AB0894 Efficacy and Safety of Guselkumab in Biologic-Naïve Patients With Active Axial Psoriatic Arthritis: Study Design of a Phase 4, Randomized, Double-Blind, Placebo-Controlled Trial

Background

Established criteria for classifying axial psoriatic arthritis (PsA) are lacking, and assessments of disease activity often rely on measures developed for ankylosing spondylitis (AS). There is an unmet need to systematically identify and measure efficacy of treatments for axial PsA patients (pts). Guselkumab (GUS), a selective interleukin (IL)-23p19 inhibitor, was efficacious in improving signs and symptoms of active PsA in 2 phase 3, randomized, placebo (PBO)-controlled studies: DISCOVER-1 and DISCOVER-2. In a post-hoc pooled analysis of DISCOVER-1&2 pts with investigator-confirmed sacroiliitis, GUS-treated pts had greater improvements in axial symptoms compared with PBO.1 Imaging in DISCOVER-1&2 was restricted to the sacroiliac (SI) joints, occurring prior to/at screening as confirmed by the investigator, and locally read.

Objectives

To design a new, dedicated study to evaluate the effects of GUS on axial PsA prospectively.

Methods

Cumulative evidence from DISCOVER-1&2, including exposure–response relationship, covariate adjustment for modest baseline imbalances across treatment groups, subgroup analyses, and comparisons within and across these studies, was considered in designing a new trial. Data from the pivotal registrational studies suggest similar efficacy with GUS every-4-weeks (Q4W) and Q8W regimens in treating PsA signs and symptoms, including symptoms of axial involvement. Power calculations were based on mean changes in Bath AS Disease Activity Index (BASDAI) scores in DISCOVER-1&2.

Results

The phase 4, randomized, PBO-controlled STAR study is specifically designed to prospectively assess efficacy outcomes in PsA pts with magnetic resonance imaging (MRI)-confirmed axial inflammation. Based on observed mean (SD) changes from baseline in BASDAI score from DISCOVER-1&2 (Table 1), 405 pts, randomized (1:1:1) to GUS Q4W, GUS at W0, W4, then Q8W, or PBO →GUS Q8W at W24, are planned for enrollment (Figure 1). STAR eligibility criteria include PsA ≥6 months and active disease (≥3 swollen & ≥3 tender joints, C-reactive protein [CRP] ≥0.3 mg/dL) despite prior non-biologic disease-modifying antirheumatic drugs, apremilast, and/or non-steroidal anti-inflammatory drugs. Pts will be naïve to biologics and Janus kinase inhibitors and have BASDAI ≥4, spinal pain score (visual analog scale [VAS]) ≥4, and screening MRI-confirmed axial disease (positive spine and/or SI joints defined as centrally read Spondyloarthritis Research Consortium of Canada [SPARCC] score ≥3). Follow-up MRIs of spine and SI joints will be obtained at W0, W24, and W52 and also centrally read, with readers blinded to treatment group and timepoint. Spinal/SI joint inflammation will be scored using the SPARCC method, with the former also assessed using the CAN-DEN method. The primary endpoint is mean change in BASDAI at W24; controlled (hierarchical) secondary endpoints, all at W24, include AS Disease Activity Score (ASDAS-CRP), Disease Activity Index for PsA (DAPSA), ≥40% improvement in Assessment in AS criteria (ASAS40), and mean changes in spine/SI joint SPARCC scores.

Table 1.

Power calculations for the primary endpoint in the Phase 4 STAR study.

Historical trial data*Observed mean (SD) change in BASDAI from W0-24Effect sizePower(N=135; α=0.05)**PBO-1.28 (2.24)GUS 100 mg Q4W-2.51 (2.00)1.23>99%GUS 100 mg Q8W-2.61 (2.47)1.33>99%

* From the pooled DISCOVER-1&2 trials

**Power calculations based on N=135 per study group (1:1:1 randomization) and 2-sided significance of 0.05 using a 2-sample T-test assuming equal variances

BASDAI, Bath Ankylosing Spondylitis Disease Activity Index; GUS, guselkumab; PBO, placebo; Q4W, every 4 weeks; Q8W, every 8 weeks; SD, standard deviation; W, week

Conclusion

The phase 4 STAR study will allow for an in-depth, prospective evaluation of the effects of selectively inhibiting the IL-23p19 subunit with GUS in pts with MRI-confirmed axial PsA.

References

[1]Mease, et al. Lancet Rheum. 2021;3(10):e715-e723.

Disclosure of Interests

Dafna D Gladman Consultant of: AbbVie, Amgen, BMS, Celgene, Eli Lilly, Galapagos, Gilead, Janssen, Novartis, Pfizer, and UCB, Grant/research support from: Abbvie, Amgen, BMS, Celgene, Eli Lilly, Janssen, Novartis, Pfizer and UCB, Philip J Mease Speakers bureau: AbbVie, Aclaris, Amgen, BMS, Celgene, Eli Lilly, Galapagos, Gilead, GlaxoSmithKline, Inmagene, Janssen, Novartis, Pfizer, SUN Pharma, and UCB, Consultant of: AbbVie, Aclaris, Amgen, BMS, Celgene, Eli Lilly, Galapagos, Gilead, GlaxoSmithKline, Inmagene, Janssen, Novartis, Pfizer, SUN Pharma, and UCB, Grant/research support from: AbbVie, Aclaris, Amgen, BMS, Celgene, Eli Lilly, Galapagos, Gilead, GlaxoSmithKline, Inmagene, Janssen, Novartis, Pfizer, SUN Pharma, and UCB, Paul Bird Speakers bureau: AbbVie, Eli Lilly, Gilead, Janssen, MSD, Pfizer, and UCB, Consultant of: Eli Lilly, Gilead, Janssen, Novartis, and Pfizer, Enrique Soriano Speakers bureau: AbbVie, Amgen, Bristol Myers Squibb, Eli Lilly, Janssen, Novartis, Pfizer, Roche, and UCB, Consultant of: AbbVie, Janssen, Novartis, and Roche, Grant/research support from: AbbVie, Janssen, Novartis, Pfizer, Roche, and UCB, Soumya D Chakravarty Shareholder of: Johnson & Johnson, Employee of: Janssen Scientific Affairs, LLC, May Shawi Shareholder of: Johnson & Johnson, Employee of: Janssen Global Services, LLC, Stephen Xu Shareholder of: Johnson & Johnson, Employee of: Janssen Research & Development, LLC, Sean Quinn Shareholder of: Johnson & Johnson, Employee of: Janssen Scientific Affairs, LLC, Cinty Gong Shareholder of: Johnson & Johnson, Employee of: Janssen Scientific Affairs, LLC, Evan Leibowitz Shareholder of: Johnson & Johnson, Employee of: Janssen Scientific Affairs, LLC, Lai-Shan Tam Consultant of: Janssen, Pfizer, Sanofi, AbbVie, Boehringer Ingelheim, and Lilly, Grant/research support from: Amgen, Boehringer Ingelheim, Janssen, GSK, Novartis, and Pfizer, Philip Helliwell Speakers bureau: AbbVie, Janssen, and Novartis, Consultant of: Galapagos and Janssen, Grant/research support from: AbbVie, Janssen, and Pfizer, Arthur Kavanaugh Consultant of: Abbvie, Amgen, Bristol Myers Squibb, Eli Lilly, Gilead, Janssen, Novartis, Pfizer, and UCB, Atul Deodhar Speakers bureau: AbbVie, Eli Lilly, Janssen, Novartis, Pfizer, and UCB, Consultant of: AbbVie, Amgen, Boehringer Ingelheim, Bristol Myers Squibb, Celgene, Eli Lilly, Galapagos, Glaxo Smith & Kline, Janssen, Novartis, Pfizer, and UCB, Grant/research support from: AbbVie, Eli Lilly, Glaxo Smith & Kline, Novartis, Pfizer, and UCB, Mikkel Østergaard Speakers bureau: AbbVie, Boehringer-Ingelheim, Bristol Myers Squibb, Celgene, Eli-Lilly, Hospira, Janssen, Merck, Novartis, Novo, Orion, Pfizer, Regeneron, Roche, Sandoz, Sanofi, and UCB, Consultant of: AbbVie, Boehringer-Ingelheim, Bristol Myers Squibb, Celgene, Eli-Lilly, Hospira, Janssen, Merck, Novartis, Novo, Orion, Pfizer, Regeneron, Roche, Sandoz, Sanofi, and UCB, Grant/research support from: AbbVie, Bristol Myers Squibb, Celgene, and Novartis, Xenofon Baraliakos Speakers bureau: AbbVie, Biocad, Chugai, Eli Lilly, Janssen, MSD, Novartis, Pfizer, Roche, and UCB, Consultant of: AbbVie, Biocad, Chugai, Eli Lilly, Janssen, MSD, Novartis, Pfizer, Roche, and UCB, Grant/research support from: AbbVie, Biocad, Chugai, Eli Lilly, Janssen, MSD, Novartis, Pfizer, Roche, and UCB

POS1015 SAFETY OF GUSELKUMAB IN PATIENTS WITH ACTIVE PSORIATIC ARTHRITIS WHO ARE BIO-NAÏVE OR TNFi-EXPERIENCED: POOLED RESULTS FROM 4 RANDOMIZED CLINICAL TRIALS THROUGH 2 YEARS

Background

Guselkumab (GUS), a selective IL-23p19 subunit inhibitor, demonstrated efficacy and a favorable safety profile in active psoriatic arthritis (PsA) in the Phase (Ph)21, Ph3 (DISCOVER [D]-1&2)2,3, and Ph3b COSMOS4 randomized controlled trials (RCTs).

Objectives

Assess GUS safety through 2 years (Y) in biologic (bio)-naïve and tumor necrosis factor inhibitor (TNFi)-experienced (exp) active PsA patients (pts) pooled across 4 RCTs (Week [W] 56: Ph2 and COSMOS; W60: D1; W112: D2).

Methods

Eligible pts in COSMOS had inadequate response to 1 or 2 prior TNFi; 9% of Ph2 pts and 30% of D1 pts had 1 or 2 prior TNFi; D2 pts were bio-naïve. Incidence rates of adverse events (AEs) are summarized among all treated pts for the placebo (PBO)-controlled (W0-24) and active treatment periods through 2Y (max duration of exposure 100 W) according to actual treatment received, calculated as the number of events per 100 pt-Y of follow-up (PY), along with 95% confidence intervals (CI). Gastrointestinal (GI)-related serious AEs (SAEs) were identified using the Medical Dictionary for Regulatory Activities (MedDRA) system-organ class; major adverse cardiovascular events (MACE; predefined as MI, Stroke, or CV death) and opportunistic infections (OIs) were identified through medical review.

Results

Across the 4 RCTs, 1508 pts with active PsA received GUS 100 mg every 4 weeks (Q4W) or Q8W and were followed for a median of 1.2 Y, representing 2125 PY. In the overall population (N=1554), which includes PBO-treated pts that discontinued study agent prior to W24, 1138 pts were bio-naïve and 416 pts were TNFi-exp. Among all treated pts, the overall GUS safety profile was generally consistent with that of PBO through W24; rates remained low through 2Y of GUS (Table 1). The GUS safety profile was similar to that observed with PBO within the bio-naïve and TNFi-exp cohorts through W24. Incidence rates of AEs were generally consistent between cohorts in GUS-treated pts; whereas, TNFi-exp PBO-treated pts had more SAEs, study agent d/c due to AEs, and serious infections than bio-naïve PBO pts (Figure).

Table 1.

Overall Treatment-emergent AEs

PBO-controlled (W0-24)aThrough up to 2YPBOb(N=517)GUS Q8W (N=664)GUS Q4W (N=373)Combined GUS (N=1037)GUS Q8W (N=664)GUS Q4W (N=373)Combined GUSc(N=1508)Total (median) PY230 (0.5)305 (0.5)172 (0.5)478 (0.5)941 (1.1)645 (2.1)2125 (1.2)Events/100 PY (95% CI)AEs223 (204, 243)233 (216, 250)223 (201, 246)229 (216, 243)164 (156, 172)139 (130, 148)146 (141, 151)SAEs8.7 (5.3, 13)4.9 (2.8, 8.1)5.2 (2.4, 9.9)5.0 (3.2, 7.5)6.4 (4.9, 8.2)4.7 (3.1, 6.6)5.7 (4.7, 6.8)AEs leading to study agent d/c4.4 (2.1, 8.0)3.6 (1.8, 6.5)7.0 (3.6, 12.2)4.8 (3.1, 7.2)2.6 (1.6, 3.8)2.9 (1.8, 4.6)2.7 (2.1, 3.5)Infections59 (50, 70)56 (48, 65)57 (47, 70)57 (50, 64)43 (38, 47)37 (33, 42)39 (36, 42)Serious Infections2.2 (0.71, 5.1)0.33 (0.01, 1.8)1.7 (0.36, 5.1)0.84 (0.23, 2.1)1.7 (0.97, 2.8)0.77 (0.25, 1.8)1.5 (1.0, 2.1)Malignancy0.44 (0.01, 2.4)0.98 (0.20, 2.9)0.00 (0.00, 1.7)0.63 (0.13, 1.8)0.42 (0.12, 1.1)0.00 (0.00, 0.46)0.28 (0.10, 0.61)MACE0.44 (0.01, 2.4)0.33 (0.01, 1.8)0.58 (0.01, 3.2)0.42 (0.05, 1.5)0.21 (0.03, 0.77)0.46 (0.10, 1.4)0.24 (0.08, 0.55)GI-related SAEs1.3 (0.27, 3.8)0.33 (0.01, 1.8)0.00 (0.00, 1.7)0.21 (0.01, 1.2)0.32 (0.07, 0.93)0.46 (0.10, 1.4)0.28 (0.10, 0.61)OIs0.00 (0.00, 1.3)0.00 (0.00, 0.98)0.00 (0.00, 1.7)0.00 (0.00, 0.63)0.21 (0.03, 0.77)0.00 (0.00, 0.46)0.14 (0.03, 0.41)

MedDRA Version 23.1.

a Includes safety follow-up data through 2Y for pts who d/c study agent prior to W24 and did not receive any study agent at or after W24.

b Includes data prior to GUS in PBO pts who switched from PBO to GUS.

c Includes PBO to GUS cross-over at W24.

Conclusion

The favorable GUS safety profile demonstrated through W24 persisted through 2Y across bio-naïve and TNFi-exp pts.

References

[1]Deodhar A, et al. Lancet. 2018;391:2213-2224.

[2]Deodhar A, et al. Lancet. 2020;395:1115-1125.

[3]Mease PJ, et al. Lancet. 2020;395:1126-1136.

[4]Coates LC, et al. ARD. 2021;80:140-141. OP0230.

Disclosure of Interests

Proton Rahman Consultant of: AbbVie, Amgen, Bristol Myers Squibb, Celgene, Eli Lilly, Janssen, Merck, Novartis, Pfizer, and UCB, Grant/research support from: Janssen and Novartis, Wolf-Henning Boehncke Speakers bureau: AbbVie, Almirall, Janssen, Leo, Lilly, Novartis, and UCB, Consultant of: AbbVie, Almirall, Janssen, Leo, Lilly, Novartis, and UCB, Philip J Mease Speakers bureau: AbbVie, Amgen, Eli Lilly, Janssen, Novartis, Pfizer, Sun Pharma, and UCB, Consultant of: AbbVie, Aclaris, Amgen, Boehringer Ingelheim, Bristol Myers Squibb, Eli Lilly, Galapagos, Gilead, GlaxoSmithKline, Inmagene, Janssen, Novartis, Pfizer, Sun Pharma, and UCB, Grant/research support from: AbbVie, Amgen, Bristol Myers Squibb, Eli Lilly, Galapagos, Gilead, Janssen, Novartis, Pfizer, Sun Pharma, and UCB, Alice B Gottlieb Consultant of: AnaptsysBio, Avotres Therapeutics, Beiersdorf, Boehringer Ingelheim, Bristol-Myers Squibb, Incyte, GSK, Janssen, LEO Pharma, Eli Lilly, Novartis, Pfizer, Sun Pharmaceutical Industries, Inc., UCB, and Dermavant, Grant/research support from: Boehringer Ingelheim, Incyte, Janssen, Novartis, UCB, Xbiotech, and Sun Pharma, Iain McInnes Shareholder of: Causeway Therapeutics and Evelo Compugen, Consultant of: Astra Zeneca, AbbVie, Amgen, Bristol-Myers Squibb, Eli Lilly, Cabaletta, Compugen, GSK, Gilead, Janssen, Novartis, Pfizer, Sanofi, Roche, and UCB, Grant/research support from: Astra Zeneca, Bristol-Myers Squibb, Amgen, Eli Lilly, GSK, Janssen, Novartis, Roche, and UCB, Marlies Neuhold Shareholder of: Johnson & Johnson, Employee of: Janssen Scientific Affairs, LLC, May Shawi Shareholder of: Johnson & Johnson, Employee of: Janssen Pharmaceutical Companies of Johnson & Johnson, Yanli Wang Consultant of: Janssen, Employee of: IQVIA, Shihong Sheng Shareholder of: Johnson & Johnson, Employee of: Janssen Research & Development, LLC, Paul Bergmans Shareholder of: Johnson & Johnson, Employee of: Janssen Biostatistics, Alexa Kollmeier Shareholder of: Johnson & Johnson, Employee of: Janssen Research & Development, LLC, Elke Theander Employee of: Janssen Scientific Affairs, LLC, Jenny Yu Shareholder of: Johnson & Johnson, Employee of: Janssen Research & Development, LLC, Evan Leibowitz Shareholder of: Johnson & Johnson, Employee of: Janssen Scientific Affairs, LLC, Marilise Marrache Shareholder of: Johnson & Johnson, Employee of: Medical Affairs, Janssen Inc., Laura Coates Speakers bureau: AbbVie, Amgen, Biogen, Celgene, Eli Lilly, Galapagos, Gilead, Janssen, Medac, Novartis, Pfizer and UCB, Consultant of: AbbVie, Amgen, Boehringer Ingelheim, Bristol Myers Squibb, Celgene, Eli Lilly, Gilead, Galapagos, Janssen, Novartis, Pfizer, and UCB, Grant/research support from: AbbVie, Amgen, Celgene, Eli Lilly, Janssen, Novartis, Pfizer, and UCB

Low ALT values amongst hospitalized patients are associated with increased risk of hypoglycemia and overall mortality: a retrospective, big-data analysis of 51 831 patients

BACKGROUND

Sarcopenia and frailty influence clinical patients' outcomes. Low alanine aminotransferase (ALT) serum activity is a surrogate marker for sarcopenia and frailty. In-hospital hypoglycemia is associated, also with worse clinical outcomes.

AIM

We evaluated the association between low ALT, risk of in-hospital hypoglycemia and subsequent mortality.

DESIGN

This was a retrospective cohort analysis.

METHODS

We included patients hospitalized in a tertiary hospital between 2007 and 2019. Patients' data were retrieved from their electronic medical records.

RESULTS

The cohort included 51 831 patients (average age 70.88). The rate of hypoglycemia was 10.8% (amongst diabetics 19.4% whereas in non-diabetics 8.3%). The rate of hypoglycemia was higher amongst patients with ALT < 10 IU/l in the whole cohort (14.3% vs. 10.4%, P < 0.001) as well as amongst diabetics (24.6% vs. 18.8%, P < 0.001). Both the overall and in-hospital mortality were higher in the low ALT group (57.7% vs. 39.1% P < 0.001 and 4.3% vs. 3.2%, P < 0.001). A propensity score matching, after which a regression model was performed, showed that patients with ALT levels < 10 IU/l had higher risk of overall mortality (HR = 1.21, CI 1.13-1.29, P < 0.001).

CONCLUSIONS

Low ALT values amongst hospitalized patients are associated with increased risk of in-hospital hypoglycemia and overall mortality.

Baseline low ALT activity is associated with increased long-term mortality after COPD exacerbations

BACKGROUND

COPD exacerbations have negative impact on patients' survival. Several risk factors for grave outcomes of such exacerbations have been descried. Muscle dysfunction and mass loss were shown to impact negatively on prognosis and survival. Low activity of the enzyme ALT (Alanine amino-transferase) in the blood is a known indicator for sarcopenia and frailty, however, no previous studies addressed the association of low ALT amongst patients hospitalized due to COPD exacerbation and long-term survival.

METHODS

This is a historic prospective cohort study of patients hospitalized due to acute COPD exacerbation.

RESULTS

Included were 232 consecutive COPD exacerbation patients. The median time of follow-up was 34.9 months (IQR 23.13-41.73 months). During this period 104 (44.8%) patients died. All patients were grouped to quartiles according to blood ALT levels (after exclusion of cases considered to have hepatic tissue damage (ALT > 40 IU)). The risk of long-term mortality increased, in a statistically significant manner, amongst patients with low ALT values: the median survival of patients with ALT < 11 IU was 18.5 months only while the median survival for the rest of the study group was not reached. For ALT < 11 IU; 12-16 IU; 17-20 IU and > 21 IU the mortality rates were 69%; 40.9%; 36.3 and 25% respectively (p <  0.001 for comparison of lower quartile with upper three quartiles). The crude hazard ratio for mortality amongst patients with ALT levels lower than 11 IU was 2.37 (95% CI; 1.6-3.5). This increased risk of mortality remained significant after adjustment for age, weight, creatinine, albumin concentration and cardiovascular diseases (HR = 1.83; 95% CI 1.08-3.1, p <  0.05).

CONCLUSIONS

Low ALT values, a biomarker of sarcopenia and frailty, are associated with poor long-term survival amongst patients hospitalized due to COPD exacerbation.

A giant planet orbiting the ‘extreme horizontal branch’ star V 391 Pegasi

After the initial discoveries fifteen years ago, over 200 extrasolar planets have now been detected. Most of them orbit main-sequence stars similar to our Sun, although a few planets orbiting red giant stars have been recently found. When the hydrogen in their cores runs out, main-sequence stars undergo an expansion into red-giant stars. This expansion can modify the orbits of planets and can easily reach and engulf the inner planets. The same will happen to the planets of our Solar System in about five billion years and the fate of the Earth is matter of debate. Here we report the discovery of a planetary-mass body (Msini = 3.2M(Jupiter)) orbiting the star V 391 Pegasi at a distance of about 1.7 astronomical units (au), with a period of 3.2 years. This star is on the extreme horizontal branch of the Hertzsprung-Russell diagram, burning helium in its core and pulsating. The maximum radius of the red-giant precursor of V 391 Pegasi may have reached 0.7 au, while the orbital distance of the planet during the stellar main-sequence phase is estimated to be about 1 au. This detection of a planet orbiting a post-red-giant star demonstrates that planets with orbital distances of less than 2 au can survive the red-giant expansion of their parent stars.

[Tuberculous choroiditis]

Tuberculosis is a rare cause of choroiditis. In most cases there is only a presumptive diagnosis based on a history of TB, its clinical picture, and a positive skin test. A 79-year-o;d man complained of acute, right visual loss. On examination, choroiditis was found. During his 20s he had had pulmonary tuberculosis; his Mantoux test was positive.

Pseudotumor cerebri induced by vitamin A combined with minocycline

A 16-year-old girl complained about a headache of one-month's duration, accompanied by vertical diplopia that had appeared ten days earlier. The girl reported receiving vitamin A and minocycline to treat acne vulgaris for the previous six weeks. An examination revealed bilateral optic disc edema. Normal computed tomographic and magnetic resonance imaging examinations enabled a diagnosis of pseudotumor cerebri to be made. Soon after discontinuation of those medications, the headaches and diplopia diminished. We suggest a periodic ophthalmologic examination during systemic therapy with vitamin A combined with minocycline to detect the early occurrence of pseudotumor cerebri.

Are psoriatic patients at risk of heat intolerance?

Sixteen young male subjects with psoriasis (mean of 4.9% of skin surface area involvement) and 10 healthy controls underwent a heat exercise test (40 degrees C, 40% r.h.) for 2 h. Rectal temperature (Tr), mean skin temperature (Tsk), heart rate (HR) and heat storage (dS) were measured and calculated. A sharper rise was found for all parameters in the psoriatic patients as compared with controls. Statistically significant differences were found in Tr after 60 min (37.9 +/- 0.1 degrees C and 37.5 +/- 0.1 degrees C in patients and controls, respectively) and at termination of the exercise (38.3 +/- 0.1 degrees C and 37.5 +/- 0.1 degrees C). Heat storage at the end of the first hour was 78 +/- 9 and 30 +/- 7 kcal in patients and controls, respectively. At the end of 120 min, heat storage in the study group increased to 87 +/- 14 kcal, while the control group stored only 30 +/- 7 kcal. Sweat rate was lower in the psoriatic patients (590 +/- 49 g/h) than in controls (691 +/- 42 g/h), even when corrected for healthy skin area (337 +/- 26 g/h/m2 compared with 370 +/- 24 g/h/m2). It is suggested that psoriatic patients have a reduced ability to dissipate extra heat during exposure to exercise in the heat. Psoriasis should therefore be considered as a risk factor for heat intolerance.

Interferon treatment in acute progressive and fulminant hepatitis

A small proportion of patients with acute viral hepatitis run a progressive fulminant course ending in acute liver failure with encephalopathy, and with a mortality rate of 75-80%. In small children and pregnant women mortality is even higher. We have treated 32 patients of all ages with acute progressive and fulminant hepatitis over the last 7 years in an uncontrolled trial with human interferon-alpha (HulFN-alpha), with i.m. doses of 3 x 10(6) u/day (70,000 u/kg per day for infants) for 8 +/- 3 days (mean +/- SD.) In 17 patients hepatitis was due to hepatitis A virus, in 7 to hepatitis B virus, in 6 to non A-non B virus and in 1 case each to herpes and cytomegalovirus. Sixteen patients (50%) recovered including 9 of 22 (41%) who were in Grades III-IV coma when treatment was started. Only 1 of 8 children less than 4 years of age recovered, whereas 15 of 24 (62%) older children and adults survived. Two of three pregnant women with acute fulminant hepatitis survived. In patients who recovered, improvement was often noted on about the fifth day of IFN treatment: 9 of 16 patients died before completing 5 days of therapy. Our studies of the IFN system response to hepatitis viruses showed that the greater majority of patients produce IFN in the acute stage of the infection. However, a minority have a defective IFN response that is more severe and more common in progressive fulminant hepatitis, and in several of these patients IFN response was completely lacking. It is in these cases that IFN treatment is likely to have the greatest value. On the basis of these encouraging preliminary results, it is suggested that a well-controlled, double-blind study be done to evaluate the effectiveness of HulFN-alpha treatment when given early during the course of acute progressive viral hepatitis.

Interferon system in acute transient synovitis

The interferon system of 20 children aged 2 to 11 years (mean 5 years), diagnosed as having transient synovitis of the hip by clinical criteria, was studied. The mean blood interferon concentration was significantly higher than that of normal children, and the incidence of an antiviral state of cells (in 78% of patients) was also significantly higher than in the control group. These findings are compatible with the hypothesis that the aetiology of transient synovitis is an acute, possibly unusual, viral infection.

Anterior sacral meningocele contiguous with a pelvic hamartoma. Case report

A patient with an anterior sacral meningocele combined with a hamartoma was diagnosed with x-ray films, myelography, and computerized tomography. She was successfully operated on by a transabdominal approach.