AB0586 PREVALENCE OF EARLY SYMPTOMATIC KNEE OSTEOARTHRITIS ACCORDING TO THREE CLINICAL CLASSIFICATION CRITERIA

Background:

Knee osteoarthritis (KOA) is a heterogeneous disease. Different classification criteria for symptomatic KOA (SKOA) have been proposed. Determining the prevalence and comparing the different criteria of SKOA in patients with knee pain will serve as a base when studying the predictive ability of these criteria in a longer perspective.

Objectives:

To study the prevalence of SKOA in individuals with knee pain according to three different classification criteria: the American College of Rheumatology (ACR), (1), the European League Against Rheumatism (EULAR)(2), and the National Institute for Health and Care Excellence (NICE) (3).

Methods:

Baseline data from an ongoing longitudinal study (HALLOA) including 296 individuals with knee pain, recruited by advertisement, were analysed. The individuals were categorized according to the classification criteria of SKOA (ACR, EULAR and NICE) based on age, clinical examination (crepitation), and self-reported data from KOOS (pain, symptoms, ADL, and sport/recreation), and dichotomized as fulfilling the criteria (SKOA) or not (no SKOA). BMI was measured (kg/m2). Radiographic KOA (RKOA) was assessed according to Ahlbäck criteria (1-5), defined as RKOA with grade 1 or more in at least one knee. Prevalence was calculated (frequencies, %) for each criterion, and Chi-Square test or the Independent-Samples t-test were used for comparisons between individuals fulfilling SKOA or not.

Results:

The mean age was 52 (min-max 24-73) years, 70% were women and 22% were classified with RKOA. The prevalence of SKOA according to each criterion was 57% (ACR), 51% (EULAR) and 73% (NICE) respectively. In total, 48% had SKOA according to all three criteria and whereof 32% had RKOA, compared to 10% RKOA among individuals with no SKOA. Regardless of the criterion, significantly more individuals classified with SKOA also had RKOA compared to individuals with no SKOA, p<0.001. Those classified as SKOA were significantly older and had higher BMI compared with no SKOA (Table 1).

Conclusion:

Approximately 50-70% of the individuals with knee pain were classified as having SKOA, where EULAR criteria had the lowest prevalence. A better understanding of early knee pain classification according to different clinical criteria is essential for the ability to capture and follow the long-term prognosis of early SKOA. Further longitudinal studies are needed.

References:

[1]Altman R et al. Arthritis Rheum. 1986;29(8):1039-49.

[2]Zhang W et al. Ann Rheum Dis. 2010;69(3):483-9.

[3]Health NIf, Excellence C. UK: National Institute for Clinical Excellence. 2014.

Table 1.

Comparisons between the ACR, EULAR and NICE criteria of symptomatic knee osteoarthritis, stratified for symptomatic knee osteoarthritis or not

ACREULARNICETotalOANo OAP-valueOANo OAP-valueOANo OAP-valueN(%)296 (100)170 (57.4)98 (33.1)152 (51.4)114 (38.5)215 (72.6)58 (19.6)Age(Y), Mean (SD)51.6 (8.7)53.3 (7.0)49.0 (10.3)<0.00154.5 (5.1)48.1 (10.8)<0.00154.7 (4.9)40.5 (9.8)<0.001Gender, female (%)208 (70.3)121 (71.2)66 (67.3)0.511108 (58.4)77 (67.5)0.538154 (71.6)36 (62.1)0.160BMI(kg/m2), Mean (SD)26.4 (4.6)26.5 (4.5)25.8 (4.3)0.17926.9 (4.5)25.4 (4.2)0.00526.7 (4.5)24.8 (3.8)0.004RKOA, n (%)64 (21.6) 45 (26.5)12 (12.2)0.00347 (30.9)10 (8.7)<0.00158 (27.0)1 (1.7)<0.001

Independent-samples t-test and Chi-2-test. Bold=Significant correlation (p≤0.05). OA = Osteoarthritis. ACR = American College of Rheumatology. EULAR = the European League Against Rheumatism. NICE = the National Institute of Care and Excellence. BMI = Body Mass Index. RKOA = Radiographic Knee Osteoarthritis (Ahlbäck, with grade ≥1 in ≥1 knee).

Disclosure of Interests:

None declared.

Soluble urokinase plasminogen activator receptor as a prognostic marker in men participating in prostate cancer screening

BACKGROUND

The urokinase plasminogen activator (uPA) system is involved in tissue remodelling processes and is up-regulated in many types of malignancies. We investigated whether serum levels of different forms of soluble uPA receptor (suPAR) are associated with survival and in particular with prostate cancer and cardiovascular disease mortality.

METHODS

Using time-resolved fluorescence immunoassays, we measured intact suPAR [suPAR(I-III)] and intact plus cleaved suPAR [suPAR(I-III) + suPAR(II-III)] and thus calculated the amount of suPAR(II-III) in serum samples from 375 men participating in a prostate cancer screening trial. A total of 312 men were free of prostate cancer and 63 men had prostate cancer diagnosed at the time of screening. The cohort was followed for 15 years. We assessed survival using Kaplan-Meier estimation and Cox proportional hazards regression.

RESULTS

The mean age at blood sampling was 64 years. In total, 152 men died during follow-up. SuPAR(I-III) and suPAR(II-III) were significantly positively associated with mortality (P = 0.001 and P < 0.0001, respectively). In a Cox regression model adjusting for age and prostate cancer status, an increase in suPAR(I-III) and suPAR(II-III) by 1-unit (ln-scale) was associated with a hazard ratio (HR) of 2.26 [95% confidence interval (CI) 1.17-4.35] and 2.53 (95% CI 1.56-4.10), respectively. There was a trend towards an increased risk of death from prostate cancer in screening-detected prostate cancer patients with increased values of either suPAR form. However, this difference was not significant and the association disappeared after adjusting for age, tumour stage, tumour grade and prostate-specific antigen. Being in the highest quartile of any of the suPAR forms was associated with a highly significant increased risk of cardiovascular death, with HR adjusted for age of 3.27 (95% CI 1.38-7.73) for suPAR(I-III) quartile 4 versus quartile 1. Conclusions.  High concentrations of serum suPAR(I-III) and suPAR(II-III) were associated with poor overall survival. The association was particularly strong for death from cardiovascular disease. No similar association was found for prostate cancer after adjustment for other prognostic factors.

Individualized intensification of treatment based on tumor marker decline in metastatic nonseminomatous germ cell testicular cancer (NSGCT): A report from the Swedish Norwegian Testicular Cancer Group, SWENOTECA

5015

Background: From July 1995 to December 2003, 602 adult patients from Sweden and Norway with metastatic testicular NSGCT were included in a population-based multicenter SWENOTECA protocol with strict guidelines for staging, treatment and follow-up. Methods: The basic strategy of this protocol was to individualize treatment according to AFP and β-HCG decline (t1/2). Satisfactory response to treatment was defined as a t½ for AFP ≤ 7 days and/or β-HCG ≤ 3 days. Initial treatment for all patients was 2 courses of standard BEP. Tumor markers were analyzed once a week during treatment. Patients with satisfactory response went on with BEP while patients with unsatisfactory t1/2 received intensified treatment in two steps with addition of ifosfamide (BEP-if/PEI) in step 1. If still unsatisfactory response the treatment was intensified according to step 2 involving high-dose chemotherapy with stem cell rescue. Postchemotherapy surgery was performed according to protocol guidelines. Results: 99,7% (602 of 604) of all patients with metastatic testicular NSGCT in the population were included in the protocol. Median FU was 72 months. 75% of the patients were treated with BEP, median 4 courses, without intensification, 19% according to intensification step 1 and 6% according to intensification step 2. Five year progression free survival (PFS), cancer specific survival (CSS) and overall survival (OS) grouped according to IGCCCG prognostic score are given in the Table below. There was no significant difference in PFS between the good and intermediate risk group. Death due to all causes was 10,1% (n=61) and treatment related deaths were 1,3 % (n=8). Conclusions: Our results, in a population based patient material, with individualized treatment based on tumor marker decline, are highly encouraging in all risk groups, but most notably in the intermediate risk group.

[Table: see text]

No significant financial relationships to disclose.

Variation in percentage-free prostate-specific antigen (PSA) with prostate volume, age and total PSA level

OBJECTIVE

To examine the correlation between prostate volume, patient age and total prostate-specific antigen (tPSA) with the percentage-free PSA (f/tPSA) in a population-based cohort of men with no prostate cancer and with a tPSA of < 10.0 ng/mL.

SUBJECTS AND METHODS

Men who in 1988-1989, after randomized selection in the general population, participated in a population-based screening study for prostate cancer, were investigated. In all, 1622 of the men (aged 55-70 years) were considered free from prostate cancer and had a tPSA level of < 10.0 ng/mL. The f/tPSA and tPSA were determined in frozen sera from each individual, and related to prostate volume and age measured at the time of the study. The entire population was investigated, as were four subpopulations based on tPSA levels (< 2.0, 2.0-3.9, 4.0-6.9 and 7.0-9.9 ng/mL). Statistical calculations included multiple regression and correlation analysis.

RESULTS

The f/tPSA level varied with prostate volume and age, but the decisive factor for this variation was the tPSA level. The closest correlation was in the tPSA interval 7.0-9.9 ng/mL, where volume and age together explained 47% of the variation in f/tPSA. Also, for men with tPSA levels in each of the intervals 2.0-3.9, 4.0-6.9 and 7.0-9.9 ng/mL, the f/tPSA increased with higher prostate volumes and age. In men with tPSA levels of < 2.0 ng/mL the f/tPSA was not affected by variations in prostate volume or age.

CONCLUSION

The variation in f/tPSA with prostate volume, age and tPSA is highly dependent on the tPSA level. Volume and age in the tPSA interval 7.0-9.9 ng/mL can explain almost half the variation in f/tPSA, whereas this influence is insignificant in men with a tPSA of < 2.0 ng/mL.

The frequency of illegitimate TCRbeta/gamma gene recombination in human lymphocytes: influence of age, environmental exposure and cytostatic treatment, and correlation with frequencies of t(14;18) and hprt mutation

Chromosome translocations in lymphoid malignancies often involve V(D)J recombinase mediated events giving rise to aberrant T-cell receptor (TCR) and immunoglobulin genes, which have been suggested to be useful as markers of genomic instability, genotoxic exposure and cancer risk. Illegitimate rearrangements involving the TCRbeta/gamma loci on chromosome 7 create TCRbeta/gamma hybrid genes which occur at low frequency in peripheral blood lymphocytes (PBLs) of normal healthy individuals. To evaluate the utility of this marker, we studied the possible effects of age and genotoxic exposures on the TCRbeta/gamma gene variant frequency (VF), and compared the frequencies of hypoxanthine guanine phosphoribosyl transferase (hprt) mutation, hprt exon 2/3 deletion, t(14;18) and TCRbeta/gamma gene rearrangements in cells from the same donors. The TCRbeta/gamma VF ranged five-fold among 16 middle aged blood donors with a mean of 0.74+/-0.29/10(5) PBLs, which is consistent with our previous estimate in healthy subjects. The TCRbeta/gamma VF was found to increase from birth until early adult life, and then to decrease with increasing age. Four testis cancer patients, who 6 years earlier had been treated with etoposide and other cytostatic drugs, showed TCRbeta/gamma VF similar to that in healthy controls. No increase of the TCRbeta/gamma VF was found among non-smoking PAH-exposed aluminum smelter workers compared to non-smoking controls. Smoking smelter workers showed decreased TCRbeta/gamma VF compared to non-smoking workers and controls, but in a follow-up study 2 years later the difference was no longer statistically significant, although the smoking smelter workers still showed a lower TCRbeta/gamma VF than the controls. No correlation was obtained between the TCRbeta/gamma VF and the t(14;18) or hprt mutant frequency (MF) in a group of healthy individuals. However, there was a statistically significant correlation between the TCRbeta/gamma VF and the hprt exon 2/3 deletion frequency in PBL DNA from the same donors. These results show that the TCRbeta/gamma VF in healthy individuals changes with age and correlates with the frequency of hprt exon 2/3 deletion, another marker of aberrant V(D)J recombination in T-cells. However, no effect of smoking or present or previous exposure to genotoxic agents on TCRbeta/gamma VF was observed in this study. Thus, further studies are needed to prove the utility of TCRbeta/gamma gene rearrangement as a marker of genotoxic exposure.

Diagnostic value of percent free prostate-specific antigen: retrospective analysis of a population-based screening study with emphasis on men with PSA levels less than 3.0 ng/mL

OBJECTIVES

To retrospectively investigate the use of percent free prostate-specific antigen (PSA) compared with total PSA in serum as predictor of prostate cancer in men selected randomly from the general population who underwent biopsy on the basis of abnormal findings on digital rectal examination (DRE) or transrectal ultrasound (TRUS) and/or serum PSA levels greater than 10 ng/mL.

METHODS

A single intervention, population-based screening study was undertaken in 1988 and 1989. Of the 2400 men aged 55 to 70 years invited to participate, 1782 men responded and were examined with DRE, TRUS, and PSA testing (Tandem-Hybritech). In 1995, frozen serum samples from 1748 men were analyzed for percent free PSA (Prostatus, Wallac OY). Five-year follow-up data on new cancers in the screened population were obtained from the Swedish Cancer Registry (SCR).

RESULTS

Of the 1748 men, 367 underwent TRUS-guided biopsies because of abnormal findings on either DRE or TRUS or serum PSA levels of greater than 10 ng/mL. This resulted in the diagnosis of 64 cases of prostate cancer (3.7%). PSA levels of 3.0 ng/mL or greater were found in 55 (86%) of 64 cancer cases and in 399 (24%) of the 1684 benign cases. Among the 1294 men with PSA less than 3.0 ng/mL, 9 prostate cancers were diagnosed (14% of all prostate cancers). All 9 patients with cancer and with PSA less than 3.0 ng/mL had a percent free PSA of 18% or less. In the group of 1109 patients with PSA less than 3.0 ng/mL and a percent free PSA greater than 18%, 159 biopsies were performed because of abnormal DRE or TRUS. However, no prostate cancer was diagnosed in this category of patients. Five years after the screening intervention, 7 more cases of prostate cancer were clinically diagnosed in the screened population according to the SCR.

CONCLUSIONS

The combination of PSA levels less than 3.0 ng/mL and percent free PSA greater than 18% defines a large part of the population at a very low risk of cancer of the prostate both at the time of screening and during the following 5 years. Men in this group may be spared DRE, and longer screening intervals may be considered. However, the risk of having prostate cancer is not negligible in men with PSA less than 3.0 ng/mL and percent free PSA of 18% or less. The results of this study indicate that biopsy should be recommended to men fulfilling these criteria, although these results should be confirmed in larger prospective studies because of the limited number of patients with prostate cancer in the present series.

Antibiotic prophylaxis for prostate biopsy: benefits and costs

Transrectal ultrasound-guided core biopsy is a widely used method to diagnose prostate cancer. It is generally considered a safe procedure but the main concern is that significant complications such as infections do occur. To evaluate the effect of a combined two-dosage antibiotic prophylaxis with ciprofloxacin and metronidazole, a prospective study of 289 patients undergoing core-biopsy of the prostate was performed. Five patients (1.7%) developed urinary tract infection and all did recover without any further complications. The infection rate was significantly lower compared to our historic controls receiving no prophylaxis at all. This prophylactic regime resulted in a low infection rate and it was feasible from the patient perspective. The total cost of antibiotic medication and additional costs due to complications was 18 USD per patient and the cost-effectiveness compared to no prophylactic therapy at all was considered good.

Prostate-specific antigen (PSA), PSA density and age-adjusted PSA reference values in screening for prostate cancer--a study of a randomly selected population of 2,400 men

Prostate cancer screening with DRE, TRUS, and PSA testing was offered to 2,400 randomly selected men 55-70 years old. Among 1,782 examined, 65 (3.6%) men with prostate cancer were diagnosed. The PSA results were correlated to the diagnosis, the men's age, and the prostate volume. Least square regression analysis was used to calculate the 95% upper confidence intervals for PSA in each year of age in men without prostate cancer. The PPV was calculated for: (i) PSA > 4 ng/ml, (ii) PSAD > 0.15, (iii) PSAD > 0.20 and (iv) age-adjusted PSA reference values. A significant correlation was found between PSA and prostate volume, between PSA and age, and between the prostate volume and age. The calculated annual growth of the prostate was 1.6% and the annual increase in PSA was 2.4%. The age-adjusted upper PSA reference values for the three age categories studied (55-59, 60-64 and 65-70 years) were 5.2, 5.8, and 6.7 ng/ml, respectively. The PPVs for PSA > 4 ng/ml, PSAD > 0.15, PSAD > 0.20, and the age-adjusted PSA reference values were 17%, 14%, 22%, and 27%, respectively. Age-adjusted PSA or PSAD may increase the PPV compared to PSA > 4 ng/ml. The detection rate is, however, inadequate. A PSA cut-off at 4 ng/ml could therefore be maintained in men 55-70 years old. The median PSA values and median prostate volumes calculated for men with benign findings may serve as a reference in future studies.

In-vitro fertilization and intracytoplasmic sperm injection in the treatment of infertility after testicular cancer

Treatment of testicular cancer (TC) may cause infertility due to reduced sperm quality with or without an ejaculation problem. In cases of anejaculation or retrograde ejaculation, spermatozoa can be obtained by transrectal electroejaculation (TE) or testicular sperm extraction (TESE) and used for in-vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI). In this study, 15 out of 17 couples evaluated for infertility after TC, underwent a total of 21 treatment cycles, resulting in 18 embryo transfers. Spermatozoa were obtained by TE in 16 cycles, by masturbation in three cycles and by TESE in one. In one cycle no spermatozoa were found using TESE. Fertilization and cleavage was achieved by IVF in seven cycles and ICSI in 11 cycles; average fertilization rates of 57 and 55% respectively were observed. Twelve clinical pregnancies occurred, of which 11 have been delivered or are ongoing. The ongoing pregnancy rate was 57% per cycle. These results show that infertility after testicular cancer can be treated effectively with IVF and that ICSI even permits treatment of patients who have severe oligozoospermia.

Transrectal electroejaculation in combination with in-vitro fertilization: an effective treatment of anejaculatory infertility after testicular cancer

Treatment of non-seminomatous testicular cancer often leads to infertility due to anejaculation/retrograde ejaculation and poor sperm quality. In these men spermatozoa may be obtained by transrectal electroejaculation (TE), but the optimal strategy for assisted procreation in these couples is not known. Our aim was to examine whether TE and conventional in-vitro fertilization (IVF) would be successful. A total of 10 couples, with long-standing infertility due to anejaculation or retrograde ejaculation after treatment for testicular cancer 5-14 years earlier, were referred to our unit. All men underwent diagnostic TE under general anaesthesia. Spermatozoa were recovered in nine cases. The antegrade fraction was prepared and used for IVF. Sperm quality was variable and conventional IVF was considered impossible in three cases. Altogether six IVF treatment cycles in six couples resulted in five pregnancies, of which four resulted in a delivery and one resulted in a spontaneous abortion. One additional pregnancy is ongoing after transfer of cryopreserved embryos. The fertilization rate was 54% (33/61) and the cleavage rate was 97% (32/33). No complications relating to the procedure have been encountered.

Folic acid as an adjunct in the treatment of children with the autism fragile-X syndrome (AFRAX)

Four boys with the combination of infantile autism and the fragile-X syndrome were given oral folic acid and placebo, according to a double-blind crossover design. One boy's behaviour appeared to improve on folic acid, but another boy did not seem to be affected at all. For the remaining two boys the results were equivocal. Further study of folic acid in the treatment of autistic boys with the fragile-X syndrome is warranted.