A framework to guide dose & regimen strategy for clinical drug development

Optimizing new drug therapies remains a challenge for clinical development, despite the use of ever more sophisticated quantitative methodologies. Although conceptually simple, the idea of finding the right treatment at the right dose for the right patient to ensure an appropriate balance of risks and benefits is challenging and requires a multidisciplinary approach. In this paper, we present a framework developed as a tool for organizing knowledge and facilitating collaboration in development teams.

Siponimod: Disentangling disability and relapses in secondary progressive multiple sclerosis

Background:

In multiple sclerosis, impact of treatment on disability progression can be confounded if treatment also reduces relapses.

Objective:

To distinguish siponimod’s direct effects on disability progression from those on relapses in the EXPAND phase 3 trial.

Methods:

Three estimands, one based on principal stratum and two on hypothetical scenarios (no relapses, or equal relapses in both treatment arms), were defined to determine the extent to which siponimod’s effects on 3- and 6-month confirmed disability progression were independent of on-study relapses.

Results:

Principal stratum analysis estimated that siponimod reduced the risk of 3- and 6-month confirmed disability progression by 14%–20% and 29%–33%, respectively, compared with placebo in non-relapsing patients. In the hypothetical scenarios, risk reductions independent of relapses were 14%–18% and 23% for 3- and 6-month confirmed disability progression, respectively.

Conclusion:

By controlling the confounding impact of on-study relapses on confirmed disability progression, these statistical approaches provide a methodological framework to assess treatment effects on disability progression in relapsing and non-relapsing patients. The analyses support that siponimod may be useful for treating secondary progressive multiple sclerosis in patients with or without relapses.

OP0197 THE INITIAL TREATMENT OF SYSTEMIC JUVENILE IDIOPATHIC ARTHRITIS: AN INTERNATIONAL COLLABORATION AMONG 10 REGISTRIES

Background:

The introduction of biologics has transformed care for children with systemic juvenile idiopathic arthritis (SJIA). Differences in treatment approaches between countries and how they have changed over time are not well studied.

Objectives:

We contrast the initial features, treatment and 12-month outcome in SJIA across 10 JIA registers in Europe and North America.

Methods:

Data were extracted locally from 10 Registers including manifestations at diagnosis, medication use over first year and outcomes (Physician Global Assessment (PGA), active joint count (AJC)) at 12 months. Data was compared before/after 2012 to assess change over time. Weighted (w) means were used to adjust for varying number of patients/Register.

Results:

1,149 patients; 553 had medication data for 2012-2018; primarily female and Caucasian; median age at diagnosis 5.3-8 years. Median duration of symptoms prior to first visit varied (0-3.3 months). Glucocorticoid (GC) use was common in the first year (w_average 72% (range 33-96%)). Biologic use included IL-1, IL-6 and TNF inhibitors. The proportion of patients treated with biologics, primarily anakinra, increased after 2012 (Table 1). W_mean PGA and AJC at the 12±3 month visit were 1.55 and 1.57, respectively (Table 2). At one year, the proportion of patients prescribed GC varied (w_mean 40%, range 26-60%).

Conclusion:

Analysis of SJIA patients across 10 countries show that time to first rheumatology visit was highly variable. Although local factors influence treatment decisions, biologic use increased after 2011; anakinra most common. Nearly 75% of patients were prescribed steroids within the first year but seemed to decrease after 1 year. More study is needed on long-term outcomes in SJIA patients within this modern era.

1: Medication Usage within First Year (pre/post 2012 where available)Glucocorticoids (IV+PO)%Methotrexate%Biologic%Anti-IL-1%Anakinra%Tocilizumab%USA2010-2011n=922563333330USA2012-2018n=91501771705717Canada2005-2010n=8876601710100UK2001-2011n=69787110330UK2012-2018n=31485829191919Portugal2008-2011n=7342364330Portugal2012-2018n=19744732161621Sweden2009-2015n=50964662302830Denmark1997-2011n=83864013662Denmark2012-2018n=325012.575636319Turkey2000-2011n=71937758423720Turkey2012-2018n=11498524032289Germany2000-2011n=27173621376<1Germany2012-2018n=249574727191020Norway1997-2011n=26816212448Norway2012-2018n=510060100202080Finland2006-2011n=12424217008Finland2012-2018n=1225880082: Clinical Outcomes at 12 Months -all yearsAJCMedian [IQR]PGAMedian [IQR]GC Use, %USA0 [0, 0]0 [0,0]47Canada0 [0, 2]0.1 [0, 2.7]41UK0 [0, 0]0.5 [0, 1.7]53Portugal0 [0, 0]0.3 [0, 1]53Sweden0 [0, 0.5]0 [0, 0.5]31Denmark0 [0, 0]-26Turkey4 [2, 7]4 [3, 7]60Germany0 [0, 1]0 [0,2]36Norway0 [0, 0]0.5 [0, 2]45Finland0 [0, 0]0 [0, 0]33

Disclosure of Interests:

Mary Beth Son: None declared, Yukiko Kimura Consultant of: Genetech, Kristiina Aalto: None declared, Lillemor Berntson: None declared, Johnathan Dallas: None declared, Ciaran Duffy: None declared, Mia Glerup: None declared, Jaime Guzman: None declared, Troels Herlin: None declared, Petteri Hovi: None declared, Kimme Hyrich Grant/research support from: Pfizer, UCB, BMS, Speakers bureau: Abbvie, Jens Klotsche: None declared, Bo Magnusson: None declared, Vanessa McItyre: None declared, Ellen Nordal: None declared, Seza Özen: None declared, Maria Jose Santos Speakers bureau: Novartis and Pfizer, Betül Sözeri: None declared, Timothy Beukelman Consultant of: UCB, Novartis

White matter lesion location correlates with disability in relapsing multiple sclerosis

Background

Lesion location is a prognostic factor of disease progression and disability accrual.

Objective

To investigate lesion formation in 11 brain regions, assess correlation between lesion location and physical and cognitive disability measures and investigate treatment effects by region.

Methods

In 2355 relapsing–remitting multiple sclerosis patients from the FREEDOMS and FREEDOMS II studies, we extracted T2-weighted lesion number, volume and density for each brain region; we investigated the (Spearman) correlation in lesion formation between brain regions, studied association between location and disability (at baseline and change over 2 years) using linear/logistic regression and assessed the regional effects of fingolimod versus placebo in negative binomial models.

Results

At baseline, the majority of lesions were found in the supratentorial brain. New and enlarging lesions over 24 months developed mainly in the frontal and sublobar regions and were substantially correlated to pre-existing lesions at baseline in the supratentorial brain (p = 0.37–0.52), less so infratentorially (p = −0.04–0.23). High sublobar lesion density was consistently and significantly associated with most disability measures at baseline and worsening of physical disability over 24 months. The treatment effect of fingolimod 0.5 mg was consistent across the investigated areas and tracts.

Conclusion

These results highlight the role of sublobar lesions for the accrual of disability in relapsing–remitting multiple sclerosis.

Effective Visual Communication for the Quantitative Scientist

Effective visual communication is a core competency for pharmacometricians, statisticians, and, more generally, any quantitative scientist. It is essential in every step of a quantitative workflow, from scoping to execution and communicating results and conclusions. With this competency, we can better understand data and influence decisions toward appropriate actions. Without it, we can fool ourselves and others and pave the way to wrong conclusions and actions. The goal of this tutorial is to convey this competency. We posit three laws of effective visual communication for the quantitative scientist: have a clear purpose, show the data clearly, and make the message obvious. A concise "Cheat Sheet," available on https://graphicsprinciples.github.io, distills more granular recommendations for everyday practical use. Finally, these laws and recommendations are illustrated in four case studies.

How can we make better graphs? An initiative to increase the graphical expertise and productivity of quantitative scientists

Graphics are at the core of exploring and understanding data, communicating results and conclusions, and supporting decision-making. Increasing our graphical expertise can significantly strengthen our impact as professional statisticians and quantitative scientists. In this article, we present a concerted effort to improve the way we create graphics at Novartis. We provide our vision and guiding principles, before describing seven work packages in more detail. The actions, principles, and experiences laid out in this paper are applicable generally, also beyond drug development, which is our field of work. The purpose of this article is to share our experiences and help foster the use of good graphs in pharmaceutical statistics and beyond. A Graphics Principles "Cheat Sheet" is available online at https://graphicsprinciples.github.io/.

The Safety and Antiviral Activity of BZF961 with or without Ritonavir in Patients Infected with Hepatitis C Virus: A Randomized, Multicenter Trial

PURPOSE

Infection with hepatitis C virus is the leading cause of infectious disease mortality in the United States. BZF961 is a novel small molecule inhibitor of the hepatitis C virus NS3-4A protease. Here we present the results of a randomized, double-blinded, placebo-controlled, multicentered study in treatment-naïve patients with chronic hepatitis C virus genotype-1 infection.

METHODS

Patients were enrolled sequentially in 2 parts and treated for 3days. BZF961 was administered as monotherapy (500mg BID for 3 days) or in combination with the cytochrome P450 3A4 inhibitor ritonavir to boost its exposure (BZF961 10, 20, or 50mg QD or BID).

FINDINGS

BZF961 was safe and well tolerated in the patients studied with no serious adverse events. There were no appreciable differences in adverse events among patients who received BZF961, BZF961 with ritonavir, or placebo. There was a significant, clinically meaningful reduction in viral load from baseline in patients treated either with BZF961 500mg every 12hours alone or BZF961 50mg every 12hours in combination with ritonavir. Activity against the hepatitis C virus of the lower-dose regimens was apparent but more modest. There were no relevant changes from baseline viral loads in placebo-treated patients.

IMPLICATIONS

Coadministration of ritonavir with BZF961 boosted BZF961 exposure (including C_min, which is the clinically relevant parameter associated with antiviral activity) in a therapeutic range with less variability compared with BZF961 alone. For strategic reasons, BZF961 is no longer under development.

How Often Do Safety Signals Occur by Chance in First-in-Human Trials?

Clinicians working on first-in-human clinical studies need to be able to judge whether safety signals observed on an investigational drug were more likely to have occurred by chance or to have been caused by the drug. We retrospectively reviewed 84 Novartis studies including 1,234 healthy volunteers receiving placebo to determine the expected incidence of changes in commonly measured laboratory parameters and vital signs, in the absence of any active agent. We calculated the frequency of random incidence of safety signals, focusing on the liver, cardiovascular system, kidney, and pancreas. Using the liver enzyme alanine aminotransferase (ALT) as an example, we illustrate how a predictive model can be used to determine the probability of a given subject to experience an elevation of ALT above the upper limit of the normal range under placebo, conditional on the characteristics of this subject and the study.

Antimalarial Activity of KAF156 in Falciparum and Vivax Malaria

BACKGROUND

KAF156 belongs to a new class of antimalarial agents (imidazolopiperazines), with activity against asexual and sexual blood stages and the preerythrocytic liver stages of malarial parasites.

METHODS

We conducted a phase 2, open-label, two-part study at five centers in Thailand and Vietnam to assess the antimalarial efficacy, safety, and pharmacokinetic profile of KAF156 in adults with acute Plasmodium vivax or P. falciparum malaria. Assessment of parasite clearance rates in cohorts of patients with vivax or falciparum malaria who were treated with multiple doses (400 mg once daily for 3 days) was followed by assessment of the cure rate at 28 days in a separate cohort of patients with falciparum malaria who received a single dose (800 mg).

RESULTS

Median parasite clearance times were 45 hours (interquartile range, 42 to 48) in 10 patients with falciparum malaria and 24 hours (interquartile range, 20 to 30) in 10 patients with vivax malaria after treatment with the multiple-dose regimen and 49 hours (interquartile range, 42 to 54) in 21 patients with falciparum malaria after treatment with the single dose. Among the 21 patients who received the single dose and were followed for 28 days, 1 had reinfection and 7 had recrudescent infections (cure rate, 67%; 95% credible interval, 46 to 84). The mean (±SD) KAF156 terminal elimination half-life was 44.1±8.9 hours. There were no serious adverse events in this small study. The most common adverse events included sinus bradycardia, thrombocytopenia, hypokalemia, anemia, and hyperbilirubinemia. Vomiting of grade 2 or higher occurred in 2 patients, 1 of whom discontinued treatment because of repeated vomiting after receiving the single 800-mg dose. More adverse events were reported in the single-dose cohort, which had longer follow-up, than in the multiple-dose cohorts.

CONCLUSIONS

KAF156 showed antimalarial activity without evident safety concerns in a small number of adults with uncomplicated P. vivax or P. falciparum malaria. (Funded by Novartis and others; ClinicalTrials.gov number, NCT01753323 .).

Data on the oral CRTh2 antagonist QAW039 (fevipiprant) in patients with uncontrolled allergic asthma

This article contains data on clinical endpoints (Peak Flow Expiratory Rate, fractional exhaled nitric oxide and total IgE serum levels) and plasma pharmacokinetic parameters concerning the use of the oral CRTh2 antagonist QAW039 (fevipiprant) in mild to moderate asthma patients. Information on experimental design and methods on how this data was obtained is also described. Further interpretation and discussion of this data can be found in the article "The oral CRTh2 antagonist QAW039 (fevipiprant): a phase II study in uncontrolled allergic asthma" (Erpenbeck et al., in press) [1].

Silicon carbide--a high-transparency nonlinear material for THz applications

Optical properties of 4H-SiC were measured using time-domain and Fourier transform spectroscopy in the range of 0.1-20 THz. A high-transparency region was found between <0.1-10 THz. Based on the obtained data and published results, the refractive indices for o-wave and e-wave were approximated in the form of Sellmeier equations for the entire transparency range. Phase matched frequency conversion was found to be possible at wavelengths from the visible through the mid-IR and further into the far-IR (THz) region beyond 17 μm. Extremely low absorption coefficient, high damage threshold, and the possibility of phase matching make this material highly suited for high power THz optics and generation.

Spiroindolone KAE609 for falciparum and vivax malaria

BACKGROUND

KAE609 (cipargamin; formerly NITD609, Novartis Institute for Tropical Diseases) is a new synthetic antimalarial spiroindolone analogue with potent, dose-dependent antimalarial activity against asexual and sexual stages of Plasmodium falciparum.

METHODS

We conducted a phase 2, open-label study at three centers in Thailand to assess the antimalarial efficacy, safety, and adverse-event profile of KAE609, at a dose of 30 mg per day for 3 days, in two sequential cohorts of adults with uncomplicated P. vivax malaria (10 patients) or P. falciparum malaria (11). The primary end point was the parasite clearance time.

RESULTS

The median parasite clearance time was 12 hours in each cohort (interquartile range, 8 to 16 hours in patients with P. vivax malaria and 10 to 16 hours in those with P. falciparum malaria). The median half-lives for parasite clearance were 0.95 hours (range, 0.68 to 2.01; interquartile range, 0.85 to 1.14) in the patients with P. vivax malaria and 0.90 hours (range, 0.68 to 1.64; interquartile range, 0.78 to 1.07) in those with P. falciparum malaria. By comparison, only 19 of 5076 patients with P. falciparum malaria (<1%) who were treated with oral artesunate in Southeast Asia had a parasite clearance half-life of less than 1 hour. Adverse events were reported in 14 patients (67%), with nausea being the most common. The adverse events were generally mild and did not lead to any discontinuations of the drug. The mean terminal half-life for the elimination of KAE609 was 20.8 hours (range, 11.3 to 37.6), supporting a once-daily oral dosing regimen.

CONCLUSIONS

KAE609, at dose of 30 mg daily for 3 days, cleared parasitemia rapidly in adults with uncomplicated P. vivax or P. falciparum malaria. (Funded by Novartis and others; ClinicalTrials.gov number, NCT01524341.).

Incidence and outcomes of surgical resection for giant pulmonary bullae--a population-based study

BACKGROUND

Giant pulmonary bullae (GPB) are rare and there is little information on incidence, long-term prognosis, and outcome of treatment.

OBJECTIVES

To assess the incidence of GPB in the Icelandic population and to evaluate the outcome of surgical treatment.

METHODS

Twelve consecutive patients (11 males; mean age 60 ± 15.7 years) underwent resection for GPB in Iceland between 1992 and 2009. All were heavy smokers and had bullae occupying > 30% of the involved lung. There were 8 bilateral and 3 unilateral bullectomies and one lobectomy. Pulmonary function tests were performed preoperatively, and at one month and 5.4 years postoperatively. Age-standardized incidence rate (ASR) was calculated, complications and operative mortality were registered, and overall survival was estimated. Mean follow-up time was 8.2 years.

RESULTS

The ASR for GPB was 0.40 and 0.03 per 100,000 per year for men and women, respectively. There was no operative mortality, but prolonged air leakage (75%) and pneumonia (17%) were the most common postoperative complications. One month postoperatively, mean FEV1 increased from 1.0 ± 0.48 L (33% predicted) to 1.75 ± 0.75 L (57.5% predicted) (p < 0.01), but FVC remained unchanged. RV decreased from 3.9 ± 0.8 L (177% predicted) to 3.0 ± 1.0 L (128% predicted) (p < 0.05), but TLC and DLCO did not change after operation. At long-term follow-up the FEV1 and FVC had declined to near-baseline values. Five-year and 10-year survival were 100% and 60%, respectively.

CONCLUSIONS

The ASR of GPB in Iceland was 0.21 per 100,000 per year. In this small series, bullectomy was found to be a safe procedure that significantly improved pulmonary function. The functional improvement then declined over time. Prolonged air leakage was a common postoperative complication that prolonged hospital stay.

Langerhans cells and T cells sense cell dysplasia in oral leukoplakias and oral squamous cell carcinomas--evidence for immunosurveillance

Leukoplakias (LPLs) are lesions in the oral mucosa that may develop into oral squamous cell carcinoma (OSCC). The objective of this study was to assess presence and distribution of dendritic Langerhans cells (LCs) and T cells in patients with LPLs with or without cell dysplasia and in oral squamous cell carcinoma (OSCC). Biopsy specimens from patients with leukoplakias (LPLs) with or without dysplasia and oral squamous cell carcinoma (OSCC) were immunostained with antibodies against CD1a, Langerin, CD3, CD4, CD8 and Ki67, followed by quantitative analysis. Analyses of epithelium and connective tissue revealed a significantly higher number of CD1a + LCs in LPLs with dysplasia compared with LPLs without dysplasia. Presence of Langerin + LCs in epithelium did not differ significantly between LPLs either with or without dysplasia and OSCC. T cells were found in significantly increased numbers in LPLs with dysplasia and OSCC. The number of CD4+ cells did not differ significantly between LPLs with and without dysplasia, but a significant increase was detected when comparing LPLs with dysplasia with OSCC. CD8+ cells were significantly more abundant in OSCC and LPLs with dysplasia compared with LPLs without dysplasia. Proliferating cells (Ki67+) were significantly more abundant in OSCC compared to LPLs with dysplasia. Confocal laser scanning microscopy revealed colocalization of LCs and T cells in LPLs with dysplasia and in OSCC. LCs and T cells are more numerous in tissue compartments with dysplastic epithelial cells and dramatically increase in OSCC. This indicates an ongoing immune response against cells with dysplasia.

Assessment of Bone Viability After Heat Trauma: A Histological, Histochemical and Vital Microscopic Study in the Rabbit

In the present investigation a comparison was made between conventional histology, histochemistry and vital microscopy for assessment of heat-induced bone tissue injury. The extent of the bone damage around a burr hole or after heating fibular bone samples in saline solutions of various temperatures was evaluated by means of histology and histochemistry, using the absence of filled osteocyte lacunae or lack of oxidative enzyme activities as indication of bone death, respectively. In both cases a wider necrotic border zone was detected with histochemistry than with histology. The vital microscopic method is based on a titanium chamber which, after insertion in the rabbit tibia, allows observation and registration of the same bone compartment for a follow-up period of more than one year. The dynamic tissue events taking place after heating to 50 degrees C for one minute were investigated and compared with histological and histochemical data of the bone. The vital microscopic method showed a consistent and widespread bone tissue injury after heating to 50 degrees C for one minute while, on the other hand, the indirect methods exhibited only inconsistent signs of tissue injury. It is concluded that histochemistry using the presence or otherwise of diaphorase enzyme activities is a more reliable method than is histology for the estimation of bone viability after heat trauma. Vital microscopy is more sensitive than indirect, morphologic and metabolic techniques for detection of heat-induced bone tissue injury.

Alprenolol-induced thrombocytopenia

A case of alprenolol-induced thrombocytopenia in a 65-year-old woman is reported. She was admitted to the hospital twice with platelet counts below 10X10(9)/l. The platelet count rapidly returned to normal after discontinuation of alprenolol. The reason for the thrombocytopenia was increased platelet destruction.

Pneumococcal vaccination in splenectomized patients with hematological disorders

Seventy splenectomized patients were vaccinated with Pneumovax, a pneumococcal polysaccharide vaccine. Twenty-four of the patients had a malignant and 30 a nonmalignant hematological disorder. The remaining 16 were patients with no known hematological disorder, seven with intra-abdominal carcinomas and nine with non-malignant reasons for splenectomy. About 90% of the patients with non-malignant hematological disorders responded to vaccination with a rise in antibody titres, which was significantly higher than in the other two groups studied. Malignant hematological disorders lowered the response rate to 61-67%. Patients with no known hematological disorder but with intra-abdominal carcinomas also responded less frequently, while those in this group with other surgical reasons for splenectomy had a response rate comparable to healthy individuals. No serious side-effects were reported and we therefore conclude that all splenectomized patients should be vaccinated with a pneumococcal vaccine. However, it must always be born in mind that one third of the patients with malignant disease did not respond to vaccination.

Lipopolysaccharide induced-in vivo increases in β-defensins of the rat parotid gland

Antimicrobial beta-defensins are thought to protect epithelial surfaces. Their mobilization in response to inflammation was studied in the rat parotid gland using an ELISA assay. Bacterial lipopolysaccharide (LPS), injected into the parotid duct on one side, induced a marked local inflammatory response in the parotid gland as judged by several fold increases in myeloperoxidase activity and, in histological sections, infiltration of neutrophils. Three hours after the injection, beta-defensin 1 and 3 were increased (by 41% and 15%, respectively, P<0.01) as compared to the contralateral gland. Though still elevated 6h after the injection, the percentage figures for beta-defensin 1 were, at this time, somewhat lower (30%) compared to the situation at 3h, while those for defensin 3 were significantly higher 65% (P<0.01); neither at the early nor at the late time of observation were any changes in the level of beta-defensin 2 observed. The beta-defensins under study were not detected in submandibular and sublingual glands, neither were they detected in the inflamed submandibular gland, showing also here several fold increases in myeloperoxidase activity and, in addition, the presence of inflammatory cells, following ductal injection of LPS towards the gland.

Environmental changes in the North Atlantic Region: SCANNET as a collaborative approach for documenting, understanding and predicting changes

The lands surrounding the North Atlantic Region (the SCANNET Region) cover a wide range of climate regimes, physical environments and availability of natural resources. Except in the extreme North, they have supported human populations and various cultures since at least the end of the last ice age. However, the region is also important at a wider geographical scale in that it influences the global climate and supports animals that migrate between the Arctic and all the other continents of the world. Climate, environment and land use in the region are changing rapidly and projections suggest that global warming will be amplified there while increasing land use might dramatically reduce the remaining wilderness areas. Because much of the region is sparsely populated--if populated at all--observational records of past environmental changes and their impacts are both few and of short duration. However, it is becoming very important to record the changes that are now in progress, to understand the drivers of these changes, and to predict future consequences of the changes. To facilitate research into understanding impacts of global change on the lands of the North Atlantic Regions, and also to monitor changes in real time, an EU-funded network of research sites and infrastructures was formed in 2000: this was called SCANNET--SCANdinavian/North European NETwork of Terrestrial Field Bases. SCANNET currently consists of 9 core sites and 5 sites within local networks that together cover the broad range of current climate and predicted change in the region. Climate observations are well replicated across the network, whereas each site has tended to select particular environmental and ecological subjects for intensive observation. This provides diversity of both subject coverage and expertise. In this paper, we summarize the findings of SCANNET to-date and outline its information bases in order to increase awareness of data on environmental change in the North Atlantic Region. We also identify important gaps in our understanding and identify where the roles of existing infrastructures and activities represented by SCANNET can facilitate future research, monitoring and ground-truthing activities.

The Swedish version of the Childhood Health Assessment Questionnaire (CHAQ) and the Child Health Questionnaire (CHQ)

We report herein the results of the cross-cultural adaptation and validation into the Swedish language of the parent's version of two health related quality of life instruments. The Childhood Health Assessment Questionnaire (CHAQ) is a disease specific health instrument that measures functional ability in daily living activities in children with juvenile idiopathic arthritis (JIA). The Child Health Questionnaire (CHQ) is a generic health instrument designed to capture the physical and psychosocial well-being of children independently from the underlying disease. The Swedish CHAQ CHQ were already published and therefore were revalidated in this study. A total of 129 subjects were enrolled: 69 patients with JIA (13% systemic onset, 39% polyarticular onset, 25% extended oligoarticular subtype, and 23% persistent oligoarticular subtype) and 60 healthy children. The CHAQ clinically discriminated between healthy subjects and JIA patients, with the systemic, polyarticular and extended oligoarticular subtypes having a higher degree of disability, pain, and a lower overall well-being when compared to their healthy peers. Also the CHQ clinically discriminated between healthy subjects and JIA patients, with the systemic onset, polyarticular onset and extended oligoarticular subtypes having a lower physical and psychosocial well-being when compared to their healthy peers. In conclusion the Swedish version of the CHAQ-CHQ are reliable, and valid tools for the functional, physical and psychosocial assessment of children with JIA.

Presence of human papilloma viruses in intraosseous ameloblastoma

PURPOSE

This study investigated the possibility that human papilloma virus (HPV) is a possible etiologic agent in the development of ameloblastoma.

MATERIALS AND METHODS

DNA was extracted from 18 formalin-fixed, paraffin-embedded biopsy specimens and assayed for the presence of HPV DNA by PCR using the L1 consensus primer and specific primers for HPV types 6/11, 16 and 18.

RESULTS

Eight samples (67%) were positive for HPV. Of the 8 HPV-positive samples, 7 were positive for HPV 18. Four of the HPV 18-positive samples were also positive for HPV 6/11. One HPV-positive sample was not positive for any of the type-specific primers.

CONCLUSIONS

No conclusions can be drawn about the etiologic role of HPV from this study, but surgical manipulation is suggested to be one of the reasons for HPV presence attributable to contamination from the surface mucosal epithelium in these tumors.

The immunohistochemical expression of DNA-PKCS and Ku (p70/p80) in head and neck cancers: relationships with radiosensitivity

PURPOSE

The DNA-PK complex is one of the major pathways by which mammalian cells respond to DNA double-strand breaks induced by ionizing radiation. This study evaluated the relationship between the immunohistochemical expression of the individual components of DNA-PK and cellular radiosensitivity in head and neck cancers.

METHODS AND MATERIALS

Biopsies from patients with previously untreated squamous cell carcinomas of the head and neck were assessed for inherent tumor radiosensitivity measured as the surviving fraction at 2 Gy (SF2) using a soft agar clonogenic assay. Paraffin-embedded tumor material from 64 successfully grown specimens was immunohistochemically stained for expression of DNA-PKcs and Ku (p70/p80). The same tumor material was previously analyzed for the immunohistochemical expression of p53.

RESULTS

A significant correlation was found between the degree of expression of DNA-PKcs and Ku (p70/p80) (r = 0.55, p<0.001). There were no overall significant differences in the levels of expression of DNA-PKcs and Ku (p70/p80) in tumors from patients of either sex, different sites, histologies, and stages. No relationship was found between SF2 and the expression of either DNA-PKcs (r = 0.22, p = 0.081) or Ku (p70/p80) (r = 0.064, p = 0.62). Comparison with previous immunohistochemical characterization showed no significant correlations between the expression levels of p53 and either DNA-PKcs (r = 0.093, p = 0.46) or Ku (p70/p80) (r = -0.17, p = 0.17).

CONCLUSIONS

This study suggests that determining the immunohistochemical expression of DNA-PK in head and neck cancers from multiple sites does not have a role as a predictive assay of tumor in vitro radiosensitivity.

The lack of correlation between proliferation (Ki-67, PCNA, LI, Tpot), p53 expression and radiosensitivity for head and neck cancers

A study was made of the relationship between measurements of radiosensitivity versus proliferation and p53 status in head and neck cancers. Inherent tumour radiosensitivity was assessed as surviving fraction at 2 Gy (SF2) using a clonogenic soft agar assay (n = 77). The results were compared to data on proliferation obtained by both flow cytometry (labelling index (LI), the potential doubling time (Tpot) n = 55) and immunohistochemistry (Ki-67 and PCNA; n = 68), together with immunohistochemical p53 expression (n = 68). There were no overall significant differences in the median values of the various parameters analysed for the different sites within the head and neck region, disease stages, grades of tumour differentiation or nodal states. A subgroup analysis showed that oropharyngeal (n = 22) versus oral cavity (n = 35) tumours were more radiosensitive (P = 0.056) and had a higher Ki-67 index (P = 0.001). Node-positive tumours had higher LI (P = 0.021) and a trend towards lower Tpot (P = 0.067) values than node-negative ones. No correlations were seen between SF2 and any of the parameters studied. The long-standing dogma of an increased radiosensitivity of rapidly proliferating cells in contrast to slowly proliferating cells was not confirmed. The study shows that parallel measurements of different biological markers can be obtained for a large number of patients with head and neck cancers. The independence of the various parameters studied suggests that there may be potential for their combined use as prognostic factors for the outcome of radiotherapy.

Mutations of the p53 gene in oral squamous-cell carcinomas from Sudanese dippers of nitrosamine-rich toombak and non-snuff-dippers from the Sudan and Scandinavia

Using PCR-SSCP/DNA sequencing methods, we analyzed 14 oral squamous-cell carcinomas (OSCCs) and 8 pre-malignant oral lesions from different Sudanese patients for prevalence of mutations in exons 5 to 9 of the p53 gene in relation to toombak-dipping status. OSCCs (14 from Sudan, 28 from Scandinavia), and 3 pre-malignant oral lesions from Sudanese non-dippers were used as controls. A statistically significant increased incidence in mutations of the p53 gene was found in OSCCs from toombak dippers (93%; 13/14), as compared with those from non-dippers in Sudan (57%; 8/14) and in Scandinavia (61%; 17/28) respectively. In OSCCs from dippers, mutations were found in exons 5 to 9, while in those from non-dippers they were found in exons 5, 7, 8, 9, and no mutations were found in exon 8 in any of the OSCCs from Sudan. Certain types of mutations, however, were similar with respect to exposure to toombak. OSCCs from dippers showed 15 transversions, 9 transitions, 3 insertions and one deletion, compared with 7 transversions, 2 transitions and one deletion found in OSCCs from Sudanese non-dippers, and 9 transversions, 17 transitions and 2 insertions found in those from non-dippers in Scandinavia. No mutations were found in any of the non-malignant oral lesions in relation to dipping or non-dipping status. These findings suggest that (i) the use of toombak plays a significant role in induction of increased p53 gene mutations, (ii) mutations observed were similar to those induced by tobacco-specific N-nitrosamines (TSNAs) in experimental animal models and those already reported in toombak dippers, (iii) types of mutations associated with TSNAs were similar in the exposed and the control groups, (iv) a novel mutation in exon 6 was found in the OSCCs from toombak dippers, (v) the p53 exons 5 (codon 130), 6 (codons 190, 216) and 7 (codons 229, 249, 252) mutations are probable hot spots for toombak-related OSCCs. Further studies are necessary to validate the increased incidence and exon locations of the p53-gene mutations as a biomarker of malignant transformation in populations in which the oral use of tobacco is habitual.

Myxoid variant of follicular dendritic cell sarcoma arising in the breast

Follicular dendritic cell sarcoma is a malignant tumor of the follicular dendritic cell which can arise in extranodal sites. We present here a case arising as a mass in the breast of a 41-year-old woman. The tumor was composed of mildly pleomorphic spindly cells with pale ovoid nuclei and cell processes intimately admixed with mature lymphocytes. In much of the lesion the cells were dispersed in cords in a myxoid stroma, and elsewhere there were solid sheets. The neoplastic cells were immunoreactive for CD21, CD35, EMA, and S100 protein, but not for other lymphoid markers or cytokeratin. Electron microscopy showed interdigitating cytoplasmic processes with junctions but no external lamina. The differential diagnosis includes carcinoma, lymphomas, and a variety of myxoid sarcomas. The tumor recurred within a few months and displayed increased nuclear pleomorphism and lymphatic invasion but the patient appears free of disease 3 years after the further excision. This case extends the spectrum of follicular dendritic cell sarcoma in soft tissue sites.

The Swedish snus and the Sudanese toombak: are they different?

In Sweden, snuff (locally known as snus), was introduced since the year 1637. Presently, Sweden has the highest per capita consumption and sale figures of snuff in the world, and the habit is becoming increasingly popular. Snus is manufactured into a dry form used in the nasal cavity and a moist form used in the oral cavity. Snus manufactured for oral use is a moist ground tobacco of Dark Kentucky or Virginia species mixed with an aqueous solution of water and other blending ingredients. This form of snuff is found in two types: (1) loose and (2) portion-bag-packed. These are the most widely used. The loose moist form (1-2 g a quid) is the most popular type consumed by 73% of the males, followed by the portion-bag-packed form (0.5-1 g a quid), consumed by 13% of the males, while 14% of the males are mixed users. The majority of snus users place the quid in the vestibular area of the upper lip, and the prevalence among persons 15 years of age or older in 15.9% among males and 0.2% among females. The pH of snus has declined from a previous range of 8-9 to a range of 7.8-8.5, moisture content ranges 35-60% and nicotine content is in the order of 5-11 mg/g dry wt tobacco-specific N-nitrosamines (TSNAs) in micrograms (N'-nitrosonornicotine: NNN 5-9; 4-(methyl-nitrosamino)-1-(3-pyridyl)-1-butanone: NNK 1-2; N'-nitrosoanatabine: NAT 2-5). In the Sudan, snuff, locally known as toombak, was introduced approximately 400 years ago. It is always processed into a loose moist form, and its use is widespread in the country. Tobacco used for manufacture of toombak is of the species Nicotiana rustica, and the fermented ground powder is mixed with an aqueous solution of sodium bicarbonate. The resultant product is moist, with a strong aroma, highly addictive and its use is widespread particularly among males. Its pH range is 8-11, moisture content ranges 6-60% and nicotine content is from 8 to 102 mg/g dry wt, and TSNAs contents in micrograms (NNN 420-1 550; NNK 620-7 870; NAT 20-290). Snus and toombak dippers develop a clinically and histologically characteristic lesion at the site of dipping. Probably due to control of the TSNAs in snus, this type of snuff is associated with a lower risk of cancer of the oral cavity (relative risk: RR 5-6-fold), whereas the risk for cancer of the oral cavity among toombak users was high (RR 7.3-73.0-fold). In conclusion, the two snuff products significantly differ in many aspects. Most notable differences are tobacco species, fermentation and ageing, nicotine and TSNAs content, pH, expression of the p53 tumour suppressor gene, and keratin types 13, 14, and 19. It was, therefore, the object of the present study to highlight the oral health hazards of toombak, and to compare it with snus regarding the aforementioned differences.

Structural alterations in the TMJ disk in patients surgically treated for internal derangements (ADD)

Twenty-eight patients with temporomandibular dysfunction problem have been subjected to diskectomy unilaterally. The diagnosis was in 23 patients ADD (anterior disk displacement) without reduction and in another five ADD with reduction. The disk was removed in total according to a routine procedure. Surgical observation of a firm connection between the inferior surface of the disk and the condylar head was noted in eighteen patients. The disk tissue was orientated on a cork sheet according to its position in the fossa and subjected to histological examination. Histopathological analysis showed that the posterior attachment was a considerable part of the specimen in 12 out of 28 disks. Splitting of the disk was confined to the inferior surface. Chondrocytes were found close to the inferior surface. Surface irregularities, tags, were noticed on the inferior surface in thirteen cases. However, cellular signs of inflammation were found in the retrodiskal tissue in eight cases.

Chronic recurrent multifocal osteomyelitis involving both jaws: report of a case including magnetic resonance correlation

A case of chronic recurrent multifocal osteomyelitis in a 14-year-old girl is presented. The disease had an initial aggressive osteolytic appearance involving both the maxilla and the mandible. Conservative treatment with minimal surgical intervention has been successful in this case during a 2-year follow-up period. The value of magnetic resonance imaging and bone scintigraphy in this case and the cause of chronic recurrent multifocal osteomyelitis is discussed.

Glandular odontogenic cyst. Report of seven cases

This study describes the clinical, radiographic and histopathological features of seven glandular odontogenic cysts. These cysts comprised 0.012% of 5800 jaw cysts diagnosed in a 19-year period. There was strong predilection for the mandible (five of the seven cases). Both clinical and radiographic features were nonspecific. The main histological findings were a nonkeratinized, stratified squamous epithelium lining to the cyst cavity which varied in thickness with superficial eosinophilic cuboidal cells and mucous pools within the spinous cell layer. Daughter cysts were found in the wall of 2 cysts. At surgery, most walls were found to be thin and lumen to contain a serous, low viscosity exudate. Because of the high rate of recurrence found in three cases out of the seven after conservative surgical treatment, careful clinical and radiographic follow-up is recommended.

Immunohistochemical detection of p53 in non-malignant and malignant oral lesions associated with snuff dipping in the Sudan and Sweden

Immunohistochemistry was used to examine the expression of p53 in pre-malignant oral lesions and oral squamous-cell carcinomas (SCCs) from Swedish and Sudanese snuff-dippers, as well as in pre-malignant oral lesions and oral SCCs from non-snuff-dippers from the Sudan, Sweden and Norway. Of the 14 SCCs from Sudanese snuff-dippers, 21% (3/14) expressed p53. Of the 14, 60 and 41 SCCs from non-snuff-dippers from the Sudan, Sweden and Norway, 64% (9/14), 65% (39/60) and 68% (28/41) expressed p53, respectively. A statistically significant difference in expression of p53 was found in SCCs from Sudanese snuff-dippers compared to those from non-snuff-dippers from all/or any of the 3 countries. None of the suspected pre-malignant oral lesions from Sudanese snuff dippers or non-snuff-dippers expressed p53. Only 2 out of the 15 oral fibro-epithelial hyperplastic lesions from Swedish snuff-dippers expressed p53. Some of the oral epithelial dysplastic lesions, as well as the carcinoma in situ lesions from Norwegian non-snuff-dippers, expressed p53, while the oral fibro-epithelial hyperplastic lesions did not. The low relative frequency of p53 expression found in oral SCCs from snuff-dippers compared to those from non-snuff-dippers might suggest differences in mechanisms of oncogenic action induced by snuff. Alternatively, the pathogenesis of malignant oral lesions from snuff-dippers may follow a p53-independent pathway. In view of the unusually high levels of the tobacco-specific nitrosamines (TSNA) found in the type of snuff used in the Sudan, investigations of p53 mutations or oncogenes are needed.

[Epidemiology of liver cirrhosis morbitity and mortality in Iceland.]

BACKGROUND

The mortality from liver cirrhosis in Iceland is the lowest in the Western world.

OBJECTIVE

To study the epidemiology of liver cirrhosis mortality and morbitity in Iceland and to obtain a reliable separation between alcoholic cirrhosis (AC) and non alcoholic cirrhosis (NAC) by using multiple data sources.

METHODS

The study included the whole population of Iceland. Mortality was studied through death certificate data for the period 1951-1990 and morbidity (clinical incidence) through hospital, autopsy and biopsy records for the period 1971-1990.

RESULTS

1) The average mortality for AC in age group 20 years and older was 8.6 and for NAC 19.2 per 106 per year and the average clinical incidence was 22.1 for AC and 25.9 for NAC. 2) In the morbitity study 44% were due to AC. In the mortality study 24% were due to AC but the data suggested an underreporting of AC for males at a rate of 30%. 3) There was a significant decrease in AC mortality with time but no change in NAC. 4) Alcohol consumption per inhabitant over 15 years increased from 2.1 to 4.9 litre (130%) during the period 1951-1990.

CONCLUSION

The incidence of cirrhosis in Iceland is very low for both AC and NAC accounting for only 0.2% of total deaths. The reasons are unknown. The low incidence of AC in Iceland is probably partly due to a low population alcohol consumption. The decreasing incidence of AC despite 130% increase in alcohol consumption is thought to be due to intensive treatment of alcoholism. A low prevalence of hepatitis B and C probably contributes to the low incidence of NAC.

Microanatomy of the moose temporomandibular joint (Alces alces; Linnaeus, 1758)

Temporomandibular joint (TMJ) histology was investigated in 8 female Scandinavian moose. 5 were 1-year-old with a carcass weight (cw) of 125-140 kg, and 3 were 2-years-old (160-175 kg cw). The condylar articular surface consisted of a connective tissue lining with parallel collagen fibres. Numerous blood vessels were observed adjacent to the joint chamber. Below the fibrous layer, a proliferative cellular zone of undifferentiated mesenchymal cells was situated. These cells differentiated into chondroblasts and hypertrophied chondrocytes. Further down, an endochondral ossification process was initiated. Vertically directed invaginations were observed. A similar cellular organization was identified in the temporal component. However, the undifferentiated mesenchymal cell layer was discontinuous. The disc showed dense collagen bundles without main alignment. Vessels were identified throughout the entire disc. The results indicate that the cellular organization of the moose TMJ is similar to the TMJ histology found in other mammals but differences do occur.

Palisaded encapsulated neuroma (solitary circumscribed neuroma) of the oral mucosa

The objective of this study was to describe the clinical, histologic, and immunohistochemical features of 12 cases of palisaded encapsulated neuromas occurring on oral mucosa. The lesions were found in adults with a mean age of 54 years (median 58 years), and the most common sites of involvement were the palate and the maxillary labial mucosa. On microscopic evaluation the lesions were well circumscribed, and the tumor cells were spindle-shaped with a fascicular and sometimes whorled pattern. The tumor cells were consistently intensely positive for S-100 protein.

Ileal conduit stenosis--an enigma

Ileal conduit stenosis was diagnosed in 12 patients in the period 1981-1994. The time between urinary diversion and this diagnosis was 7-30 (mean 14) years. The clinical picture, i.e. colicky flank pain and/or fever, was produced by upper urinary tract obstruction. Intravenous urography, loopography and looposcopy were used in diagnosis. Treatment consisted of removal of the conduit and replacement by a new ileal loop or a continent reservoir, or partial resection with or without ureteric reimplantation. Light microscopy of the removed conduits showed severe, sometimes transmural inflammation with submucosal fibrosis. Transmission electron microscopy (TEM) demonstrated reduced height of microvilli, presence of glycocalyceal bodies and an increased number of lysosomes. Other subcellular structures were intact. The pathogenesis of the stenosis is obscure. Microvascular insufficiency, infection in conjunction with exposure to urine, reaction to some noxious agent in the urine or immunologic causation have been proposed. This late stenosis seems to arise only when ileum is used as conduit. Its insidious course calls for lifelong observation of the upper urinary tracts in these patients.

Inter-examiner variation in the assessment of age-related factors in teeth

Inter-observer variations in the registration of dental age-related characteristics have not previously been studied. Examination and registration were made by 6 dentists with varying experience in age estimation. A total of 13 age-related dental characteristics in 30 teeth extracted from adults were assessed macroscopically, by stereomicroscope and from radiographs. The measurements were analysed in a microcomputer, using the SPSS/PC+ statistical package. The results showed that, except for the score on surface roughness, significant differences were found between some of the observers for all types of measurements, when a paired t-test analysis was made. The correlation coefficients between the observers varied and were rather weak for the surface roughness score. The study revealed systematic differences among the observers as well as differences in interpreting the definitions of the scores for the different parameters. Thus age estimation using statistical methods is seen to be dependent upon the experience of the individual observer and interpretation. Care should therefore be taken not to rely too much upon the results of an odontological age estimation. The possible implications of these results for forensic work are also discussed.