS did not significantly change (P = 0.849) and incidence of VFs was not significantly different from women untreated with bone-active drugs (P = 0.427). In the whole population, women with incident VFs showed higher decrease in TBS vs. non-fractured women (P = 0.003), without significant differences in changes of BMD at any skeletal site.

CONCLUSIONS

TBS variation predicts fracture risk in AIs treated women. Denosumab is effective to induce early increase of TBS and reduction in risk of VFs.

Serum testosterone mirrors inflammation parameters in females hospitalized with COVID-19

BACKGROUND

While low testosterone (T) was described as a predictor of unfavorable coronavirus-disease 19 (COVID-19) outcome in men, data concerning the role of T in women with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection are scant and limited to small cohorts. This study investigated the relationship between serum T values and outcomes of COVID-19 in a large female hospitalized cohort.

METHODS

One-hundred-sixty-eight adult women (median age 77, range 18-100 years; 154 in post-menopause) hospitalized for COVID-19 were assessed for PaO2/Fio2 ratio, serum T and inflammatory parameters.

RESULTS

Median duration for hospital stay was 14.2 days (range 1-115) with overall mortality of 26% (n = 44). Subjects who died were significantly older (p < 0.001), had significantly more comorbidities (p = 0.015) and higher serum T (p = 0.040), white blood cells (p = 0.007), c-reactive protein (CRP; p < 0.001), interleukin-6 (IL-6; p < 0.001), procalcitonin (PCT; p < 0.001), lactate dehydrogenase (LDH; p = 0.001), D-dimer (p = 0.035), fibrinogen (p = 0.038) and lower serum free-triiodothyronine (FT3; p < 0.001) and luteinizing hormone (LH; p = 0.024) values. In post-menopausal women, significant associations were observed between T levels and serum CRP (rho: 0.23; p = 0.002), IL-6 (rho: 0.41; p < 0.001), LDH (rho: 0.34; p < 0.001), D-Dimer (rho: 0.21; p = 0.008), PCT (rho: 0.26; p = 0.001) and HDL cholesterol (rho:  - 0,22, p = 0.008). In multivariate regression analyses, serum T maintained the significant association with mortality after correction for age, coexistent comorbidities and serum LH and FT3, whereas it was lost after correction for inflammatory parameters.

CONCLUSION

In females, high serum T levels might be a mirror of inflammatory phenotype and worse COVID-19 course.

Hormonothérapie injectable et réduction des risques : pratiques, difficultés, santé des personnes trans en France

INTRODUCTION

Hormone therapy (HT) adherence practices among trans people are poorly studied. For a large proportion of these people, HT is administered parenterally. The unavailability of certain treatments in France, combined with poor institutional care, keeps injectors away from the health care system and encourages potentially risky injection practices. Following a significant increase in the number of trans people in its active list, the association Safe, coordinator of the remote harm reduction system in France, conducted a cross-sectional descriptive study from December 2020 to February 2021 using an anonymous self-administered online questionnaire.

PURPOSE OF RESEARCH

The objective is to better understand the profile of trans people who inject their HT and their injection practices.

RESULTS

We observed that a significant proportion of trans injectors do not benefit from professional support, either to obtain treatment or to carry out the injection. This situation can lead to certain misuses of medical supplies, such as needle sharing or reuse, which present significant health risks. This is especially true for injectors whose treatment is not legally available and who obtain it through parallel markets. This study also underlines the importance of self-support associations to accompany transition.

CONCLUSIONS

We therefore propose that a harm reduction policy adapted to the practices of trans people be implemented in order to better support this population and avoid the emergence of major health problems such as HIV infection.

Assessment of skeletal relationships in cleft palate with or without cleft lip: A cone-beam computed tomography study in a pakistani population

BACKGROUND

Understanding the different skeletal relationships in orofacial clefts by using cone-beam computed tomography (CBCT) may eventually lead to developing better diagnosis and treatment protocols for facial deformities.

AIMS

The objective of this study was to investigate the different skeletal relationships in the cleft palate with or without cleft lip (CP ± L), using CBCT scans. This is a retrospective study conducted at the Orthodontics and Oral Radiology department, CMH-Lahore medical college and Institute of dentistry. In the current study, 4,152 CBCT scans (dcm format) were collected from a radiology center in Lahore, Pakistan between February 2015 and February 2018. All CBCT scans were imported to the Romexis Viewer, version 4.4.0 (Planmeca, Finland). Data sorting was performed to identify age, sex, cleft phenotype, unilateral cleft quadrant, sagittal skeletal relationship, and facial soft tissue involvement.

MATERIALS AND METHODS

Statistics were generated, using the Chi-square test. A P value <0.05 was considered statistically significant.

RESULTS

We identified 73 cases of CP ± L in the sample. The male-to-female ratio was 1.21:1. Bilateral cleft lip and palate (BCLP) mostly affected males (60%), whereas unilateral cleft lip and palate (UCLP) mainly affected females (57.6%), with a left-side female predominance. The different cleft phenotypes do not show any statistically significant difference regarding skeletal relationships and sex (P > 0.05).

CONCLUSIONS

Skeletal class III relationships were found to be predominant in both sexes, followed by class II, and class I skeletal relationships. Henceforth, such CP ± L patients should be pre-emptively screened in early life to avoid such skeletal complications.

POS0902 RISK FACTORS FOR LUNG FUNCTION DECLINE IN SYSTEMIC SCLEROSIS INTERSTITIAL LUNG DISEASE IN A LARGE SINGLE-CENTER COHORT

Background

Systemic sclerosis associated interstitial lung disease (SSc-ILD) is the leading cause of scleroderma-related mortality.

Objectives

This work identifies factors associated with SSc-ILD decline on pulmonary function testing (PFT).

Methods

This single center cohort identified 312 patients with ILD as determined by high resolution chest. 184 patients (59% of 312) completed baseline and serial PFTs (with at least two follow-up PFTs) and were included in this analysis. Mixed linear models were fit to assess the decline in the percent predicted forced vital capacity (ppFVC) over time. Demographics, disease factors, autoantibodies, and ILD features were included in the univariate mixed linear model; those achieving a p-value <0.20 were included in the multivariable mixed linear model. Patients were followed longitudinally, with survival as an endpoint identified using the National Death Registry Index, reviewing death certificates, and hospital records.

Results

The 184 patients were an average of 53.2 [12.1] years old; the median [IQR] disease duration from the first non-Raynaud’s phenomenon symptom was 1.8 [0.7, 4.8] years. SSc subtype was diffuse in 55.4% (n=102), limited in 32.6% (n=60), overlap syndrome in 8.2% (n=15), and SSc sine scleroderma in 3.87% (n=7). Serologies were positive for anti-topoisomerase I (ATA), anti-centromere and anti-RNA polymerase III in 31.4% (n=53/169), 10.4% (16/154) and 22.9% (25/109) respectively. Mean ppFVC was 70.8 (18.9) and ppDLco 57.2 (20.8). Whole lung involvement (WLI%) of ≥20% on visual read was found in 49.3% of subjects (74/150 (49.3%)) where quantification was available. Over a median of 4.9 (2.4, 6.8) years, 21 patients (11.4%) died. The ppFVC declined a mean of 0.28/year in the overall group. There were differences in terms of ppFVC decline/year between patients who died in the first 2 years (n=10, -8.28%), 2-8 years (n=5, -3.89%), after 8 years (n=6, -1.00%), or who were still alive (n=163, -0.13%). The primary cause of death was ILD (6/21, 28.6%); those who died in the first 2 years most often died from progressive ILD (4/6, 67%). Factors significantly associated with decline in ppFVC on univariate analyses, included longer disease duration (ref. < median, P=0.0048), ATA positivity (ref. negative, P=0.0081), and WLI ≥20% (ref. 0-20%, P=0.0484). In multivariate analysis the only statistically significant variable associated with decline in ppFVC/ year was ATA positivity.

Conclusion

In a large single center cohort of SSc-ILD, ATA positivity is a risk factor for developing progressive SSc-ILD, consistent with other SSc-ILD cohorts. Stratifying patients by survival demonstrates that lung function declines dramatically in those who died within 2 years, whose main cause of death was progressive ILD. These data support the growing need to identify risk factors for disease severity and risk for progression, and to target intervention in patients most likely to develop progressive SSc-ILD1,2.

References

[1]Roofeh D, Lin CJF, Goldin JG, et al. Tocilizumab Prevents Progression of Early Systemic Sclerosis Associated Interstitial Lung Disease. Arthritis Rheum. 2021

[2]Roofeh D, Lescoat A, Khanna D. Treatment for systemic sclerosis-associated interstitial lung disease. Curr Opin Rheumatol. 2021

Disclosure of Interests

None declared

Clinical characteristics, visceral involvement, and mortality in at-risk or early diffuse systemic sclerosis: a longitudinal analysis of an observational prospective multicenter US cohort

BACKGROUND

Early diffuse cutaneous systemic sclerosis (dcSSc) has the highest case fatality among rheumatic diseases. We report baseline characteristics, current immunosuppressive therapies, progression of skin and internal organ involvement, and mortality in a multicenter prospective cohort from the United States (US) of America.

METHODS

We performed a longitudinal analysis of participants from 12 US centers, from April 2012 to July 2020. All participants had early dcSSc or were at-risk for dcSSc, with ≤2 years since the first non-Raynaud's phenomenon (RP) symptom.

RESULTS

Three hundred one patients were included with a baseline median disease duration of 1.2 years since RP and a mean modified skin score of 21.1 units. At baseline, 263 (87.3%) had definite dcSSc and 38 (12.7%) were classified as at-risk; 112 (49.6%) patients were positive for anti-RNA polymerase III antibodies. The median follow-up duration was 24.5 months (IQR = 10.3-40.7 months). One hundred ninety (63.1%) participants were treated with an immunosuppressive therapy, of which mycophenolate mofetil was most used at baseline and follow-up. Of 38 who were classified as at-risk at baseline, 27 (71%) went on to develop dcSSc; these patients were characterized by higher baseline mean HAQ-DI (0.8 versus 0.4, p = 0.05) and higher baseline mRSS (8.8 versus 4.4, p < 0.01) in comparison with those who remained as limited cutaneous SSc. In the overall cohort, 48 participants (21.1%) had clinically significant worsening of skin fibrosis, mainly occurring in the first year of follow-up; 41 (23.3%) had an absolute forced vital capacity decline of ≥10%. Twenty participants (6.6%) died, of which 18 died in the first 3 years of follow-up. Cardiac involvement (33.3%), gastrointestinal dysmotility (22.2%), and progressive interstitial lung disease (ILD) (16.7%) were the main causes of death.

CONCLUSION

This US cohort highlights the management of early SSc in the current era, demonstrating progression of skin and lung involvement despite immunosuppressive therapy and high mortality due to cardiac involvement.

POS0135 REDUCING IMMUNOGENICITY OF PEGLOTICASE (RECIPE) WITH CONCOMITANT USE OF MYCOPHENOLATE MOFETIL IN PATIENTS WITH REFRACTORY GOUT: A PHASE II RANDOMIZED CONTROLLED TRIAL

Background:

Pegloticase is a recombinant, pegylated uricase, used for treatment of gout patients who fail oral urate lowering therapy (ULT). Its use has been limited due to immunogenicity leading to infusion reactions.1

Objectives:

We evaluated if co-administration of an immunomodulatory agent could prolong the efficacy of pegloticase.

Methods:

Participants were recruited in a Phase II, double-blind, placebo-controlled trial over 18 months and randomized in a 3:1 ratio by site. Inclusion criteria were: a) Age ≥ 18 years who met 2015 ACR/EULAR gout classification criteria and b) chronic refractory gout defined as symptoms inadequately controlled with ULT or contraindications. After a 2-week run-in of mycophenolate mofetil (MMF) 1000 mg twice daily or matching placebo (PBO), they received a combination of pegloticase 8 mg biweekly with MMF or PBO for 12 weeks. Subsequent to this MMF or PBO were discontinued but pegloticase was continued for another 12 weeks. The primary endpoint was proportion of patients who sustained a serum urate (SU) level of ≤ 6 mg/dl at 12 weeks. Secondary endpoints included 24-week durability of SU ≤ 6 mg/dl and rate of adverse events (AEs). Fisher’s exact test and Wilcoxon two-sample test were used for analyses along with Kaplan-Meier estimates and log-rank tests to compare survival curves between groups. Hypothesis tests were two-tailed and p-value (p) < 0.05 indicated statistical significance.

Results:

Of 42 subjects screened, 35 were randomized, and 32 who received at least one dose of pegloticase were included in modified intention to treat analyses. Subjects were predominantly men (88%), mean age of 55.2 years (SD=9.7). Mean duration of gout was 13.4 years (SD=9.0), mean baseline sUA was 9.2 mg/dL (SD=1.6). Tophi were present in 88% and majority were on optimized ULT - 59% on allopurinol and 16% on febuxostat, with 63% reporting > 1 flare in the past year. At baseline both arms (MMF vs. PBO) had similar comorbidities – (82% vs 70%), diabetes mellitus/metabolic syndrome (14% vs 20%), coronary artery disease/peripheral vascular disease (41% vs.70%), BMI>30 (86% vs. 90%) and renal insufficiency (defined as eGFR < 90 mL/min; 73% vs. 70%). At 12 weeks, 19 of 22 (86%) in the MMF arm achieved SU ≤ 6 mg/dl compared to 4 of 10 (40%) in PBO arm (p-value = 0.01). At 24 weeks, the SU was ≤ 6 mg/dl in 68% of MMF arm vs. 30% in PBO (p-value = 0.06), and rates of AEs per month were similar between groups with the PBO arm having more infusion reactions (30% vs. 0%). The MMF arm had higher AEs compared to placebo: musculoskeletal (41% vs. 10%), gastrointestinal (18% vs. 10%), and infections (9% vs. 0%). Figure 1 shows that the percentage of subjects maintaining a sUA < 6 mg/dL at 12 weeks was significantly higher (p=0.02) in the MMF arm, and a significant difference (p=0.03) at 24 weeks indicates sustained benefit from MMF.

Conclusion:

To our knowledge this is the first randomized-controlled proof of concept trial to demonstrate the ability of an immunomodulatory agent in prolonging the efficacy of pegloticase. Short-term concomitant use of MMF therapy with pegloticase was well tolerated and showed a clinically meaningful improvement in the targeted SU ≤6 mg/dL at 12 and 24 weeks. This study suggests an innovative approach to utilize pegloticase therapy in patients with chronic gout.

References:

[1]Sundy et al. Efficacy and tolerability of pegloticase for the treatment of chronic gout in patients refractory to conventional treatment: two randomized controlled trials. JAMA. 2011;306(7):711-20.

Figure 1.

Proportion of subjects maintaining serum urate (SU) ≤ 6 mg/dL over 24 week study period in mycophenolate mofetil + pegloticase vs. placebo + pegloticase

Disclosure of Interests:

Puja Khanna Consultant of: Horizon Pharmaceuticals, Swedish Orphan Biovitrum A, Grant/research support from: Selecta, 2)DYVE, Dinesh Khanna Consultant of: Horizon Pharmaceuticals, Gary Cutter: None declared, Jeff Foster: None declared, Josh Melnick: None declared, Sara Jaafar: None declared, Stephanie Biggers: None declared, Fazlur Rahman: None declared, Hui-Chen Kuo: None declared, Michelle Feese: None declared, Kenneth Saag Consultant of: AbbVie, Inc., Bayer, Daiichi Sankyo Company LTD, Gilead Services, Inc., Horizon Pharma plc, Mallinkrodt, Radius Health, Inc., Roche/Genentech, Shanton Pharma Co., LTD, Teijin, Dyve Bioscience, LG Chem, Regeneron Pharmaceuticals., Swedish Orphan Biovitrum AB, Takeda Pharmaceuticals America, Inc.,

Performance of the DETECT Algorithm for Pulmonary Hypertension Screening in a Systemic Sclerosis Cohort

OBJECTIVE

Pulmonary arterial hypertension (PAH) is one of the leading causes of mortality in systemic sclerosis (SSc). This study was undertaken to assess predictive accuracies of the DETECT algorithm and the 2015 European Society of Cardiology/European Respiratory Society (ESC/ERS) guidelines in SSc patients who underwent right-sided heart catheterization (RHC) for pulmonary hypertension (PH) evaluation.

METHODS

Patients with SSc who had diagnostic RHC, had no PH or had PAH, and had available data on variables to allow application of the DETECT and 2015 ESC/ERS guidelines were included for analysis. PH classification was based on hemodynamics using the 2018 revised criteria and extent of lung fibrosis shown on high-resolution computed tomography. Sensitivity and predictive accuracies of the DETECT algorithm and 2015 ESC/ERS guidelines were calculated, including analysis of subjects with a diffusing capacity for carbon monoxide (DLco) of ≥60% predicted.

RESULTS

Sixty-eight patients with SSc had RHC, of whom 58 had no PH and 10 had PAH. The mean age was 60.0 years, and 58.8% had limited cutaneous SSc. The DETECT algorithm had a sensitivity of 1.00 (95% confidence interval [95% CI] 0.69-1.00) and a negative predictive value (NPV) of 1.00 (95% CI 0.80-1.00), whereas the 2015 ESC/ERS guidelines had a sensitivity of 0.80 (95% CI 0.44-0.97) and an NPV of 0.94 (95% CI 0.81-0.99). In patients with a DLco of ≥60% (n = 27), the DETECT algorithm had a sensitivity of 1.00 (95% CI 0.29-1.00) and an NPV of 1.00 (95% CI 0.59-1.00), whereas the 2015 ESC/ERS guidelines had a sensitivity of 0.67 (95% CI 0.09-0.99) and an NPV of 0.94 (95% CI 0.71-1.00).

CONCLUSION

The DETECT algorithm has high sensitivity and NPV for diagnosis of PAH, including among individuals with a DLco of ≥60%.

Reducing Immunogenicity of Pegloticase With Concomitant Use of Mycophenolate Mofetil in Patients With Refractory Gout: A Phase II, Randomized, Double-Blind, Placebo-Controlled Trial

OBJECTIVE

Pegloticase is used for the treatment of severe gout, but its use is limited by immunogenicity. This study was undertaken to evaluate whether mycophenolate mofetil (MMF) prolongs the efficacy of pegloticase.

METHODS

Participants were randomized 3:1 to receive 1,000 mg MMF twice daily or placebo for 14 weeks, starting 2 weeks before receiving pegloticase and continuing while receiving intravenous pegloticase 8 mg biweekly for 12 weeks. Participants then received pegloticase alone from week 12 to week 24. The primary end points were the proportion of patients who sustained a serum urate level of ≤6 mg/dl at 12 weeks and the rate of adverse events (AEs). Secondary end points included 24-week durability of serum urate level ≤6 mg/dl. Fisher's exact test and Wilcoxon's 2-sample test were used for analyses, along with Kaplan-Meier estimates and log rank tests.

RESULTS

A total of 32 participants received ≥1 dose of pegloticase. Participants were predominantly men (88%), with a mean age of 55.2 years, mean gout duration of 13.4 years, and mean baseline serum urate level of 9.2 mg/dl. At 12 weeks, a serum urate level of ≤6 mg/dl was achieved in 19 (86%) of 22 participants in the MMF arm compared to 4 (40%) of 10 in the placebo arm (P = 0.01). At week 24, the serum urate level was ≤6 mg/dl in 68% of MMF-treated patients versus 30% of placebo-treated patients (P = 0.06), and rates of AEs were similar between groups, with more infusion reactions occurring in the placebo arm (30% versus 0%).

CONCLUSION

Our findings indicate that MMF therapy with pegloticase is well tolerated and shows a clinically meaningful improvement in targeted serum urate level of ≤6 mg/dl at 12 and 24 weeks. This study suggests an innovative approach to pegloticase therapy in gout.

Performance Characteristics of Pulmonary Function Tests for the Detection of Interstitial Lung Disease in Adults With Early Diffuse Cutaneous Systemic Sclerosis

OBJECTIVE

Interstitial lung disease (ILD) is the leading cause of death in patients with systemic sclerosis (SSc). Although pulmonary function tests (PFTs) are commonly used to screen for ILD in patients with SSc, studies have shown that they lack sensitivity for the detection of ILD in general SSc cohorts. This study was undertaken to assess the performance characteristics of PFTs for the detection of ILD in patients with early diffuse cutaneous SSc (dcSSc), a population at high risk for the development of ILD.

METHODS

We performed a retrospective cohort study of patients enrolled in the Prospective Registry of Early Systemic Sclerosis at 11 sites in the US between April 2012 and January 2019. Patients were included if they underwent spirometry and high-resolution computed tomography (HRCT) of the chest. We calculated the performance characteristics of PFTs for the detection of ILD on HRCT.

RESULTS

The study included 212 patients, 54% of whom had radiographic ILD. For the detection of ILD on HRCT imaging, a forced vital capacity (FVC) <80% predicted had a sensitivity of 63%. The combination of FVC <80% predicted or diffusing capacity for carbon monoxide (DLco) <80% predicted improved the sensitivity to 85%. An FVC <80% predicted had a negative predictive value (NPV) of 61%, while the combination of FVC <80% predicted or DLco <80% predicted had an NPV of 70%.

CONCLUSION

PFTs alone are an inadequate screening tool for the diagnosis of ILD in patients with early dcSSc. HRCT should be part of the ILD screening algorithm in patients with dcSSc.

Impact of the revised haemodynamic definition on the diagnosis of pulmonary hypertension in patients with systemic sclerosis

INTRODUCTION

Pulmonary arterial hypertension (PAH) is one of the leading causes of mortality in systemic sclerosis (SSc). We explored the impact of the updated haemodynamic definition of pulmonary hypertension (PH), as proposed by the 6th World Symposium on Pulmonary Hypertension.

METHODS

In this single-centre retrospective analysis, patients with SSc who had right heart catheterisation (RHC) were included. We compared the prior PH definition to the updated PH definition. The prior definition classified PH as mean pulmonary arterial pressure (mPAP) ≥25 mmHg and further divided into pre-capillary PH (PAH and PH due to lung disease and/or hypoxia), post-capillary PH, and combined pre- and post-capillary PH groups. For the updated definition, PH was classified as mPAP >20 mmHg and further divided into the different groups. We validated our findings in the DETECT cohort.

RESULTS

Between 2005 and March 2019, 268 RHCs were performed in this single-centre cohort. Using the prior definition, 137 (51%) were diagnosed with PH, with 89 classified as pre-capillary PH (56 with PAH and 33 with PH due to lung disease and/or hypoxia), 29 as post-capillary PH, and 19 as combined pre- and post-capillary PH. When the updated definition was applied to the cohort, seven out of 131 (5%) with no PH were reclassified to pre-capillary PH (PAH (n=1), PH due to lung disease (n=3) and post-capillary PH (n=3)). In those with mPAP 21-24 mmHg, with no left heart or significant lung disease, one out of 28 (4%) in our cohort and four out of 36 (11%) in the DETECT cohort were reclassified as PAH.

CONCLUSION

The updated PH definition does not appear to have a significant impact on the diagnosis of PH in two different screening cohorts.

Reliability, construct validity and responsiveness to change of the PROMIS-29 in systemic sclerosis-associated interstitial lung disease

OBJECTIVES

PROMIS-29 is a generic health-related quality of life instrument. Our objective was to assess the reliability, construct validity, and responsiveness to change of PROMIS-29 in systemic sclerosis-associated interstitial lung disease (SSc-ILD).

METHODS

Seventy-three participants with SSc-ILD were administered patient reported outcomes (PROs) at baseline and follow-up visits which included PROMIS-29 and other measures of generic health, dyspnea, and cough instruments. We assessed internal consistency reliability using Cronbach's α, an alpha of ≥ 0.70 was considered satisfactory. We assessed the responsiveness to change using linear regression models.

RESULTS

Mean age of the participants was 51.9 years and the mean disease duration was 7.9 years after first non-Raynaud's symptom. Of the 73 participants, 56.2% were classified as diffuse SSc and 26% limited SSc. The baseline (mean ± SD) FVC % predicted was 73.9±15.5 with a DLCO % predicted of 57.7±21.1; 95.9% had fibrotic NSIP pattern on HRCT. PROMIS-29 scores were 0.2 to 0.9 SD below the US population. Cronbach's α reliability was acceptable for all domains (ranged from 0.77 to 0.98). All scales showed statistically significant correlations with hypothesised PROMIS-29 domains (p≤0.05 for all comparisons). PROMIS-29 showed none-to-small discriminatory ability in comparison with physiologic measures (FVC and DLCO). There was no significant relationship between the change in FVC versus the change in PROMIS-29 measures over time.

CONCLUSIONS

PROMIS-29 has adequate reliability and construct validity for evaluation in SSc-ILD. It has moderate-to-large correlations with other PROs. The PROMIS-29 domains were not found to change over time in this cohort, likely due to stable nature of the observational cohort.

Role of a nosX homolog in Streptococcus gordonii in aerobic growth and biofilm formation

Oral streptococci such as Streptococcus gordonii are facultative anaerobes that initiate biofilm formation on tooth surfaces. An isolated S. gordonii::Tn917-lac biofilm-defective mutant contained a transposon insertion in an open reading frame (ORF) encoding a homolog of NosX of Ralstonia eutropha, a putative maturation factor of nitrous oxide reductase. Located downstream are two genes, qor1 and qor2, predicted to encode two putative NADPH quinone oxidoreductases. These three genes are cotranscribed, forming a putative oxidative stress response (osr) operon in S. gordonii. Inactivation of nosX, qor1, or qor2 resulted in biofilm-defective phenotypes. Expression of nosX, measured by the beta-galactosidase activity of the nosX::Tn917-lac mutant, was growth-phase dependent and enhanced when grown under aerobic conditions or in the presence of paraquat. Real-time reverse transcription-PCR revealed that nosX-specific mRNA levels were increased approximately 8.4 and 3.5 fold in biofilm-derived cells grown on plastic and glass, respectively, when compared to planktonic cells. Expression of nosX increased 19.9 fold in cells grown under aerated aerobic conditions and 4.7 fold in cells grown under static aerobic conditions. Two ORFs immediately adjacent to the osr operon encode a putative NADH oxidase (Nox) and a putative thiol-specific antioxidant enzyme (AhpC, for alkyl hydroperoxide peroxidase C). Expression of nox and ahpC was also significantly increased in cells grown under aerated and static aerobic conditions when compared to anaerobic conditions. In addition, nox expression was increased in biofilm cells compared to planktonic cells. These genes may be part of an island that deals with oxidoreductive response, some of which may be important in S. gordonii biofilm formation.

Identification of two novel HLA class II alleles, DQB1*030503 and DRB1*0447

Two novel human leukocyte antigen (HLA) class II alleles have been identified in routine typing of bone marrow donors for the Australian Bone Marrow Donor Registry in Sydney, Australia. Sequence analysis of exon 2 of both the DQB1 and DRB1 genes revealed the novel polymorphism. A silent substitution of G to A at nucleotide position 210 has been identified for the DQB1*030503 allele when compared to the closest matched allele, DQB1*030501. There is no associated amino acid difference between the translated products of the two alleles. The second new allele is a variant of the DRB1 gene. The DRB1*0447 allele was identified with three nucleotide substitutions compared to the closest matched allele DRB1*0436. There is a silent mutation at nucleotide position 303, G to C and two substitutions at adjacent nucleotide positions 344 and 345, T to G and G to T, respectively. The latter two substitutions result in an amino acid change from valine to glycine at position 86, implicating a different specificity and affinity of antigen binding.

[Value of sonography in the diagnosis and follow-up of patients with cryptogenic inflammatory bowel diseases in current practice: review of a 10-year experience in a community hospital]

Inflammatory bowel diseases (IBD) are chronic inflammatory diseases of the bowel that are of unknown etiology. These diseases either progress with intermittent flare-ups interrupted by periods of remission or on a chronic active progressive mode. IBDs include Crohn disease (CD) and ulcerative colitis (UC). Clinical and imaging diagnosis often is challenging, hence explaining the frequent time delay between onset of disease and initiation of therapy. Clinical evaluation is characterized by three consecutive steps: consider a diagnosis of IBD; exclude other causes of inflammatory bowel disease; differentiate CD from UC since a definitive curative surgical treatment is available for UC. US is non-invasive, widely available, easy to perform, and relatively inexpensive and thus represents a significant advance in the evaluation of these three steps. The role of US in the evaluation of patients with suspected IBD will be reviewed.

[Respiratory manifestations of hemorrhagic fever with renal syndrome. Retrospective study of 129 cases in Champagne-Ardenne and Lorraine]

OBJECTIVES

The contradiction between airborne transmission of Puumala virus and the low rate of airway manifestations reported in hemorrhagic fever with renal syndrome (HFRS) caused by this virus led us to conduct this study to check whether the incidence of respiratory manifestations may have been underestimated.

PATIENTS AND METHODS

We retrospectively reviewed 129 consecutive cases of HFRS diagnosed between 1983 and 1995 in the eastern France.

RESULTS

Clinical manifestations of airway involvement and chest X-ray abnormalities were observed in 30% and 50% of the patients respectively. Analysing the radiological anomalies by serum creatinine level showed that in two-thirds of the cases (33% of all the HFRS cases) they were concomitant with acute renal failure and probably related to pulmonary edema, and that in one-third (17% of the HFRS cases) they were compatible with pneumonia. These cases of pneumonia could correspond to specific manifestations of the hantavirus Puumala at the site of penetration.

CONCLUSION

Although minimally expressive, respiratory manifestations were found to be more frequent than expected in hemorrhagic fever with renal syndrome. Incidence may have been formerly underestimated.

Obesity among years 1 and 6 primary school children in Selangor Darul Ehsan

A study was conducted from March to June 1991 to determine the prevalence of obesity among primary school children in the State of Selangor. One School Health Team in each of the 9 Districts of Selangor participated in the collection of data, the whole project being coordinated by the Selangor State Health Department. A total of 28 rural and 24 urban schools were selected for the study, involving a total of 2,688 pupils in Standard 1 and Standard 6. The prevalence of obesity, using >120% of the reference weight-for-height as the criteria, varied considerably in the different districts, with an overall prevalence of 7.8% in the State. The proportion of boys affected (66.7%) was twice that among girls (33.3%). The prevalence of obesity of 9.8% in the urban schools was significantly higher than the 6.1% found for rural schools (p<0.0001). 151 (11.1%) were from Standard 6 and 59 (4.4%) were from Standard 1 (p<0.0001). It was also found that there was a significantly higher prevalence of obesity amongst primary 6 children (p<0.0001). Whilst the problem may not be as serious as that found in developed countries, the findings of this study should serve as an early warning to health authorities of the seriousness of the problem.

Superior vena cava stent placement: results with the Wallstent endoprosthesis

PURPOSE

To assess the clinical success and short-term patency of the Wallstent endoprosthesis in the treatment of superior vena cava (SVC) syndrome.

MATERIALS AND METHODS

Twenty-one 14-mm-diameter endoprostheses were implanted in 15 patients (mean age, 60 years) treated for SVC syndrome due to malignant compression (n = 14) or postirradiation fibrotic stenosis (n = 1) of the SVC.

RESULTS

Immediate technical success was achieved in all patients. Two early complications occurred: retroperitoneal hemorrhage due to venous iliac tear and early stent thrombosis. In the 14 patients without early stent occlusion, stent placement resulted in complete relief of SVC syndrome; clinical success was 93%. SVC syndrome did not recur from 1 to 14 months, until the patient died (n = 11) or until the end of the study (n = 3). Helical CT showed a patent stent in five patients, respectively, at 3, 6, 8, 10, and 11 months.

CONCLUSION

SVC stent placement has good clinical results and a high patency rate at short-term follow-up in patients with SVC syndrome.

Examination of the eye as a means to determine the early postmortem period: a review of the literature

Reported are various techniques to determine the early postmortem period by examining the eye. These include corneal opacity, retinal vessel segmentation, pupil reaction, retinal changes and intraocular pressure. All are subjective, requiring experience to implement the techniques.

The use of either the nose or outer ear as a means of determining the postmortem period of a human corpse

Presented in this paper are the initial results involving the use of the nose or outer ear as temperature measurement sites to determine the postmortem period of the human corpse. Simple mathematical models for both sites are developed based on cooling curves of five corpses. Analysis of errors between actual and calculated postmortem intervals suggest that in its present form, the described methods would not be suitable for use in accurately determining the time since death of human corpses.

Recurrent re-expansion pulmonary oedema complicating rapid decompression of large pneumothoraces

A young male who developed ipsilateral pulmonary oedema on two occasions as a complication of treatment of pneumothoraces involving the left lung is reported. The importance of large pneumothoraces, the rapidity of decompression and the application of suction to the pleural space as factors predisposing to the development of re-expansion pulmonary oedema is well demonstrated by this case. The re-expansion pulmonary oedema was more severe on the second occasion when the lung had collapsed for a longer duration compared to the first pneumothorax which was of more recent onset.