2013 classification criteria for systemic sclerosis: an American college of rheumatology/European league against rheumatism collaborative initiative

OBJECTIVE

The 1980 American College of Rheumatology (ACR) classification criteria for systemic sclerosis (SSc) lack sensitivity for early SSc and limited cutaneous SSc. The present work, by a joint committee of the ACR and the European League Against Rheumatism (EULAR), was undertaken for the purpose of developing new classification criteria for SSc.

METHODS

Using consensus methods, 23 candidate items were arranged in a multicriteria additive point system with a threshold to classify cases as SSc. The classification system was reduced by clustering items and simplifying weights. The system was tested by (1) determining specificity and sensitivity in SSc cases and controls with scleroderma-like disorders, and (2) validating against the combined view of a group of experts on a set of cases with or without SSc.

RESULTS

It was determined that skin thickening of the fingers extending proximal to the metacarpophalangeal joints is sufficient for the patient to be classified as having SSc; if that is not present, seven additive items apply, with varying weights for each: skin thickening of the fingers, fingertip lesions, telangiectasia, abnormal nailfold capillaries, interstitial lung disease or pulmonary arterial hypertension, Raynaud's phenomenon, and SSc-related autoantibodies. Sensitivity and specificity in the validation sample were, respectively, 0.91 and 0.92 for the new classification criteria and 0.75 and 0.72 for the 1980 ACR classification criteria. All selected cases were classified in accordance with consensus-based expert opinion. All cases classified as SSc according to the 1980 ACR criteria were classified as SSc with the new criteria, and several additional cases were now considered to be SSc.

CONCLUSIONS

The ACR/EULAR classification criteria for SSc performed better than the 1980 ACR criteria for SSc and should allow for more patients to be classified correctly as having the disease.

2013 classification criteria for systemic sclerosis: an American College of Rheumatology/European League against Rheumatism collaborative initiative

OBJECTIVE

The 1980 American College of Rheumatology (ACR) classification criteria for systemic sclerosis (SSc) lack sensitivity for early SSc and limited cutaneous SSc. The present work, by a joint committee of the ACR and the European League Against Rheumatism (EULAR), was undertaken for the purpose of developing new classification criteria for SSc.

METHODS

Using consensus methods, 23 candidate items were arranged in a multicriteria additive point system with a threshold to classify cases as SSc. The classification system was reduced by clustering items and simplifying weights. The system was tested by 1) determining specificity and sensitivity in SSc cases and controls with scleroderma-like disorders, and 2) validating against the combined view of a group of experts on a set of cases with or without SSc.

RESULTS

It was determined that skin thickening of the fingers extending proximal to the metacarpophalangeal joints is sufficient for the patient to be classified as having SSc; if that is not present, 7 additive items apply, with varying weights for each: skin thickening of the fingers, fingertip lesions, telangiectasia, abnormal nailfold capillaries, interstitial lung disease or pulmonary arterial hypertension, Raynaud's phenomenon, and SSc-related autoantibodies. Sensitivity and specificity in the validation sample were, respectively, 0.91 and 0.92 for the new classification criteria and 0.75 and 0.72 for the 1980 ACR classification criteria. All selected cases were classified in accordance with consensus-based expert opinion. All cases classified as SSc according to the 1980 ACR criteria were classified as SSc with the new criteria, and several additional cases were now considered to be SSc.

CONCLUSION

The ACR/EULAR classification criteria for SSc performed better than the 1980 ACR criteria for SSc and should allow for more patients to be classified correctly as having the disease.

Survival after lung transplantation in systemic sclerosis. A systematic review

BACKGROUND

Lung transplantation is a life-saving option for systemic sclerosis (SSc)-associated pulmonary arterial hypertension (PAH) and interstitial lung disease (SSc-ILD) patients. However, some programs may be concerned about the possibility of excess post-transplantation mortality related to the extra-pulmonary manifestations of SSc. The objective of this study was to evaluate survival of SSc patients post-lung transplantation. We secondarily evaluated SSc lung transplant recipient characteristics (age, sex, and type of SSc lung disease), and discussed post-lung transplantation survival of SSc patients and non-SSc patients (idiopathic PAH, and ILD).

METHODS

A systematic review of MEDLINE, EMBASE, Cochrane Central Registry of Controlled Trials and CINAHL (all inception to 2012) was performed to identify studies evaluating post-lung transplant survival in SSc compared to PAH and ILD patients. Two reviewers independently abstracted study and survival data.

RESULTS

Two hundred twenty-six citations were screened to identify 7 observational studies reporting SSc patients who underwent single lung, double lung, or heart-lung transplantation. Mean age at transplantation ranged 46-53 years. SSc post-transplantation survival ranged 69%-91% at 30-days, 69%-85% at 6-months, 59%-93% at 1-year, 49%-80% at 2-years, and 46%-79% at 3-years. Causes of death included graft failure, infection, cardiac events, hemorrhagic stroke, respiratory failure, malignancy, pulmonary hypertension, complications of bronchiolitis obliterans syndrome, anesthetic complication, and scleroderma renal crisis. There were no reports of recurrence of SSc in the lung allograft.

CONCLUSION

The short-term and intermediate-term survival post-lung transplantation are similar to IPAH and ILD patients requiring lung transplantation.

Low bone density in systemic sclerosis. A systematic review

OBJECTIVE

The effect of systemic sclerosis (SSc) on bone density is not well understood. Through systematic review of the literature, the objectives of this study were to synthesize data about the prevalence of low bone mineral density (BMD), risk factors for low BMD, and occurrence of fracture and fracture-related mortality in SSc.

METHODS

A search was conducted of MEDLINE (1948-2012), Evidence Based Medicine Reviews (1991-2012), EMBASE (1980-2012), and CINAHL (1981-2012). Abstracts were screened to identify studies that evaluated low BMD in patients with SSc. Two investigators independently used a standardized form to abstract prevalence of osteopenia and osteoporosis (OP); risk factors for low BMD, BMD measurements, frequency of fracture, and fracture-related mortality.

RESULTS

Screening of 1032 citations identified 19 articles. Fifteen studies compared patients with SSc to controls. Most patients were white, female (prevalence 74%-100%), and postmenopausal (prevalence 45.9%-100%). The prevalence of low BMD and OP was 27%-53.3% and 3%-51.1%, respectively. Ten studies reported a lower BMD in patients with SSc compared to matched controls, whereas 2 studies reported no difference. Candidate risk factors for low BMD in SSc include family history of OP, age, menopause, diffuse subtype, presence of internal organ involvement, low vitamin D levels, and calcinosis. However, the studies supporting these factors were conflicting. Fracture rate ranged between 0% and 38%. No study reported OP-related fracture mortality.

CONCLUSION

The data suggest that patients with SSc are at risk of low BMD and fracture, especially when other risk factors for OP are present. The interaction of SSc manifestations, traditional OP risk factors, and clinically relevant outcomes is complex and warrants further research.

Hypoglycaemia, fear of hypoglycaemia and quality of life in children with Type 1 diabetes and their parents

AIM

To evaluate the association between fear of hypoglycaemia, episodes of hypoglycaemia and quality of life in children with Type 1 diabetes and their parents.

METHODS

This was a cross-sectional, population-based study of 325 children with Type 1 diabetes and their parents. The children were aged 2-18 years. A total of 325 parents of the patients aged 2-18 years and 196 of the patients themselves (aged 8-18 years) completed questionnaires including the PedsQL Diabetes Module, the Hypoglycaemia Fear Survey and Clarke's hypoglycaemia awareness questionnaire. Data were compared with HbA1c results and the history of severe hypoglycaemia episodes.

RESULTS

Parents with the highest levels of fear of hypoglycaemia reported that their children had a reduced quality of life (P < 0.001). Similarly children with the greatest fear also reported a reduced quality of life (P < 0.001); however a history of severe hypoglycaemia was not associated with the child's quality of life as perceived by the child or parent. Episodes of severe hypoglycaemia were associated with an increased fear of hypoglycaemia for the parents (P = 0.004) but not the children. Children in the highest fear quartile also had a higher HbA(1c) concentration compared with those in the lowest fear quartile [increase in HbA(1c) 7 mmol/mol (0.6%), P < 0.01].

CONCLUSIONS

Fear of hypoglycaemia and not episodes of hypoglycaemia per se is associated with increased psychological burden for children with Type 1 diabetes. Interventions to reduce fear of hypoglycaemia in these families may improve their quality of life.

Development, sensibility, and reliability of the Toronto Axial Spondyloarthritis Questionnaire in inflammatory bowel disease

OBJECTIVE

There is an unacceptable delay in the diagnosis of axial spondyloarthritis (axSpA) in its early stages among patients at high risk, in particular those with inflammatory bowel disease (IBD). Our objectives were to develop a sensible and reliable questionnaire to identify undetected axSpA among patients with IBD.

METHODS

Literature was reviewed for item generation in the Toronto axSpA Questionnaire on IBD (TASQ-IBD). Sensibility of the questionnaire was assessed among healthcare professionals and patients. This assessment was related to purpose and framework (clinical function, clinical justification, and clinical applicability), face validity, comprehensiveness [oligo-variability (limiting the questionnaire to important items) and transparency], replicability, content validity, and feasibility. The test-retest reliability study was administered to 77 patients with established IBD and axSpA. Kappa agreement coefficients and absolute agreement were calculated for items.

RESULTS

Three domains included IBD, inflammatory back symptoms, and extraaxial features. The entry criterion required a patient to have IBD and back pain or stiffness that ever persisted for ≥ 3 months. Iterative sensibility assessment involved 16 items and a diagram of the back. Kappa coefficients ranged from 0.81-1.00 for each item. Absolute agreement across all items ranged from 91% to 100%.

CONCLUSION

TASQ-IBD is a newly developed, sensible, and reliable case-finding questionnaire to be administered to patients with IBD who have ever had chronic back pain or stiffness persisting for ≥ 3 months. It should facilitate identification and timely referral of patients with IBD to rheumatologists and minimize the delay in diagnosis of axSpA. Consequently, it should assess the prevalence of axSpA in IBD.

CCR3 induced-p42/44 MAPK activation protects against staurosporine induced-DNA fragmentation but not apoptosis in airway smooth muscle cells

BACKGROUND

Chemokine receptors (CCRs) are expressed on airway smooth muscle (ASM) cells. As their ligands are present in the airways in asthma, we hypothesized that ASM CCR activation could promote the increase in ASM mass seen in patients with chronic asthma.

OBJECTIVE

To determine which CCRs are expressed by ASM cells and their potential functional relevance to the chronic airway changes seen in asthma.

METHODS

CCR expression in primary ASM cell cultures and airway biopsies from patients with and without asthma was examined by RT-PCR, fluorescence-activated cell sorting and immunohistochemistry. ASM p42/44 MAPK activity, proliferation, migration and apoptosis were examined by western blotting, thymidine incorporation, transwell assay and TUNEL assay respectively.

RESULTS

CCR3 was the most frequently expressed CCR protein and was present on 79 ± 14% of cells. CX3CR1 and CXCR6 were present on 6% and 11% of cells respectively. CCR3 ligands CCL11 and CCL24 caused rapid activation of p42/44 MAPK but not Akt. CCR3 activation did not affect ASM proliferation, migration or VEGF secretion. DNA fragmentation detected by TUNEL staining could be induced by staurosporine and Fas activation although only Fas activation resulted in caspase 3 cleavage. CCL11 and CCL24 protected ASM cells against DNA fragmentation dependent upon p42/44 MAPK activity only via caspase 3 independent pathways. CCR3 was expressed in the smooth muscle and epithelium in the airways of patients with and without asthma. Smooth muscle cell DNA fragmentation in the airways of patients with stable asthma and controls was very uncommon.

CONCLUSIONS AND CLINICAL RELEVANCE

CCR3 is strongly expressed by ASM cells in vitro and in vivo. Protection against cell death by CCR3 activation is dependent on p42/44 MAPK but does not affect caspase 3 mediated apoptosis.

Items for developing revised classification criteria in systemic sclerosis: Results of a consensus exercise

OBJECTIVE

Classification criteria for systemic sclerosis (SSc; scleroderma) are being updated. Our objective was to select a set of items potentially useful for the classification of SSc using consensus procedures, including the Delphi and nominal group techniques (NGT).

METHODS

Items were identified through 2 independent consensus exercises performed by the Scleroderma Clinical Trials Consortium and the European League Against Rheumatism Scleroderma Trials and Research Group. The first-round items from both exercises were collated and redundancies were removed, leaving 168 items. A 3-round Delphi exercise was performed using a 1-9 scale (where 1 = completely inappropriate and 9 = completely appropriate) and a consensus meeting using NGT was conducted. During the last Delphi round, the items were ranked on a 1-10 scale.

RESULTS

In round 1, 106 experts rated the 168 items. Those with a median score of <4 were removed, resulting in a list of 102 items. In round 2, the items were again rated for appropriateness and subjected to a consensus meeting using NGT by European and North American SSc experts (n = 16), resulting in 23 items. In round 3, SSc experts (n = 26) then individually scored each of the 23 items in a last Delphi round using an appropriateness score (1-9) and ranking their 10 most appropriate items for the classification of SSc. Presence of skin thickening, SSc-specific autoantibodies, abnormal nailfold capillary pattern, and Raynaud's phenomenon ranked highest in the final list that also included items indicating internal organ involvement.

CONCLUSION

The Delphi exercise and NGT resulted in a set of 23 items for the classification of SSc that will be assessed for their discriminative properties in a prospective study.

Clinical evidence, practice guidelines, and β-blocker utilization before major noncardiac surgery

BACKGROUND

Largely on the basis of 2 randomized trials published in the 1990s, β-blockers were initially promoted as an evidence-based intervention for preventing cardiac complications of noncardiac surgery. However, subsequent studies raised concerns about a widespread use of perioperative β-blockade. Little is known regarding how this changing evidence influenced the use of perioperative β-blockers in clinical practice.

METHODS AND RESULTS

We conducted a population-based, time-series analysis (April 1999 to March 2010) among residents of Ontario, Canada (age 66 years and older), to evaluate the influence of research publications and practice guidelines on rates of new β-blocker prescriptions before major elective noncardiac surgery. In an analysis of 249 828 procedures, the rate of new β-blocker prescriptions increased from 26.3 per 1000 procedures in April 1999 to 62.7 per 1000 procedures in the first quarter of 2005, after which it decreased to 19.7 per 1000 procedures by March 2010. We observed a marked decrease in prescriptions (P=0.004) during early 2005, without any preceding publications that raised concerns about perioperative β-blockade. There was no change (P=0.98) in prescription rates after the May 2008 publication of a multicenter, randomized trial that showed increased mortality from perioperative β-blockade. Prescribing trends remain unchanged after revisions of related practice guidelines in 2002 (P=0.28) and 2006 (P=0.53).

CONCLUSIONS

After a period characterized by increasing adoption of preoperative β-blockade between 1999 and 2005, prescriptions rates subsequently fell from 2005 to 2010. Further research is needed to understand the basis for these changes, which are only partially explained by evidence of potential harm.

Validation of potential classification criteria for systemic sclerosis

OBJECTIVE

Classification criteria for systemic sclerosis (SSc; scleroderma) are being updated jointly by the American College of Rheumatology and European League Against Rheumatism. Potential items for classification were reduced to 23 using Delphi and nominal group techniques. We evaluated the face, discriminant, and construct validity of the items to be further studied as potential criteria.

METHODS

Face validity was evaluated using the frequency of items in patients sampled from the Canadian Scleroderma Research Group, 1000 Faces of Lupus, and the Pittsburgh, Toronto, Madrid, and Berlin connective tissue disease (CTD) databases. Patients with SSc (n = 783) were compared to 1,071 patients with diseases similar to SSc (mimickers): systemic lupus erythematosus (n = 499), myositis (n = 171), Sjögren's syndrome (n = 95), Raynaud's phenomenon (RP; n = 228), mixed CTD (n = 29), and idiopathic pulmonary arterial hypertension (PAH; n = 49). Discriminant validity was evaluated using odds ratios (ORs). For construct validity, empirical ranking was compared to expert ranking.

RESULTS

Compared to mimickers, patients with SSc were more likely to have skin thickening (OR 427); telangiectasias (OR 91); anti-RNA polymerase III antibody (OR 75); puffy fingers (OR 35); finger flexion contractures (OR 29); tendon/bursal friction rubs (OR 27); anti-topoisomerase I antibody (OR 25); RP (OR 24); fingertip ulcers/pitting scars (OR 19); anticentromere antibody (OR 14); abnormal nailfold capillaries (OR 10); gastroesophageal reflux disease symptoms (OR 8); antinuclear antibody, calcinosis, dysphagia, and esophageal dilation (all OR 6); interstitial lung disease/pulmonary fibrosis (OR 5); and anti-PM-Scl antibody (OR 2). Reduced carbon monoxide diffusing capacity, PAH, and reduced forced vital capacity had ORs of <2. Renal crisis and digital pulp loss/acroosteolysis did not occur in SSc mimickers (OR not estimated). Empirical and expert ranking were correlated (Spearman's ρ = 0.53, P = 0.01).

CONCLUSION

The candidate items have good face, discriminant, and construct validity. Further item reduction will be evaluated in prospective SSc and mimicker cases.

Long-term safety and effectiveness of tumour necrosis factor inhibitors in systemic sclerosis patients with inflammatory arthritis

OBJECTIVES

To assess the long-term safety and effectiveness of tumour necrosis factor (TNF) inhibitors in the treatment of systemic sclerosis (SSc) patients with inflammatory arthritis.

METHODS

SSc patients who fulfilled the ACR criteria and had inflammatory arthritis followed in The Scleroderma Programme at the Mount Sinai and Toronto Western Hospitals, Toronto, Canada who received a TNF inhibitors for 12 months or more were retrospectively reviewed. Safety outcomes included development of TNF inhibitor related side effects, malignancy and death. Effectiveness outcomes included swollen joint count, tender joint count, skin score, and self-reported pain score at 12 months, compared to baseline.

RESULTS

Ten SSc patients were identified: 7 (70%) were female and 6 (60%) had diffuse disease with a median skin score of 6. Six patients (60%) had ILD. At 12 months, the median swollen joint count and tender joint count significantly decreased from 10 to 0 (p<0.01) and 15 to 3 (p=0.02), respectively. The median pain score decreased from 6 to 3.5 (p=0.10). The median skin score remained unchanged at 6 months. The FVC and DLCO changed from 86% and 65% respectively, to 80% and 75% respectively. One patient developed uncomplicated herpes zoster. After 30 months, 3 patients (30%) developed malignancy. No death or other adverse events were observed.

CONCLUSIONS

TNF inhibitors appear to be effective in the treatment of SSc-associated inflammatory arthritis. Skin score and lung function did not change significantly with therapy. However, malignancy occurred in one third of patients. Further studies are required to confirm these findings.

Dual therapy in IPAH and SSc-PAH. A qualitative systematic review

BACKGROUND

Use of endothelin receptor antagonists (ERA), phosphodiesterase type-5 (PDE-5) inhibitors and prostaglandin analogues has resulted in improved outcomes in idiopathic pulmonary arterial hypertension (IPAH) and systemic sclerosis-associated PAH (SSc-PAH) patients. However, patients often deteriorate on monotherapy. The objective of this study is to evaluate the effect of dual therapy on outcomes in IPAH and SSc-PAH.

METHODS

A systematic review of MEDLINE (1950-2011), EMBASE (1980-2011) and CINAHL (inception-2011) was conducted to identify studies that evaluated the effect of any dual combination of ERA, PDE-5 inhibitors or prostaglandin analogues on 6-min walk distance (6MWD), functional class (FC), haemodynamics, quality-of-life (QoL) or time-to-clinical-worsening in IPAH or SSc-PAH. A standardized form was used to abstract design, sample size, aetiology, outcome and treatment effect.

RESULTS

Twenty-six observational studies and 6 randomized trials were identified. Using combination PDE-5 inhibitor and prostaglandin analogues, 6/7 studies reported improvement in 6MWD, 6/8 studies reported improvement in FC, 6/6 studies reported improvement in haemodynamics and 1 trial demonstrated improvement in QoL and time-to-clinical-worsening. Using combination ERA and prostaglandin analogues, 4/6 studies and 1 trial reported improvement in 6MWD, 3/3 studies and 1 trial reported improvement in FC, 4/5 studies and 1 trial reported improvement in PAP. Using combination ERA and PDE-5 inhibitor, 4/7 studies reported an improvement in 6MWD, and 2/6 report improvement in FC.

CONCLUSION

The evidence suggests a beneficial effect of dual therapy in IPAH and SSc-PAH, particularly those who are deteriorating on monotherapy. Research should focus on subsets of patients to identify the optimal timing and combination of dual therapy.

Warfarin in systemic sclerosis-associated and idiopathic pulmonary arterial hypertension. A Bayesian approach to evaluating treatment for uncommon disease

OBJECTIVE

Warfarin is recommended in systemic sclerosis-associated pulmonary arterial hypertension (SSc-PAH) and idiopathic PAH (IPAH) to improve survival. There is no evidence to support this in SSc-PAH and the evidence in IPAH is conflicting. We evaluated the ability of warfarin to improve survival using 2 large SSc-PAH and IPAH cohorts.

METHODS

The effect of warfarin on all-cause mortality was evaluated. Bayesian propensity scores (PS) were used to adjust for baseline differences between patients exposed and not exposed to warfarin, and to assemble a matched cohort. Bayesian Cox proportional hazards models were constructed using informative priors based on international PAH expert elicitation.

RESULTS

Review of 1138 charts identified 275 patients with SSc-PAH (n = 78; 28% treated with warfarin) and 155 patients with IPAH (n = 91; 59% treated with warfarin). Baseline differences in PAH severity and medications were resolved using PS matching. In the matched cohort of 98 patients with SSc-PAH (49 treated with warfarin), the posterior median hazard ratio (HR) was 1.06 [95% credible interval (CrI) 0.70, 1.63]. In the matched cohort of 66 patients with IPAH (33 treated with warfarin), the posterior median HR was 1.07 (95% CrI 0.57, 1.98). The probability that warfarin improves median survival by 6 months or more is 23.5% in SSc-PAH and 27.7% in IPAH. Conversely, there is a > 70% probability that warfarin provides no significant benefit or is harmful.

CONCLUSION

There is a low probability that warfarin improves survival in SSc-PAH and IPAH. Given the availability of other PAH therapies with demonstrable benefits, there is little reason to use warfarin to improve survival for these patients.

Prognostic factors for survival in systemic lupus erythematosus associated pulmonary hypertension

Objective: Pulmonary hypertension (PH) is a rare but severe manifestation of systemic lupus erythematosus (SLE) that can ultimately result in death. The identification of factors that prognosticate survival in SLE-PH is necessary for appropriate monitoring, timing of therapeutics and lung transplantation. The primary objective of this study was to identify prognostic factors for survival in SLE-PH through review of the literature. The methodological quality of the prognostic studies was also evaluated .Methods: A systematic review of the literature was performed to identify studies evaluating prognostic factors for survival in SLE-PH. Medline, EMBASE, CINAHL, and Cochrane Central Registry of Controlled Trials (inception – week 2 2010) were searched. A standardized abstraction form was used by two independent reviewers to extract prognostic factors. Methodological quality was evaluated using a validated quality index. Results: Twenty-three observational studies from 375 citations were evaluated. Elevated mean pulmonary artery pressure, Raynaud’s phenomenon, thrombocytopenia, plexiform lesion, infection, thrombosis, pregnancy, pulmonary vasculitis and anticardiolipin antibodies were associated with decreased survival. Lupus disease activity, nephritis and central nervous system disease were not associated with survival. The sample sizes were small and methodological quality of the studies was variable. Conclusion: This study summarizes factors that may be associated with decreased survival in SLE-PH. The small sample sizes and variable methodological quality preclude definitive conclusions. This study provides the groundwork for further research using large cohorts.

Use of variability in national and regional data to estimate the prevalence of lymphangioleiomyomatosis

BACKGROUND

Understanding the true prevalence of lymphangioleiomyomatosis (LAM) is important in estimating disease burden and targeting specific interventions. As with all rare diseases, obtaining reliable epidemiological data is difficult and requires innovative approaches.

AIM

To determine the prevalence and incidence of LAM using data from patient organizations in seven countries, and to use the extent to which the prevalence of LAM varies regionally and nationally to determine whether prevalence estimates are related to health-care provision.

METHODS

Numbers of women with LAM were obtained from patient groups and national databases from seven countries (n = 1001). Prevalence was calculated for regions within countries using female population figures from census data. Incidence estimates were calculated for the USA, UK and Switzerland. Regional variation in prevalence and changes in incidence over time were analysed using Poisson regression and linear regression.

RESULTS

Prevalence of LAM in the seven countries ranged from 3.4 to 7.8/million women with significant variation, both between countries and between states in the USA. This variation did not relate to the number of pulmonary specialists in the region nor the percentage of population with health insurance, but suggests a large number of patients remain undiagnosed. The incidence of LAM from 2004 to 2008 ranged from 0.23 to 0.31/million women/per year in the USA, UK and Switzerland.

CONCLUSION

Using this method, we have found that the prevalence of LAM is higher than that previously recorded and that many patients with LAM are undiagnosed.

Optical evidence of a quantum well channel in low temperature molecular beam epitaxy grown Ga(AsBi)/GaAs nanostructure

A Ga(AsBi) quantum well (QW) with Bi content reaching 6% and well width of 11 nm embedded in GaAs is grown by molecular beam epitaxy at low temperature and studied by means of high-resolution x-ray diffraction, photoluminescence (PL), and time-resolved PL. It is shown that for this growth regime, the QW is coherently strained to the substrate with a low dislocation density. The low temperature PL demonstrates a comparatively narrow excitonic linewidth of ∼ 40 meV. For high excitation density distinct QW excited states evolve in the emission spectra. The origins of peculiar PL dependences on temperature and excitation density are interpreted in terms of intra-well optical transitions.

Effect of warfarin on survival in scleroderma-associated pulmonary arterial hypertension (SSc-PAH) and idiopathic PAH. Belief elicitation for Bayesian priors

OBJECTIVE

Warfarin use in scleroderma (SSc)-associated pulmonary arterial hypertension (PAH) and idiopathic PAH (IPAH) is controversial. A prerequisite for a trial is the demonstration of community uncertainty. We evaluated experts' beliefs about the effect of warfarin on 3-year survival in SSc-PAH and IPAH, and factors that influence warfarin use.

METHODS

PAH experts attending the 2008 American College of Rheumatology or American Thoracic Society meetings expressed the probability of 3-year survival without and with warfarin and their degree of uncertainty by applying adhesive dots, each representing a 5% weight of probability, in "bins" on a line, creating a prior probability distribution or prior. Using a numeric rating scale, participants rated factors that influence their use of warfarin.

RESULTS

Forty-five experts (44% pulmonologists, 38% rheumatologists, 16% cardiologists, 2% internists) underwent the belief elicitation interview. In SSc-PAH, the mean probabilities of 3-year survival without and with warfarin were 54% and 56%, respectively. Pessimistic experts believe that warfarin worsens survival by 7%. Optimistic experts believe that warfarin improves survival by 13%. In IPAH, the mean probabilities of 3-year survival without and with warfarin were 68% and 76%. Factors (mean rating out of 10, 0 = not at all important, 10 = extremely important) that influence experts' use of warfarin were functional class (5.4), age (5.4), pulmonary artery pressure (5.2), peripheral vascular disease (3.6), disease duration (2.8), and sex (1.7).

CONCLUSION

Bayesian priors effectively quantify and illustrate experts' beliefs about the effect of warfarin on survival in SSc-PAH and IPAH. This study demonstrates the presence of uncertainty about the effect of warfarin, and provides justification for a clinical trial.

Biologic therapy for systemic sclerosis: a systematic review

OBJECTIVE

Biologic agents are increasingly used in the rheumatic diseases. Their role in patients with systemic sclerosis (SSc) is uncertain. Our aim was to evaluate the effectiveness and safety of biologic agents in SSc. We review the evidence for the use of biologic agents to improve inflammatory arthritis, disability, and skin score, and we review adverse effects with biologic agents in patients with SSc.

METHODS

A systematic literature review was performed to identify studies evaluating the use of biologic agents in SSc. Medline, Embase, CINAHL, and Cochrane Database of Systematic Reviews were searched. A standardized abstraction form was used to extract biologic agent, study design, sample size, treatment effect, and adverse effects.

RESULTS

A total of 23 studies from 1413 citations were evaluated. Three studies evaluated infliximab, 3 evaluated etanercept, 3 evaluated antithymocyte globulin, 3 evaluated imatinib, 6 evaluated rituximab, and 1 study each evaluated interferon-γ (IFN-γ), IFN-α, relaxin, delipidated, deglycolipidated Mycobacterium vaccae, human anti-transforming growth factor ß1 antibody, and oral type I collagen. Studies of etanercept and infliximab suggest improvements in inflammatory arthritis and Health Assessment Questionnaire Disability Index (HAQ-DI). None of the other biologic agents demonstrated reproducible, statistically significant improvements in joint count, HAQ-DI, or skin score.

CONCLUSION

Anti-tumor necrosis factor-α agents may improve inflammatory arthritis and disability in SSc. The effect on skin score is uncertain. Adequately powered trials are needed to evaluate efficacy, and longitudinal studies are needed to evaluate longterm safety of these agents in SSc.

Discoidin domain receptor 1 regulates bronchial epithelial repair and matrix metalloproteinase production

Discoidin domain receptor (DDR)1 is an extracellular matrix (ECM)-sensing receptor tyrosine kinase, which is activated by collagen and expressed in bronchial epithelium. DDR1 is responsible for maintaining the normal structure of skin and kidney epithelia and we hypothesised that DDR1 plays a regulatory role in bronchial epithelial integrity by transducing signals from the airway ECM. Effects of DDR1 depletion were studied using RNA interference in primary human bronchial epithelial cells (HBECs) and BEAS-2B cells. The effects of overexpression of DDR1a and DDR1b in BEAS-2B cells were studied using a plasmid vector. We measured the effects on epithelial repair using a scratch wounding model, and levels of matrix metalloproteinases (MMPs) by gelatin zymography (MMP-2 and -9) and ELISA (MMP-7). We showed that knockdown of DDR1 slowed epithelial repair by 50%, which was associated with a reduction in levels of MMP-7, whilst DDR1 overexpression enhanced epithelial repair. DDR1 knockdown reduced proliferation of HBECs, but had no significant effect on adhesion to collagen I or other matrix substrates. These data suggest that ECM signalling via DDR1 regulates aspects of bronchial epithelial repair, integrity and MMP expression in the airways.

Cancer, employment, and American Indians: A participatory action research pilot study

American Indian cancer survivors are an underserved and understudied group. In this pilot study we attempted to address, through participatory action research, missing information about those factors that serve to either facilitate employment or hinder it for adult cancer survivors. One task of the study was to develop and/or modify instrumentation that could be used in a subsequent, in-depth census study. The pilot sample consisted of 10 cancer survivors, all members of a Northern Minnesota American Indian tribe, and 10 family members. All survivors reported having health problems such as fatigue since their cancer treatments. Rehabilitation counselors can assist survivors and their family members by advising them in regard to employment discrimination and accommodations such as flexible work schedules.

Contaminant concentrations in Asian carps, invasive species in the Mississippi and Illinois Rivers

Populations of invasive fishes quickly reach extremely high biomass. Before control methods can be applied, however, an understanding of the contaminant loads of these invaders carry is needed. We investigated differences in concentrations of selected elements in two invasive carp species as a function of sampling site, fish species, length and trophic differences using stable isotopes (delta (15)N, delta (13)C). Fish were collected from three different sites, the Illinois River near Havana, Illinois, and two sites in the Mississippi River, upstream and downstream of the Illinois River confluence. Five bighead carp (Hypophthalmichthys nobilis) and five silver carp (Hypophthalmichthys molitrix) from each site were collected for muscle tissue analyses. Freshwater mussels (Amblema plicata) previously collected in the same areas were used as an isotopic baseline to standardize fish results among sites. Total fish length, trophic position, and corrected (13)C, were significantly related to concentrations of metals in muscle. Fish length explained the most variation in metal concentrations, with most of that variation related to mercury levels. This result was not unexpected because larger fish are older, giving them a higher probability of exposure and accumulation of contaminants. There was a significant difference in stable isotope profiles between the two species. Bighead carp occupied a higher trophic position and had higher levels of corrected (13)C than silver carp. Additionally bighead carp had significantly lower concentrations of arsenic and selenium than silver carp. Stable isotope ratios of nitrogen in Asian carp were at levels that are more commonly associated with higher-level predators, or from organisms in areas containing high loads of wastewater effluent.

Prognostic factors for survival in scleroderma associated pulmonary arterial hypertension

OBJECTIVE

Identification of prognostic factors for survival in systemic sclerosis-associated pulmonary arterial hypertension (SSc-PAH) is necessary for appropriate monitoring, interventions, and timely referral for lung transplantation. Our objectives were (1) to identify factors associated with survival in SSc-PAH and (2) to evaluate the methodologic quality of prognostic studies against current standards.

METHODS

A systematic review was performed to identify studies evaluating factors associated with survival in SSc-PAH. The methodologic quality of each study was evaluated using a methodologic quality index.

RESULTS

HLA-DRw6 (RR 54.52, p = 0.01), HLA-DRw52 (RR not reported, p = 0.02), initial systolic pulmonary artery pressure (sPAP) > 60 mmHg (HR 3.60, 95% CI 1.42, 9.15), elevated mean right atrial pressure (mRAP) (HR 20.7, p = 0.0001), and shorter time between SSc onset and observed PAH (5.24 vs 9.93 yrs, p < 0.01) were associated with decreased survival. Age > 50 years (HR 2.34, 95% CI 0.54, 10.2), male sex (HR 2.02, 95% CI 0.65, 6.20), limited subtype (HR 2.37, 95% CI 0.68, 8.20), pulmonary fibrosis [Kaplan-Meier (KM) curves, p = 0.3], change in pulmonary vascular resistance (KM curves, p = 0.8), anti-centromere (HR 1.67, 95% CI 0.66, 4.26) and anti-ScL-70 (HR 0.28, 95% CI 0.03, 1.99) antibodies were not definitively associated with survival. Attributes of participants, prognostic factors, and outcome measures were well reported. Study attrition, confounding, and analysis were not well reported.

CONCLUSION

HLA-DRw52 and -DRw6, initial sPAP > 60 mmHg, mRAP, and shorter time between SSc onset and observed PAH were associated with decreased survival; however, methodologic quality of study reporting was variable. Prognostic factor research is needed using current methodologic standards.

Quality factor control and lasing characteristics of InAs/InGaAs quantum dots embedded in photonic-crystal nanocavities

We demonstrate lasing action with a high spontaneous emission factor and temperature insensitivity in InAs/InGaAs quantum dots (QD) embedded in photonic crystal nanocavities. A quality factor (Q) of over 10,000 was achieved by suppressing the material absorption by QDs uncoupled to the cavity mode. High Q cavities exhibited ultra low threshold lasing with a spontaneous emission factor of 0.7. Less frequent carrier escape from the QDs, which was primarily favored by high potential barrier energy, enabled low threshold lasing up to 90 K.

Quality of randomized clinical trials in juvenile idiopathic arthritis

OBJECTIVES

We evaluated the quality of randomized clinical trials (RCTs) of therapy for juvenile idiopathic arthritis (JIA) using an individual component approach and assessed temporal changes.

METHODS

A systematic review of the literature was performed to identify all RCTs involving exclusively JIA patients. Two investigators independently assessed the identified articles for six quality indicators: generation of allocation sequence, allocation concealment, masking, intention-to-treat (ITT) analysis, dropout rates and clearly stated primary outcome.

RESULTS

Fifty-two RCTs involving JIA patients were assessed. Generation of allocation sequence was unclear in 79% of the studies. Reporting of allocation concealment was adequate in only one-third of the studies. Masking was adequate in 73%, inadequate in 19% and unclear in 8% of the reports. ITT analysis was employed in 37% of the reports. Per-protocol analysis was used in 40% and in 23% the method was unclear. Most of the reports (67%) had dropout rates < or = 20%. About half of the reports (n = 25) failed to show a significant effect of the experimental treatment. No significant associations were found between the study results and quality indicators. With the exception of adequate masking and dropout rate, all quality indicators showed a trend of improvement over the decades.

CONCLUSIONS

The quality of RCTs in JIA based on the selected indicators was poor. Although there were some positive changes over time, the reporting and methodological quality of trials should be improved. New, more powerful and acceptable RCT designs should be developed in this patient population.

Classification criteria in rheumatic diseases: a review of methodologic properties

OBJECTIVE

To identify classification criteria for the rheumatic diseases and to evaluate their measurement properties and methodologic rigor using current measurement standards.

METHODS

We performed a systematic review of published literature and evaluated criteria sets for stated purpose, derivation and validation sample characteristics, methods of criteria generation and reduction, and consideration of validity, and reliability.

RESULTS

We identified 47 classification criteria sets encompassing 13 conditions. Approximately 50% of the criteria sets were developed based on expert opinion rather than patient data. Of the 47 criteria sets, control samples were derived from patients with rheumatic disease in 15 (32%) sets, from patients with nonrheumatic diseases in 4 (9%) sets, and from healthy participants in 2 (4%) sets. Where patient data were used, the number of cases ranged from 20-588 and the number of controls from 50-787. In only 1 (2%) criteria set was there a distinct separation between investigators who derived the criteria set and clinicians who provided cases and controls. Authors commented on the need for individual criterion to be reliable in 5 (11%) sets, precise in 5 (11%) sets; authors noted the importance of content validity in 12 (26%) sets, and construct validity in 12 (26%) sets.

CONCLUSION

The variation in methodologic rigor used in sample selection affects the validity and reliability of the criteria sets in different clinical and research settings. Despite potential deficiencies in the methods used for some criteria development, the sensitivity and specificity of many criteria sets is moderate to strong.

Feeding of western gray whales during a seismic survey near Sakhalin Island, Russia

Exxon Neftegas Limited, as operator of the Sakhalin-1 consortium, is developing oil and gas reserves on the continental shelf off northeast Sakhalin Island, Russia. DalMorNefteGeofizika (DMNG) on behalf of the Sakhalin-1 consortium conducted a 3-D seismic survey of the Odoptu license area during 17 August-9 September 2001. A portion of the primary feeding area of the endangered western gray whale (Eschrichtius robustus) is located in the vicinity of the seismic survey. This paper presents data to assess whether western gray whale bottom feeding activity, as indicated by visible mud plumes, was affected by seismic operations. The mitigation and monitoring program associated with the seismic survey included aerial surveys during 19 July-19 November 2001. These aerial surveys documented the local and regional distribution, abundance, and bottom feeding activity of western gray whales. Data on gray whale feeding activity before, during and after the seismic survey were collected, with the whales assumed to be feeding on the benthos if mud plumes were observed on the surface. The data were used to assess the influence of seismic survey and other factors (including environmental) on feeding activity of western gray whales. A stepwise multiple regression analysis failed to find a statistically significant effect (alpha = 0.05) of the seismic survey on frequency of occurrence of mud plumes of western gray whales used as a proxy to evaluate bottom feeding activity in Piltun feeding area. The regression indicated that transect number (a proxy for water depth, related to distance from shore) and swell height (a proxy for sea state) were the only variables that had a significant effect on frequency of whale mud plumes. It is concluded that the 2001 seismic survey had no measurable effect (alpha = 0.05) on bottom feeding activity of western gray whales off Sakhalin Island.

Distribution and abundance of western gray whales during a seismic survey near Sakhalin Island, Russia

Exxon Neftegas Limited, operator of the Sakhalin-1 consortium, is developing oil and gas reserves on the continental shelf off northeast Sakhalin Island, Russia. DalMorNefteGeofizika (DMNG), on behalf of the Sakhalin-1 consortium, conducted a 3-D seismic survey of the Odoptu license area during 17 August-9 September 2001. A portion of the primary known feeding area of the endangered western gray whale (Eschrichtius robustus) is located adjacent to the seismic block. The data presented here were collected as part of daily monitoring to determine if there was any measurable effect of the seismic survey on the distribution and abundance of western gray whales. Mitigation and monitoring program included aerial surveys conducted between 19 July and 19 November using the methodology outlined by the Southern California High Energy Seismic Survey team (HESS). These surveys provided documentation of the distribution, abundance and bottom feeding activity of western gray whales in relation to seismic survey sounds. From an operations perspective, the aerial surveys provided near real-time data on the location of whales in and outside the feeding area, and documented whether whales were displaced out of an area normally used as feeding habitat. The objectives of this study were to assess (a) temporal changes in the distribution and abundance of gray whales in relation to seismic survey, and (b) the influence of seismic survey, environmental factors, and other variables on the distribution and abundance of gray whales within their preferred feeding area adjacent to Piltun Bay. Multiple regression analysis revealed a limited redistribution of gray whales southward within the Piltun feeding area when the seismic survey was fully operational. A total of five environmental and other variables unrelated to seismic survey (date and proxies of depth, sea state and visibility) and one seismic survey-related variable (seg3d, i.e., received sound energy accumulated over 3 days) had statistically significant effects on the distribution and abundance of gray whales. The distribution of two to four gray whales observed on the surface (i.e., about five to ten whales in total) has likely been affected by the seismic survey. However, the total number of gray whales observed within the Piltun feeding area remained stable during the seismic survey.

A western gray whale mitigation and monitoring program for a 3-D seismic survey, Sakhalin Island, Russia

The introduction of anthropogenic sounds into the marine environment can impact some marine mammals. Impacts can be greatly reduced if appropriate mitigation measures and monitoring are implemented. This paper concerns such measures undertaken by Exxon Neftegas Limited, as operator of the Sakhalin-1 Consortium, during the Odoptu 3-D seismic survey conducted during 17 August-9 September 2001. The key environmental issue was protection of the critically endangered western gray whale (Eschrichtius robustus), which feeds in summer and fall primarily in the Piltun feeding area off northeast Sakhalin Island. Existing mitigation and monitoring practices for seismic surveys in other jurisdictions were evaluated to identify best practices for reducing impacts on feeding activity by western gray whales. Two buffer zones were established to protect whales from physical injury or undue disturbance during feeding. A 1 km buffer protected all whales from exposure to levels of sound energy potentially capable of producing physical injury. A 4-5 km buffer was established to avoid displacing western gray whales from feeding areas. Trained Marine Mammal Observers (MMOs) on the seismic ship Nordic Explorer had the authority to shut down the air guns if whales were sighted within these buffers. Additional mitigation measures were also incorporated: Temporal mitigation was provided by rescheduling the program from June-August to August-September to avoid interference with spring arrival of migrating gray whales. The survey area was reduced by 19% to avoid certain waters <20 m deep where feeding whales concentrated and where seismic acquisition was a lower priority. The number of air guns and total volume of the air guns were reduced by about half (from 28 to 14 air guns and from 3,390 in(3) to 1,640 in(3)) relative to initial plans. "Ramp-up" (="soft-start") procedures were implemented. Monitoring activities were conducted as needed to implement some mitigation measures, and to assess residual impacts. Aerial and vessel-based surveys determined the distribution of whales before, during and after the seismic survey. Daily aerial reconnaissance helped verify whale-free areas and select the sequence of seismic lines to be surveyed. A scout vessel with MMOs aboard was positioned 4 km shoreward of the active seismic vessel to provide better visual coverage of the 4-5 km buffer and to help define the inshore edge of the 4-5 km buffer. A second scout vessel remained near the seismic vessel. Shore-based observers determined whale numbers, distribution, and behavior during and after the seismic survey. Acoustic monitoring documented received sound levels near and in the main whale feeding area. Statistical analyses of aerial survey data indicated that about 5-10 gray whales moved away from waters near (inshore of) the seismic survey during seismic operations. They shifted into the core gray whale feeding area farther south, and the proportion of gray whales observed feeding did not change over the study period. Five shutdowns of the air guns were invoked for gray whales seen within or near the buffer. A previously unknown gray whale feeding area (the Offshore feeding area) was discovered south and offshore from the nearshore Piltun feeding area. The Offshore area has subsequently been shown to be used by feeding gray whales during several years when no anthropogenic activity occurred near the Piltun feeding area.Shore-based counts indicated that whales continued to feed inshore of the Odoptu block throughout the seismic survey, with no significant correlation between gray whale abundance and seismic activity. Average values of most behavioral parameters were similar to those without seismic surveys. Univariate analysis showed no correlation between seismic sound levels and any behavioral parameter. Multiple regression analyses indicated that, after allowance for environmental covariates, 5 of 11 behavioral parameters were statistically correlated with estimated seismic survey-related variables; 6 of 11 behavioral parameters were not statistically correlated with seismic survey-related variables. Behavioral parameters that were correlated with seismic variables were transient and within the range of variation attributable to environmental effects. Acoustic monitoring determined that the 4-5 km buffer zone, in conjunction with reduction of the air gun array to 14 guns and 1,640 in(3), was effective in limiting sound exposure. Within the Piltun feeding area, these mitigation measures were designed to insure that western gray whales were not exposed to received levels exceeding the 163 dB re 1 microPa (rms) threshold. This was among the most complex and intensive mitigation programs ever conducted for any marine mammal. It provided valuable new information about underwater sounds and gray whale responses during a nearshore seismic program that will be useful in planning future work. Overall, the efforts in 2001 were successful in reducing impacts to levels tolerable by western gray whales. Research in 2002-2005 suggested no biologically significant or population-level impacts of the 2001 seismic survey.

The medical evaluation of living kidney donors: a survey of US transplant centers

The use of living donors for kidney transplantation in the United States is common, and long-term studies have demonstrated the safety of donation by young, healthy individuals. However, transplant programs have little data to guide them in deciding which donors are unacceptable, and which characteristics are associated with kidney disease or poor psychosocial outcomes after donation. To document current practices in evaluating potential donors, we surveyed all US kidney transplant programs. Compared to a survey 12 years ago, medical criteria for donation are more inclusive in several areas. All responding programs now accept living unrelated donors. Most programs no longer have an upper age limit to be eligible. Programs are now more likely to accept donors with treated hypertension, or a history of kidney stones, provided that certain additional criteria are met. In contrast, medical criteria for donation are more restrictive in other areas, such as younger donor age and low creatinine clearance. Overall, significant variability remains among transplant programs in the criteria used to evaluate donors. These findings highlight the need for more data on long-term outcomes in various types of donors with potential morbidities related to donation.

Evaluating living kidney donors: relationship types, psychosocial criteria, and consent processes at US transplant programs

We conducted a survey of 132 US kidney transplant programs to examine how they evaluate and select potential living kidney donors, focusing on donor-recipient relationships, psychosocial criteria, and consent processes. There is heterogeneity in donor-recipient relationships that are considered acceptable, although most programs (70%) will not consider publicly solicited donors. Most programs (75%) require a psychosocial evaluation for all potential living donors. Most programs agree that knowledge of financial reward (90%), active substance abuse (86%), and active mental health problems (76%) are absolute contraindications to donation. However, there is greater variability in how other psychosocial issues are considered in the selection process. Consent processes are highly variable across programs: donor and recipient consent for the donor evaluation is presumed in 57% and 76% of programs, respectively. The use of 13 different informed consent elements varied from 65% (alternative donation procedures) to 86% (description of evaluation, surgery and recuperative period) of programs. Forty-three percent use a 'cooling off' period. Findings demonstrate high variability in current practice regarding acceptable donor-recipient relationships, psychosocial criteria, and consent processes. Whether greater consensus should be reached on these donor evaluation practices, especially in the context of more expansive use of living donor kidney transplantation, is discussed.

Improving the sensitivity of the American College of Rheumatology classification criteria for systemic sclerosis

OBJECTIVE

A large proportion of patients with limited systemic sclerosis (SSc) do not meet the current American College of Rheumatology (ACR) classification criteria for SSc. We undertook this study to determine whether the addition of easily available clinical variables, namely nailfold capillary abnormalities identified using a dermatoscope and visible telangiectasias, could improve the sensitivity of the current ACR classification criteria for patients with limited SSc.

METHODS

Patients in the Canadian Scleroderma Research Group Registry with skin involvement distal to the metacarpophalangeal joints were identified and divided into two groups according to whether they fulfilled the current ACR classification criteria for SSc or not. Sensitivity of the criteria was calculated. Regression tree analysis was performed to determine whether the addition of nailfold capillary abnormalities identified using a dermatoscope and visible telangiectasias could improve the sensitivity of the criteria.

RESULTS

One hundred and one (101) patients were included, in majority women with a mean age of 59 (+/- 13). Of these, 68 (67%) met the ACR classification criteria. The sensitivity of the criteria increased from 67% to 99% with the addition of nailfold capillary abnormalities identified using a dermatoscope and visible telangiectasias.

CONCLUSIONS

The SSc research community would benefit from having better classification criteria to identify patients with limited SSc. The current classification criteria for SSc may be significantly improved by the inclusion of easily identified clinical variables including nailfold capillary abnormalities using a dermatoscope.

Classification criteria for systemic sclerosis subsets

OBJECTIVE

To evaluate the measurement properties of criteria for systemic sclerosis (SSc) subsets for classification of patients in SSc trials, and to determine if any one criteria set confers measurement advantage over others.

METHODS

A systematic review of articles describing classification criteria for SSc subsets was performed. Evidence supporting the sensibility (statement of purpose for which the criteria will be used, population, setting, face and content validity, and feasibility), validity, and reliability of the criteria was evaluated.

RESULTS

Fourteen sets of criteria for SSc subsets were identified. There is variability in the intended purpose and setting for which criteria sets are to be applied. Although face validity improves with the addition of less commonly encountered subsets or disease manifestations as criteria, the feasibility of implementing such criteria is conversely limited. Content validity for most criteria sets has not been evaluated due to lack of an explicitly stated conceptual framework for SSc. The criteria with 3 or more subsets do not provide incremental predictive validity over the 2-subset criteria. Our ability to compare subset criteria on divergent validity and reliability is limited by a lack of data.

CONCLUSION

The 2-subset criteria of LeRoy, et al have good feasibility, acceptable face validity, and good predictive validity. Further research is needed to compare the content validity, divergent validity, and reliability of these with other subset criteria for use in SSc trials.

A review of the sapporo and revised Sapporo criteria for the classification of antiphospholipid syndrome. Where do the revised sapporo criteria add value?

OBJECTIVE

The preliminary classification criteria for antiphospholipid syndrome (APS), or the Sapporo criteria, are widely used for the inclusion of patients with APS into clinical studies. Revised Sapporo criteria have been proposed as an improved criteria set. Whether these criteria sets fulfill the current standards of measurement science are unknown. The purpose of this study was (1) to evaluate the developmental methodology and measurement properties of the Sapporo and the revised Sapporo criteria for use in clinical trials; and (2) to evaluate if the revised Sapporo criteria provide added value over the Sapporo criteria.

METHODS

A computer search for articles describing use of the Sapporo and the revised Sapporo criteria was performed. Item generation, item reduction, sensibility, validity, and reliability of the criteria were evaluated.

RESULTS

The Sapporo criteria set has incremental face and content validity over its predecessors. However, through separation of anti-ss2-glycoprotein I antibodies as a sub-item, the specification of a wider time interval between serologic testing, the specification of a time interval between serology and clinical manifestations, and specification of definitions for clinical manifestations and laboratory titer thresholds, the revised Sapporo criteria set has incremental face and content validity over the Sapporo criteria. The complexity of the criteria, diagnostic tests, and immunologic tests limits their feasibility. The reliability of each criterion is unknown. The discriminative capacity of the Sapporo criteria is good, with sensitivity, specificity, and positive and negative predictive values of 0.71, 0.98, 0.95, and 0.88, respectively, compared to patients with systemic lupus erythematosus. The discriminative capacity of the revised Sapporo criteria is unknown.

CONCLUSION

The revised Sapporo criteria set has incremental face and content validity compared its predecessors. Reliability testing of each criterion is needed before these criteria can be confidently used in multicenter APS trials. Discriminatory testing of the revised Sapporo criteria is required.

Primary nonfunction (PNF) in the MELD Era: An SRTR database analysis

PNF following liver transplantation (LT) is an infrequent but life-threatening complication. Liver allocation under MELD is based upon recipient severity of illness, a known risk factor for the occurrence of PNF. The incidence of PNF since the application of MELD has not previously been reported. The SRTR database was studied since inception of MELD until September 2004 for all adult recipients of deceased donor LT. PNF was defined as graft loss or death within 14 days of LT secondary to PNF or without defined cause. A total of 10545 transplants met inclusion criteria and PNF occurred in 613 (5.81%) of recipients. Univariate analysis demonstrated donor age, serum creatinine >1.5 mg/mL, hypertension and CVA as risk factors for PNF. Recipient factors included life support, mechanical ventilation, use of inotropes, hemodialysis, initial status 1 and use of a shared transplant. In the multivariate model only donor age and recipient serum creatinine, bilirubin, on life support and status 1 at transplant were significant risk factors for PNF. In this analysis of PNF in the MELD era the incidence of PNF does not appear to have increased from prior reports. Risk factors for PNF are related to donor age and severity of recipient illness.

Anticoagulation in pulmonary arterial hypertension: a qualitative systematic review

Thrombotic arteriopathy has been implicated in the pathophysiology of pulmonary arterial hypertension (PAH). However, the role of anticoagulants in the treatment of PAH is uncertain. Through a qualitative systematic review of epidemiological studies, the effectiveness of anticoagulation therapy with warfarin on survival was evaluated in patients with PAH. MEDLINE (1966 to November 2005), EMBASE (1966 to November 2005), bibliographies of included studies and published reviews were searched without language restriction. Epidemiological studies evaluating the effectiveness of warfarin in PAH were included. Studies had to report mortality as an outcome. Seven observational studies evaluating the effectiveness of warfarin comprising 488 patients were identified. Five studies support the effectiveness of anticoagulation therapy, whereas two do not. Data from observational studies suggest that anticoagulation therapy may be an effective intervention in pulmonary arterial hypertension. However, given the methodological limitations and the small number of existing observational studies, a randomised controlled trial is needed in order to definitively address this important clinical issue.

Is self-reported improvement in osteoarthritis pain and disability reflected in objective measures?

OBJECTIVE

To determine if self-reported improvements in pain and function correlate with improvement in objective measures of disease in osteoarthritis (OA).

METHODS

Individuals with disabling hip/knee OA were assessed 7 years apart by questionnaire [sociodemographics, body mass index, and Western Ontario and McMaster University Osteoarthritis Index (WOMAC) scores] and physical [range of motion (ROM), disease activity based on joint stress pain, erythema, warmth, effusion] and radiographic examination of the hips and knees (Kellgren-Lawrence grade). Changes over time were expressed as improved, unchanged, or worse based on a priori criteria.

RESULTS

Of 69 eligible patients, 43 (64%) with a mean age of 76.3 years participated; 77% were female. For WOMAC scores, 25% and 19% reported improved pain and function, respectively. For joint ROM, disease activity, and radiographic grade, 0% to 30% of participants were improved. However, improvements in WOMAC scores were not associated with improvements in any of the other measures (r < 0.24 for all).

CONCLUSION

One-quarter of participants reported significant improvements in WOMAC pain and disability after 7 years' followup. However, these improvements were not associated with similar improvements in joint ROM, disease activity, or radiographic grade. Greater understanding of the determinants of self-reported improvements in arthritis status, in particular the role of adaptation, is warranted.

Office capillaroscopy in systemic sclerosis

The aims of this study are to assess the reliability of two office techniques, the ophthalmoscope and the Dermlite dermatoscope, and to detect nailfold capillaroscopy abnormalities in systemic sclerosis (SSc). Two separate studies were performed. In the first, the nailfolds of two fingers on one hand of 13 SSc patients and two normals were examined by four rheumatologists using an ophthalmoscope. In the second, the nailfolds of the two fingers of each hand of six SSc patients and two normals were examined by six rheumatologists with a Dermlite dermatoscope. Widefield capillary microscopy was performed by one observer in the ophthalmoscope study to assess validity. The examiners determined the presence or absence of dilated loops, giant capillary loops, and/or avascular areas on each digit. The kappa coefficient was calculated to demonstrate agreement. With the ophtalmoscope, the inter-observer kappa coefficients were 0.43, 0.54, and 0.19; the average intra-observer agreements were 0.61, 0.56, and 0.31; and the ophthalmoscope-microscope agreement were 0.63, 0.52, and <0.1 for dilated capillaries, giant capillaries, and avascular areas, respectively. With the dermatoscope, the kappa values for inter-observer reliability were 0.63, 0.40, and 0.20; and intra-observer reliability was 0.71, 0.55, and 0.40 for dilated capillaries, giant capillaries, and avascular areas, respectively. The ophthalmoscope and the dermatoscope provide moderate to substantial reliability to detect the presence of giant and dilated capillaries but poor inter-observer agreement for avascular areas. The ophthalmoscope is valid when compared to the microscope for detecting giant or dilated capillaries. We conclude that these techniques are useful office tools to detect capillary abnormalities in SSc.

Pulmonary veno-occlusive disease and scleroderma associated pulmonary hypertension

OBJECTIVE

Pulmonary veno-occlusive disease (PVOD) is a rare cause of pulmonary hypertension (PH). We describe a series of 4 patients with systemic sclerosis (SSc), concomitant PH, and biopsy-proven/presumed PVOD. We review the literature describing the association of PVOD and SSc and discuss diagnostic features and treatment implications. In our case series, treatment with an endothelin receptor antagonist did not confer a beneficial treatment effect.