Association Between Autoimmune Diseases and Monoclonal Gammopathy of Undetermined Significance : An Analysis From a Population-Based Screening Study

BACKGROUND

Monoclonal gammopathy of undetermined significance (MGUS) is a precursor of multiple myeloma (MM) and related conditions. In previous registry-based, retrospective studies, autoimmune diseases have been associated with MGUS. However, these studies were not based on a screened population and are therefore prone to ascertainment bias.

OBJECTIVE

To examine whether MGUS is associated with autoimmune diseases.

DESIGN

A cross-sectional study within iStopMM (Iceland Screens, Treats, or Prevents MM), a prospective, population-based screening study of MGUS.

SETTING

Icelandic population of adults aged 40 years or older.

PATIENTS

75 422 persons screened for MGUS.

MEASUREMENTS

Poisson regression for prevalence ratios (PRs) of MGUS among persons with or without an autoimmune disease, adjusted for age and sex.

RESULTS

A total of 10 818 participants had an autoimmune disorder, of whom 599 had MGUS (61 with a prior clinical diagnosis and 538 diagnosed at study screening or evaluation). A diagnosis of an autoimmune disease was not associated with MGUS (PR, 1.05 [95% CI, 0.97 to 1.15]). However, autoimmune disease diagnoses were associated with a prior clinical diagnosis of MGUS (PR, 2.11 [CI, 1.64 to 2.70]).

LIMITATION

Registry data were used to gather information on autoimmune diseases, and the homogeneity of the Icelandic population may limit the generalizability of these results.

CONCLUSION

The study did not find an association between autoimmune disease and MGUS in a systematically screened population. Previous studies not done in systematically screened populations have likely been subject to ascertainment bias. The findings indicate that recommendations to routinely screen patients with autoimmune disease for MGUS may not be warranted.

PRIMARY FUNDING SOURCE

The International Myeloma Foundation and the European Research Council.

Development of a Multivariable Model to Predict the Need for Bone Marrow Sampling in Persons With Monoclonal Gammopathy of Undetermined Significance : A Cohort Study Nested in a Clinical Trial

BACKGROUND

Monoclonal gammopathy of undetermined significance (MGUS) and smoldering multiple myeloma (SMM) are asymptomatic precursor conditions to multiple myeloma and related disorders. Smoldering multiple myeloma is distinguished from MGUS by 10% or greater bone marrow plasma cells (BMPC) on sampling, has a higher risk for progression, and requires specialist management.

OBJECTIVE

To develop a multivariable prediction model that predicts the probability that a person with presumed MGUS has 10% or greater BMPC (SMM or worse by bone marrow criteria) to inform the decision to obtain a bone marrow sample and compare its performance to the Mayo Clinic risk stratification model.

DESIGN

iStopMM (Iceland Screens, Treats or Prevents Multiple Myeloma), a prospective population-based screening study of MGUS. (ClinicalTrials.gov: NCT03327597).

SETTING

Icelandic population of adults aged 40 years or older.

PATIENTS

1043 persons with IgG, IgA, light-chain, and biclonal MGUS detected by screening and an interpretable bone marrow sample.

MEASUREMENTS

Monoclonal gammopathy of undetermined significance isotype; monoclonal protein concentration; free light-chain ratio; and total IgG, IgM, and IgA concentrations were used as predictors. Bone marrow plasma cells were categorized as 0% to 4%, 5% to 9%, 10% to 14%, or 15% or greater.

RESULTS

The c-statistic for SMM or worse was 0.85 (95% CI, 0.82 to 0.88), and calibration was excellent (intercept, -0.07; slope, 0.95). At a threshold of 10% predicted risk for SMM or worse, sensitivity was 86%, specificity was 67%, positive predictive value was 32%, and negative predictive value was 96%. Compared with the Mayo Clinic model, the net benefit for the decision to refer for sampling was between 0.13 and 0.30 higher over a range of plausible low-risk thresholds.

LIMITATION

The prediction model will require external validation.

CONCLUSION

This accurate prediction model for SMM or worse was developed in a population-based cohort of persons with presumed MGUS and may be used to defer bone marrow sampling and referral to hematology.

PRIMARY FUNDING SOURCE

International Myeloma Foundation and the European Research Council.

The IGF system and longitudinal growth in preterm infants in relation to gestational age, birth weight and gender

OBJECTIVE

Growth factors in the blood of very preterm infants may reflect growth and contribute to the understanding of early development. We investigated postnatal levels of insulin-like growth factors (IGFs) in infants born very preterm and related them to early growth development.

DESIGN

Blood samples were analyzed weekly for IGF-I, IGF-II, IGF binding protein (BP)-1, IGFBP-3, and acid-label subunit (ALS).

METHODS

73 children born very preterm (gestational age (GA) <32 weeks) were divided according to their gender-specific birth weight standard deviation score (SDS) into either appropriate for GA (AGA) or small for GA (SGA). Fifty-two (71%) and forty-three (59%) infants completed follow-up with anthropometry at approximately 3 years and at 5 years of age respectively. Thirty-six subjects (49%) had blood sampling for IGF-I and IGFBP-3 measurements up to 3 years of age.

RESULTS

IGF-I, IGFBP-3, and ALS levels increased in all groups from week 31 to week 36, with generally lower levels in the SGAs, with a concomitant lower growth velocity. Postnatal ALS was strongly associated with IGF-I and IGFBP-3 in boys, girls and AGA infants. IGF-II was higher in earlier born preterms (GA < 27 weeks) at postmenstrual ages 27.5-29.9 weeks compared with SGAs and late GA (GA ≥ 27 weeks) preterms (p < .0001). IGF-II, in contrast to IGF-I, did not differ between SGAs and AGAs at weeks 31-36. Mean IGFBP-1 was highest in the SGAs compared to AGAs at mean week 28,5 and 31 (p = .001) and IGFBP-1 levels were elevated in relation to IGF-I in the SGAs at that period. At follow-up, the increase in IGF-I between week 31 and 33.5 was a significant positive determinant of height SDS at 3 and 5 years of age in forward multiple regression analysis, independent of target height.

CONCLUSION

This is the first study to investigate postnatal ALS levels in preterm infants. In very preterm infants, IGF-II is less affected by size at birth during early postnatal weeks compared with IGF-I. Early elevated IGFBP-1 might protect the SGA infants from an intense metabolic rate. Our results indicate that anabolic and metabolic processes during weeks 31-36 predicts later height.

The External Genitalia Score (EGS): A European Multicenter Validation Study

CONTEXT

Standardized description of external genitalia is needed in the assessment of children with atypical genitalia.

OBJECTIVES

To validate the External Genitalia Score (EGS), to present reference values for preterm and term babies up to 24 months and correlate obtained scores with anogenital distances (AGDs).

DESIGN, SETTING

A European multicenter (n = 8) validation study was conducted from July 2016 to July 2018.

PATIENTS AND METHODS

EGS is based on the external masculinization score but uses a gradual scale from female to male (range, 0-12) and terminology appropriate for both sexes. The reliability of EGS and AGDs was determined by the interclass correlation coefficient (ICC). Cross-sectional data were obtained in 686 term babies (0-24 months) and 181 preterm babies, and 111 babies with atypical genitalia.

RESULTS

The ICC of EGS in typical and atypical genitalia is excellent and good, respectively. Median EGS (10th to 90th centile) in males < 28 weeks gestation is 10 (8.6-11.5); in males 28-32 weeks 11.5 (9.2-12); in males 33-36 weeks 11.5 (10.5-12) and in full-term males 12 (10.5-12). In all female babies, EGS is 0 (0-0). The mean (SD) lower/upper AGD ratio (AGDl/u) is 0.45 (0.1), with significant difference between AGDl/u in males 0.49 (0.1) and females 0.39 (0.1) and intermediate values in differences of sex development (DSDs) 0.43 (0.1). The AGDl/u correlates with EGS in males with typical genitalia and in atypical genitalia.

CONCLUSIONS

EGS is a reliable and valid tool to describe external genitalia in premature and term babies up to 24 months. EGS correlates with AGDl/u in males. It facilitates standardized assessment, clinical decision-making and multicenter research.

Neonatal IGF-1/IGFBP-1 axis and retinopathy of prematurity are associated with increased blood pressure in preterm children

Aim

Preterm children are at risk of developing increased blood pressure (BP). We evaluated possible associations between BP, early insulin-like growth factor-1 (IGF-1) and IGF-binding protein-1 (IGFBP-1) levels and retinopathy of prematurity (ROP) in preterm children.

Methods

The study included 32 infants: median gestational age 28.1 weeks (range 24.6–31.3) and birthweight standard deviation scores (SDS) (±SD) 1.0 ± 2.7. IGF-1 and IGFBP-1 at postnatal weeks 32.6–34.6 and ROP stages were established after birth. BP was measured at the age of 4 years. The ratio (IGF-1)²/IGFBP-1 was created to investigate the influence of both IGF-1 and IGFBP-1 to later BP.

Results

Diastolic BP correlated with IGFBP-1, inversely correlated with IGF-1 and IGF-1²/IGFBP-1 (r = −0.71, p < 0.0001) and positively correlated with catch-up growth velocity from lowest weight SDS to age 36.5 weeks (r = 0.48, p < 0.01), independent of gestational age. Children with moderate-to-severe ROP as neonates had higher mean arterial BP [78 (±95%CI 74–83) vs 71 (±95%CI 68–75) mm Hg, p < 0.05] adjusted for gestational age and birthweight SDS compared to children diagnosed with no to mild ROP.

Conclusion

Low neonatal IGF-1²/IGFBP-1 and severe ROP were associated with higher BP in 4-year-old children born very preterm and may thus predict future cardiovascular morbidity.

Longitudinal postnatal weight and insulin-like growth factor I measurements in the prediction of retinopathy of prematurity

OBJECTIVE

To investigate whether postnatal growth and development influence retinopathy of prematurity (ROP) and may be included in screening for ROP.

DESIGN

We developed an algorithm to predict for individual infants the risk of later ROP development requiring treatment based on the postnatal longitudinal systemic factors of insulin-like growth factor I (IGF-I) level, IGF binding protein 3 level, and postnatal weight gain. We developed the algorithm based on 79 preterm infants considered at risk for ROP by standard criteria (gestational age, 23.6-31.7 weeks) in a longitudinal study measuring weight gain and serum IGF-I and IGF binding protein 3 levels weekly from birth until discharge from the hospital. We monitored deviations from reference models for weight and IGF-I level (preterm children who developed no or minimal ROP) to detect indications for treatable ROP by Early Treatment for Retinopathy of Prematurity study criteria.

RESULTS

This monitoring method detected 6 (100%) of 6 infants in this cohort who required treatment for ROP with a warning signal at least 5 weeks before requiring treatment and at least 3 weeks before the onset of stage 3 ROP. The majority of infants (61/73 infants) requiring no treatment were also correctly identified.

CONCLUSIONS

Monitoring the postnatal factors of weight, IGF-I level, and IGF binding protein 3 level substantially enhances the clinician's ability to identify patients who will require treatment for ROP.

Postnatal head growth deficit among premature infants parallels retinopathy of prematurity and insulin-like growth factor-1 deficit

BACKGROUND

We hypothesized that in premature infants, retinal vascular growth retardation between birth and postmenstrual age of approximately 30 to 32 weeks that initiates retinopathy of prematurity is paralleled by brain growth retardation.

METHODS

In a prospective longitudinal study, we measured postnatal head growth, retinopathy of prematurity stage, protein and energy intake, severity of illness and serum insulin-like growth factor-1 levels in 58 preterm infants (mean gestational age at birth: 27.6 weeks) from birth until postmenstrual age of approximately 40 weeks.

RESULTS

Premature infant head growth decelerates dramatically after birth until postmenstrual age of approximately 30 weeks. Head growth retardation coincides with retinal vascular growth suppression. Accelerated growth follows between post menstrual ages of approximately 30 to 32 weeks and approximately 40 weeks. The degree of head growth retardation up to postmenstrual age of 31 weeks corresponds to the degree of retinopathy of prematurity and to the degree of suppression of serum levels of insulin-like growth factor-1. At postmenstrual age of 31 weeks, if a child's head circumference SD is below -2.5, then the probability of also developing at least stage 3 retinopathy of prematurity increases fivefold compared with head circumference above -2.5 SD (32% vs 6%) suggesting parallel processes in brain and retina. Serum insulin-like growth factor-1 levels correlate positively with head circumference SD score and with the degree of retinopathy of prematurity.

CONCLUSIONS

The correlation between head and retinal growth is consistent with insulin growth factor-1 being one of the postnatal growth factors involved in this multifactorial process and also suggests that factors that contribute to retinopathy of prematurity during this critical period may also affect neurological dysfunction. Additional studies are required to establish this connection.

The wandering central venous catheter. An unusual case of catheter displacement

A subclavian central venous catheter wandered spontaneously between the superior caval and the internal jugular veins. The case supports the routine of regular X-ray checks for catheter position.

Enflurane hepatitis. A report of a case with a previous history of halothane hepatitis

"Enflurane hepatitis" has only recently been accepted as a disease entity. As far as the authors know, this paper is the first report on enflurane hepatitis in a patient with a previous history of halothane hepatitis. Our conclusion is that a potent halogenated inhalation agent should never be given to a patient if a prior administration of another such agent has led to the development of hepatic injury.

Formic acid burn--local and systemic effects. Report of a case

Formic acid is an organic acid which has mainly been used in industry, but in recent years its use in agriculture has greatly increased in the Scandinavian countries. Formic acid is more caustic to the skin than acetic acid. However, reports on formic acid burns are scarce in the medical literature, and no serious burn has previously been described. A few reports on formic acid ingestion have been published. It is of great interest that formic acid has been shown to play the major role in the methanol poisoning syndrome. A case of severe burn with undiluted formic acid is reported. In the beginning, the dermal injury seemed to be of minor degree, but then the patient, a 15-year-old girl, developed signs of systemic formic acid intoxication, including metabolic acidosis, intravascular hemolysis and hemoglobinuria. These signs were similar to those described as a result of formic acid ingestion. The systemic effects were successfully treated without late sequelae, but the burn turned out mainly to be full-thickness, resulting in major scarring, as commonly seen after various chemical burns.

Effect of a three-day course of nalidixic acid in the frequency-dysuria syndrome with significant bacteriuria in women

The effect of a 3-day course of nalidixic acid was studied in 82 women, presenting with the dysuria-frequency syndrome and significant bacteriuria, mostly Escherichia coli sensitive to nalidixic acid. 62/76 patients (82%) that could be evaluated about 1 week after initiation of therapy were subjectively cured. Negative urinary cultures were found in 64/76 patients (84%). Two patients (2.4%) developed resistance to nalidixic acid. Bacteriological cure rate was 76% of 71 patients that could be controlled 1 month after the initiation of therapy. Nalidixic acid in the used granulate preparation initiated only mild side-effects.

The anaesthetic management of a patient with familial dysautonomia

Familial dysautonomia is a rare inherited disease of the nervous system, involving mainly peripheral sensory and sympathetic nerves. The autonomic instability is of greatest importance for the anaesthetist although the sensory defect is the most dramatic symptom of the disease. A case report of a 15-year-old girl undergoing two operations for severe scoliosis is presented with a discussion of the anaesthetic problems encountered in this disease.

Sleep disturbances, nightmares and other possible central nervous disturbances in a population sample of women, with special reference to those on antihypertensive drugs

Of 1302 women aged 44-66 years in a population study in Göteborg, Sweden, in 1974-75, who were representative of women of all the ages studied in the area, 165 were taking antihypertensive drugs, mostly beta-blockers and diuretics. The prevalence of sleep disturbances, nightmares, tiredness and melancholia or depression was studied in the total population sample, and a comparison was made between women who were or were not taking antihypertensive drugs. In the entire population sample no significant difference was found between the various age strata studied, although with increasing age there was a trend towards fewer complaints of nightmares, but a larger number of sleep disturbances as a whole. No difference was found between women taking or not taking various types of single-drug therapy or combinations of antihypertensive drugs.