Entrustable professional activities (EPAs) for undergraduate medical education - development and exploration of social validity

BACKGROUND

The development of entrustable professional activities (EPAs) as a framework for work-based training and assessment in undergraduate medical education has become popular. EPAs are defined as units of a professional activity requiring adequate knowledge, skills, and attitudes, with a recognized output of professional labor, independently executable within a time frame, observable and measurable in its process and outcome, and reflecting one or more competencies. Before a new framework is implemented in a specific context, it is valuable to explore social validity, that is, the acceptability by relevant stakeholders.

AIM

The aim of our work was to define Core EPAs for undergraduate medical education and further explore the social validity of the constructs.

METHOD AND MATERIAL

In a nationwide collaboration, EPAs were developed using a modified Delphi procedure and validated according to EQual by a group consisting of teachers nominated from each of the seven Swedish medical schools, two student representatives, and an educational developer (n = 16). In the next step, social validity was explored in a nationwide survey. The survey introduced the suggested EPAs. For each EPA, the importance of the EPA was rated, as was the rater's perception of the present graduates' required level of supervision when performing the activity. Free-text comments were also included and analyzed.

RESULTS

Ten Core EPAs were defined and validated. The validation scores for EQual ranged from 4.1 to 4.9. The nationwide survey had 473 responders. All activities were rated as "important" by most responders, ranging from 54 to 96%. When asked how independent current graduates were in performing the ten activities, 6 to 35% reported "independent". The three themes of the free text comments were: 'relevant target areas and content'; 'definition of the activities'; and 'clinical practice and learning'.

CONCLUSION

Ten Core EPAs were defined and assessed as relevant for Swedish undergraduate medical education. There was a consistent gap between the perceived importance and the certainty that the students could perform these professional activities independently at the time of graduation. These results indicate that the ten EPAs may have a role in undergraduate education by creating clarity for all stakeholders.

Occurrence and relative risks for non-vertebral fractures in patients with ankylosing spondylitis compared with the general population: a register-based study from Sweden

OBJECTIVES

To estimate the incidence of non-vertebral fractures in ankylosing spondylitis (AS) compared with the general population.

METHODS

Nationwide register-based cohort study including patients with AS (n=11 611, 65% men, mean age 48 years), and matched general population controls (n=58 050). Five prespecified fracture outcomes: (1) non-vertebral; (2) fracture of the proximal humerus, distal forearm or hip; (3) proximal humerus; (4) distal forearm and (5) hip) were identified through register linkages with follow-up 2007-2016. We used Poisson regression to calculate incidence rates (IRs), number of fractures per 1000 person-years at risk and IR ratios (IRRs), overall and by sex and age. IRRs were adjusted for history of any prior fracture.

RESULTS

IRs (men/women) for non-vertebral fracture in AS were 11.9 (95% CI 11.0 to 12.9)/14.5 (95% CI 13.1 to 16.1) and in controls 10.0 (95% CI 9.7 to 10.4)/11.8 (95% CI 11.1 to 12.4), IRR (men/women) 1.2 (95% CI 1.1 to 1.3)/1.2 (95% CI 1.1 to 1.4). IRs (men/women) for fractures of the humerus, forearm or hip in AS were 4.0 (95% CI 3.5 to 4.6)/6.3 (95% CI 5.4 to 7.3) and in controls 2.7 (95% CI 2.5 to 2.9)/5.5 (95% CI 5.1 to 6.0), IRR (men/women) 1.5 (95% CI 1.3 to 1.7)/1.1 (95% CI 0.9 to 1.3). IRRs were statistically significantly elevated in men with AS versus controls for forearm fracture (1.4 (95% CI 1.1 to 1.7)) and hip fracture (1.8 (95% CI 1.4 to 2.3)), whereas not in women with AS where the IRRs were 1.1 (95% CI 0.9 to 1.4) and 1.0 (95% CI 0.6 to 1.4). For humerus fracture, IRRs were 1.4 (95% CI 0.99 to 1.9) in men with AS versus controls and 1.1 (95% CI 0.8 to 1.6) in women.

CONCLUSIONS

Both men and women with AS have a slightly higher risk of non-vertebral fractures than the general population. A statistically significantly higher risk of fractures of the proximal humerus, distal forearm or hip was found in men with AS in comparison to general population, where the relative risk was especially pronounced for hip fracture.

POS0959 RISK FACTORS FOR NON-VERTEBRAL FRACTURES IN ANKYLOSING SPONDYLITIS

Background

Osteoporosis is common in patients with ankylosing spondylitis (AS) and a risk factor for fragility fractures. Additional established risk factors for fractures in the general population include higher age, female sex, previous fracture, fall tendency, glucocorticoid treatment, insulin dependent diabetes, smoking and high alcohol consumption.

Objectives

To estimate the influence of established risk factors for fragility fractures on the development of non-vertebral fractures in AS and population controls.

Methods

Through linkage of national population and health care registers 2001-2016, patients with AS (n=11611, 65.5% men, mean age 48 years) and age-, sex- and geography-matched population controls (n=58050) were identified and from 1 January 2007 (or 3 months after the first registered AS diagnosis if this occurred later) followed prospectively until the time of a non-vertebral fracture, death, emigration or end of study (30 December 2016). Occurrence of established risk factors for a fracture and AS related characteristics at start of follow-up were identified in the National Patient and Prescribed Drug Registers using ICD-10 and ATC codes. Smoking status and anthropometric measurements are not available in these registers. Chi-square, Fischer’s exact test and T tests were used to compare between subjects with and without a non-vertebral fracture during follow-up, separately for AS and controls. Multivariable Poisson regression was used to estimate the influence of each established risk factor in AS and controls. Risk factors for which there were ≤20 observed events in the AS cohort were not included. Results are presented as incidence rate ratios (IRR) with 95% confidence intervals.

Results

In total 974 (8.4%) patients with AS and 4106 (7.1%) of their controls were registered with a non-vertebral fracture during the study period. The characteristics of the patients and controls at start of follow-up are presented in Table 1 stratified by fracture status during follow-up. Figure 1 displays the results from the Poisson regression.

Table 1.ASControlsNo fracture (n=10637)Fracture (n=974)P-valueNo fracture (n=53944)Fracture (n=4106)P-valueMale sex7002 (65.8)603 (61.9)0.01435448 (65.7)2572 (62.6)<0.001Mean age (SD)47.6 (14.7)53.8 (14.8)<0.00147.8 (14.7)53.0 (15.0)<0.001Prior fracture667 (6.3)140 (14.4)<0.0012715 (5.0)486 (11.8)<0.001Osteoporosis*359 (3.4)83 (8.5)<0.001367 (0.7)85 (2.1)<0.001Fall injury without fracture714 (6.7)97 (10.0)<0.0013205 (5.9)350 (8.5)<0.001Harmful use of alcohol158 (1.5)26 (2.7)0.005889 (1.6)171 (4.2)<0.001Hyperthyroidism39 (0.4)7 (0.7)0.105180 (0.3)19 (0.5)0.173Diabetes type 1178 (1.7)30 (3.1)0.002651 (1.2)80 (1.9)<0.001Liver disease66 (0.6)10 (1.0)0.132197 (0.4)32 (0.8)<0.001Malnutrition8 (0.1)3 (0.3)0.05816 (0.0)2 (0.0)0.367Hypogonadism or premature menopause11 (0.1)1 (0.1)1.00033 (0.1)0 (0.0)0.169Use of oral glucocorticoids#1531 (14.4)152 (15.6)0.304839 (1.6)97 (2.4)<0.001Anterior uveitis2168 (20.4)204 (20.9)0.677317 (0.6)32 (0.8)0.126Psoriasis316 (3.0)34 (3.5)0.364605 (1.1)58 (1.4)0.091Inflammatory bowel disease675 (6.3)64 (6.6)0.783441 (0.8)35 (0.9)0.811Use of any DMARD¤3411 (32.1)266 (27.3)0.002465 (0.9)52 (1.3)0.008Use of TNF inhibitor¤1539 (14.5)109 (11.2)0.00543 (0.1)4 (0.1)0.573

The data is presented as number (%) if not stated otherwise. *Diagnosed osteoporosis and/or use of osteoporosis medication. #Prednisolone equivalent cumulative dose of ≥450 mg within the last year before start of follow-up. ¤Use within the last year before start of follow-up.

Figure 1.

Multivariable Poisson regression analyses for a non-vertebral fracture during follow-up, with results presented for each included baseline variable as IRR with 95% CI, separately for AS and controls.

Conclusion

The influence of established risk factors for fragility fractures in AS is similar to that in the general population; in both populations with advanced age, prior fracture and harmful use of alcohol being the strongest risk factors.

Disclosure of Interests

Karin Bengtsson: None declared, Johan Askling Grant/research support from: AbbVie, AstraZeneca, Bristol Myers Squibb, Eli Lilly, Janssen, Merck, Pfizer, Roche, Samsung Bioepis, Sanofi, and UCB, Mattias Lorentzon: None declared, Björn Rosengren: None declared, Anna Deminger: None declared, Eva Klingberg: None declared, Lennart T.H. Jacobsson Speakers bureau: Lecture and consulting fees from Novartis, Eli Lilly and Janssen, Helena Forsblad-d’Elia: None declared

Physical activity spectrum discriminant analysis-A method to compare detailed patterns between groups

Investigating physical activity (PA) patterns as a detailed intensity spectrum instead of crude intensity categories have improved the ability to analyze the relationship between measured PA and health variables. The aim of this methodological study was to introduce and investigate the utility of using detailed PA intensity spectrum compared to crude PA intensity categories for comparison of PA between groups and between repeated measures. The study sample consisted of two groups of children, where one group was scheduled for extended physical education (PE) by daily classes while the other group followed usual PE schedule. Accelerometer data was processed into traditional crude PA intensity categories and into detailed PA intensity spectrum. Multivariate partial least squares regression for discriminant analysis (PLS-DA) was applied for PA intensity spectrum group comparison and compared to traditional univariate statistical analysis. Repeated measures were investigated using independent PLS-DA as well as multilevel PLS-DA for paired analysis. While traditional analysis of crude PA intensity categories was unable to find any group differences, multivariate analysis of the PA intensity spectrum identified statistically significant differences. By the extension of multilevel PLS-DA for paired comparison, a clear difference in the PA intensity spectrum was demonstrated between repeated measures. In conclusion, analysis of detailed PA intensity spectrum demonstrates utility for comparing detailed PA data between groups and between repeated measures in interventional and observational research.

FRI0310 HIGHER RISK OF INCIDENT FRACTURE IN PATIENTS WITH ANKYLOSING SPONDYLITIS COMPARED TO THE GENERAL POPULATION

Background:

Ankylosing spondylitis (AS) is characterized by pathologic new bone formation and bone loss. Vertebral fracture (VF) is a known complication of AS, whereas the risk of other major osteoporotic fractures (MOFs) is less studied.

Objectives:

To estimate incidence rates (IRs) of incident fractures (any, VF and other MOF (humerus, forearm and hip)) in patients with AS compared to controls from general population.

Methods:

This is a nationwide, register-based and observational cohort study including patients diagnosed with AS (n=11611, 65% men, mean age 48 years) identified in the National patient register (NPR) 2001 through 2015, and age- and sex-matched controls (n=58050) from the Swedish Population Register. The study period started 1 January 2007 or 3 months after the first AS diagnosis, whichever came later, and ended at the first occurrence of each fracture outcome (identified in the NPR), death, emigration or 31 December 2016. Patients and controls with any prior fracture in NPR within a 6-year period before start of the study period were not included. Any fracture (except skull and phalangeal fractures), VF and other MOF were identified in NPR according to pre-specified ICD codes. Each fracture outcome was analysed separately. Poisson regression was used to calculate IRs and incidence rate ratios (IRRs), overall and stratified by sex. Kaplan-Meier curves were plotted.

Results:

In total 807 (7.0%) of patients with AS and 3201 (5.5%) of matched controls had a history of prior fracture within a 6-year period, and were excluded from further analyses. We noted higher IRs for any fracture, VF and other MOF in AS vs controls, see Figure for Kaplan-Meier curves and Table for IRs and IRRs. In sex-stratified analyses, men with AS (vs. male controls) had a higher relative risk for all fracture outcomes, whereas among women with AS (vs. female controls), a higher relative risk was demonstrated for any fracture and VF. 5-year cumulative incidence for any fracture, VF and other MOF was 6.2%, 1.6% and 1.7%, respectively in AS and 4.3%, 0.3% and 1.2%, respectively in controls.

Figure.

Kaplan-Meier curves. A) Vertebral fractures B) Other MOF (humerus, hip, forearm)

Conclusion:

Patients with AS have a higher risk of any fracture, VF and other MOF compared to general population. This was especially pronounced for VF in both sexes and for hip fracture in men with AS.

Table.

Disclosure of Interests:

Karin Bengtsson: None declared, Johan Askling Grant/research support from: JA acts or has acted as PI for agreements between Karolinska Institutet and the following entities, mainly in the context of the ARTIS national safety monitoring programme of immunomodulators in rheumatology: Abbvie, BMS, Eli Lilly, Merck, MSD, Pfizer, Roche, Samsung Bioepis, Sanofi, and UCB Pharma, Mattias Lorentzon Consultant of: Lecture or consulting fees from Amgen, Lilly, UCB Pharma, Radius Health, Renapharma, Meda, GE-Lunar, Consilient Health, and Tromp Medical., Björn Rosengren: None declared, Anna Deminger: None declared, Eva Klingberg Grant/research support from: Roche, Consultant of: Novartis, Speakers bureau: Eli Lilly, Lennart T.H. Jacobsson Consultant of: AbbVie, Eli Lilly, Janssen, Novartis and Pfizer, Helena Forsblad-d’Elia Grant/research support from: Unrestricted grant from Novartis., Consultant of: Advisory Board Fees from Sandoz, Novartis, and Abbvie

Smoking and Alcohol Intake but Not Muscle Strength in Young Men Increase Fracture Risk at Middle Age: A Cohort Study Linked to the Swedish National Patient Registry

We aimed to determine the relationship between handgrip strength, smoking, and alcohol consumption in young men and fracture risk at middle age. Thus, we carried out a cohort study including young men undergoing conscription examination in Sweden from September 1969 to May 1970 at a typical age of 18 years. Data on muscle strength, height, weight, and lifestyle factors were linked to the National Patient Register 1987-2010. Handgrip strength was considered the main exposure and smoking and alcohol consumption as secondary exposures. Outcomes were all fractures (except face, skull, digits), major osteoporotic fractures (thoracic/lumbar spine, proximal humerus, distal forearm or hip), and major traumatic fractures (shaft of humerus, forearm, femur, or lower leg) based on ICD-9 and -10 codes. We used Cox regression models to estimate hazard ratios (HR) and 95% confidence intervals (CI) according to handgrip strength as a continuous variable (per 1 SD), after adjustment for weight, height, parental education, smoking, and alcohol consumption. A total of 40,112 men were included, contributing 892,572 person-years. Overall, 3974 men fractured in middle age with the incidence rate (95% CI) of 44.5 (43.2-45.9) per 1000 person-years. The corresponding rates were12.2 and 5.6 per 1000 person-years for major osteoporotic and traumatic fractures, respectively. Handgrip strength-adjusted HR (95% CI) was 1.01 (0.98-1.05), 0.94 (0.88-1.00), and 0.98 (0.88-1.08) per SD for all, major osteoporotic, and major traumatic fractures, respectively. Adjusted HR (95% CI) for smokers (>21 cigarettes/d) was 1.44 (1.21, 1.71) for all fractures, while the association between alcohol consumption and hazards of fracture was J-shaped. Therefore, young adult handgrip strength was not associated with fracture risk in middle-age men, although smoking and high alcohol consumption did confer an increased risk. © 2019 American Society for Bone and Mineral Research. © 2019 American Society for Bone and Mineral Research.

[EPA (Entrustable professional activities) - an international approach to define key tasks that a doctor should be able to perform]

Entrustable Professional Activities (EPAs) define observable key tasks that a doctor should be able to do independently after having completed a certain level of education. Progression is facilitated by frequent assessments of the defined activities, with increased degree of independence. The observations should be supported by constructive feed-forward. EPA is currently used in several countries both in undergraduate and post graduate education. In the context of pending changes in Swedish legislation regarding undergraduate education qualifications ordinance and medical licensing, a Swedish national work group has begun to define Swedish EPA for the future undergraduate education.

[Daily school physical activity increases bone mass and gradually reduce the fracture risk]

In the Bunkeflo project, one elementary school increased duration of school physical activity (PA) to 200 minutes/week while 3 control schools continued with 60 minutes/week throughout the nine elementary school years. We then registered fractures in 3534 children, and evaluated the duration of PA, bone mass and muscle strength in a subsample (n=140) during the intervention and 3 years after. The PA intervention was associated with higher duration of PA both during and 3 years after the intervention. With each year of intervention, the fracture incidence rate ratio (IRR) declined in the intervention children so that it was 0.48 (95% CI 0.25, 0.91) the eighth year of intervention. These findings were accompanied by beneficial gain in musculoskeletal traits in both intervention girls and boys (p<0.05). Nine years of daily school-based PA is associated with a progressive reduction in fracture risk, accompanied by beneficial musculoskeletal gains and a more physically active lifestyle.

[Daily physical activity during the nine compulsory school years improves academic school results in boys but not girls - a prospective controlled intervention study]

One aim of the Bunkeflo project is to evaluate if daily school physical activity (PA) is associated with higher final school grades and improved eligibility for upper secondary school. One elementary school extended PA throughout elementary school to 200 minutes/week while control schools continued with in mean 60 minutes/week. We then registered final school grades and eligibility for upper secondary school in children who began first grade in the intervention school during the years before the intervention (1994-1997) and in the children who started 1998-2003 (that is, who had daily PA during the 9 compulsory school years). We also registered final school grades and eligibility for upper secondary school in all Swedish children who started school 1998-2003. We found that boys in the intervention group had higher eligibility rates and higher grade scores than boys who finished the same school before the intervention was implemented as well as higher in all Swedish boys. These differences in were not seen in girls. Daily school PA through elementary school is associated with higher final grade scores and higher eligibility rates for upper secondary school in boys.

Physical function tests predict incident falls: A prospective study of 2969 men in the Swedish Osteoporotic Fractures in Men study

Aims: Falls are common in the elderly population, and fall-related injuries are a major health issue. We investigated the ability of simple physical tests to predict incident falls. Methods: The Swedish Osteoporotic Fractures in Men (MrOS) study includes 3014 population-based men aged 69-81 years at the start of the study. These men performed five different physical tests at baseline: right-hand grip strength, left-hand grip strength, timed stand test, 6 m walking test (time and steps) and narrow walking test. During the first study year, we asked participants to fill out questionnaires regarding falls 4, 8 and 12 months after baseline. A total of 2969 men completed at least one questionnaire and were included in this study. We used generalised estimating equations and logarithmic regression models to estimate odds ratios for fallers and recurrent fallers (more than one fall during the one-year examination period) in each quartile of men for each physical test. Results: The proportions of fallers and recurrent fallers were higher in the lowest quartile of the physical tests than in the other three quartiles combined for all physical tests. A reduction of one standard deviation in respective physical test resulted in a 13-21% higher risk of becoming a faller and a 13-31% higher risk of becoming a recurrent faller. Conclusions: Low results on simple physical tests is a risk factor for incident falls in elderly Swedish men and may facilitate identification of high-risk individuals suitable for fall-intervention programs.

Increased risk of hip fracture among spouses-evidence of a homogamy effect

Spouses tend to share habits and therefore have an increased risk of same diseases. We followed all married couples in Sweden, born 1902 to 1942, in hospital records from 1987 to 2002, and found that individuals whose spouse had a hip fracture had an increased risk of hip fracture.

INTRODUCTION

The purpose of this study was to determine whether spouses of hip fracture patients have an elevated risk of hip fracture.

METHODS

We performed a retrospective cohort study of all couples married for at least 5 years in Sweden and born between 1902 and 1942 (n = 904,451) and all patients registered with a hip fracture (n = 218,285) in the National Inpatients Register in Sweden from 1987 to 2002.

RESULTS

During the period 1987 to 2002 hip fractures occurred among spouses in 4212 married couples. The hazard ratio (HR) for hip fracture in a married woman following hip fracture in the husband was 1.11 (95 % confidence interval 1.07 to 1.16) compared to a woman whose husband did not have hip fracture. The corresponding HR for a married man was 1.20 (1.15 to 1.26) compared to a man whose wife did not have hip fracture. The risk was significantly elevated over the age range 60 to 90 years. The increased risk for hip fracture among spouses remained after adjustments for income, education, geographical latitude and urbanisation. In a common model with spouses and their siblings, the HR for spousal effect were 1.63 (1.01 to 2.64) and for sibling effect 2.18 (1.55 to 3.06) compared to married with spouse and sibling respectively without hip fracture.

CONCLUSION

The novel finding of an increased risk for hip fracture among spouses provides evidence indicating that there is a homogamy effect due to common social and lifestyle factors but could also be due to assortative mating.

Bilateral Arthrodesis of the Ankle Joint: Self-Reported Outcomes in 35 Patients From the Swedish Ankle Registry

Bilateral ankle arthrodesis is seldom performed, and results concerning the outcome and satisfaction can only sparsely be found in published studies. We analyzed the data from 35 patients who had undergone bilateral ankle arthrodesis in the Swedish Ankle Registry using patient-reported generic and region-specific outcome measures. Of 36 talocrural arthrodeses and 34 tibio-talar-calcaneal arthrodeses, 6 ankles (9%) had undergone repeat arthrodesis because of nonunion. After a mean follow-up period of 47 ± 5 (range 12 to 194) months, the mean scores were as follows: self-reported foot and ankle score, 33 ± 10 (range 4 to 48); the EuroQol Group's EQ-5D^™ score, 0.67 ± 0.28 (range -0.11 to 1), the EuroQol Group's visual analog scale score, 70 ± 19 (range 20 to 95), 36-item Short Form Health Survey (SF-36) physical domain, 39 ± 11 (range 16 to 58); and SF-36 mental domain, 54 ± 14 (range 17 to 71). Patients with rheumatoid arthritis seemed to have similar self-reported foot and ankle scores but possibly lower EQ-5D^™ and SF-36 scores. Those with talocrural arthrodeses scored higher than did those with tibio-talar-calcaneal arthrodeses on the EQ5D^™ and SF-36 questionnaires (p = .03 and p = .04). In 64 of 70 ankles (91%), the patients were satisfied or very satisfied with the outcome. In conclusion, we consider bilateral ankle arthrodesis to be a reasonable treatment for symptomatic hindfoot arthritis, with high postoperative mid-term satisfaction and satisfactory scores on the patient-reported generic and region-specific outcome measures, when no other treatment option is available.

A Meta-Analysis of Trabecular Bone Score in Fracture Risk Prediction and Its Relationship to FRAX

Trabecular bone score (TBS) is a gray-level textural index of bone microarchitecture derived from lumbar spine dual-energy X-ray absorptiometry (DXA) images. TBS is a bone mineral density (BMD)-independent predictor of fracture risk. The objective of this meta-analysis was to determine whether TBS predicted fracture risk independently of FRAX probability and to examine their combined performance by adjusting the FRAX probability for TBS. We utilized individual-level data from 17,809 men and women in 14 prospective population-based cohorts. Baseline evaluation included TBS and the FRAX risk variables, and outcomes during follow-up (mean 6.7 years) comprised major osteoporotic fractures. The association between TBS, FRAX probabilities, and the risk of fracture was examined using an extension of the Poisson regression model in each cohort and for each sex and expressed as the gradient of risk (GR; hazard ratio per 1 SD change in risk variable in direction of increased risk). FRAX probabilities were adjusted for TBS using an adjustment factor derived from an independent cohort (the Manitoba Bone Density Cohort). Overall, the GR of TBS for major osteoporotic fracture was 1.44 (95% confidence interval [CI] 1.35-1.53) when adjusted for age and time since baseline and was similar in men and women (p > 0.10). When additionally adjusted for FRAX 10-year probability of major osteoporotic fracture, TBS remained a significant, independent predictor for fracture (GR = 1.32, 95% CI 1.24-1.41). The adjustment of FRAX probability for TBS resulted in a small increase in the GR (1.76, 95% CI 1.65-1.87 versus 1.70, 95% CI 1.60-1.81). A smaller change in GR for hip fracture was observed (FRAX hip fracture probability GR 2.25 vs. 2.22). TBS is a significant predictor of fracture risk independently of FRAX. The findings support the use of TBS as a potential adjustment for FRAX probability, though the impact of the adjustment remains to be determined in the context of clinical assessment guidelines. © 2015 American Society for Bone and Mineral Research.

Preterm Children Born Small for Gestational Age are at Risk for Low Adult Bone Mass

Cross-sectional studies suggest that premature birth and low birth weight may both be associated with low peak bone mass. We followed bone traits in preterm individuals and controls for 27 years and examined the effects of birth weight relative to gestational age [stratified as small for gestational age (SGA) or appropriate for gestational (AGA)] on adult bone mineral density (BMD). We measured distal forearm BMC (g/cm) and BMD (g/cm(2)) with single-photon absorptiometry (SPA) in 46 preterm children (31 AGA and 15 SGA) at mean age 10.1 years (range 4-16) and in 84 healthy age-matched children. The measurements were repeated 27 years later with the same SPA apparatus but then also with dual energy absorptiometry and peripheral computed tomography (pQCT). Preterm individuals were shorter (p = 0.03) in adulthood than controls. Preterm AGA individuals had similar BMC and BMD height-adjusted Z-scores in adulthood compared to controls. Preterm SGA individuals had lower distal forearm BMC and BMD height-adjusted Z-scores in adulthood than both controls and preterm AGA individuals. Preterm SGA individuals had lower gain from childhood to adulthood in distal forearm BMC height-adjusted Z-scores than controls (p = 0.03). The deficits in preterm SGA individuals in adulthood were also captured by DEXA in height-adjusted femoral neck (FN) BMC Z-score and height-adjusted FN BMD Z-score and by pQCT in tibial cross-sectional area (CSA) Z-score and stress strain index (SSI) Z-score, where all measurements were lower than controls (all p values <0.05). Preterm SGA individuals are at increased risk of reaching low adult bone mass, at least partly due to a deficit in the accrual of bone mineral during growth. In our cohort, we were unable to find a similar risk in preterm AGA individuals.

[Patient-reported SEFAS: Questionnaire good evaluation method in foot and ankle disorders]

There is need for structured evaluation of disability before and after surgery. The patients' subjective aspects of their symptoms should be one part of this evaluation, preferably captured by patient-reported outcome measures (PROMs). There are several PROMs, either generic or region-specific questionnaires, but no » gold standard « for foot or ankle evaluation. We translated the Self-reported Foot and Ankle Score (SEFAS) and evaluated the psychometric properties of the score in terms of reliability, validity and responsiveness in patients with a variety of foot and ankle disorders. In this report we recommend a validation process for PROMs and report that SEFAS shows good results when doing this. As SEFAS is a PROM, the instrument seems suitable for use in national registers.

Normative calcaneal quantitative ultrasound data as an estimation of skeletal development in Swedish children and adolescents

We present age- and gender-specific normative bone status data evaluated by quantitative ultrasound (QUS) in the calcaneus with the Lunar Achilles device and compare these estimates with bone mineral content (BMC) and bone mineral density (BMD) estimated by dual X-ray absorptiometry (DXA). Included were a sample of 518 population-based collected Swedish girls and 558 boys aged 6-19 years. QUS measurements included speed of sound (SOS), broadband ultrasound attenuation (BUA), and stiffness index (SI) in the calcaneus. DXA measurements included BMC and BMD in the femoral neck (FN), lumbar spine (L2-L4), and total body (TB). Height and weight were measured with standard equipment. Age, height, and weight were significantly associated with SOS, BUA, and SI. Compared to SOS, in both girls and boys there was a higher correlation between BUA and FN BMC (r = 0.71 and r = 0.73, respectively), FN BMD (r = 0.68 and r = 0.67, respectively), L2-L4 BMC (r = 0.70 and r = 0.64, respectively), L2-L4 BMD (r = 0.69 and r = 0.64, respectively), TB BMC (r = 0.76 and r = 0.75, respectively), and TB BMD (r = 0.74 and r = 0.74, respectively). The correlations between SOS and FN BMC (r = 0.38 and r = 0.52, respectively), FN BMD (r = 0.41 and r = 0.52, respectively), L2-L4 BMC (r = 0.31 and r = 0.40, respectively), L2-L4 BMD (r = 0.32 and r = 0.41, respectively), TB BMC (r = 0.42 and r = 0.49, respectively), and TB BMD (r = 0.48 and r = 0.54, respectively) were lower, although still significant (all P < 0.001). BUA seems to be the QUS parameter that best resembles the changes in BMC during growth.

Normative dual energy X-ray absorptiometry data in Swedish children and adolescents

AIM

To present normative dual energy X-ray absorptiometry data in healthy young Swedes.

METHODS

Included were 710 girls and 759 boys aged 6-30 years from southern Sweden. Bone mineral content, bone mineral density, bone size, lean body and fat mass were measured by dual energy X-ray absorptiometry in total body, lumbar spine, hip, arms and legs.

RESULTS

Swedish children had similar bone mass to children in the Netherlands but higher than children in Canada and Korea. Height, weight, bone mass, bone size and lean mass increased at a constant rate from age 6 until the rapid increase in all traits at puberty. The pubertal growth spurt started earlier in girls than in boys, while the spurt in boys was larger in magnitude and occurred for a longer period. Around one-quarter of the adult total body and lumbar spine peak bone mineral content was gained during the 2 years with the fastest gain in both genders.

CONCLUSION

This study presents normative bone mass data in Swedish children, data that are similar to that in Dutch children but higher than in Canadian and Korean children. The gain in Swedish children seems to mimic the gain seen in children in other settings.

Increased lipolysis by secretory phospholipase A(2) group V of lipoproteins in diabetic dyslipidaemia

BACKGROUND

Lipolysis of lipoproteins by secretory phospholipase A(2) group V (sPLA(2)-V) promotes inflammation, lipoprotein aggregation and foam cell formation--all considered as atherogenic mechanisms.

OBJECTIVE

In this study, we compared the susceptibility to sPLA(2)-V lipolysis of VLDL and LDL from individuals with type 2 diabetes and the metabolic syndrome (T2D-MetS) and from healthy controls. Design. VLDL and LDL were isolated from 38 T2D-MetS subjects and 38 controls, treated pair-wise. Extent of sPLA(2)-V lipolysis was measured as release of nonesterified free fatty acids (NEFA). In a subset of the subjects, lipoprotein composition was determined as a relationship between lipid and apolipoprotein components.

RESULTS

Mean paired increase in sPLA(2)-V lipolysis after 1 h for T2D-MetS versus control was 2.0 micromol NEFA l(-1) for VLDL (P = 0.004) and 0.75 micromol NEFA l(-1) for LDL (P = 0.001). There were also substantial differences in lipoprotein composition between the groups. T2D-MetS VLDL had higher triglyceride and cholesterol contents than control VLDL. T2D-MetS LDL was smaller and contained more triglycerides and less cholesterol than control LDL. Both VLDL and LDL from T2D-MetS subjects also contained more apolipoprotein CIII per particle.

CONCLUSION

VLDL and LDL from T2D-MetS individuals were more susceptible to sPLA(2)-V lipolysis than those from control individuals. This may result in elevated levels of NEFA and lysophosphatidylcholine, both in circulation and in LDL, possibly contributing to the elevated inflammatory state and increased risk of cardiovascular diseases seen in these individuals.

Elevated levels of small, low-density lipoprotein with high affinity for arterial matrix components in patients with rheumatoid arthritis: possible contribution of phospholipase A2 to this atherogenic profile

OBJECTIVE

This work studied the presence of inflammatory and atherogenic lipoprotein markers that could explain the high incidence of cardiovascular disease (CVD) reported in rheumatoid arthritis (RA) patients.

METHODS

Inflammatory markers were 1) soluble adhesion molecules (intercellular adhesion molecule [ICAM] and vascular cell adhesion molecule [VCAM]), 2) C-reactive protein (CRP), 3) fibrinogen (Fb), 4) cytokines (interferon-gamma [IFNgamma], tumor necrosis factor alpha [TNFalpha]), and 5) secretory group IIA phospholipase A2 (sPLA2-IIA). Atherogenic lipoprotein markers were 1) the size distribution of plasma lipoprotein subclasses, and 2) the binding affinity of low-density lipoprotein (LDL) to chondroitin 6-sulfate glycosaminoglycan (GAG).

RESULTS

RA patients (n = 31) and matched controls (n = 28) had similar plasma concentrations of total cholesterol, triglycerides, Apo B, Apo A-I, very low-density lipoprotein, intermediate-density lipoprotein, and high-density lipoprotein (HDL). RA patients had significantly higher plasma levels of sPLA2-IIA, ICAM, CRP, Fb, TNFalpha, and IFNgamma compared with controls. RA patients also had significantly higher levels of small, dense LDL-1 (P < 0.05) and lower levels of small HDL-2 particles (P < 0.001) compared with controls. In addition, LDL from RA patients had a significantly higher binding affinity (Kd) to GAG (mean +/- SD Kd 204+/-22.4 nM Apo B) than did LDL from control subjects (Kd 312+/-36 nM Apo B) (P < 0.05). This Kd value showed a significant negative correlation with the plasma levels of LDL-1 (r = -0.566, P < or = 0.004). In RA patients, a significant positive correlation was obtained between sPLA2-IIA and CRP, ICAM, and LDL-1. HDL-2 showed a negative correlation with sPLA2-IIA.

CONCLUSION

These atherogenic lipoprotein factors combined with the presence of chronic inflammation may contribute to the high CVD-related mortality in RA patients.

Silicon diodes as detectors for backscatter radiation in photon fields

We investigated the use of unencapsulated silicon semiconductor detectors for backscatter radiation detection. The results were compared with Monte Carlo (MC) calculations modelling the experimental set-up. A special diode was manufactured, which was designed so that it allowed the positioning of different materials in close contact with the detector surface. Polymethylmethacrylate (PMMA), Pb, Ti and Fe (stainless steel) were used as backscatter materials. The diode signal was measured by integrating the current when irradiating the diode with an equal photon fluence obtained from a medical Co-60 source. When compared to the signal with PMMA as backscatter material the increase in signal was 21%, 27% and 73% for Ti, Fe and Pb, respectively. This is in reasonable agreement with the MC calculations, when taking the effective measurement depth in the Si diode detector into account.

Interferon-gamma induces secretory group IIA phospholipase A2 in human arterial smooth muscle cells. Involvement of cell differentiation, STAT-3 activation, and modulation by other cytokines

Increased expression of secretory non-pancreatic phospholipase A(2) (sPLA(2)-IIA) could be part of the inflammatory reaction in atherosclerosis. However, the factors controlling sPLA(2)-IIA production in human vascular cells are unknown. We investigated regulation of sPLA(2)-IIA expression and secretion by human arterial smooth muscle cells in culture (HASMC). SPLA(2)-IIA was induced after 3-14 days of culture in non-proliferating conditions. SPLA(2)-IIA was co-expressed with heavy caldesmon, a cytoskeleton protein, and p27, a G(1) cyclin inhibitor, proteins characteristically expressed by differentiated cells. Further incubation with 50-500 units/ml of interferon (IFN)-gamma significantly increased sPLA(2)-IIA mRNA and secretion. IFN-gamma-induced sPLA(2)-IIA was found to be active in cell media and associated with cell membrane proteoglycans. IFN-gamma induced sPLA(2)-IIA expression was antagonized by tumor necrosis factor (TNF)-alpha and interleukin (IL)-10. TNF-alpha added individually induced a significant but transient (4 h) increase in sPLA(2)-IIA secretion. IL-10 by itself did not affect sPLA(2)-IIA expression and secretion. IFN-gamma-stimulated sPLA(2)-IIA transcription involved STAT-3 protein. Interestingly, IL-6 but not IFN-gamma up-regulated the sPLA(2)-IIA expression in HepG2 cells, thus sPLA(2)-IIA induction by IFN-gamma response appears to be cell specific. In summary, conditions leading to cell differentiation induced sPLA(2)-IIA expression in HASMC and further exposure to IFN-gamma can up-regulate sPLA(2)-IIA transcription and secretion. This IFN-gamma stimulatory effect can be modulated by other cytokines.

CD44, a cell surface chondroitin sulfate proteoglycan, mediates binding of interferon-gamma and some of its biological effects on human vascular smooth muscle cells

Several cytokines and growth factors act on cells after their association with the glycosaminoglycan (GAG) moiety of cell surface proteoglycans (PGs). Interferon-gamma (IFN-gamma) binds to GAG; however, the relevance of this interaction for the biological activity of IFN-gamma on human cells remains to be established. Human arterial smooth muscle cells (HASMC), the main cells synthesizing PG in the vascular wall, respond markedly to IFN-gamma. We found that treatment of HASMC with chondroitinase ABC, an enzyme that degrades chondroitin sulfate GAG, reduced IFN-gamma binding by more than 50%. This treatment increased the affinity of 125I-IFN-gamma for cells from a Kd value of about 93 nM to a Kd value of about 33 nM. However, the total binding was reduced from 9. 3 +/- 0.77 pmol/microg to 3.0 +/- 0.23 pmol/mg (n = 4). Interestingly, pretreatment with chondroitinase ABC reduced significantly the cellular response toward IFN-gamma. The interaction of IFN-gamma with chondroitin sulfate GAG was confirmed by affinity chromatography of isolated cell-associated 35S-, 3H-labeled PG on a column with immobilized IFN-gamma. The cell-associated PG that binds to IFN-gamma was a chondroitin sulfate PG (CSPG). This CSPG had a core protein of approximately 110 kDa that was recognized by anti-CD44 antibodies on Western blots. High molecular weight complexes between IFN-gamma and chondroitin 6-sulfate were observed in gel exclusion chromatography. Additions of chondroitin 6-sulfate to cultured HASMC antagonized the antiproliferative effect and expression of major histocompatibility complex II antigens induced by IFN-gamma. These results indicate that IFN-gamma binds with low affinity to the chondroitin sulfate GAG moiety of the cell surface CSPG receptor CD44. This interaction may increase the local concentration of IFN-gamma at the cell surface, thus facilitating its binding to high affinity receptors and modulating the ability of IFN-gamma to signal a cellular response.

Hemin binding and oxidation of lipoproteins in serum: mechanisms and effect on the interaction of LDL with human macrophages

Most models of lipoprotein oxidation by free radicals have excluded macromolecular plasma components from the system. This limits their biological significance because oxidation of lipoproteins appears to occur in the intima in the presence of a plasma ultrafiltrate. Hemin, a product of in vivo hemoglobin degradation, binds and oxidizes purified lipoproteins. However, it is not known whether this occurs in the presence of plasma components that may sequester hemin. We found that hemin in serum diluted to protein levels of the extracellular fluid (10-30%) binds to low and high density lipoproteins (LDL, HDL) with association constants in the nmol/L range. In the presence of H2O2, hemin oxidizes both lipoproteins in diluted serum with formation of conjugated dienes, thiobarbituric acid reacting substances, and F2-isoprostanes. This appeared to be caused by the high affinity of hemin with LDL and by the Fe3+ liberated that remains associated with the particles after hemin is degraded. Spectrophotometric and fluorescence experiments and electrophoresis of porphyrins complex with LDL indicated that the heme ring is buried in the lipoprotein surface-monolayer with the carboxylic groups in contact with positive regions of the protein and the solvent. Human macrophages associated and degraded 3- to 4-times more hemin-oxidized LDL in diluted serum than native LDL. It is possible then that at sites of LDL, accumulation in the extracellular intima, hemin and H2O2 production could cause oxidation with potential atherogenic consequences for cellular lipoprotein processing. This may occur even when other macromolecules of the extracellular fluid are present.

Neoadjuvant chemotherapy with cisplatin and 5-fluorouracil in advanced squamous cell carcinoma of the head and neck: a randomized phase III study

BACKGROUND AND PURPOSE

In 1986 a prospective, randomized, multi-centre trial for evaluation of neoadjuvant chemotherapy with cisplatin and 5-fluorouracil in the treatment of advanced squamous cell carcinoma of the head and neck was initiated. As survival in this group of patients is poor the purpose was to find a possible survival benefit of the chemotherapy in addition to radiotherapy compared to radiotherapy only.

METHODS

Four-hundred sixty-one patients from Denmark, Norway and Sweden with tumors in oral cavity, oropharynx, hypopharynx and larynx were randomized to receive either standard treatment (radiotherapy or radiotherapy followed by surgery) or neoadjuvant chemotherapy followed by standard treatment. Chemotherapy included three courses of cisplatin 100 mg/m2 i.v. infusion on day 1 followed by 5-fluorouracil 1000 mg/m2 per day continuous i.v. infusion for 120 hours. Radiotherapy 64-70 Gy in 2 Gy per fraction, 5 times/week, was given to patients in both treatment arms.

RESULTS

Response rate was 71% for patients randomized to chemotherapy-radiotherapy and 66% for patients randomized to standard treatment (not statistically significant). Residual tumors were excised if possible. After surgery 62% of the patients randomized to chemotherapy-radiotherapy and 60% of the patients in the standard treatment group were clinically tumor free.

CONCLUSIONS

No statistically significant benefit in survival was observed for patients treated with neoadjuvant chemotherapy followed by radiotherapy. Nor was there any impact of chemotherapy on the number of patients achieving loco-regional tumor control after primary treatment.

Localization of nonpancreatic secretory phospholipase A2 in normal and atherosclerotic arteries. Activity of the isolated enzyme on low-density lipoproteins

Secretory nonpancreatic type II phospholipase A2 (snpPLA2) hydrolyzes fatty acids at the sn-2 position in phospholipids releasing free fatty acids (FFAs) and lysophospholipids. These products may act as intracellular second messengers or can be further metabolized into proinflammatory lipid mediators. The presence of snpPLA2 in extracellular fluids and serum during inflammation has suggested a role of the enzyme in this process. However, the presence of snpPLA2 in a variety of normal tissues suggests that snpPLA2 may also have physiological functions. Atherosclerosis appears to have an inflammatory component. Here we report on the snpPLA2 localization in normal and atherosclerotic lesions and on the properties of the isolated enzyme. A strong snpPLA2 immunoreactivity was observed in the arterial media that was colocalized with alpha-actin-positive vascular smooth muscle cells (SMCs) in both normal and atherosclerotic vessels. In aortic atherosclerotic lesions, snpPLA2 was observed colocalized with CD68-positive macrophages and HHF-35-positive SMCs and extracellularly in the lipid core. snpPLA2 was isolated from human normal arteries and from aorta with lesions. The enzyme was isolated by acid extraction of normal arterial tissues followed by immunoaffinity chromatography. The purified snpPLA2 had an expected molecular weight of 14 kD by polyacrylamide gel electrophoresis and appeared as a single band in immunoblotting. The enzymatic activity was followed by measuring release of fatty acids from phospholipid liposomes or LDL as substrates. The enzymatic activity was inhibited with two specific inhibitors for human snpPLA2: (1) monoclonal antibody 187 and (2) LY311727, a synthetic selective inhibitor. The mRNA for snpPLA2 was detected with reverse transcriptase polymerase chain reaction. These results indicate that snpPLA2 is present in human arteries and that it is able to hydrolyze phospholipids in LDL. The results support the hypothesis that snpPLA2 can release proinflammatory lipids at places of LDL deposition in the arterial wall.

Binding of human phospholipase A2 type II to proteoglycans. Differential effect of glycosaminoglycans on enzyme activity

Phospholipase A2 acting on low density lipoproteins in the extracellular arterial intima may form proinflammatory lipid mediators. Human nonpancreatic secretory phospholipase A2 has three regions that may associate with sulfated glycosaminoglycans. The apoB-100 molecule in low density lipoproteins also has glycosaminoglycan binding regions that could mediate its retention in the arterial intima. Here we report that human nonpancreatic phospholipase A2 isolated from a transfected cell line binds to glycosaminoglycans secreted by cultured human arterial smooth muscle cells. A gel mobility shift assay showed that the affinity of phospholipase A2 for glycosaminoglycans from a heparan sulfate/chondroitin sulfate proteoglycan was higher than for chondroitin sulfate glycosaminoglycans from a larger versican-like proteoglycan. Affinity chromatography confirmed these results. All glycosaminoglycans tested, at concentrations up to 100 microM, increased the activity of phospholipase A2 toward phosphatidylcholine liposomes. Above this concentration, heparan sulfate and heparin inhibited the enzyme. Heparin and chondroitin 6-sulfate increased phospholipase A2 activity on low density lipoproteins up to 4-fold at 100 microM, whereas heparan sulfate had no effect. The results indicate that human nonpancreatic secretory phospholipase A2 interacts with proteoglycans via their glycosaminoglycan moiety and that the enzyme activity may be modulated by the association of the enzyme and its substrate to the sulfated polysaccharides.