The feasibility of existing JADAS10 cut-off values in clinical practice: a study of data from The Finnish Rheumatology Quality Register

BACKGROUND

The ten-joint juvenile arthritis disease activity score (JADAS10) is designed to measure the level of disease activity in non-systemic juvenile idiopathic arthritis by providing a single numeric score. The clinical JADAS10 (cJADAS10) is a modification of the JADAS10 that excludes erythrocyte sedimentation rate (ESR). Three different sets of JADAS10/cJADAS10 cut-offs for disease activity states have been published, i.e., the Backström, Consolaro, and Trincianti cut-offs. The objective of this study was to investigate the performance of existing JADAS10 cut-offs in real-life settings using patient data from The Finnish Rheumatology Quality Register (FinRheuma).

METHODS

Data were collected from the FinRheuma register. The proportion of patients with an active joint count (AJC) above zero when classified as being in clinically inactive disease (CID) or low disease activity (LDA) groups according to existing JADAS10/cJADAS10 cut-off levels were analyzed.

RESULTS

A significantly larger proportion of the patients classified as being in CID had an AJC > 0 when using the JADAS10/cJADAS10 cut-offs by Trincianti et al. compared to those for the other cut-offs. In the LDA group, a significantly larger proportion of the polyarticular patients (35%/29%) had an AJC of two when Trincianti JADAS10/cJADAS10 cut-offs were used compared with when Backström (11%/10%) and Consolaro (7%/3%) JADAS10/cJADAS10 cut-offs were used.

CONCLUSIONS

We found the cut-offs proposed by Consolaro et al. to be the most feasible, since these cut-off levels for CID do not result in the misclassification of active disease as remission, and the proportion of patients with AJC > 1 in the LDA group is lowest using these cut-offs.

A novel cancer vaccine for melanoma based on an approved vaccine against measles, mumps, and rubella

Common vaccines for infectious diseases have been repurposed as cancer immunotherapies. The intratumoral administration of these repurposed vaccines can induce immune cell infiltration into the treated tumor. Here, we have used an approved trivalent live attenuated measles, mumps, and rubella (MMR) vaccine in our previously developed PeptiENV cancer vaccine platform. The intratumoral administration of this novel MMR-containing PeptiENV cancer vaccine significantly increased both intratumoral as well as systemic tumor-specific T cell responses. In addition, PeptiENV therapy, in combination with immune checkpoint inhibitor therapy, improved tumor growth control and survival as well as increased the number of mice responsive to immune checkpoint inhibitor therapy. Importantly, mice pre-vaccinated with the MMR vaccine responded equally well, if not better, to the PeptiENV therapy, indicating that pre-existing immunity against the MMR vaccine viruses does not compromise the use of this novel cancer vaccine platform.

POS0335 IMPROVED PAIN COPING SCALE FOR CHILDREN AND THEIR CAREGIVERS

Background

Pain can be a problem in a subgroup of juvenile idiopathic arthritis (JIA) patients even though in clinical remission. This can at least partly be due to their pain coping strategy of catastrophizing [1]. In a chronic disease such as JIA, the quality of coping with pain is crucial. The importance of coping with pain is well recognized in children [2]. The understanding of the parental role in supporting the child in pain is growing [3]; yet measuring the precise mechanism of parental pain coping is less studied. Thus, it seems important to measure also parental coping quality.

Objectives

The aim of this study was to develop a pain coping scale (PCSpar) for assessing the parents’ coping strategies to their child´s pain and a shorter improved PCSped for children feasible for use in clinical practice.

Methods

The original pain coping questionnaire (PCQ) [4] has been validated in Finnish [5] resulting in a 38-item, eight-factor structured PCQ. The items in the new version of PCQ were reduced into twenty by an interdisciplinary team (mPCQped). A corresponding scale was created for parental use (mPCQpar). Consecutive patients aged 8-16 years, visiting pediatric rheumatology outpatient clinic, reporting musculoskeletal pain during the last week before visit or longer, were recruited to participate in this study. Both the patient and the caregiver rated the child’s pain VAS from 0 to 100, completed the mPCQped /the mPCQpar and Children´s Depression Inventory (CDI) [6]/the Beck´s depression Inventory (BDI) [7] as appropriate. The selection process of pain questionnaire items was performed with factor analyses. The construct validity, the associations of the mPCQ factors, CDI, BDI and pain VAS, were tested by Spearman´s correlation coefficient.

Results

The study was conducted in all five tertiary and four secondary hospitals evenly distributed throughout Finland. Of the 153 families invited to the study, 130 attended. The average (SD) age of the attending patients was 13.0 (2.3) years. Of the patients, 91 (70%) were girls. Several steps in the exploratory factor analyses preceded the final factor analyses mPCQped and mPCQpar results. The four factors retained in the new improved Pain Coping Scale for children (iPCSped) were named positive cognitive distraction, catastrophizing (CATped), seeking social support (SSSped) and behavioral distraction. The factors in the improved Pain Coping Scale for caregivers (iPCSpar) were positive self-statement, catastrophizing (CATpar), seeking social support and distraction. In both iPCSped and iPCSpar there are a total of 15 items, 2-5 items/factor. The factor´s Cronbach´s alpha reliability coefficients were satisfactory, and the goodness-of-fit statistics were good. The CATpar correlated to BDI Rs= 0.33, p<0.05 and parent’s assessment of the child’s pain Rs= 0.23, p<0.05 in caregivers. The CATped correlated to CDI Rs= 0.49, p<0.05 and SSSped Rs= 0.26, p=0.05 but not to patient pain VAS Rs= 0.08, p>0.05.

Conclusion

In this study, we created a shorter pain coping scale for children (iPCSped) and a novel scale for caregivers (iPCSpar). Both showed good validity and reliability.

References

[1]Lomholt JJ et al. Pediatric Rheumatology 2013;11:21-28.

[2]Gaultney, AC et al. Children 2017;4:11.

[3]Caes L et al. Front. Psychol 12:680546. doi: 10.3389/fpsyg.2021.680546

[4]Reid GJ et al. Pain 1998;76:83-96.

[5]Marttinen MK et al. Eur J Pain 2018;22:1016-1025.

[6]Kovacs M et al. Psychopharmacil Bull 1985;21:995-8.

[7]Beck AT et al. Arch Gen Psychiatry 1961;4:561–71.

Disclosure of Interests

None declared

Transition to adult care in Finnish adolescents with juvenile idiopathic arthritis

OBJECTIVE

The symptoms of juvenile idiopathic arthritis (JIA) and the necessity for continuous treatment may persist in adulthood. Therefore, patients with JIA need to be appropriately transferred to adult care. We aimed to analyse the timing of the patients' transition to adult care, and patients' self-management skills with the process and the quality of the transition.

METHOD

This study included 161 Finnish participants of the population-based Nordic JIA cohort who attended a 17 year follow-up appointment. Special attention was paid to the three groups: those referred by the paediatric rheumatology outpatient clinic to primary healthcare (PHC), those who were directly transferred to adult rheumatology care, and those who were later referred.

RESULTS

A total of 136 patients (84%) were eligible to participate in the study, and 40% of them were directly transferred to an adult rheumatology clinic. Of the patients, 72% eventually ended up being referred to an adult rheumatology outpatient clinic. However, 16% of the patients in the PHC group had active disease during the study appointment and were referred to adult services after the study visit.

CONCLUSION

This study reveals the need to improve the transition process from paediatric care to adult care and to find the variables that can indicate the need for immediate transition. Although challenging, it is important to avoid treatment delay in adult patients with JIA who may have active disease but who do not have appropriate access to an adult rheumatological outpatient clinic.

Initiating disease-modifying anti-rheumatic drugs rapidly reduces purchases of analgesic drugs in juvenile idiopathic arthritis

Objective: To describe the use of analgesics 12 months before and after initiation of the first disease-modifying anti-rheumatic drug (DMARD) in children with juvenile idiopathic arthritis (JIA). Method: A register-based study linked three nationwide registers in Finland: the Register on Reimbursement for Prescription Medicines, the Drug Purchase Register (both maintained by the Finnish Social Insurance Institution), and the Finnish Population Register. The study ran from 1 January 2010 to 31 December 2014. It included 1481 patients aged < 16 years with diagnosed JIA and 4511 matched controls. Index day was the date when reimbursement for JIA medication was approved and treatment was initiated. The study period included 12 months pre- and post-index date, and purchases of prescription drugs were assessed for 3 month periods. Results: Non-steroidal anti-inflammatory drugs (NSAIDs) were purchased for 60% of the patients. Compared to controls, NSAID purchases for JIA patients were at their highest during the last 3 months before the index day [relative rate (RR) 21.2, 95% confidence interval (CI) 17.1-26.2], and they decreased steeply over the 10-12 months post-index (RR 4.0, 95% CI 3.1-5.0). Similar trends were seen with paracetamol and opioid purchases, but only 2% of patients purchased opioids during the 12 months pre-index and 1% during the 12 months post-index. Methotrexate was the most commonly used DMARD (91.9%), biologic DMARDs were used by 2.8% and glucocorticoids by 24.8% in the 3 months after the index day. Conclusion: Initiation of DMARDs rapidly reduces the need for analgesics in patients with JIA.

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

SAT0488 ETANERCEPT CONCENTRATION IN PATIENTS WITH JUVENILE IDIOPATHIC ARTHRITIS

Background:

Etanercept (ETN) is the most used TNF blocker in children with JIA. There is still limited real-life data of etanercept concentrations in children, especially in association with dosing.

Objectives:

The aim of the study was to investigate association between ETN dosing and serum trough concentration in children with non-systemic JIA.

Methods:

We conducted a multicenter retrospective study of 180 Finnish JIA patients (Table 1) receiving ETN either as monotherapy or in combination with one or more DMARDs (Table 2). Prior biologicals were used by 17 % of the patients. Patients were divided into two groups, ETN started before or after one year of diagnosis (Figure 1). ETN concentration samples (collected 2014-2017) were analyzed using validated enzyme-linked immunosorbent assay (ELISA) in Sanquin Diagnostics, Amsterdam, the Netherlands.

Results:

Demographics at etanercept start and diagnoses are shown in Table 1. Duration of the treatment with ETN, ETN doses, concentrations and concomitant medications at the time of concentration measurement are shown in Table 2.

Association between ETN dose and concentration is shown in Figure 1.

Those who started medication early (< 1 year from diagnosis) were younger than those who started later (Table 1) and association between ETN dose and concentration was more obvious (Figure 1).

Conclusion:

There was an association between etanercept dose used and serum trough concentration and it was more evident when medication was started early after diagnosis, when the patients were younger and BSA lower.

References:

[1]Kneepkens EL et al. Lower etanercept levels are associated with high disease activity in ankylosing spondylitis patients at 24 weeks of follow-up. Ann Rheum Dis 2015;74(10):1825-9.

[2]Bader-Meunier B et al. Etanercept concentration and immunogenicity do not influence the response to Etanercept in patients with juvenile idiopathic arthritis. Semin Arthritis Rheum 2019;48(6):1014-1018.

Disclosure of Interests:

None declared

Disability and health-related quality of life are associated with restricted social participation in young adults with juvenile idiopathic arthritis

OBJECTIVES

To describe a cohort of Finnish juvenile idiopathic arthritis (JIA) patients, to recognize those young adults who are at risk of becoming socially restricted by their long-term rheumatic disease, and to assess which areas of self-rated health-related quality of life (HRQoL) are associated with the emergence of restricted social participation.

METHODS

A total of 195 young adults with JIA completed questionnaires addressing demographics, health behaviour, physical activity, functional ability, HRQoL, depressive symptoms, and self-esteem. Patients were classified as having non-restricted social participation if they were engaged in studying, working, maternity leave, or military service, and restricted social participation if they were unemployed or on disability pension.

RESULTS

Of the patients, 162 (83%) were considered as having non-restricted social participation and 33 (16%) restricted social participation. Among patients with restricted social participation, five (15%) were on disability pension and 28 (85%) were unemployed. Patients with restricted social participation participated less in leisure-time non-physical activities (p = 0.033), felt more disturbed during their leisure time (p = 0.010), had lower self-esteem (p = 0.005), and had higher disability scores (p = 0.024). HRQoL scores revealed statistically significant differences between the groups: physical functioning (p = 0.043), social functioning (p = 0.016), and emotional well-being (p = 0.049) were all lower in patients with restricted social participation.

CONCLUSIONS

Socially restricted patients showed a higher degree of disability, and lower levels of physical functioning, self-esteem, emotional well-being, and social functioning. These patients should be recognized earlier and interventions provided to enhance their social participation.

Body composition and adipokines in patients with juvenile idiopathic arthritis and systemic glucocorticoids

OBJECTIVES

The aim of this cross-sectional study was to explore body composition, and the relationship of serum adipokines with bone mass and disease activity, in a cohort of JIA patients with at least three months' exposure to systemic glucocorticoids (GC).

METHODS

Fifty patients with JIA (34 girls, median age 12.4 years and disease duration 6.3 years) and 88 controls matched for gender and age participated in this study. Bone mineral content (BMC) and areal bone mineral density (BMD) of the lumbar spine and whole body, as well as body composition were assessed with dual-energy x-ray absorptiometry. Fasting serum leptin and adiponectin were measured.

RESULTS

Fat and lean mass were similar between patients and controls, but patients had slightly decreased BMD Z-scores. Serum leptin and adiponectin concentrations were similar. Disease activity was low, and no correlation with adipokines was observed. Patients with bone age-corrected lumbar spine BMD Z-score ≤-1.0 ("low BMD") did not show alterations in body composition, GC exposure or current disease activity, but had decreased BMC-to-lean mass ratio (p<0.001) and tendency for increased serum leptin (p=0.064). However, no association of leptin with BMD in multivariate analysis existed in patients or controls. An inverse association between adiponectin and whole body BMD was observed in both groups.

CONCLUSIONS

Normal body composition was observed in a JIA cohort with low-dose GC exposure. Patients with "low BMD" tended to have increased serum leptin, but leptin did not associate with BMD. In this cohort with low disease activity, no correlation between adipokines and disease activity was present.

Prevention of acute adverse events related to infliximab infusions in pediatric patients

OBJECTIVE

To study whether premedication with an oral antifebrile agent (acetaminophen) and antihistamine (cetirizine) could decrease the frequency of acute infusion reactions in pediatric patients.

METHODS

All pediatric patients scheduled for infliximab infusions at the Helsinki University Central Hospital, a tertiary care center, were prospectively introduced to a standard oral premedication of acetaminophen (20 mg/kg) and cetirizine (10 mg) prior to infliximab infusions for a period of 1 year. All acute adverse events related to infliximab infusions given according to the guidelines of pediatric rheumatologists or gastroenterologists were registered for this time period and retrospectively during the preceding year.

RESULTS

During the study period, infliximab infusions with premedication were given to 64 pediatric patients (48 with rheumatic disease and l6 with inflammatory bowel disease, mean age 13 years, n = 34 boys, and n = 30 girls). Infliximab was introduced to 14 children; the rest were on maintenance therapy. Twelve infusion reactions, 4 mild and 8 severe, were observed in 8 (12.5%) of the 64 subjects, and in 1 subject 4 times. During the preceding year, 60 pediatric patients had received infliximab infusions without premedication. In this latter group, infusion reactions occurred in 5 children (8.3%; P > 0.05). The presentation of an acute infusion reaction was not related to the sex or diagnosis of the patient.

CONCLUSION

In pediatric patients, acute infusion reactions related to infliximab could not be prevented with premedication with oral acetaminophen and cetirizine.

Adalimumab in juvenile idiopathic arthritis-associated chronic anterior uveitis

OBJECTIVE

To evaluate the efficacy of adalimumab in juvenile idiopathic arthritis (JIA)-associated uveitis.

METHODS

Retrospective observational study of 20 patients with JIA and chronic uveitis on adalimumab treatment. The ocular inflammation and improvement was assessed according to the Standardization of Uveitis Nomenclature criteria.

RESULTS

At the initiation of adalimumab, the mean age of patients was 13.4 yrs and the mean duration of uveitis 8.7 yrs. Seventeen (85%) patients had polyarticular JIA and 19 (95%) had previously been on anti-TNF treatment. The mean duration of adalimumab therapy was 18.7 months. Of the 20 patients, 7 (35%) showed improved activity, 1 (5%) worsening activity and in 12 (60%) no change was observed in the activity of uveitis. Those with improved activity were younger and had shorter disease duration. The mean number of flares/yr decreased from 1.9 to 1.4 during adalimumab treatment. Serious adverse events or side-effects were not observed. Seven patients discontinued adalimumab during the follow-up: six because of inefficacy and one because of inactive uveitis.

CONCLUSION

Adalimumab is a potential treatment option in JIA-associated uveitis, even in patients non-responsive to previous other anti-TNF therapy.

Lactate inhibits germ cell apoptosis in the human testis

Dysregulation of male germ cell apoptosis has been associated with the pathogenesis of male infertility. Therefore, factors involved in the regulation of germ cell death are being actively investigated. Here, we studied the effects of lactate on human male germ cell death, using as a model a testis tissue culture in which physiological contacts are maintained between the germ cells and the supportive somatic Sertoli cells. Apoptosis of spermatocytes, spermatids and a few spermatogonia was induced by culturing segments of seminiferous tubules under serum-free conditions. This germ cell death was inhibited effectively and dose-dependently by lactate, indicating that it plays a crucial role in controlling cell death cascades of male germ cells. Interestingly, the anti-apoptotic role of lactate was not associated with changes in testicular adenine nucleotide (ATP, ADP and AMP) levels. In the seminiferous tubules, the final site of the death-suppressing action of lactate appeared to be downstream along the cell death pathway activated by the Fas receptor of the germ cells. In conclusion, testicular cell death was effectively regulated by lactate, which may be regarded as a potential compound for optimizing in-vitro methods involving male germ cells for assisted reproduction.

Operative versus closed treatment of primary dislocation of the patella. Similar 2-year results in 125 randomized patients

To assess whether initial surgery is beneficial for patients with primary dislocation of the patella, we carried out a prospective randomized study. Knee stability was examined under anesthesia, and associated injuries were excluded by diagnostic arthroscopy. 55 patients then had closed treatment and 70 patients were operated on with individually adjusted proximal realignment procedures. Surgery gave no benefit based on 2 years of follow-up. The subjective result was better in the non-operative group in respect of mean Houghston VAS knee score (closed 90, operative 87), but similar in terms of the patient's own overall opinion and mean Lysholm II knee score. Recurrent instability episodes (redislocation or recurrent subluxation) occurred in 20 nonoperated and in 18 operated patients. Of these, 15 and 12, respectively, then suffered redislocations. Function was better after closed treatment. Serious complications occurred after surgery in 4 patients. In conclusion, the recurrence of patellar dislocation may be more frequent than reported, whatever the form of treatment. Routine operative management cannot be recommended for primary dislocation of the patella.

The cartilaginous femoral sulcus in children with patellar dislocation: an ultrasonographic study

One hundred and sixteen knees of 33 patients with patellar dislocation and 25 normal children 12-18 years of age were examined by ultrasonography to measure the cartilaginous sulcus angle on the patellar surface of the femur. In knees with patellar dislocation, the cartilaginous sulcus angle measured between 154 and 195 degrees, exceeding the corresponding values of normal knees (134-153 degrees). In patient knees, the cartilaginous sulcus was also consistently wider than the underlying osseous sulcus. This suggests that in pediatric patients with patellar dislocation, the actual patella-stabilizing ability of the femoral sulcus is weaker than the osseous outline in axial radiographs would lead one to suppose. It would appear also that by measuring the cartilaginous sulcus angle of the femur, a clear distinction can be made between normal knee joints and joints displaying patellar instability.

Intracellular high energy metabolite depletion and cell membrane injury with antioxidant enzymes during oxidant exposure in vitro

We compared oxidant-induced intracellular adenine nucleotide catabolism and cell membrane injury in 4 different human cell types. Responses to oxidant exposure were correlated with endogenous antioxidant enzyme activities in these cells. Blood monocytes, amniotic fibroblasts, umbilical vein endothelial cells in primary culture, and transformed bronchial epithelial cells (BEAS 2B) were exposed to 0.1-5 mM hydrogen peroxide (H2O2) for 4 h. Some experiments were conducted in cells pretreated with 3-amino 1:2,4-triazole (ATZ) to inactivate catalase or with 1,3-bis(2-chloroethyl)-1-nitrosourea (BCNU) to inactivate glutathione (GSH) reductase. Depletion of adenine nucleotides and accumulation of their catabolic products (hypoxanthine, xanthine and uric acid) occurred to varying extent, monocytes being the most resistant. There was a mutual relationship between catalase and GSH reductase activities and maintenance of cellular adenine nucleotide levels during H2O2 exposure. GSH reductase inhibition rendered BEAS 2B cells susceptible to lytic injury by H2O2, assessed by release of lactate dehydrogenase and intact nucleotides into the medium, there was no correlation between these markers of such injury and endogenous antioxidant enzymes. We conclude that adenine nucleotide depletion and nucleotide catabolite accumulation relate closely with the antioxidant enzyme activities, whereas the lack of a similar correlation between the enzyme levels and markers of lytic cell injury suggest that intracellular antioxidant enzymes do not protect cells from membrane damage due to extracellular oxidants.

Mitochondrial superoxide dismutase induction does not protect epithelial cells during oxidant exposure in vitro

The significance of manganese superoxide dismutase (MnSOD) induction in cells and tissues during oxidant stress is still poorly understood. In this study, transformed human bronchial epithelial cells (BEAS 2B) were treated with interferon-gamma (IFN-gamma), tumor necrosis factor-alpha (TNF-alpha), or with combination of these cytokines (10 ng/ml concentrations) for 48 or 72 h and exposed to selected oxidants. TNF-alpha and IFN-gamma + TNF-alpha combination resulted in a marked increase of MnSOD protein and MnSOD activity. When cells pretreated with the cytokines were exposed to hyperoxia (95% O2, 72 h), menadione (5-50 microM, 4 h), or H2O2 (0.5 and 5 mM, 4 h), in all cases IFN-gamma and TNF-alpha enhanced oxidant-related cell injury. The effect was most significant with cells pretreated with a combination of IFN-gamma and TNF-alpha. Antioxidant enzymes such as total SOD, glutathione peroxidase, glutathione reductase, and glucose-6-phosphate dehydrogenase did not change significantly during the cytokine treatment. Catalase activity was not changed by IFN-gamma or TNF-alpha but it decreased significantly (34%) in IFN-gamma + TNF-alpha-treated cells. Free radical generation was not changed by these cytokines in acute (30 min) experimental conditions or after 48-h treatment. These results suggest that cytokine-induced MnSOD does not protect bronchial epithelial cells against endogenously or exogenously generated oxidants in vitro. In fact, cells that contained the highest MnSOD activity were the most sensitive to subsequent oxidant damage.

High hydrostatic pressures in traumatic joints require elevated synovial capillary pressure probably associated with arteriolar vasodilatation

Three out of the four Starling pressures were determined at arthroscopy of traumatic effusions of the knee. The range of the joint fluid hydrostatic pressure Pjoint was 5-83 cmH2O (0.5-8.1 kPa, 4-61 mmHg), that of the colloid osmotic pressure difference COPplasma-COPjoint 0-21.7 cmH2O. In 11 of 15 cases the sum Pjoint+COP difference exceeded 32.6 cmH2O (3.19 kPa, 24 mmHg), a high estimate of average capillary pressure at the level of the heart. The number of 'exceeding' cases was 8/15 if only 80% of the COP difference was considered effective. Pjoint and the COP difference oppose filtration of fluid from plasma into joints, indicating that mean capillary pressure, the only Starling pressure not determined, was elevated unless the effusions were being resorbed back into the blood. The findings can be explained by tamponade compensated by arteriolar vasodilatation, suspected to be metabolically mediated.

Acute patellar dislocation in children: incidence and associated osteochondral fractures

In a prospective two-year study on urban (city of Helsinki) Finnish children, 72 acute patellar dislocations were observed. The calculated annual incidence rate was 43/100,000 in children under 16 years. A total of 28 knees (39%) had associated osteochondral fractures. These fractures comprised 15 capsular avulsions of the medial patellar margin and 15 loose intra-articular fragments detached from the patella and/or lateral femoral condyle. The intra-articular fragments were found only after spontaneous relocation of the patella. The femoral fracture constantly involved the edge of the articular surface in the middle third of the condylar arc.

Cytotoxicity of oxidants and asbestos fibers in cultured human mesothelial cells

The authors investigated the mechanisms caused by oxidants (superoxide and hydrogen peroxide) and asbestos (amosite) fibers in human mesothelial cells. Immortalized human pleural mesothelial cells (MET 5A) were exposed in vitro to one of the following: hypoxanthine (100-200 microM) plus xanthine oxidase (10-20 mU/ml) as a superoxide-generating system, H2O2 (50 microM-5 mM); or amosite (1-100 micrograms/cm2). Cellular adenine nucleotide depletion, DNA single strand breaks, extracellular release of nucleotides, and their catabolites and lactate dehydrogenase (LDH) were assessed as markers of cell damage after 4-6 h exposure to the oxidants or fibers. The effect of intracellular antioxidant enzymes and exogenous antioxidants on cell damage were investigated during oxidant and amosite exposure. Superoxide radical and H2O2 exposure resulted in the depletion of adenine nucleotides, accumulation of the products of nucleotide catabolism, induction of DNA single strand breaks, and extracellular LDH release. Amosite exposure did not cause nucleotide depletion or induction of DNA single strand breaks. Inactivation of the intracellular antioxidant enzymes glutathione reductase or catalase augmented cell damage during H2O2 exposure but not during amosite exposure.

Distraction bone healing

Bone formation by distraction was studied using three different experimental models: (1) Physeal distraction of the sheep radius was performed in 20 animals. (2) Distraction after osteotomy of the radius was carried out in 39 sheep. (3) Mandibular distraction after osteotomy was performed in 17 sheep. Formation of the organic matrix and osteogenesis were studied by radiographic, histologic, and biochemical methods as well as by electron microscopy. The mode of osteogenesis was essentially similar in all of these distraction models. Bone formation was preceded by organization of the collagenous matrix in the distraction area. In the beginning of the distraction, the gap was composed of a heterogeneous cell population, with large polymorphic fibroblast-like cells. The cells in the central part differentiated into fibroblasts, which remained functionally active as long as distraction proceeded. During physeal distraction, bone formed from the epiphyseal and metaphyseal sides as well as from the surrounding perichondrium. Also, in osteotomy distraction of both tubular bone and mandible, bone formed centripetally from the osteotomized bone ends toward the center of the gap. The organic matrix was composed almost solely of Type I collagen in the earliest stages, suggesting that the mode of osteogenesis differs from bone repair by fracture callus. The structure of the distracted segment was mainly lamellar trabecular. Corticalization of the lengthened bone segment occurred gradually after several months.

Collagen synthesis and mineralization in the early phase of distraction bone healing

Corticotomy of the distal radius followed by gradual distraction by external fixation was performed on three sheep. Collagen synthesis and mineral deposition were analysed from sequential biopsies obtained from the center of the distraction area during the first 4 weeks of distraction. The whole distraction area was rapidly filled with organic matrix the amount of which, due to fluctuation in its nonprotein component, initially decreased from 88 to 66% of the level in control bone but gained its initial level in 4 weeks. Total protein in the matrix represented 70% of that in the control bone during the 4-week follow up period while the proportion of collagen of the total protein increased from 53 to 88%, a level comparable with the unoperated bone. Determination of the type of fibrillar collagen by characterization of their cyanogen bromide peptides showed that in the distraction area production of type II collagen does not occur but the heteropolymer type I (alpha 1(I)2 alpha 2(I)1) collagen represents almost totally the collagen synthesized. Deposition of mineral into the distraction gap was detectable already after 2 weeks and increased rapidly after 3 weeks of distraction. The results suggest that unlike in other processes, e.g., direct osteonal and callus-type bone repair, in distraction bone healing gradual distraction of osteotomized bone leads directly to synthesis of mature fibrous organic matrix of bone followed by its rapid mineralization.

Leg lengthening by osteotomy and gradual distraction: an experimental study

Osteotomy and gradual distraction of the distal radius was performed on 12 sheep. After 3-6 weeks of daily distraction by external fixation, lengthening of 0.5-1.8 cm was achieved. Three weeks after distraction was begun, striae of new bone, organized in the direction of the distraction, were noted radiologically. The bony consolidation developed from the osteotomized bone ends to the center of the distraction area. Medullary structures also contributed to bone formation in the distraction area. Collagen bundles, organized in the direction of distraction, formed a template for the developing bone. The medullary canal remodeled 16 weeks after the operation. Solid bone formed after the distraction procedure with no additional bone transplantation.

Experimental lengthening of tibial diaphysis: gap healing with or without gradual distraction

Stepwise distraction of the rabbit tibia after a transverse diaphyseal osteotomy was performed in an external fixator. The goal was to clarify the fine-structural parameters of long-bone lengthening. The tibias were vertically cut and studied 5 weeks after the osteotomy, and the specimens with an initial gap without further lengthening were compared with those with a gap and stepwise distraction. The role of periosteal bone induction was essential for the ossification of a growing gap, whereas the ossification of a simple gap proceeded equally by the endosteal and periosteal routes. The distraction resulted in vertical organization of the premature callus tissue at the proximal pole of the distracted gap, while the distal part of the gap area was deficiently filled by endosteal bone but preliminary fixed by a bridge of periosteal callus tissue.

Fracture repair during external fixation. Torsion tests of rabbit osteotomies

Bone repair was studied in the rabbit tibiofibular bone after a midshaft transverse osteotomy stabilized by external fixation and heavy compression. Both subendosteal and subperiosteal callus formation with concomitant contact healing were observed within 3 weeks, and were further succeeded by subendosteal resorption and increased porosis resulting in atrophy of the cortical bone. Subjected to the torsion test, the bones exhibited restoration of strength within 3 weeks, with maximal energy absorption and elasticity at 6 weeks. The failure of the osteotomy in the torsion test, with radiographic visibility of the osteotomy, characterized the soft-tissue type of behavior of the bones. Hard-tissue like behaviour of the bones with resistance to torsion at the osteotomy site and radiographic obliteration of the osteotomy line occurred by 12 weeks, indicating complete union of the osteotomy. Our experiments demonstrate that elastic external fixation is preferable to the rigid compression plate.

Pin-hole changes after external fixation of tubular bone

K-wire-pin-induced changes in cortical bone were studied in the intact rabbit tibiofibular bone. Using a bilateral external fixator two pairs of pins were applied under compression (10 kp), under distraction (10 kp), and in a neutralization sense. After defined intervals the pin-holes were investigated macroscopically and radiologically. Reactive and resorptive changes were present in 101 of 576 (17.5%) pin-holes, infection in 13 (2.3%) pin-holes. Changes were significantly more frequent in the distal pin-holes. The appearance of the pin-holes was not influenced by the type of external fixation used nor did the occurrence depend on the duration of metal implantation.

Blood flow in rabbit osteotomies studied with radioactive microspheres

Arterial embolisation with radio-active microspheres was used to measure the proportion of cardiac output to the skeleton and the tibiofibular bone both in unoperated rabbits and in rabbits after tibial osteotomy and subsequent external fixation. The mean uptake of the intact tibiofibula was 0.11 per cent of the cardiac output and, correspondingly, 0.21 per cent after the osteotomy. Maximal uptake occurred 18 days after the operation which was accompanied by a slight decrease in overall skeletal circulation.

Total rupture of pectoralis major muscle in athletes

Total rupture of the pectoralis major muscle is rare. It may follow a severe trauma or strenuous athletic exercise or performance. Five cases of total rupture of the pectoralis major muscle treated in athletes are reported. Two of them had made an extremely exerted effort in weight lifting, one was injured during a parachute landing, one was tackled in an ice hockey match, and one injured his pectoralis major muscle while pushing himself up from a swimming pool. In two cases the diagnosis was made early and in three cases 2-4 months after the injury. All of the patients were male and were treated successfully with surgery. Later they were able to exercise their sports. The weight lifters did not go on with competitive sports.

Experimental epiphyseal separation by torsional force

Separation of the proximal tibial epiphysis from the metaphysis by torsional force was experimentally studied using cadaver bone preparations from 19 adolescent sheep. The energy needed to displace the epiphysis increased in correlation with an increase in the age of the animal. The separated epiphyseal and metaphyseal surfaces were examined using scanning electron microscopy. In the younger animals the separation line passed through the area of hypertrophied chondrocytes. In the animals more near skeletal maturity the separation occurred in a more sinuous fashion and also through spongious bone.

Articular cartilage after meniscectomy. Rabbit knees studied with the scanning electron microscope

Ten rabbits had a medial meniscectomy in both knees. The articular surface was studied with a scanning electron microscope 2, 4 or 12 weeks after the operation. Three sham operated and two unoperated rabbits served as controls. Progressive articular cartilage damage was observed on the weight-bearing areas of the medial condyles. The findings are compatible with clinical observations after meniscectomy; they confirm that meniscectomy is not a harmless operation.

Changes in erythrocyte sedimentation rate and C-reactive protein after total hip arthroplasty

Uncomplicated total hip arthroplasty (THA) was performed in 40 osteoarthritic patients, and changes in erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) levels were registered. The follow-up period was one year. Preoperative ESR appeared to be slightly elevated, and CRP levels were normal, with no exceptions. A postoperative maximum ESR of 64 mm/hour was reached six days after surgery. A slow decrease followed, but ESR remained slightly elevated one year later. The changes in CRP were more rapid; a maximum of 134 mg/l was registered on the second day after surgery, and the values were consistently normalized three weeks after surgery. Thus, uneventful recovery after THA seems to be indicated by a normalizing CRP, regardless of ESR values.

Fever, C-reactive protein, and erythrocyte sedimentation rate in monitoring recovery from septic arthritis: a preliminary study

Body temperature, C-reactive protein (CRP), and erythrocyte sedimentation rate (ESR) were measured sequentially in nine children less than 11 years old during their recovery from culture-positive septic arthritis (SA). The measurements were compared with those of two other children who recovered without antibiotic therapy. A clinical investigation carried out several months after discharge suggested permanent recovery in all cases, including the spontaneously recovered patients. Defervescence and normalization of the primarily elevated CRP and ESR values occurred in a similar manner in both groups. On average, fever lasted 5 days, CRP level decreased below 20 mg/L in 7 days, and ESR reached a value of less than or equal to 20-25 mm/h in 22 days. The normalization time of ESR differed highly significantly (p less than 0.001) both from the duration of fever and from the normalization time of CRP level. Because CRP behaved in a similar manner in both the medicated and the nonmedicated groups, its normalization suggests true extinction of the active inflammatory process. If so, CRP level may be of benefit in monitoring the duration of antibiotic therapy for SA, but the hypothesis has to be confirmed in a larger clinical trial.

The deformation of external fixation devices during loading

The stability of four different types of external fixation devices was studied when they were subjected to torsion, bending and deformation under axial compression. The most stable fixation was achieved when the bone ends were in contact. The frames were weakest when the stress was applied at right angles to the plane of the frame. All four had adequate stability for fracture healing.

Biochemical changes in bone grafts stabilized with rigid plates. I. Cancellous grafts

The effect of rigid plate fixation on the chemical composition of cancellous interposition grafts was studied in rabbit-fibular bones. The concentrations of hexosamines and, to a lesser degree, of hydroxyproline and nitrogen, were high in the graft for the first 6 weeks, decreased from weeks 6 to 12, but remained higher than the corresponding values for the controls throughout the experiment (52 weeks). The ratio of hexosamines to hydroxyproline was highest for the graft at 3 weeks, indicating formation of cartilage and osteoid. The initially low calcium concentration of the graft increased by 35 per cent from weeks 1 to 6, decreased from weeks 6 to 12, and remained below normal thereafter in comparison with corresponding values for the cortical host bone. The ratio of calcium to hydroxyproline increased throughout the experiment, reflecting maturation of the graft to lamellar bone. Thus, biochemically the early incorporation of rigidly fixed cancellous interposition grafts resembles the healing of unimmobilized fractures by callus formation.

Classification of ankle fractures in children

The roentgenograms of 310 children treated for ankle fractures were evaluated for grouping according to the classifications of Ashhurst-Bromer-Weber, Lauge-Hansen, and Salter-Harris. The mean age of the children at the time of injury was 11.1 years (range 2-14 years). Two hundred twenty-one (71.3%) children had malleolar fractures, 71 (22.9%) had tibial epiphyseal fractures, and 18 (5.8%) had syndesmotic lesions. The age distribution of fractures was typical: malleolar fractures predominated among the younger children, epiphyseal fractures among the older. Only the oldest children had avulsion fractures of the syndesmosis. Grouping of the fractures according to Lauge-Hansen and Ashhurst-Bromer-Weber, classifications suited to adults was largely unsuccessful. Epiphyseal fractures, moreover, were easily classified according to Salter-Harris. In spite of their complexity, ankle fractures in children can be roughly divided into avulsional and epiphyseal fractures. Adequately reduced avulsional fractures can be expected to heal well; epiphyseal fractures, however, may five rise to late complications. We propose, therefore, that ankle fractures in children be classified on the basis of roentgenological findings with respect primarily to epiphyseal lesions as well as on an additional simple grouping as to risk for clinical purposes: Group I, low risk, avulsional fractures and epiphyseal separations; Group II, high risk, fractures through the epiphyseal plate.

Meniscectomy in children

The results of 42 meniscectomies in 41 children were evaluated 1 to 13 years (mean 5.6 years) after the operation. At the follow-up 11 patients (12 operated knees) had complaints. In four of these patients, all having had removel of the lateral meniscus, roentgenological examination revealed degenerative changes. The results of the clinical and roentgenological follow-up examination showed that insufficiently rigorous appraisal of the indications for surgery had led, in some cases, to unnecessary meniscectomies. The results of operations had not always been satisfactory. The reliability of arthrographic findings alone as an indication for surgery are discussed and the indications for operative treatment are presented.

Medial dislocation of the tendon of the long head of the biceps brachii

Medial displacement of the long tendon of the biceps brachii muscle is a rare condition associated with degenerative or traumatic ruptures of the rotator cuff. This condition was recorded in nine shoulders during 45 reconstructive procedures on the rotator cuff. Five of the displacements were complete, leaving the tendon medially displaced in a fascial sling; four were incomplete, allowing a to-and-fro medial displacement of the tendon out of the intertubercular groove. Anatomical dissections on eight shoulders showed that the coracohumeral ligament is the key ligament which keeps the biceps tendon aligned in the sulcus: transection of the medial part of the ligament allows the tendon to be medially displaced. There was no pathognomonic clinical sign of the luxation or subluxation. Since abnormal movement of the tendon in the sulcus may be an important cause of shoulder pain, the condition should be carefully looked for during reconstructive procedures on the rotator cuff. Tenodesis of the displaced tendon is recommended, either as the sole procedure or in combination with other reconstructive measures.