Phenotypic characteristics of patients with chronic widespread pain and fibromyalgia: a cross-sectional cluster analysis

OBJECTIVE

This study aimed to explore whether phenotypic characteristics of patients with chronic widespread pain (CWP) and fibromyalgia (FM) can be aggregated into definable clusters that may help to tailor treatments.

METHOD

Baseline variables (sex, age, education, marital/employment status, pain duration, prior CWP/FM diagnosis, concomitant rheumatic disease, analgesics, tender point count, and disease variables derived from standardized questionnaires) collected from 1099 patients (93.4% females, mean age 44.6 years) with a confirmed CWP or FM diagnosis were evaluated by hierarchical cluster analysis. The number of clusters was based on coefficients in the agglomeration schedule, supported by dendrograms and silhouette plots. Simple and multiple regression analyses using all variables as independent predictors were used to assess the likelihood of cluster assignment, reported as odds ratios (ORs) with 95% confidence intervals (CIs).

RESULTS

Only one cluster emerged (Cluster 1: 455 patients). Participants in this cluster were characterized as working (OR 66.67, 95% CI 7.14 to 500.00), with a medium-term/higher education (OR 16.80, 95% CI 1.94 to 145.41), married/cohabiting (OR 14.29, 95% CI 1.26 to 166.67), and using mild analgesics (OR 25.64, 95% CI 0.58 to > 999.99). The odds of being an individual in Cluster 1 were lower when having a worse score on the PDQ (score ≥ 18) (OR < 0.001, 95% CI < 0.001 to 0.02).

CONCLUSION

We identified one cluster, where participants were characterized by a potentially favourable clinical profile. More studies are needed to evaluate whether these characteristics could be used to guide the management of patients with CWP and FM.

Validity of the Brief Illness Perception Questionnaire in people with knee pain: a Rasch analysis

OBJECTIVE

The Brief Illness Perception Questionnaire (B-IPQ) is a frequently used measure of illness perception (IP). The aim of this study was to explore the psychometric properties of the questionnaire when used in elderly people with knee pain.

METHOD

Based on data from the Frederiksberg Cohort on elderly people reporting knee pain (N = 836), the psychometric properties of the eight B-IPQ items (1 'Consequences', 2 'Timeline', 3 'Personal control', 4 'Treatment control', 5 'Identity', 6 'Concern', 7 'Coherence', and 8 'Emotions') were analysed using Rasch analysis to establish whether the questionnaire provides reliable and valid measures of IP.

RESULTS

Threshold disordering was found on the 1-10 rating scale in all items. When rescaling to a 0-2 rating scale, disordering was resolved in six items. Item goodness-of-fit analyses revealed that two items displayed underfit misfit and four items overfit misfit; hence, the B-IPQ does not present unidimensionality. The person separation index indicated that items separate respondents into only two IP levels. Finally, floor and ceiling effects were found, indicating that the B-IPQ may not fully describe the extent of IP in this population.

CONCLUSION

The 1-10 rating scale used in the Danish B-IPQ targeting knee pain is suboptimal, while a 0-2 scale improves the psychometric properties of the scale. The B-IPQ does not present unidimensionality and the use of a sum score is therefore not recommended when assessing IP. The B-IPQ may not cover the extent of IP in elderly people with knee pain.

Exercise and education vs intra-articular saline for knee osteoarthritis: a 1-year follow-up of a randomized trial

OBJECTIVE

To assess the longer-term effect of the Good Life with osteoarthritis in Denmark (GLAD) exercise and education program relative to open-label placebo (OLP) on changes from baseline in core outcomes in individuals with knee osteoarthritis (OA).

METHODS

In this 1-year follow-up of an open-label, randomized trial, patients with symptomatic and radiographically confirmed knee OA were monitored after being randomized to either the 8-week GLAD program or OLP given as 4 intra-articular saline injections over 8 weeks. The primary outcome was the change from baseline in the Knee injury and Osteoarthritis Outcome Score questionnaire (KOOS) pain subscale after 1 year in the intention-to-treat population. Key secondary outcomes were the KOOS function and quality of life subscales, and Patients' Global Assessment of disease impact.

RESULTS

206 adults were randomly assigned: 102 to GLAD and 104 to OLP, of which only 137 (63/74 GLAD/OLP) provided data at 1 year. At one year the mean changes in KOOS pain were 8.4 for GLAD and 7.0 for OLP (Difference: 1.5 points; 95% CI -2.6 to 5.5). There were no between-group differences in any of the secondary outcomes.

CONCLUSIONS

In this 1-year follow-up of individuals with knee OA, the 8-week GLAD program and OLP both provided minor longer-term benefits with no group difference. These results require confirmation given the significant loss to follow-up.

TRIAL REGISTRATION NUMBER

NCT03843931.

Who are likely to benefit from the Good Life with osteoArthritis in Denmark (GLAD) exercise and education program? An effect modifier analysis of a randomised controlled trial

OBJECTIVE

To identify contextual factors that modify the treatment effect of the 'Good Life with osteoArthritis in Denmark' (GLAD) exercise and education programme compared to open-label placebo (OLP) on knee pain in individuals with knee osteoarthritis (OA).

METHODS

Secondary effect modifier analysis of a randomised controlled trial. 206 participants with symptomatic and radiographic knee OA were randomised to either the 8-week GLAD programme (n = 102) or OLP given as 4 intra-articular saline injections over 8 weeks (n = 104). The primary outcome was change from baseline to week 9 in the Knee injury and Osteoarthritis Outcome Score questionnaire (KOOS) pain subscale (range 0 (worst) to 100 (best)). Subgroups were created based on baseline information: BMI, swollen study knee, bilateral radiographic knee OA, sports participation as a young adult, sex, median age, a priori treatment preference, regular use of analgesics (NSAIDs or paracetamol), radiographic disease severity, and presence of constant or intermittent pain.

RESULTS

Participants who reported use of analgesics at baseline seem to benefit from the GLAD programme over OLP (subgroup contrast: 10.3 KOOS pain points (95% CI 3.0 to 17.6)). Participants with constant pain at baseline also seem to benefit from GLAD over OLP (subgroup contrast: 10.0 points (95% CI 2.8 to 17.2)).

CONCLUSIONS

These results imply that patients who take analgesics or report constant knee pain, GLAD seems to yield clinically relevant benefits on knee pain when compared to OLP. The results support a stratified recommendation of GLAD as management of knee OA.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03843931. EudraCT number 2019-000809-71.

POS0182 WHO ARE LIKELY TO BENEFIT FROM THE GOOD LIFE WITH OSTEOARTHRITIS IN DENMARK (GLAD) EXERCISE AND EDUCATION PROGRAM? AN EFFECT MODIFIER ANALYSIS OF A RANDOMISED CONTROLLED TRIAL

Background

EULAR clinical guidelines have identified moderators of knee osteoarthritis (OA) outcomes as an important research priority to optimize individualized treatment. In our recent trial the GLAD exercise and education program was proved equivalent to open-label placebo (OLP) in 206 people with knee OA, which calls for evaluation of factors that may predict differential treatment response to GLAD versus OLP.

Objectives

To identify contextual factors that might modify the treatment effect of the ‘Good Life with osteoArthritis in Denmark’ (GLAD) exercise and education programme on knee osteoarthritis (OA) pain compared to that of open-label placebo (OLP) in individuals with knee OA, i.e. explore who are likely to benefit from participating in exercise and education programs.

Methods

Secondary effect modifier analysis of a randomised controlled trial, in which 206 adults aged ≥ 50 years, with symptomatic and radiographic knee OA were randomised to either an 8-week exercise and education programme (GLAD; n=102) or OLP in the form of 4 intra-articular saline injections over 8 weeks (n=104). Primary outcome was change from baseline to week 9 in the Knee injury and Osteoarthritis Outcome Score questionnaire (KOOS) pain subscale (range 0 (worst) to 100 (best)). Subgroups were created based on baseline information: BMI, swollen study knee, bilateral radiographic knee OA, sports participation as a young adult, sex, median age, a priori treatment preference, regular use of analgesics (NSAIDs or paracetamol), radiographic disease severity, and presence of constant and intermittent pain using the Intermittent and Constant Osteoarthritis Pain questionnaire. Analyses were based on the intention-to-treat principle with simple conservative non-responder imputation of missing outcome data.

Results

Participants who at baseline reported use of analgesics at baseline seem to benefit from the GLAD programme over OLP (subgroup contrast: 10.3 KOOS pain points (95% CI 3.0 to 17.6)). Further, participants with constant pain at baseline also seem to benefit from GLAD over OLP (subgroup contrast: 10.0 KOOS pain points (95%CI 2.8 to 17.2; P=0.007)). Further, a priori preference for GLAD also seemed to predict treatment effect in favour of GLAD. Presence of intermittent pain predicted beneficial effects of OLP, albeit the precision of the estimate was low. See Figure 1.

Figure 1.

Forest plot showing the results of the subgroup analyses based on the intention-to-treat population with missing outcome data at week 9 replaced with the baseline observation (non-responder imputation). The outcome is change from baseline in KOOS pain at week 9 (after 8 weeks of intervention). GLAD: The Good Life with osteoArthritis in Denmark exercise and education programme. OLP: Open-label placebo consisting of 4 intra-articular saline injections. K-L: Kellgren-Lawrence grading of radiographic disease severity.

The full vertical line indicates the overall treatment effect, and the dashed line indicates zero effect. *24 GLAD and 26 OLP had no preference and are not included in the analyses, and 8 GLAD and 5 OLP had missing data; †For study knee.

Conclusion

These results imply that GLAD should not be considered as a one-size-fits-all intervention. For patients who take analgesics for their knee pain or report constant knee pain, GLAD seems to yield clinically relevant benefits when compared to an open-label placebo. The results support a stratified recommendation of GLAD as management of knee OA.

Disclosure of Interests

None declared

POS1130 A RANDOMISED CONTROLLED STUDY OF POLYACRYLAMIDE HYDROGEL VS. HYALURONIC ACID IN KNEE OSTEOARTHRITIS: RESULTS AT 12-MONTHS

Background

Polyacrylamide hydrogel (iPAAG), manufactured by Contura International, is CE marked for the symptomatic treatment of patients with knee osteoarthritis (OA).

iPAAG fulfils an unmet clinical need for an effective, long-acting, safe and minimally invasive treatment that may postpone and potentially prevent knee surgery for those with OA.

Objectives

To compare the effectiveness of single intra-articular injections of iPAAG and hyaluronic acid (HA) in participants with moderate to severe knee OA.

To compare the effectiveness of iPAAG and HA in subgroups based on age, BMI or Kellgren-Lawrence (KL) grade at baseline by assessing changes from baseline in transformed WOMAC pain subscale scores.

Methods

This prospective, double-blind study (NCT04045431) randomized 239 participants to receive a single intra-articular injection of either 6 mL iPAAG (n=119) or 6 mL HA (n=120). The study was approved by the Capital Region’s Committee on Health Research Ethics. All participants provided informed consent prior to study activities.

Outcomes included changes in the WOMAC pain, stiffness and function subscales and Patient Global Assessment of disease impact (PGA) at 52 weeks. All statistical analyses were based on the ITT principle using a mixed model for repeated measurement with a restricted maximum likelihood-based approach. The estimated mean treatment difference based on this model was reported with 95 % CI and p-value.

Results

Demographic and baseline characteristics were similar between treatment groups with an average age at treatment of approximately 67 years (range 31 – 90 years) and slightly more females (53%) than males.

There was a clinically relevant decrease in WOMAC pain subscale score from baseline to 52 weeks in both groups (Figure 1). There were also clinically relevant decreases in the WOMAC stiffness subscale and physical function subscale and PGA in both groups. Treatment differences in favor of iPAAG compared to HA, were measured for the 3 WOMAC subscales and PGA. However, none of these differences reached statistical significance.

Figure 1.

Mean plot of transformed WOMAC pain subscale (0-100) – ITT analysis set

The treatment difference in favor of iPAAG compared to HA for the WOMAC pain subscale score was statistically significant in the subgroup with age at baseline <70 years but did not reach statistical significance in the subgroup with age at baseline ≥70 years.

The treatment difference in favor of IPAAG compared to HA for the WOMAC pain subscale score was statistically significant in the subgroup with normal BMI but did not reach statistical significance in the subgroups with overweight or obese BMI.

The treatment difference in favor of IPAAG compared to HA for the WOMAC pain subscale score was statistically significant in the subgroup with KL grade 2 or 3. In the subgroup with KL grade 4, a treatment difference in favor of HA was not statistically significant.

Table 1.

Change from baseline in transformed (0-100) WOMAC pain subscale at week 52

LSMean (95% CI)Treatment difference (95% CI)p-valueOverall  HA-13.3 (-16.7; -10.0)  iPAAG-17.9 (-21.3; -14.6)4.6 (-0.1; 9.4)0.0572Age <70 years  HA-14.0 (-18.3; -9.6)0.0195  iPAAG-21.3 (-25.5; -17.0)7.3 (1.2; 13.4)Age ≥ 70 years  HA-12.5 (-17.6; -7.4)0.7970  iPAAG-13.4 (-18.7; -8.2)1.0 (-6.3; 8.2)BMI normal  HA-13.5 (-18.1; -8.9)0.0110  iPAAG-17.5 (-22.2; -12.9)10.9 (2.6; 19.1)BMI overweight  HA-14.3 (-19.5; -9.2)0.6114  iPAAG-16.1 (-21.0; -11.3)1.8 (-5.3; 8.9)BMI obese  HA-14.5 (-22.7; -6.2)0.5565  iPAAG-17.8 (-25.6; -10.0)3.3 (-8.0; 14.7)KL grade 2 or 3  HA-13.4 (-17.0; -9.7)0.0332  iPAAG-18.9 (-22.5; -15.4)5.6 (0.5; 10.7)KL grade 4)  HA-13.1 (-21.9; -4.3)0.6757  iPAAG-10.3 (-20.6; 0.0)-2.8 (-16.4; 10.8)

Conclusion

At 52 weeks after treatment, the effectiveness of iPAAG was numerically superior to HA but not statistically significantly different.

In subgroups of participants with normal BMI, participants <70 years old or participants with KL grade 2 or 3 iPAAG performed statistically significantly better than HA at 52 weeks after treatment.

Disclosure of Interests

None declared

POS1107 CHANGE IN ULTRASOUND-BASED KNEE JOINT INFLAMMATORY MARKERS AFTER WEIGHT LOSS IN PATIENTS WITH OSTEOARTHRITIS: A PROSPECTIVE COHORT STUDY

Background

Pain and impaired function due to knee OA (KOA) can be reduced with weight loss in obese patients. The role of synovitis in symptom improvement after weight loss is not fully understood. MRI and ultrasound (US) can be used in assessment of inflammation in the KOA. Knee joint synovitis assessed by MRI does not seem to change with weight loss, however, the typical MRI score is semiquantitative, which might be less sensitive to change than a quantitative score. US has a higher resolution than MRI and borders between synovium and surrounding tissues might be clearer allowing for a quantitative score. Changes in US-based synovitis following a weight has not been assessed.

Objectives

To assess changes in US synovitis in the knee joint after 8 weeks low-calorie weight loss intervention in overweight persons with KOA.

Methods

prospective cohort study (NCT02931370) including overweight persons (BMI ≥ 27 kg/m2) with KOA. Weight loss was induced by an intensive 8-week diet (1200 kcal/day), participants had symptomatic and radiographically confirmed KOA (KL grade 1-3). At week 0 and 8 all participants filled in the KOOS questionnaire assessing pain, physical function, symptoms, quality of life, and sport/recreation in relation to KOA (0= worst; 100=best). Furthermore, an US examination of the most affected knee was performed assessing the amount of synovial hypertrophy (SH) and effusion in medial and lateral recesses. The US examination was performed in a strictly standardized manner on a high-end US machine. The subsequent image evaluation was done both according to a semiquantitative score from 0 to 3 (0=no SH/effusion and 3=pronounced SH/effusion) and a quantitative scoring system using specific anatomic landmarks to measure the synovial hypertrophy/effusion in millimeter.

Statistical analyses were performed on the per protocol population (participants completing diet intervention).

Results

135 patients with KOA with a mean age of 60y (SD 9.8), a body weight of 106.0 kg (SD18.5) and mean BMI of 36.4 (SD5.4) completed the weight loss intervention. After the diet intervention mean weight change was -12.8 kg (95%CI -13.3 to -12.4) and the reductions in SH were -0.3mm (95%CI -0.5 to -0.1) (medial recess) and -0.4mm (95%CI -0.6 to -0.1) (lateral recess), and -0.03 (-0.13 to 0.07) (medial recess) and -0.07 (-0.20 to 0.05) using the semi-quantitative system. The mean change in the KOOS subscales range from 15.8 (sport/recreation) to 7.4 (QoL). See Table 1.

Table 1.n=135BaselineChangeMean (SD)Mean (95%CI)PAge60.0 (9.8)--Females, n (%)87 (64.4%)--BMI36.4 (5.4)-4.4 (-4.5 to -4.3)<.0001KL-scores; 122 (16.3%)--KL-scores; 256 (41.5%)--KL-scores; 357 (42.2%)--KL-scores; 40 (0%)--Synovial HypertrophyMedial, mm3.8 (1.8)-0.3 (-0.5 to -0.1)0.0198Lateral, mm5.3 (2.3)-0.4 (-0.6 to -0.1)0.0210Medial, 0-31.2 (0.6)-0.03 (-0.13 to 0.07)0.5584Lateral, 0-31.8 (0.8)-0.07 (-0.20 to 0.05)0.2311KOOS, 0-100Pain64.1 (16.0)12 (10.2 to 13.8)<.0001Function68.4 (17.3)14 (12.4 to 15.6)<.0001Symptoms68.9 (16.4)9 (7.2 to 10.8)<.0001Sports/Recreation35.9 (24.0)15.8 (13.2 to 18.3)<.0001QoL43.8 (17.5)7.4 (5.7 to 9.2)<.0001

SD = Standard Deviation; CI = Confidence Interval; BMI = Body Mass Index;

KOOS = Knee injury and Osteoarthritis Outcome Score; QoL = Knee-related Quality of Life

Conclusion

Quantitative measures of SH assessed by US decreased after a significant weight loss over 8-weeks; however, no linear association with weight loss magnitude was seen. A weak correlation between changes in SH in the lateral recess and change in pain was seen. This indicates changes in SH assessed by US examination is associated with a low-calorie diet but seems uncoupled with weight loss magnitude. The weight loss induced changes in synovitis and KOA symptoms seem vaguely related.

Disclosure of Interests

None declared

POS0144 NOVEL APPLICATION OF OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHY AND NAILFOLD CAPILLAROSCOPY IN PSORIATIC ARTHRITIS - DIAGNOSTIC AND PROGNOSTIC ACCURACY IN RELATION TO PSORIASIS AND HAND OSTEOARTHRITIS

Background:

Nailfold video capillaroscopy (NVC) and angiographic optical coherence tomography (OCTA) have potential in diagnosing psoriatic arthritis (PsA) and differentiating it from psoriasis vulgaris (PsO) and hand osteoarthritis (OA).

Objectives:

To assess the diagnostic properties of NVC and OCTA in patients with PsA compared to patients with PsO and hand OA based on nailfold capillary patterns.

Methods:

Patients with distal interphalangeal-joint PsA and nail involvement (n=50), PsO with nail involvement (n=12); and OA (n=13) were included in this cross-sectional study. Capillaries were evaluated semi-quantitatively and qualitatively. Differences in capillary findings between groups were assessed using mixed linear models. Binary logistic regression analyses were performed to determine the probability for PsA diagnosis based on capillaroscopy findings.

Results:

Reduced capillary density and reduced nailfold blood flow in OCTA images distinguished PsA from both PsO (p=0.004 and p=0.052) and OA (p=0.024 and p<0.001). Qualitative analysis revealed that glomerular capillaries were found in only 3% of PsA patients but in 13% of PsO patients (P=0.003). Furthermore, coiled vessels were only seen in 55% of PsA patients and 71% in PsO patients (P=0.043). NVC microhaemorrhage was dominant in PsA patients (13 % and 17 %) and significantly different to OA patients (p=0.05). No capillary pattern was associated with an increased probability of the PsA diagnosis.

Conclusion:

A pathognomic pattern for PsA diagnosis was not identified, however we demonstrated characteristics significant capillaroscopy findings for PsA such as decreased capillary density, reduced blood flow, and less coiled vessels in OCTA and presence of NVC microhemorrhages.

Table 1.NVC-ratingPsA (n=188)PsO (n=42)OA (n=48)PsA vs PsOPsA vs OANVC ad modum CutoloReduced capillary density51 %31 %51 %P=0.1070.770Irregularly enlarged capillaries22 %33 %25 %P=0.082P=0.988Giant capillary2 %00P=0.400P=0.375Microhaemorrhages13 %7 %2 %P=0.327P=0.05Capillary ramifications14 %24 %29 %P=0.054P=0.307Capillary disorganisation45 %57 %48 %P=0.170P=0.685OCTA-ratingPsA n=193PsO n=48OA n=52PsA vs PsOPsA vs OAOCTA ad modum CutoloReduced capillary density53 %21 %33 %P=0.004P=0.024Irregularly enlarged capillaries34 %56 %19 %p=0.015P=0.178Giant capillary000--Microhaemorrhages000--Capillary ramifications000--Capillary disorganisation55 %46 %49 %P=0.2090.723OCTNail thickness*, mm., mean (SD)0.62 (0.13)0.73 (0.39)0.59 (0.08)p=0.876P=0.020OCTA blood flow percentage, mean (SD)6.00 (2.94)6.94 (3.08)7.88 (3.30)P=0.052P<0.001Capillary morphologyPsA n=192PsO n=48OA n=52PsA vs PsOPsA vs OAQualitative evaluation of NVC morphologyTortuous/Coiled capillaries55 %71 %56 %P=0.043P=0.890Enlarged capillary diameter17 %21 %17 %P=0.557P=0.984Ramified capillaries13 %15 %19 %P=0.701P=0.215Microhaemorrhages17 %6 %8 %P=0.068P=0.106Elongated capillaries6 %4 %4 %P=0.669P=0.592Different capillary shapes, glomerular3 %13 %2 %P=0.003P=0.779

The distribution of NVC and OCTA capillary morphology between PsA, PsO and OA, and qualitative evaluation of NVC morphology. Data are presented as percentage of capillary findings within the group. Differences between PsA and the other groups are presented as p-values. PsA: psoriatic arthritis, PsO: psoriasis vulgaris, OA: hand osteoarthritis, NVC nailfold video capillaroscopy, OCTA: angiographic optical coherence tomography. *: 1 patient (PsO group) was excluded from the analysis because of nail thickness>2.0 mm exceeding the maximum penetration depth of the OCT laser, representing an outlier.

Figure 1.

Optical coherence tomography angiography of the nail and nailbed blood vessels in patients with psoriatic arthritis, psoriasis, and hand osteoarthritis. *: nail plate. ¤: cuticle. #: proximal nailfold. §: one-millimetre field.

Acknowledgements:

The data-analysis of blood flow in angiographic OCT images was kindly performed as a batch analysis by CEO Jon Holmes, Michelson Diagnostics Ltd., Kent.

Disclosure of Interests:

Jørgen Guldberg-Møller Speakers bureau: AbbVie, NOVARTIS, Eli-Lilly and BK Ultrasound outside the present work., Tanja Schjødt Jørgensen Speakers bureau: AbbVie, Pfizer, Roche, Novartis, UCB, Biogen and Eli Lilly., Consultant of: AbbVie, Pfizer, Roche, Novartis, UCB, Biogen and Eli Lilly., Marius Henriksen Consultant of: Advisory Board member of Thuasne Group, France, Karen Ellegaard: None declared, Mette Mogensen: None declared, Lars Erik Kristensen Speakers bureau: Pfizer, AbbVie, Amgen, UCB, Gilead, Biogen, BMS, MSD, Novartis, Eli Lilly, and Janssen pharmaceuticals., Consultant of: Pfizer, AbbVie, Amgen, UCB, Gilead, Biogen, BMS, MSD, Novartis, Eli Lilly, and Janssen pharmaceuticals.

Why do mentally ill, homeless people use substances?

Introduction

In the Danish social welfare system, few people are homeless solely for economic reasons. In fact, 38% of homeless people suffer from both substance use and a psychiatric disorder, making diagnostic assessment and treatment difficult. This patient group, with dual diagnoses, often fail to receive effective treatment, and the consequences are far reaching and detrimental. A more comprehensive grasp of the history and patterns of substance use in these patients may contribute to improve their treatment.

Objectives

To identify the role and patterns of substance use in mentally ill, homeless people.

Methods

50 homeless, mentally ill patients are examined in comprehensive interviews, exploring the relationship between substance use, homelessness, and suffering from a mental disorder. The data are analyzed quantitatively as well as qualitatively using thematic analysis.

Results

Preliminary results indicate that substance use in mentally ill homeless patients is a complex phenomenon. On the one hand, substance use seems to contribute to keep the patient homeless and makes it difficult for the patient to get the necessary psychiatric help. On the other hand, substance use also appear to play an important part in coping with life on the streets by offering some kind of social contact and some relief from a desperate situation.

Conclusions

It seems that the triad of substance use, mental illness, and homelessness somehow reinforce each other and simultaneously locks the situation. New approaches for disentangling this locked situation and avoiding this ‘Bermuda triangle’ is needed.

OP0172 EFFECT OF WEIGHT LOSS AND LIRAGLUTIDE ON SERUM URATE LEVELS AMONG OBESE KNEE OSTEOARTHRITIS PATIENTS: SECONDARY ANALYSIS OF A RANDOMISED CONTROLLED TRIAL

Background:

There is a strong association between gout and obesity. Lowering urate is the cornerstone of gout management [1] and urate levels correlate strongly with central obesity. Previous studies suggest that weight loss has a positive effect on serum urate, however, the studies are sparse and small [2].

Objectives:

To assess the impact of an initial low-calorie diet-induced weight loss and subsequent randomisation to the body weight-lowering drug liraglutide (a glucagon-like peptide 1 receptor agonist) or placebo on serum urate levels.

Methods:

In the LOSE-IT trial (NCT02905864), a randomised, double-blinded, placebo-controlled, parallel group, single-centre trial [3], 156 obese individuals with knee osteoarthritis, but without gout, were offered an initial 8-week intensive diet intervention (week -8 to 0) on Cambridge Weight Plan (800-1000 kcal/day) followed by a weight loss maintenance period in which participants were randomised to either liraglutide 3 mg/day or placebo for 52 weeks. We conducted a secondary analysis of blood samples collected at week -8, 0 and 52. The primary outcome measure was change in serum urate. We used paired t-test for the change from week -8 to 0, and for change from week 0 to 52 we used an ANCOVA model adjusted for stratification factors (sex, age category and obesity class), and the level of the outcome at baseline. Data were analysed as observed (i.e. no imputation of missing data).

Results:

156 individuals were randomised and 155 had blood samples taken at baseline. In the initial intensive diet intervention period (week -8 to 0) they lost a mean of 12.5 kg (95% CI -13.1 to -11.9, n 156). In the following 52 weeks, the liraglutide group lost an additional 4.1 kg (SE 1.2, n 71) whereas the control group was almost unchanged with a weight loss of 0.2 kg (SE 1.2, n 66). Looking at the main outcome of serum urate levels change, the initial intensive diet resulted in a mean decrease of 0.21 mg/dL (95% CI 0.35 to 0.07, n 155) for the entire cohort. In the following year (week 0 to 52) the liraglutide group exhibited a further mean decrease in serum urate of 0.48 mg/dL (SE 0.11, n 69), whereas the placebo group exhibited a slight decrease in mean serum urate of 0.07 mg/dL (SE 0.12, n 65) resulting in a significant between-group difference of -0.40 mg/dL (95% CI -0.69 to -0.12, n 134) – see Figure 1. Four participants in each group experienced serious adverse events; no deaths were observed.

Conclusion:

This secondary analysis of the LOSE-IT trial suggests that liraglutide provides a potential novel serum urate lowering drug mechanism in obese patient populations, with potential implication for gout treatment.

References:

[1]Richette P et al. 2016.Ann Rheum Dis2017;76:29–42.

[2]Nielsen SM et al.Ann Rheum Dis2017 76(11):1870-1882.

[3]Gudbergsen H et al.BMJ2019. 71–2.

Disclosure of Interests:

Kristian Zobbe: None declared, Sabrina Mai Nielsen: None declared, Robin Christensen: None declared, Anders Overgaard: None declared, henrik gudbergsen Speakers bureau: Pfizer 2016, Marius Henriksen: None declared, Henning Bliddal Grant/research support from: received research grant fra NOVO Nordic, Consultant of: consultant fee fra NOVO Nordic, Lene Dreyer: None declared, Lisa Stamp: None declared, Filip Krag Knop Shareholder of: Minority shareholder in Antag Therapeutics Aps, Grant/research support from: AstraZeneca, Gubra, Novo Nordisk, Sanofi and Zealand Pharma, Consultant of: Amgen, AstraZeneca, Boehringer Ingelheim, Carmot Therapeutics, Eli Lilly, MSD/Merck, Mundipharma, Novo Nordisk, Sanofi and Zealand Pharma., Speakers bureau: AstraZeneca, Bayer, Boehringer Ingelheim, Eli Lilly, MedImmune, MSD/Merck, Mundipharma, Norgine, Novo Nordisk, Sanofi and Zealand Pharma., Lars Erik Kristensen Consultant of: UCB Pharma (Advisory Board), Sannofi (Advisory Board), Abbvie (Advisory Board), Biogen (Advisory Board), Speakers bureau: AbbVie, Amgen, Biogen, Bristol-Myers Squibb, Celgene, Eli Lilly, Gilead, Forward Pharma, Janssen Pharmaceuticals, MSD, Novartis, Pfizer, and UCB Pharma

The impact of a significant weight loss on inflammation assessed on DCE-MRI and static MRI in knee osteoarthritis: a prospective cohort study

OBJECTIVE

To study the impact of weight loss on inflammation in individuals with overweight and knee osteoarthritis (OA) using both static- and dynamic contrast-enhanced (DCE)-MRI and assess the association of these changes to pain.

DESIGN

Individuals with overweight (BMI > 27) and knee OA were examined before and after a >5% weight loss over 8 weeks (ClinicalTrials.gov NCT02905864). Using 3-T MRI, inflammation was quantified from non-contrast enhanced static-MRI according to MOAKS and contrast enhanced static MRI according to BLOKS and 11-point whole-knee synovitis score. DCE-MRI was used to assess the inflammation in the infra patellar fat pad (IPFP). Pain was assessed using KOOS.

RESULTS

Complete data were available in 117 participants with a mean age of 60 years, BMI of 35 kg/m² and KOOS pain score of 64. Mean weight loss was 12 kg and KOOS pain was improved by 13 points at follow-up. Change in inflammation was not associated with weight loss in static MRI. None of the MRI variables correlated with the change in KOOS pain.

CONCLUSION

Weight loss did not induce a significant change in inflammation in individuals with overweight and OA. The significant clinical beneficial effect of weight loss on knee pain in individuals with overweight and knee OA seems uncoupled to changes in imaging markers of synovitis.

THU0619-HPR PREVALENCE OF DISTAL INTERPHALANGEAL JOINT ULTRASONOGRAPHY FEATURES IN PSORIATIC ARTHRITIS, SKIN PSORIASIS, OSTEOARTHRITIS AND HEALTHY INDIVIDUALS: A CROSS-SECTIONAL STUDY

Background:

Distal interphalangeal (DIP) joint involvement is a feature of both psoriatic arthritis (PsA) and hand osteoarthritis (OA), and nail-changes are features seen both in PsA and nail psoriasis patients without joint involvement (PsO). In both PsA and OA, ultrasonography (US) is used to quantify DIP joint inflammation.

Objectives:

To explore disease-specific US-detected characteristics in the DIP-joints and extensor tendon entheses in patients with DIP-joint OA, PsA, PsO with nail involvement, and healthy controls (HC).

Methods:

In PsA, PsO, OA and HC US examination of DIP joints 2-5 and the extensor tendon were performed. The US images were scored for DIP joint grey-scale synovitis, DIP joint Doppler, osteophytes and erosions (grade 0-3) and presence/absence of enthesitis and peritendonitis of the extensor tendon according to OMERACT standards. Prevalences were calculated on all included fingers (i.e. four fingers per participant), and differences in prevalences were tested using Chi-square statistics.

Results:

Fifty PsA patients (44% females; mean age: 55y), 13 PsO patients (38% females; mean age 54y), 12 OA patients (100% females, mean age 71y), and 29 HC (52% females, mean age 48y) participated. The prevalences across the diagnosis groups are shown in figure 1, and the distribution of US outcomes was significantly different (highest Chi-square P-value: 0.0127). The PsA group had the largest prevalence of extensor tendon enthesitis (45.5%), peritendonitis (15%), and DIP joint erosions (11%), but also exhibited a considerable prevalence of osteophytes (46%). In the PsO group, the most marked findings were synovitis (33%) and enthesitis (35%). The OA group had the largest prevalence of DIP joint synovitis (67%) and osteophytes (88%) but also 25% prevalence of enthesitis. 24% of the HC group had a grade 1 synovitis.

Conclusion:

This cross-sectional study found significant patterns of US findings distributed dependent on the underlying condition. PsA patients were mainly differentiated by the presence of extensor tendon enthesitis and peritendonitis. A high prevalence of enthesitis and synovitis was seen in patients with DIP joint OA. The high prevalence of enthesitis in PsO is consistent with a preclinical phase of PsA in this group.

Disclosure of Interests:

Jørgen Guldberg-Møller Speakers bureau: Novartis, Ely Lilly, AbbVie, BK Ultrasound, Marius Henriksen: None declared, Mikael Boesen Speakers bureau: Image Analysis Group, AbbVie, AstraZeneca, Eli Lilly, Esaote, Glenmark, Novartis, Pfizer, UCB, Lene Dreyer: None declared, Karen Ellegaard: None declared, Marie Skougaard: None declared, Christine Ballegaard: None declared, Ai Lyn Tan: None declared, Richard Wakefield Speakers bureau: Novartis, Janssen, GE, Lars Erik Kristensen Consultant of: UCB Pharma (Advisory Board), Sannofi (Advisory Board), Abbvie (Advisory Board), Biogen (Advisory Board), Speakers bureau: AbbVie, Amgen, Biogen, Bristol-Myers Squibb,Celgene, Eli Lilly, Gilead, Forward Pharma, Janssen Pharmaceuticals, MSD, Novartis, Pfizer, and UCB Pharma

Explosion characteristics for Li-ion battery electrolytes at elevated temperatures

Li-ion batteries are used in electronic devices and electric cars, yet they create safety concerns due to the possibility of the release of combustible materials. The electrolyte, one of the main components in a Li-ion cell, consists of organic carbonates. Venting and thermal runaway release organic carbonates and when mixed with air, it can result in fires and explosions. A 20-liter explosion sphere was used to determine the explosion characteristics for three typical carbonates used in electrolytes, at 373 K, and 100 kPa absolute pressure. The explosion pressure and the maximum rate of explosion pressure rise are presented for the carbonates and for hydrogen, methane, and propane, and the explosive limits for the carbonates are also identified at the same conditions. This allowed a comparison of the explosion characteristics for the carbonates with those for hydrogen, methane, and propane. Theoretical calculations gave a higher explosion pressure than that from the experimental results most likely due to losses in the hydrocarbon experiments. The carbonates analyzed have very similar explosion pressures and rate of explosion pressure rise as propane. The explosion characteristics found for the three carbonates can be used in future consequence and risk assessments for Li-ion battery installations.

Long-term efficacy and safety of biosimilar infliximab (CT-P13) after switching from originator infliximab: open-label extension of the NOR-SWITCH trial

BACKGROUND AND OBJECTIVES

The 52-week, randomized, double-blind, noninferiority, government-funded NOR-SWITCH trial demonstrated that switching from infliximab originator to less expensive biosimilar CT-P13 was not inferior to continued treatment with infliximab originator. The NOR-SWITCH extension trial aimed to assess efficacy, safety and immunogenicity in patients on CT-P13 throughout the 78-week study period (maintenance group) versus patients switched to CT-P13 at week 52 (switch group). The primary outcome was disease worsening during follow-up based on disease-specific composite measures.

METHODS

Patients were recruited from 24 Norwegian hospitals, 380 of 438 patients who completed the main study: 197 in the maintenance group and 183 in the switch group. In the full analysis set, 127 (33%) had Crohn's disease, 80 (21%) ulcerative colitis, 67 (18%) spondyloarthritis, 55 (15%) rheumatoid arthritis, 20 (5%) psoriatic arthritis and 31 (8%) chronic plaque psoriasis.

RESULTS

Baseline characteristics were similar in the two groups at the time of switching (week 52). Disease worsening occurred in 32 (16.8%) patients in the maintenance group vs. 20 (11.6%) in the switch group (per-protocol set). Adjusted risk difference was 5.9% (95% CI -1.1 to 12.9). Frequency of adverse events, anti-drug antibodies, changes in generic disease variables and disease-specific composite measures were comparable between arms. The study was inadequately powered to detect noninferiority within individual diseases.

CONCLUSION

The NOR-SWITCH extension showed no difference in safety and efficacy between patients who maintained CT-P13 and patients who switched from originator infliximab to CT-P13, supporting that switching from originator infliximab to CT-P13 is safe and efficacious.

Poor replicability of recommended exercise interventions for knee osteoarthritis: a descriptive analysis of evidence informing current guidelines and recommendations

OBJECTIVE

To examine the reporting completeness of exercise-based interventions for knee osteoarthritis (OA) in studies that form the basis of current clinical guidelines, and examine if the clinical benefit (pain and disability) from exercise is associated with the intervention reporting completeness.

DESIGN

Review of clinical OA guidelines METHODS: We searched MEDLINE and EMBASE for guidelines published between 2006 and 2016 including recommendations about exercise for knee OA. The studies used to inform a recommendation were reviewed for exercise reporting completeness. Reporting completeness was evaluated using a 12-item checklist; a combination of the Template for Intervention Description and Replication (TIDieR) and Consensus on Exercise Reporting Template (CERT). Each item was scored 'YES' or 'NO' and summarized as a proportion of interventions with complete descriptions and each intervention's completeness was summarized as the percentage of completely described items. The association between intervention description completeness score and clinical benefits was analyzed with a multilevel meta-regression.

RESULTS

From 10 clinical guidelines, we identified 103 original studies of which 100 were retrievable (including 133 interventions with 6,926 patients). No interventions were completely described on all 12 items (median 33% of items complete; range 17-75%). The meta-regression analysis indicated that poorer reporting was associated with greater effects on pain and no association with effects on disability.

CONCLUSION

The inadequate description of recommended interventions for knee OA is a serious problem that precludes replication of effective interventions in clinical practice. By consequence, the relevance and usability of clinical guideline documents and original study reports are diminished.

PROSPERO

CRD42016039742.

Day-to-Day Reliability of Nonlinear Methods to Assess Walking Dynamics

The present study investigated the day-to-day reliability (quantified by the absolute and relative reliability) of nonlinear methods used to assess human locomotion dynamics. Twenty-four participants of whom twelve were diagnosed with knee osteoarthritis completed 5 min of treadmill walking at self-selected preferred speed on two separate days. Lower limb kinematics were recorded at 100 Hz and hip, knee, and ankle joint angles, three-dimensional (3D) sacrum marker displacement and stride time intervals were extracted for 170 consecutive strides. The largest Lyapunov exponent and correlation dimension were calculated for the joint angle and sacrum displacement data using three different state space reconstruction methods (group average, test-retest average, individual time delay and embedding dimension). Sample entropy and detrended fluctuation analysis (DFA) were applied to the stride time interval time series. Relative reliability was assessed using intraclass correlation coefficients and absolute reliability was determined using measurement error (ME). For both joint angles and sacrum displacement, there was a general pattern that the group average state space reconstruction method provided the highest relative reliability and lowest ME compared to the individual and test-retest average methods. The DFA exhibited good reliability, while the sample entropy showed poor reliability. The results comprise a reference material that can inspire and guide future studies of nonlinear gait dynamics.

The effect of intra-articular glucocorticosteroids and exercise on symptoms and bone marrow lesions in knee osteoarthritis: a secondary analysis of results from a randomized controlled trial

OBJECTIVE

To evaluate if the relative volume of bone marrow lesions (BMLs) changed in patients with knee osteoarthritis (OA) during a therapeutic study.

DESIGN

This study is a sub-study to a larger clinical trial which compared the clinical effects of intra-articular corticosteroid injection in knee OA to placebo injection, both given prior to exercise therapy. Clinical assessment using the Knee injury and Osteoarthritis Outcome Score (KOOS) and magnetic resonance imaging (MRI) examinations with BML assessments were performed at baseline and follow-up after 14 weeks and 26 weeks, respectively. The BML volume was determined using a computer assisted method focusing on participants with valid baseline and follow-up MRI examinations. Any changes in BML and KOOS were analyzed and investigated for associations.

RESULTS

Fifty participants received steroid and placebo injection, respectively, of which 41 and 45 had complete MRI examinations at week 14, and 36 and 33 at week 26, respectively. All participants received 12 weeks of exercise. A significant change in relative BML volume was observed between the corticosteroid group and the placebo group after 14 weeks [-1.1% vs 2.7%; between-group difference, 3.8% (95% CI 0.5-7.0)] but not after 26 weeks [0.8% vs 1.6%; between-group difference, 0.8% (95% CI -2.8 to 4.4)]. No significant association was found between changes in relative BML volume and KOOS.

CONCLUSIONS

Despite the statistically significant difference in BML volume at 14 weeks after corticosteroid injection and 12 weeks exercise therapy compared to placebo injection and exercise, there is very little evidence on a relationship between corticosteroids and BML volume.

EU CLINICAL TRIALS REGISTER

EudraCT number: 2012-002607-18.

Relationship between weight loss in obese knee osteoarthritis patients and serum biomarkers of cartilage breakdown: secondary analyses of a randomised trial

OBJECTIVE

To explore effects of weight loss and maintenance on serum cartilage biomarkers denaturation neoepitope for Collagen2 (Coll2-1) and Fibulin3 fragment (Fib3-2), as well as correlations between Coll2-1 and Fib3-2 and symptomatic improvement, in a knee osteoarthritis (KOA) population.

DESIGN

192 obese KOA patients followed a 16 week weight loss intervention and 52 weeks weight maintenance (ClinicalTrials.gov identifier: NCT00655941). Assessments were at 0, 8, 16 and 68 weeks. Serum Coll2-1 and Fib3-2 were determined with ELISA, and symptoms by the Knee Osteoarthritis Outcome Score (KOOS) questionnaire. Changes from week 0 and association between changes from baseline in body weight and Coll2-1, Fib3-2, and the 5 KOOS domains were assessed at all time points.

RESULTS

Coll2-1 changes from baseline showed a decrease at week 8 (P = 0.0002), no change at week 16 (P = 0.49), and an increase at week 68 (P = 0.036). Fib3-2 showed an increase from baseline at week 8 (P = 0.0015) and 16 (P < 0.0001), but none at week 68 (P = 0.23). No statistically significant correlations were found between changes in body weight and Coll2-1 and Fib3-2 at any time point (r < 0.05; P > 0.49). At all time-points there were significant positive correlations between changes from baseline in Coll2-1 and in KOOS_{Sports/Recreation} (week 8, 16, 68: r = 0.17; P = 0.03; r = 0.16; P = 0.04; and r = 0.17; P = 0.04, respectively).

CONCLUSION

The clinical improvement after a substantial weight loss and weight maintenance in KOA patients was not associated with decrease in markers of cartilage breakdown Coll2-1 or Fib3-2, even with indications of a slightly negative effect.

The effects of intra-articular glucocorticoids and exercise on pain and synovitis assessed on static and dynamic magnetic resonance imaging in knee osteoarthritis: exploratory outcomes from a randomized controlled trial

OBJECTIVE

The aims of the present knee osteoarthritis (KOA)-study were to: (1) describe and compare the changes in magnetic resonance imaging (MRI)-measures of synovitis following an exercise program preceded by an intra-articular injection of either corticosteroid or isotonic saline and (2) investigate if any of the changes in patient reported outcome measures (PROMs) were associated with changes in MRI-measures of synovitis.

DESIGN

We performed a randomized, double-blinded, placebo-controlled clinical trial evaluating the effects of intra-articular corticosteroid vs placebo injections given before exercise therapy in KOA-patients. PROMs were assessed using the KOOS (knee injury and osteoarthritis outcome score). Synovitis was assessed on conventional non-contrast-enhanced, conventional contrast-enhanced (CE) and dynamic contrast-enhanced (DCE) MRI. PROMs and MRIs were obtained prior to the intra-articular injection, after termination of the exercise program (week 14-primary time point) and week 26.

RESULTS

Of 100 randomized participants (50 in each allocation group), 91 had complete MRI-data at baseline (63% female, mean age: 62 years, median Kellgren-Lawrence-grade: 3). There were no statistically significant differences between the two interventions in regards of changes in MRI-measures of synovitis at any time-point. At week 14, we found no statistical significant MRI-explanatory variables of either of the PROMs.

CONCLUSIONS

The present study does not justify the use of intra-articular corticosteroids over intra-articular saline when combined with an exercise program for reduction of synovitis in KOA. The improvement in pain and function following the intervention with intra-articular corticosteroids/saline and exercise could not be explained by a decrease in synovitis on MRI indicating other pain causing/relieving mechanisms in KOA.

The association between histological, macroscopic and magnetic resonance imaging assessed synovitis in end-stage knee osteoarthritis: a cross-sectional study

OBJECTIVES

To investigate the association between magnetic resonance imaging (MRI), macroscopic and histological assessments of synovitis in end-stage knee osteoarthritis (KOA).

METHODS

Synovitis of end-stage osteoarthritic knees was assessed using non-contrast-enhanced (CE), contrast-enhanced magnetic resonance imaging (CE-MRI) and dynamic contrast-enhanced (DCE)-MRI prior to (TKR) and correlated with microscopic and macroscopic assessments of synovitis obtained intraoperatively. Multiple bivariate correlations were used with a pre-specified threshold of 0.70 for significance. Also, multiple regression analyses with different subsets of MRI-variables as explanatory variables and the histology score as outcome variable were performed with the intention to find MRI-variables that best explain the variance in histological synovitis (i.e., highest R²). A stepped approach was taken starting with basic characteristics and non-CE MRI-variables (model 1), after which CE-MRI-variables were added (model 2) with the final model also including DCE-MRI-variables (model 3).

RESULTS

39 patients (56.4% women, mean age 68 years, Kellgren-Lawrence (KL) grade 4) had complete MRI and histological data. Only the DCE-MRI variable MExNvoxel (surrogate of the volume and degree of synovitis) and the macroscopic score showed correlations above the pre-specified threshold for acceptance with histological inflammation. The maximum R²-value obtained in Model 1 was R² = 0.39. In Model 2, where the CE-MRI-variables were added, the highest R² = 0.52. In Model 3, a four-variable model consisting of the gender, one CE-MRI and two DCE-MRI-variables yielded a R² = 0.71.

CONCLUSION

DCE-MRI is correlated with histological synovitis in end-stage KOA and the combination of CE and DCE-MRI may be a useful, non-invasive tool in characterising synovitis in KOA.

Short communication: Iodine concentrations in serum, milk, and tears after feeding Ascophyllum nodosum to dairy cows-A pilot study

Kelp (Ascophyllum nodosum) is rich in iodine and often fed by organic dairy producers as a mineral supplement to support animal health. A commonly held belief is that kelp supplementation decreases susceptibility to infectious bovine keratoconjunctivitis due to increased iodine concentrations in tears. Whereas serum and milk iodine concentrations are positively correlated and modulated by oral iodine supplementation, nothing is known about the iodine concentration of tears. Therefore, the 3 objectives of this pilot study were to determine (1) the iodine content of tears, milk, and serum of cows after being fed kelp for 30d; (2) the trace mineral and thyroid status of cows before (d 0) and after being fed kelp for 30d; and (3) the in vitro growth rate of bacteria in tears (Moraxella bovis) or milk (Staphylococcus aureus, Escherichia coli, Streptococcus uberis) collected from cows fed no kelp (d 0) or kelp (d 30). Cows (n=3/treatment) were individually fed 56g of kelp per day (n=3/treatment) or not (n=3/no treatment) for 30 d. Daily feed intake of the TMR was recorded and weekly TMR, kelp, milk, blood and tear samples were collected and analyzed for iodine. The feed samples were pooled and further analyzed for other minerals. On d 0 and 30, liver biopsies and blood samples were collected and analyzed for mineral content and thyroid hormone concentrations, respectively. An inhibition test used milk and tear-soaked plates from kelp-fed cows (d 0 and 30) as well as 1 and 7.5% iodine as positive and distilled water as negative control. As expected, serum iodine concentrations were positively correlated with milk and tear iodine concentrations. Whereas the iodine concentrations in serum increased significantly in the kelp-fed cows during the 30-d study, milk and tear iodine concentrations increased only numerically in these cows compared with the control group. Liver mineral profiles were comparable between groups and generally did not change over the course of the study. Thyroid hormones remained overall within the reference range throughout the trial. Neither milk nor tears from kelp-fed cows inhibited in vitro growth of any of the plated bacteria. In summary, serum iodine concentration was correlated with the iodine concentration in milk and tears and feeding kelp increased only the serum iodine levels of cows in this trial. Bacterial growth was not inhibited in milk and tears of kelp-fed cattle in vitro, and prevention of infectious bovine keratoconjunctivitis would not be based solely on increased iodine concentrations in tears.

Changes in ultrasound assessed markers of inflammation following intra-articular steroid injection combined with exercise in knee osteoarthritis: exploratory outcome from a randomized trial

OBJECTIVE

Knee osteoarthritis (KOA) is a multifactorial joint disease affecting many people worldwide. Recommended treatments for KOA include exercise and steroid injections, or a combination of these. The objective of this exploratory outcome analysis of a randomized trial was to assess changes in inflammation markers assessed by ultrasound imaging (US) in KOA secondary to intra-articular corticosteroid injection given prior to exercise therapy.

DESIGN

This study is a sub-study to a larger clinical trial which compared the clinical effects of steroid injection in KOA to placebo injection, both given prior to exercise therapy. The US outcomes were changes from baseline in US-assessed synovial size, Doppler activity presence in the synovial membrane, and numbers of US-detected Baker's cysts. US was performed at baseline, week 14 (exercise stop), and week 26 (follow-up).

RESULTS

Fifty participants received steroid injection, and 50 received placebo injection. All participants received 12 weeks of exercise. Forty-five and 44, respectively, completed the study. At week 14, the group difference in the change in synovium thickness was 2.2 mm (95%, confidence interval (CI) -0.5 to 4.8), P = 0.11. There were no group differences in the changes in distribution of patients with presence of synovial Doppler activity (P = 0.98) or Baker's cysts (P = 0.35). There were no statistically significant differences between groups at week 26 in any outcome.

CONCLUSION

Intra-articular steroid injection of KOA-patients prior to a 3 months exercise programme did not reduce synovial hypertrophy, synovial Doppler activity, or Baker's cyst presence more than a placebo saline injection according to US-assessments.

TRIAL REGISTRATION

EudraCT: 2012-002607-18.

Effect of a 16 weeks weight loss program on osteoarthritis biomarkers in obese patients with knee osteoarthritis: a prospective cohort study

OBJECTIVE

Changes in biomarkers for bone and cartilage in knee osteoarthritis (KOA) may reflect changes in tissue turnover induced by interventions. The aim of this study was to assess the effect on osteoarthritis biomarkers of an intensive weight loss intervention in obese KOA patients.

METHODS

192 obese KOA patients followed a 16 weeks weight loss intervention (ClinicalTrials.gov: NCT00655941). Serum Cartilage Oligomeric Matrix Protein (sCOMP), Urine C-terminal telopeptide of collagen type II (uCTX-II) and type I (uCTX-I) were determined by enzyme-linked immunoassay (ELISA) at baseline and after 16 weeks. Patient-reported symptoms were assessed by the Knee Injury and Osteoarthritis Outcome Score (KOOS) Questionnaire without the sports and recreation score (KOOS-4). Change from baseline was analyzed using Analysis of CoVariance (ANCOVA) adjusting for sex, age, and body mass index (BMI). Bivariate associations were analyzed using Spearman's test of rank correlation.

RESULTS

175 patients completed the treatment and lost mean 13.4 (95% CI: 12.5-14.4) kg. sCOMP concentration decreased on average 1.1 (95% CI: -1.5 to -0.8) U/L with a correlation to weight loss (r = -0.17, P = 0.028), but not to change in KOOS-4 (r = -0.13, P = 0.091). uCTX-II increased significantly, mean 69 (95% CI: 31-106) ng/mmol creatinine, with no relation to weight loss (P = 0.14). Change in uCTX-II was reversely related to change in KOOS-4 (r = -0.28, P = 0.0003). uCTX-I increased, mean 67 (95% CI: 47-87) μg/mmol creatinine, and correlated to weight loss (r = 0.22, P = 0.0007), while not to KOOS-4 (P = 0.93).

CONCLUSION

A rapid substantial weight loss in obese KOA patients was weakly, while significantly associated with a reduction in sCOMP, and increases in both uCTX-II and uCTX-I.

Structural changes in the knee during weight loss maintenance after a significant weight loss in obese patients with osteoarthritis: a report of secondary outcome analyses from a randomized controlled trial

OBJECTIVE

To compare structural knee joint changes in obese patients with knee osteoarthritis (OA) that after an intensive weight loss therapy were randomized to continuous dietetic support, a specialized knee exercise program, or 'no attention' for 1 year.

METHODS

192 obese individuals with knee OA underwent an intensive 16-week weight loss program with subsequent randomization to one of the three treatment groups. Changes in cartilage loss, bone marrow lesions (BMLs), synovitis, and effusion were assessed using semi quantitative assessments of magnetic resonance imaging (MRI) obtained at weeks 0 and 68 applying the BLOKS score.

RESULTS

During the 52 weeks maintenance period the continuous dietary maintenance group support on average gained 1.1 kg (95% CI: -0.3:2.5) body mass, the exercise group gained 6.6 kg (95% CI 5.4:7.8) and the no-attention group gained 4.8 kg (95% CI: 2.9:6.7). There were no statistically significant between-group differences in changes in cartilage loss, synovitis or effusion at the follow-up (analysis of covariance; ANCOVA, P > 0.16), while there was an increased number of medial tibiofemoral BMLs in the exercise group (ANCOVA, P = 0.015) compared to both diet (difference: -0.21 [95%CI -0.40:-0.03]) and "no attention" (difference: -0.26 [95%CI -0.44:-0.07]) groups.

CONCLUSION

In this 1 year follow-up after weight-loss in obese knee OA patients, we found a potentially increased number of BMLs in the exercise group compared to the diet and no attention groups, with no between-group differences in changes in cartilage loss, synovitis or effusion. These findings should be interpreted with caution for exercise compliance, MRI methodology and follow-up time. (ClinicalTrials.gov identifier: NCT00655941).

Validity and reliability of 3D US for the detection of erosions in patients with rheumatoid arthritis using MRI as the gold standard

PURPOSE

To test the reliability and validity of a 3D US erosion score in RA using MRI as the gold standard.

MATERIALS AND METHODS

RA patients were examined with 3D US and 3 T MRI over the 2nd and 3rd metacarpophalangeal joints. 3D blocks were evaluated by two investigators. The erosions were estimated according to a semi-quantitative score (SQS) (0 - 3) and a quantitative score (QS) (mm²). MRI was evaluated according to the RAMRIS score. For the estimation of reliability, intra-class correlation coefficients (ICC) were used. Validity was tested using Spearman's rho (rs). The sensitivity and specificity were also calculated.

RESULTS

28 patients with RA were included. The ICC for the inter-observer reliability in the QS was 0.41 and 0.13 for the metacarpal bone and phalangeal bone, respectively, and 0.86 and 0.16, respectively, in the SQS.  The ICC for the intra-observer reliability in the QS was 0.75 and 0.48 for the metacarpal bone and phalangeal bone, respectively, and 0.83 and 0.60, respectively, in the SQS.  The correlation with MRI for the metacarpal bone was significant, with values of 0.73 (p = 0.0001) (SQ) and 0.74 (p = 0.0001) (SQS). For the phalangeal bone, bad correlation was found: 0.28 (p = 0.145) (SQ) and 0.26 (p = 0.57) (SQS). The sensitivity and specificity for the metacarpal bone were 86 % and 85 % respectively. For the phalangeal bone they were 60 % and 97 %, respectively.

CONCLUSION

Good inter- and intra-observer reliability and correlation with MRI were seen in the assessment of erosions with 3D US in the metacarpal bone, while the results were low and insignificant for the phalangeal bone, indicating that 3D US still has room for improvement.

Is increased joint loading detrimental to obese patients with knee osteoarthritis? A secondary data analysis from a randomized trial

OBJECTIVE

To investigate whether increased knee joint loading due to improved ambulatory function and walking speed following weight loss achieved over 16 weeks accelerates symptomatic and structural disease progression over a subsequent 1 year weight maintenance period in an obese population with knee osteoarthritis (OA).

METHODS

Data from a prospective study of weight loss in obese patients with knee OA (the CARtilage in obese knee OsteoarThritis (CAROT) study) were used to determine changes in knee joint compressive loadings (model estimated) during walking after a successful 16 week weight loss intervention. The participants were divided into 'Unloaders' (participants that reduced joint loads) and 'Loaders' (participants that increased joint loads). The primary symptomatic outcome was changes in knee symptoms, measured with the Knee injury and Osteoarthritis Outcome Score (KOOS) questionnaire, during a subsequent 52 weeks weight maintenance period. The primary structural outcome was changes in tibiofemoral cartilage loss assessed semi-quantitatively (Boston Leeds Knee Osteoarthritis Score (BLOKS) from MRI after the 52 weight maintenance period.

RESULTS

157 participants (82% of the CAROT cohort) with medial and/or lateral knee OA were classified as Unloaders (n = 100) or Loaders (n = 57). The groups showed similar significant changes in symptoms (group difference: -2.4 KOOS points [95% CI -6.8:1.9]) and cartilage loss (group difference: -0.06 BLOKS points [95% CI -0.22:0.11) after 1 year, with no statistically significant differences between Loaders and Unloaders.

CONCLUSION

For obese patients undergoing a significant weight loss, increased knee joint loading for 1 year was not associated with accelerated symptomatic and structural disease progression compared to a similar weight loss group that had reduced ambulatory compressive knee joint loads.

CLINICALTRIALSGOV

NCT00655941.

Weight loss is effective for symptomatic relief in obese subjects with knee osteoarthritis independently of joint damage severity assessed by high-field MRI and radiography

OBJECTIVE

With an increasing prevalence of older and obese citizens, the problems of knee osteoarthritis (KOA) will escalate. Weight loss is recommended for obese KOA patients and in a majority of cases this leads to symptomatic relief. We hypothesized that pre-treatment structural status of the knee joint, assessed by radiographs, 1.5 T magnetic resonance imaging (MRI) and knee-joint alignment, may influence the symptomatic changes following a significant weight reduction.

DESIGN

Patients were recruited from a Department of Rheumatology. Eligibility criteria were age above 50 years, body mass index ≥ 30 kg/m(2), primary KOA diagnosed according to the American College of Rheumatology (ACR) criteria and having verified structural damage. Patients underwent a 16 weeks dietary programme with formula products and counselling. MRI and radiographs of the most symptomatic knee were obtained at baseline and assessed for structural damage using the Boston-Leeds Osteoarthritis of the Knee Score, minimum joint space width and Kellgren-Lawrence score. Imaging variables, muscle strength and degree of alignment, were examined as predictors of changes in Knee Osteoarthritis Outcome Score (KOOS) and Outcome Measures in Rheumatoid Arthritis Clinical Trials (OMERACT) - Osteoarthritis Research Society International (OARSI) Responder Criterion.

RESULTS

Structural damage at baseline assessed by imaging, muscle strength or knee-joint alignment showed no statistically significant association to changes in KOOS pain and function in daily living (r ≤ 0.13; P>0.05) or the OMERACT-OARSI Responder Criterion (OR 0.48-1.68; P-values ≥ 0.13).

CONCLUSIONS

Presence of joint damage did not preclude symptomatic relief following a clinically relevant weight loss in older obese patients with KOA. Neither muscle strength nor knee-joint alignment was associated with the degree of symptomatic relief.

Experimental knee joint pain during strength training and muscle strength gain in healthy subjects: a randomized controlled trial

OBJECTIVE

Knee joint pain and reduced quadriceps strength are cardinal symptoms in many knee pathologies. In people with painful knee pathologies, quadriceps exercise reduces pain, improves physical function, and increases muscle strength. A general assumption is that pain compromises muscle function and thus may prevent effective rehabilitation. This study evaluated the effects of experimental knee joint pain during quadriceps strength training on muscle strength gain in healthy individuals.

METHODS

Twenty-seven healthy untrained volunteers participated in a randomized controlled trial of quadriceps strengthening (3 times per week for 8 weeks). Participants were randomized to perform resistance training either during pain induced by injections of painful hypertonic saline (pain group, n = 13) or during a nonpainful control condition with injection of isotonic saline (control group, n = 14) into the infrapatellar fat pad. The primary outcome measure was change in maximal isokinetic muscle strength in knee extension/flexion (60, 120, and 180 degrees/second).

RESULTS

The group who exercised with pain had a significantly larger improvement in isokinetic muscle strength at all angular velocities of knee extension compared to the control group. In knee flexion there were improvements in isokinetic muscle strength in both groups with no between-group differences.

CONCLUSION

Experimental knee joint pain improved the training-induced gain in muscle strength following 8 weeks of quadriceps training. It remains to be studied whether knee joint pain has a positive effect on strength gain in patients with knee pathology.

Effects of an intensive weight loss program on knee joint loading in obese adults with knee osteoarthritis

OBJECTIVE

To determine the effect of an intensive weight loss program on knee joint loads during walking in obese patients with knee osteoarthritis (OA).

METHODS

Participants included 157 obese knee OA patients that underwent a 16-week dietary intervention. Three-dimensional gait analyses were performed before and after the intervention at the participants' freely chosen walking speed. Knee joint compression forces, axial impulses, knee flexion angle and frontal and sagittal plane knee moments were calculated to determine the biomechanical effects of the weight loss.

RESULTS

157 subjects (89% of the initial cohort) completed the 16-week intervention. The average weight loss of 13.7 kg (P<.0001) corresponded to 13.5% of the baseline body weight. The weight loss resulted in a 7% reduction in knee joint loading, a 13% lower axial impulse, and a 12% reduction in the internal knee abductor moment (KAM). There were no clear effects on sagittal plane knee moments or peak knee flexion angle. Linear regression analyses adjusted for changes in walking speed showed that for every 1 kg in weight loss, the peak knee load was reduced by 2.2 kg. Thus, every kilo reduction in body weight was related to more than twice the reduction in peak knee force at a given walking speed.

CONCLUSION

Weight loss is an excellent short-term investment in terms of joint loading for patients with combined obesity and knee OA. The effects of sustained weight loss on disease progression and symptoms in relation to biomechanical factors remain to be shown.

Chronic fatigue is associated with impaired health-related quality of life in inflammatory bowel disease

BACKGROUND

Fatigue is reported to reduce health-related quality of life (HRQOL) in chronic diseases. Studies on the importance of fatigue and its implications for the patient's HRQOL in inflammatory bowel disease (IBD) remain scarce and need to be explored.

AIM

To investigate the influence of chronic fatigue on both generic and disease-specific HRQOL in IBD.

METHODS

Patients in remission, with mild and moderate IBD completed the Fatigue Questionnaire, the Short-Form 36 (SF-36) and the Norwegian version of the Inflammatory Bowel Disease Questionnaire (N-IBDQ). In addition, demographic and clinical variables were obtained.

RESULTS

In total, 140 patients were included; the mean age of patients with chronic fatigue was 44.2 years (s.d. = 15.8), that of nonfatigued was 44.7 years (s.d. = 16.0). Ulcerative colitis (UC)/Crohn's disease (CD) = 92/48. Chronic fatigue was associated, after controlling for covariates, with a reduction of HRQOL scores in 6/8 SF-36 dimensions in UC and 5/8 dimensions in CD. In N-IBDQ, chronic fatigue was associated with a reduction of HRQOL in four subdimensions and total score in CD and all dimensions in UC.

CONCLUSIONS

Fatigue is associated with reduction of HRQOL scores in IBD. The physical HRQOL domains are particularly affected. The impact of fatigue on disability, sick leave, school and work attendance has to be studied further.

Effect of whole body vibration exercise on muscle strength and proprioception in females with knee osteoarthritis

The purpose of this study was to assess the effect of whole body vibration (WBV) exercise on muscle strength and proprioception in female patients with osteoarthritis in the knee (knee-OA). A single blinded, randomised, controlled trial was performed in an outpatient clinic on 52 female patients diagnosed with knee-OA (mean age 60.4 years+/-9.6). They were randomly assigned to one of 3 groups: 1. WBV-exercise on a stable platform (VibM; n=17 (mean age, 61.5+/-9.2)), WBV-exercise on a balance board (VibF; n=18 (mean age, 58.7+/-11.0)), or control group (Con; n=18 (mean age, 61.1+/-8.5)). The WBV groups trained twice a week for 8 weeks, with a progressively increasing intensity. The WBV groups performed unloaded static WBV exercise. The following were measured: knee muscle strength (extension/flexion) and proprioception (threshold for detection of passive movement (TDPM)). Self-reported disease status was measured using WOMAC. It was found that muscle strength increased significantly (p<0.001) in VibM compared to Con. Isometric knee-extension significantly increased (p=0.021) in VibM compared to Con. TDPM was significantly improved (p=0.033) in VibF compared to Con, while there was a tendency (p=0.051) for VibM to perform better compared to Con. There were no effects in the self-reported disease status measures. This study showed that the WBV-exercise regime on a stable platform (VibM) yielded increased muscle strength, while the WBV-exercise on a balance board (VibF) showed improved TDPM. The WBV-exercise is a time-saving and safe method for rehabilitation of women with knee-OA.

C-reactive protein: a predictive factor and marker of inflammation in inflammatory bowel disease. Results from a prospective population-based study

BACKGROUND AND AIMS

C-reactive protein (CRP) levels are often used in the follow-up of patients with inflammatory bowel disease (IBD). The aims of this study were to establish the relationship of CRP levels to disease extent in patients with ulcerative colitis and to phenotype in patients with Crohn's disease, and to investigate the predictive value of CRP levels for disease outcome.

METHODS

CRP was measured at diagnosis and after 1 and 5 years in patients diagnosed with IBD in south-eastern Norway. After 5 years, 454 patients with ulcerative colitis and 200 with Crohn's disease were alive and provided sufficient data for analysis.

RESULTS

Patients with Crohn's disease had a stronger CRP response than did those with ulcerative colitis. In patients with ulcerative colitis, CRP levels at diagnosis increased with increasing extent of disease. No differences in CRP levels at diagnosis were found between subgroups of patients with Crohn's disease as defined according to the Vienna classification. In patients with ulcerative colitis with extensive colitis, CRP levels above 23 mg/l at diagnosis predicted an increased risk of surgery (odds ratio (OR) 4.8, 95% confidence interval (CI) 1.5 to 15.1, p = 0.02). In patients with ulcerative colitis, CRP levels above 10 mg/l after 1 year predicted an increased risk of surgery during the subsequent 4 years (OR 3.0, 95% CI 1.1 to 7.8, p = 0.02). A significant association between CRP levels at diagnosis and risk of surgery was found in patients with Crohn's disease and terminal ileitis (L1), and the risk increased when CRP levels were above 53 mg/l in this subgroup (OR 6.0, 95% CI 1.1 to 31.9, p = 0.03).

CONCLUSIONS

CRP levels at diagnosis were related to the extent of disease in patients with ulcerative colitis. Phenotype had no influence on CRP levels in patients with Crohn's disease. CRP is a predictor of surgery in subgroups of patients with either ulcerative colitis or Crohn's disease.

Quantification of colour Doppler activity in the wrist in patients with rheumatoid arthritis--the reliability of different methods for image selection and evaluation

PURPOSE

The amount of colour Doppler activity in the inflamed synovium is used to quantify inflammatory activity. The measurements may vary due to image selection, quantification method, and point in cardiac cycle. This study investigated the test-retest reliability of ultrasound colour Doppler measurements in the wrist of patients with rheumatoid arthritis (RA) using different selection and quantification methods.

MATERIALS AND METHODS

14 patients with RA had their wrist scanned twice by the same investigator with an interval of 30 minutes. The images for analysis were selected either by the anatomical position only or by the anatomical position with maximum colour Doppler activity. Subsequently, the amount of colour Doppler was measured in an area defined by either the synovial tissue or by specific anatomical structures surrounding the synovial tissue.

RESULTS

The best test-retest reliability was obtained when the images were selected guided by colour Doppler and the subsequent quantification was done in an area defined by anatomical structures. With this method, the intra-class coefficient ICC (2.1) was 0.95 and the within-subject SD (SW) was 0.017, indicating good reliability. In contrast, poor test-retest reliability was found if the images were selected by anatomical position only and the quantification was done in an area defined by the synovial tissue (ICC [2.1] = 0.48 and SW = 0.049).

CONCLUSION

The study showed that colour Doppler measurements are reliable if the images for analysis are selected by anatomical position in combination with colour Doppler activity and the subsequent analysis is performed in an area defined by anatomical structures.

Investigation of chicken intestinal bacterial communities by 16S rRNA targeted fluorescence in situ hybridization

The aim of the investigation was to quantify selected dominant bacterial groups in the chicken intestinal tract. Conventional production was used as model and the effect of the supplement with Salinomycin was evaluated. Hybridization conditions were optimized for published probes with respect to a panel of reference bacteria. In chicken intestinal samples bacteria were quantified by fluorescence in situ hybridization with 16S rRNA oligonucleotides directed towards bacteria related to Lactobacillus, Bacillus, Enterococcus-Streptococcus-Lactococcus, Enterobacteriaceae, Bacteroides, Clostridium and the domain Bacteria in lumen of ileum and cecum as well as on the intestinal wall including mucus of four individuals. Salinomycin in feed reduced counts of the Lactobacillus-, Enterobacteriaceae- and Clostridium-like bacteria in lumen of ileum compared to the conventional control. Increased or decreased bacterial counts were registered by Salinomycin in the ceca compared to the control. Relatively higher counts of Bacteroides- and Clostridium-like bacteria were found on the intestinal wall including mucus compared to lumen. The increase in numbers of some bacterial groups as well as the expected reduction by Salinomycin and the observed difference in the relative distribution of bacteria between lumen and intestinal wall are new observations that will need further investigation.

Learning effect of isokinetic measurements in healthy subjects, and reliability and comparability of Biodex and Lido dynamometers

The aim of this study was to examine the learning effect during a set of isokinetic measurements, to evaluate the reliability of the Biodex System 3 PRO dynamometer, and to compare the Biodex System 3 PRO and the Lido Active dynamometers on both extension and flexion over the elbow and the knee at 60 degrees s(-1). Thirteen (nine women, four men) healthy participants were measured five times using the Biodex and once using the Lido dynamometer. The intervals between the first four tests were 20 min, and 1 week between tests 4 and 5. Between Biodex and Lido measurements there was a 20 min time interval. When comparing the first five measurements (Biodex), no systematic effect over time and an excellent reliability were found with respect to elbow and knee flexion and extension. No difference in muscle strength (Nm) between the Biodex and Lido was observed for knee flexion (P = 0.59), knee extension (P = 0.18) and elbow extension (P = 0.63). However, elbow flexion showed a 14.8% (95% CI: 11.2-18.4%; P = 0.0001) higher peak torque on Biodex. In conclusion, no learning effect was observed and the Biodex proved to be a highly reliable isokinetic dynamometer. A difference was observed when comparing Biodex and Lido on elbow flexion, but the difference did not outrange the expected variation found with a typical isokinetic measurement, which is why both sets of equipment seem applicable in clinical practice.

Minimal erythema dose after multiple UV exposures depends on pre-exposure skin pigmentation

BACKGROUND/PURPOSE

Phototherapy consists of multiple ultraviolet (UV) exposures. Most previous studies have focused on erythema following a single UV exposure in fair-skinned persons. Although it is well known that phototherapy lowers the daily UV-threshold dose for erythema in clinical practice, this is insufficiently documented under controlled experimental conditions. The purpose of this study was to quantify the change in the daily threshold for a dose specific erythema grade after 1-4 consecutive daily UV exposures.

METHODS

Forty-nine healthy volunteers (skin type II-V) with varying pigmentation quantified by skin reflectance. Two UV sources were used: a narrowband UVB (Philips TL01) and a Solar Simulator (Solar Light Co.). Just perceptible erythema after 24 h was chosen as the minimal erythema dose (+); besides + and ++ were assessed.

RESULTS

We found a positive and significant exponential relationship between skin pigmentation and UV dose to elicit a specific erythema grade on the back after 1-4 UV exposures. After repetitive UV exposures the UV dose had to be lowered more in dark-skinned persons compared with fair-skinned persons to elicit a certain erythema grade. This applied to both UV sources and all erythema grades.

CONCLUSION

In the dark-skinned persons the daily UV dose after the 4 days UV exposure should be lowered by 40-50% to avoid burns compared with the single UV exposure. For the most fair-skinned persons essentially no reduction in the daily UV dose was needed. Our results indicate that the pre-exposure pigmentation level can guide the UV dosage in phototherapy.

Health-related quality of life in patients with inflammatory bowel disease five years after the initial diagnosis

BACKGROUND

Health-related quality of life (HRQOL) has become an important tool in evaluating patient satisfaction in inflammatory bowel disease (IBD). So far, few prospective follow-up studies have been done to identify variables that influence HRQOL. We aimed to identify demographic and clinical variables that influence HRQOL 5 years after diagnosis in patients with ulcerative colitis (UC) or Crohn disease (CD) included in a prospective follow-up study from 1990 to 1994 (the IBSEN study).

METHODS

All patients completed the Inflammatory Bowel Disease Questionnaire (IBDQ), a disease-specific quality-of-life questionnaire translated into Norwegian and validated. We present data from 497 patients (328 UC patients and 169 CD patients, mean age 43.3 years, 48% female). The impact of age, gender, smoking, symptom severity, disease distribution, rheumatic symptoms and surgery on IBD patients' HRQOL was analysed.

RESULTS

Women had a reduction in IBDQ total score of 10 points compared to men, CD patients had a reduction of 7.5 compared to UC patients. The patients with moderate/severe symptoms had a 50 points lower score than the patients without symptoms. The patients with rheumatic symptoms had a 10 points lower total score than the patients without these symptoms. All differences were statistically significant. The multiple regression analysis showed that symptom severity, rheumatic symptoms and female gender were the strongest predictors of reduction in HRQOL for both diagnosis groups.

CONCLUSION

IBD symptoms, rheumatic symptoms and female gender have a significant influence on patients' HRQOL as measured by IBDQ. This was confirmed by the regression analysis.

[Assessment of the need of 24-hour availability of endoscopy]

BACKGROUND

Endoscopy is the cornerstone of the diagnosis and treatment of acute conditions in the upper part of the gastrointestinal tract. The need for 24-hour availability of gastroscopy for these conditions has not previously been assessed.

MATERIAL AND METHODS

We assessed the need for emergency gastroscopy in cases of acute upper gastrointestinal bleeding and obstruction by foreign bodies. The assessment was made by a gastroenterologist before gastroscopy was performed, and was based on the available clinical data for the period lasting from admission to hospital to the time of examination.

RESULTS

A total of 162 patients were referred and examined. About half of them arrived at the hospital outside working hours. Of these, 47% were assessed as being in need of emergency gastroscopy. We therefore found that emergency gastroscopy outside working hours was needed twice a month per 100,000 people.

INTERPRETATION

Round-the-clock endoscopy should be available at acute-care hospitals in the same way as other emergency help.

Autofluorescence of human skin is age-related after correction for skin pigmentation and redness

When measuring the skin fluorescence in vivo, the absorption of chromophores such as melanin and hemoglobin often contribute predominantly to the changes in fluorescence and obscure the information from the fluorophores. We measured in vivo the collagen-linked 375 nm fluorescence (excitation: 330 nm) and 455 nm fluorescence (excitation: 370 nm) from nonexposed buttock skin of healthy volunteers. Skin pigmentation and redness of the same sites were quantified by reflectance of the skin at 555 nm and 660 nm. Multiple regression analysis was used to find the correlation between the fluorescence and skin pigmentation and redness. The fluorescence was corrected for the impact of pigmentation and redness according to the equation found in the regression analyses. The age-related trend of the fluorescence was evaluated. The 375 nm fluorescence showed positive relation to age, whereas the 455 nm fluorescence showed no significant relation to age. The increasing rate of the 375 nm fluorescence (logarithm transformed) was 2% per year, which is comparable with previously published data. The results suggest that the correction of the autofluorescence intensity for skin pigmentation and redness is valid, and the 375 nm skin autofluorescence may be used as a biologic marker of skin aging in vivo.

Severe and fatal complications after diagnostic and therapeutic ERCP: a prospective series of claims to insurance covering public hospitals

BACKGROUND AND STUDY AIMS

Increasing numbers of patients are undergoing endoscopic retrograde cholangiopancreatography (ERCP) prior to laparoscopic cholecystectomy, and more departments and doctors are performing ERCP, while new data from large prospective series have documented the risks of both diagnostic and therapeutic ERCP. The establishment in Denmark of a Patient Insurance Association, which has covered injury caused during investigation and treatment in public hospitals since July 1992, has made it possible to collect and analyze a large prospective series of ERCP complications for which compensation has been claimed.

PATIENTS AND METHODS

Thirty-nine consecutive claims for compensation due to complications after ERCP occurring between 1 July 1992 and 31 December 1996 were investigated. Case notes were reviewed, along with laboratory reports and radiographs. The complications were classified according to the international consensus.

RESULTS

Claims for compensation were made in 39 cases from 25 hospitals. The indication for ERCP was appropriate in 31. Precut papillotomy for access had been performed in seven. The severity of the complications was mild in one patient, moderate in three patients, severe in 24, and fatal in nine; in two cases, the severity was not classifiable. The complications were: pancreatitis in 23 patients (seven cases fatal, one of which had involved a precut procedure), bleeding in two, perforation in nine (six had a precut procedure, one died), and other reasons in five (including one fatal case). Among the nine fatal cases, cannulation had not been achieved in two and the endoscopic retrograde cholangiogram was normal in four, one of whom underwent a sphincterotomy. One patient with a previous adenoma had an endoprosthesis removed, developed gangrenous cholecystitis afterward, and died. Thirty patients were eligible for compensation. The rejected cases included mild and moderate pancreatitis, a case of fatal hemorrhagic pancreatitis in which the patient had refused blood transfusion, and one patient who had pancreatitis prior to ERCP.

CONCLUSIONS

ERCP, even for diagnostic purposes, may be associated with very serious and even fatal complications. The use of the precut procedure for access should still be considered dangerous. Other means of investigating the bile ducts should be developed. If endoscopic ultrasonography and magnetic resonance cholangiography prove to have the same diagnostic value as ERCP, which must be considered the gold standard for visualizing the ducts today, they might replace ERCP as the primary investigation in patients with an intermediate or low risk of bile duct stones; this would reduce the numbers of patients exposed to the risks of ERCP.