The psychosocial burdens of living with diabetes

AIM

To better understand the prevalence of self-reported psychosocial burdens and the unmet needs identified by people with diabetes in relation to routine diabetes visits.

METHODS

An English language, online survey was distributed via social media, key stakeholder networks, charity and advocacy groups to adults with type 1 diabetes or type 2 diabetes. Survey items were designed by members of the FDA RESCUE Collaborative Community Governing Committee prior to pilot testing with potential participants. Descriptive statistical analyses were conducted, as well as thematic analyses on free-text responses using NVivo v14.

RESULTS

Four hundred and seventy-eight participants completed the survey: 373 (78%) had type 1 diabetes, 346 (73%) identified as a woman and 433 (91%) were white. Most participants had experienced self-reported (rather than diagnosed) anxiety and depression (n = 323 and n = 313, respectively), as well as fear of low blood sugars (n = 294), low mood (n = 290) and diabetes-related distress (n = 257). Sixty-eight percent reported that diabetes had negatively affected self-esteem, 62% reported the feelings of loneliness, but 93% reported that friends/family/work colleagues were supportive when needed. Two hundred and seventy-two percent (57%) reported that their diabetes team had never raised the topic of mental health. The overwhelming majority stated that the best thing their diabetes team could do to help was to simply ask about mental well-being, listen with empathy and without judgement, and practice skills to understand psychosocial issues in diabetes.

CONCLUSION

Integrating psychosocial discussions and support within routine healthcare visits is crucial to improve outcomes for people with diabetes. Such a biopsychosocial model of healthcare has long been advocated by regulatory bodies.

First International Survey on Diabetes Providers' Assessment of Skin Reactions in Youth With Type 1 Diabetes Using Technological Devices

BACKGROUND

Advances in diabetes technological devices led to optimization of diabetes care; however, long-lasting skin exposure to devices may be accompanied by an increasing occurrence of cutaneous reactions.

METHODS

We used an open-link web-based survey to evaluate diabetes-care providers' viewpoint on prevalence, management practices, and knowledge related to skin reactions with the use of diabetes technological devices. A post hoc analysis was applied to investigate differences in the level of awareness on this topic in relation to the experience in diabetes technology.

RESULTS

One hundred twenty-five responses from 39 different countries were collected. Most respondents (69%) routinely examine patients' skin at each visit. All the preventive measures are not clear and, mainly, homogenously put into clinical practice. Contact dermatitis was the most frequently reported cutaneous complication due to diabetes devices, and its most common provocative causes are not yet fully known by diabetes-care providers. Almost half of the respondents (42%) had discussed the presence of harmful allergens contained in adhesives with device manufacturers. There is general agreement on the need to strengthen knowledge on dermatological complications.

CONCLUSIONS

Although diabetes-care providers are quite aware of the chance to develop skin reactions in people with diabetes using technological devices, there are still some unmet needs. Large follow-up studies and further dissemination tools are awaited to address the gaps revealed by our survey.

POS1223 DIFFERENT ANTI-SARS-CoV-2 VACCINE RESPONSE UNDER B- AND T-CELL TARGETED THERAPIES VERSUS ANTI-CYTOKINE THERAPIES IN PATIENTS WITH INFLAMMATORY ARTHRITIDES

Background

Vaccination against SARS-CoV-2 is effective in preventing severe forms of COVID-19, but there remain concerns about a reduced vaccine response in patients suffering from inflammatory arthritides who are treated by immunosuppressive therapies.

Objectives

We analysed the impact of bDMARDs on the humoral anti-SARS-CoV-2 vaccine response of patients followed in day hospitals.

Methods

We studied the vaccine response after a complete vaccine regimen followed in day hospital in 5 French hospitals and treated with an intravenous bDMARD between September 2019 and August 2021. After obtaining their informed consent, we included patients with an anti-SARS-CoV-2 serology. They were considered non-responders if the antibody level detected was inferior to the threshold of positivity of the kit used.

Results

205 patients were included (148 females/57 males). The median age was 64 years (Interquartile Range [IQR] 56-71). 25 were treated with tocilizumab (TCZ), 36 with abatacept (ABA), 53 with infliximab (IFX) and 91 with rituximab (RTX). When considering both patients after a complete vaccination schema (2 doses, or 1 dose in case of prior COVID-19) and those with 1 booster dose, 34 patients (16.6%) were non-responders (2 [5.9%] treated by IFX, none treated by TCZ, 9 [26.5%] treated by ABA and 23 [67.7%] treated by RTX). In multivariate analysis, the only characteristics that significantly and independently differed between responders and non-responders were last bDMARD and corticosteroid therapy at the time of 1st vaccination (Table 1). In RTX-treated patients, the delay from last infusion to 1st vaccine dose was significantly shorter in non-responders (median 4.3 IQR [2.9-6.1] months in non-responders versus 8.4 IQR [5.7-14.5] in responders, p=0.0007). Median survival, i.e. achieving a vaccine response in 50% of RTX-treated subjects, was achieved after 277 days (95CI [209-310]) in patients vaccinated with 2 or 3 doses (Figure 1). In ABA-treated patients, the delay from last infusion to 1st vaccine dose was not different between non-responders and responders.

Table 1.

Patients’ characteristics and comparisons between responders and non-responders.

All patients (n=205)Responders (n=171)Non responders (n=34)Univariate p valueMultivariatep valueAge (median [IQR]), in years64 [56-71]64 [54-70]69 [57-75.5]0.070.40Female sex, n (%)148 (72.2)125 [73.1)23 (67.7)0.53Inflammatory arthritides, n (%)0.16**0.24 Rheumatoid Arthritis156 (78.0)128 (74.9)28 (82.4)0.51 Spondyloarthritis33 (16.1)31 (18.1)2 (5.9)0.12 Others*16 (7.8)12 (5.9)4 (1.9)0.31Last bDMARDs at time of 1st vaccination, n (%)0.0004ABA/RTX versus IFX/TCZ < 0.00010.00024 Infliximab53 (25.9)51 (29.8)2 (5.9) Tocilizumab25 (12.2)25 (14.6)0 Abatacept36 (17.6)27 (15.8)9 (26.5) Rituximab91 (44.4)68 (39.8)23 (67.7)Associated treatments at time of 1st vaccination CsDMARDs, n (%)126 (61.5)107 (62.6)19(55.9)0.56 Methotrexate91 (44.4)78 (45.6)13 (38.2)0.46 Median dose in users (mg /week) [IQR]15 [10-17.5]13.8 [10-15.6]15 [13.8-20]0.07 Corticosteroids, n (%)25 (12.2)19 (11.1)6 (17.6)0.29 Median dose (mg /day) [IQR]0 [0-0]0 [0-0]0 [0-2]0.0350.016Previous COVID-19 infection, n (%)23 (11.2)21 (12.3)2 (5.9)0.38Type of vaccine, n (%)0.62 Pfizer169 (82.4)142 (83.0)27 (79.4)0.62 Moderna14 (68.3)11 (6.4)3 (8.8)0.71 Astra-Zeneca17 (8.3)15 (8.8)2 (5.9)0.74 Janssen5 (2.4)3 (1.8)2 (5.9)0.19Vaccination, n (%) Complete167 (81.5)141 (82.5)28 (16.8)0.47 Complete + 1 booster dose56 (27.3)43 (25.1)13 (38.2)0.14Figure 1.

Cumulative seropositive rate according to the interval (days) between the last course of rituximab administration and vaccination

Conclusion

ABA and RTX alter the anti-SARS-CoV-2 vaccine response and were associated with nearly all vaccine non-responses in the present study. Corticosteroid therapy was associated with a lower vaccine response regardless of its indication or the concomitant use of bMARD.

Disclosure of Interests

None declared

POS1065 IMPACT OF HYPERURICEMIA ON CLINICAL PHENOTYPE, COMORBIDITIES, AND RESPONSE TO SECUKINUMAB IN PSORIATIC ARTHRITIS: POST HOC ANALYSIS OF FUTURE AND MAXIMISE STUDIES

Background

Hyperuricemia (HU) is a metabolic abnormality associated with psoriasis (PsO) and psoriatic arthritis (PsA)1. The prevalence of HU is 2–13% in general population, 19–20% in PsO patients (pts), and 27–32% in PsA pts1,2. Pts with PsO/PsA are at significantly increased risk of HU and development of gout1. The pathogenic role of chronic HU in the development and maintenance of PsA is based on epidemiological, clinical, and fundamental arguments and hence does not appear fortuitous. These processes can influence each other3. Moreover, PsA with HU has been shown to be more peripheral, destructive, and challenging to treat4.

Objectives

To evaluate the impact of HU on PsA in terms of clinical presentation, severity, comorbidities, and response to secukinumab (SEC) over 1-year.

Methods

This post hoc analysis included pooled data from PsA pts enrolled in the FUTURE 2–5 and MAXIMISE phase 3 trials. Pts were stratified into 2 groups based on baseline (BL) serum uric acid (SUA) level (HU: ≥360 µmol/L; without HU: <360 µmol/L and no history of gout and/or uric acid lowering therapies [ULT]). Demographic and disease characteristics, PsA and therapeutic history, and comorbidities data, were collected at BL. Evaluations included ACR20/50/70 responses, Psoriasis Area and Severity Index (PASI) 90 response, resolution of enthesitis and dactylitis, Health Assessment Questionnaire Disability Index (HAQ-DI), and mean change in SUA level, up to Week 52. All analyses were performed at a descriptive level and data presented as observed.

Results

Overall, 2504 PsA pts were included in the analysis, of which 822 (32.8%) had HU (62 [2.5%] with gout; 49 [2.0%] treated with ULT). At BL, pts with HU were mostly male (76.0% vs 34.2%) and had a higher body mass index (30.9 vs 28.3 kg/m2) with more comorbidities, such as hypertension (43.8% vs 31.3%), compared to pts without HU. A higher proportion of pts with HU had dactylitis (34.5% vs 25.9%), and PsO (48.3% vs 36.3%) with a greater mean PASI score (13.6 vs 10.2), compared to pts without HU (Table 1). The proportion of pts achieving ACR50, resolution of enthesitis/dactylitis, and mean change in HAQ-DI score were comparable up to Week 52 irrespective of BL HU status. The PASI90 response rate was higher in pts without HU with SEC 150 mg (with and without load) and similar in SEC 300 mg group irrespective of BL HU status (Figure 1).

Table 1.

Demographics and baseline characteristics

Parameters, mean ± SD unless specifiedWith hyperuricemia (N=822)Without hyperuricemia (N=1682)Age (Years)48.5 ± 12.4148.3 ± 12.19Gender (Male), n (%)625 (76.0)576 (34.2)Weight (kg)92.71 ± 18.6279.59 ± 17.55BMI (kg/m2)30.90 ± 5.8628.33 ± 5.91History of hypertension, n (%)360 (43.8)526 (31.3)History of diabetes mellitus, n (%)85 (10.3)144 (8.6)TJC20.6 ± 15.5221.3 ± 16.25SJC10.9 ± 9.3110.8 ± 9.13Enthesitis, n (%)412 (50.1)852 (50.7)Dactylitis, n (%)284 (34.5)436 (25.9)Evidence of current psoriasis; n (%)397 (48.3)611 (36.3)Mean PASI score*13.61 ± 11.0310.16 ± 9.13TNFi naїve, n (%)477 (58.0)938 (55.8)MTX use at randomization, n (%)321 (39.1)685 (40.7)Serum uric acid (µmol/L)420.7 ± 57.11274.9 ± 51.98CRP (mg/L)11.6 ± 18.6610.7 ± 23.36

*not collected in MAXMISE

BMI, body mass index; CRP, C-reactive protein; MTX, methotrexate; SJC, swollen joint count; TJC, tender joint count; TNFi, tumor necrosis factor inhibitor

Conclusion

In this pooled analysis of SEC PsA studies, pts with HU reported a higher prevalence of hypertension, with more clinical dactylitis, and more PsO, with higher PASI score compared to pts without HU. Efficacy across all musculoskeletal manifestations was similar with SEC 150 and 300 mg; while PASI90 response rate was slightly better in patients without HU with SEC 150 mg, and similar with SEC 300 mg irrespective of HU status, at 1-year.

References

[1]Tripolino C, et al. Front Med. 2021;8:737573

[2]AlJohani R, et al. J Rheumatol. 2018;45(2):213–7

[3]Felten R, et al. Clin Rheumatol. 2020;39:1405–13

[4]Widawski L, et al. Clin Rheumatol. 2022. https://doi.org/10.1007/s10067-022-06061-x

Disclosure of Interests

Renaud FELTEN Consultant of: Novartis (Advisory board), Laura Widawski: None declared, Lionel Spielmann: None declared, Corine Gaillez Shareholder of: Novartis, Employee of: Novartis, Weibin Bao Shareholder of: Novartis, Employee of: Novartis, Jacques-Eric Gottenberg Consultant of: Novartis (Advisory board), Pierre-Marie Duret: None declared, Laurent Messer: None declared

Cambridge hybrid closed-loop algorithm in children and adolescents with type 1 diabetes: a multicentre 6-month randomised controlled trial

BACKGROUND

Closed-loop insulin delivery systems have the potential to address suboptimal glucose control in children and adolescents with type 1 diabetes. We compared safety and efficacy of the Cambridge hybrid closed-loop algorithm with usual care over 6 months in this population.

METHODS

In a multicentre, multinational, parallel randomised controlled trial, participants aged 6-18 years using insulin pump therapy were recruited at seven UK and five US paediatric diabetes centres. Key inclusion criteria were diagnosis of type 1 diabetes for at least 12 months, insulin pump therapy for at least 3 months, and screening HbA1c levels between 53 and 86 mmol/mol (7·0-10·0%). Using block randomisation and central randomisation software, we randomly assigned participants to either closed-loop insulin delivery (closed-loop group) or to usual care with insulin pump therapy (control group) for 6 months. Randomisation was stratified at each centre by local baseline HbA1c. The Cambridge closed-loop algorithm running on a smartphone was used with either (1) a modified Medtronic 640G pump, Medtronic Guardian 3 sensor, and Medtronic prototype phone enclosure (FlorenceM configuration), or (2) a Sooil Dana RS pump and Dexcom G6 sensor (CamAPS FX configuration). The primary endpoint was change in HbA1c at 6 months combining data from both configurations. The primary analysis was done in all randomised patients (intention to treat). Trial registration ClinicalTrials.gov, NCT02925299.

FINDINGS

Of 147 people initially screened, 133 participants (mean age 13·0 years [SD 2·8]; 57% female, 43% male) were randomly assigned to either the closed-loop group (n=65) or the control group (n=68). Mean baseline HbA1c was 8·2% (SD 0·7) in the closed-loop group and 8·3% (0·7) in the control group. At 6 months, HbA1c was lower in the closed-loop group than in the control group (between-group difference -3·5 mmol/mol (95% CI -6·5 to -0·5 [-0·32 percentage points, -0·59 to -0·04]; p=0·023). Closed-loop usage was low with FlorenceM due to failing phone enclosures (median 40% [IQR 26-53]), but consistently high with CamAPS FX (93% [88-96]), impacting efficacy. A total of 155 adverse events occurred after randomisation (67 in the closed-loop group, 88 in the control group), including seven severe hypoglycaemia events (four in the closed-loop group, three in the control group), two diabetic ketoacidosis events (both in the closed-loop group), and two non-treatment-related serious adverse events. There were 23 reportable hyperglycaemia events (11 in the closed-loop group, 12 in the control group), which did not meet criteria for diabetic ketoacidosis.

INTERPRETATION

The Cambridge hybrid closed-loop algorithm had an acceptable safety profile, and improved glycaemic control in children and adolescents with type 1 diabetes. To ensure optimal efficacy of the closed-loop system, usage needs to be consistently high, as demonstrated with CamAPS FX.

FUNDING

National Institute of Diabetes and Digestive and Kidney Diseases.

Psoriatic arthritis with hyperuricemia: more peripheral, destructive, and challenging to treat

Objective

To study the impact of hyperuricemia on clinical presentation, severity, and associated comorbidities of psoriatic arthritis (PsA).

Methods

Retrospective bicentric case–control study performed in Strasbourg and Colmar, France, from 2009 to 2019. Patients with PsA (according to ICD-10 coding) and at least one available serum urate (SU) measurement were included. Demographic, comorbidities, clinical, and radiographic data were collected. Hyperuricemia was defined as SU level ≥ 360 µmol/L.

Results

We included 242 patients: 73 (30.2%) had hyperuricemia and 15 (6.2%) met 2015 ACR/EULAR criteria for gout. On univariate analysis, as compared with normo-uricemic patients, hyperuricemic patients were more frequently male (72.6% vs 39.1%, p = 1.6 × 10⁻⁶) with higher body mass index (30.9 vs 28.7 kg/m², p = 0.015) and more comorbidities (Charlson comorbidity index: 2.6 vs 1.8, p = 0.005). PsA started at an older age (47.5 vs 43 years, p = 0.016) was more polyarticular (56.2% vs 41.9%, p = 0.049) than axial (9.6% vs 22.8%, p = 0.019) and more destructive (52.8% vs 37.4%, p = 0.032). PsA patients with joint destruction more frequently had hyperuricemia than did others (37.6% vs 25.8%, p = 0.047). Multivariable analysis confirmed the association of hyperuricemic PsA with peripheral joint involvement (odds ratio 2.98; 95% confidence interval 1.15–7.75; p = 0.025) and less good response to treatment (0.35; 0.15–0.87; p = 0.024).

Conclusion

Patients with hyperuricemic PsA show poorer response to PsA treatment and have more peripheral and destructive joint damage than normo-uricemic patients.

Key Points • Gout and psoriatic arthritis (PsA) can co-exist in the same patient. • Monosodium urate crystals might have a deleterious impact on PsA. • Hyperuricemic PsA is more polyarticular, less frequently axial, and more destructive than normo-uricemic PsA. • PsA with hyperuricemia should lead to more personalized medicine.

OP0282 RITUXIMAB ASSOCIATED WITH SEVERE COVID-19 AMONG PATIENTS WITH INFLAMMATORY ARTHRITIDES: A 1-YEAR MULTICENTER STUDY IN 1116 SUCCESSIVE PATIENTS RECEIVING BIOLOGIC AGENTS

Background:

At a time when vaccines are being prioritized for individuals most at risk, there is currently no clear evidence that risk of SARS-CoV-2 infection is higher for patients with than without inflammatory arthritides (IA). Biologic use was not associated with worse COVID-19 outcomes for yet but the case of rituximab (RTX) remains an issue, given its immunological long term effect, the role of humoral response against SARS-CoV-2 and its indirect effect on T-cell response. A potential association between rituximab and worse COVID-19 outcomes was raised by case reports and retrospective, declarative studies (with few data on the total number of patients exposed).

Objectives:

To address differently the issue of the risk of COVID-19 related to RTX and limit biases, we examined the occurrence of severe COVID-19 in all patients receiving intravenous biologic agents at day-hospitals during the pandemic in France.

Methods:

From 1st September 2019 to 1st January 2021, we analyzed patients with IA prospectively treated with intravenous biologic agents (RTX, abatacept, infliximab or tocilizumab) in 7 clinical centers in France. We obtained the list of patients receiving intravenous biologic agents in each center from the pharmacist of the hospitals. Therefore, all consecutive patients receiving 1 of the 4 drugs at the time of the study were included in each center. Patients with no follow-up after September 2020 were systematically contacted by phone. The occurrence of a severe COVID -19 (i.e. resulting in death, hospitalization or increase in length of hospitalization related to COVID-19) was the primary outcome criteria.

Results:

In total, 1116 patients receiving intravenous biologic agents were included: 449 with infliximab, 392 RTX, 170 tocilizumab and 105 abatacept. From 1st September 2019, the median follow-up time was 15 months (interquartile range 14-16). In total, 10 cases of severe COVID-19 occurred, 9 treated with RTX and 1 with infliximab (supplementary Table 1). Four deaths occurred in our cohort during follow-up but none was related to COVID-19 (1 patient treated by tocilizumab, 1 by RTX and 2 by infliximab). In univariate analysis, the proportion of severe COVID-19 was significantly higher for patients receiving RTX than other biologic agents (9/392 vs 1/724, p=0.0003, OR [95%CI] 17.0 [2.1-134.6]). To take into account potential confounders, we performed multivariate analysis accounting for baseline parameters that differed between RTX and other biologic groups. RTX remained significantly associated with risk of severe COVID-19 (p=0.019) (Table 1).

Patient characteristicsRituximab (n= 392)Other bDMARDs (n= 724)Univariate analysis, p-valueMultivariate analysis, p-valueMedian age (years), — [IQR]64 [56-71]57.3 [47.0-67.0]< 0.00010.51Female — n (%)285 (72.7)426 (58.8)< 0.00010.58IA diagnosis< 0.00010.12Median follow-up from 1st September to last news14 [13-15]15 [14-16]< 0.00010.86Confirmed severe COVID-19 cases —n (%)9 (2.3)1 (0.1)0.00030.019Comorbidities** (history of) — n (%) Cardiovascular disease60 (15.4)167 (23.1)0.00250.77 Chronic lung disease,92 (23.5)84 (11.6)0.00010.88Median BMI (kg/m2) — [IQR]25.8 [23.2-29.4]27.3 [23.4-31.2]0.0150.80Treatments — n (%) Methotrexate179 (45.8)322 (44.5)0.71 Leflunomide41 (10.5)39 (5.4)0.00230.43 Hydroxychloroquine35 (8.9)24 (3.3)0.00010.15 Glucocorticoids127 (41.8)100 (19.4)< 0.00010.36 Median dose (mg/day) — [IQR]1 [0-5]0 [0-0]< 0.0001

No significant difference in terms of baseline gammaglobulins (p=0.46) or number of previous RTX infusions (p=0.57) was observed among patients receiving RTX with or without a severe COVID-19.

Conclusion:

The present results highly indicate increased risk of severe COVID-19 with RTX. Among patients with inflammatory arthritides, those receiving RTX should be prioritized for vaccination against SARS-CoV-2, sufficiently long before infusion/reinfusion and the immunization checked, or an alternative targeted therapy proposed.

Acknowledgements:

We thank Dr. Karine Demesmay and all the pharmacists who helped us for this study.

Disclosure of Interests:

Renaud FELTEN Speakers bureau: Abbvie, Biogen, BMS, Lilly, Novartis, Pfizer, Pierre-Marie Duret: None declared, Elodie BAUER: None declared, Marc Ardizzone: None declared, H Julien Djossou: None declared, Jean-Hugues Salmon: None declared, Cassandre Fabre: None declared, Julia Walther: None declared, Isabelle CHARY VALCKENAERE: None declared, marion geoffroy: None declared, Laurent Messer: None declared, Francis Berenbaum: None declared, Martin SOUBRIER: None declared, Jérémie SELLAM Speakers bureau: MSD, Pfizer, Abbvie, Roche, BMS, Lilly, Janssen, Novartis, Galapagos, Sandoz, Fresenius Kabi, Grant/research support from: Roche, MSD, Pfizer, Jacques-Eric Gottenberg: None declared

POS0947 PSORIATIC ARTHRITIS WITH HYPERURICEMIA: MORE PERIPHERAL, DESTRUCTIVE AND CHALLENGING TO TREAT

Background:

Gout and psoriatic arthritis (PsA) can co-exist in the same patient. These 2 diseases seem strongly linked, but the pathophysiological mechanisms of this link have not yet been defined. Hyperuricemia could be an important determinant of PsA1.

Objectives:

To study the impact of hyperuricemia on clinical presentation, severity and associated comorbidities of PsA.

Methods:

We conducted a retrospective bicenter case–control study in Strasbourg and Colmar, France. Patients with PsA (according to “L40.5 arthropathic psoriasis” ICD-10 coding) and at least one available serum urate level measurement, were included from 2009 to 2019. Demographic, comorbidities, clinical and radiographic data were collected. Hyperuricemia was defined as serum urate level ≥ 360 µmol/L. We defined “good responders to ongoing PsA treatment” as patients with no outbreak of PsA, biological inflammatory syndrome and therapeutic modification at the last follow-up. Patients with “destructive” disease had one or more erosion(s) seen on standard X-ray, ultrasonography, MRI or TDM.

Results:

We included 242 patients. 73 (30.2%) had hyperuricemia and 15 (6.2%) met criteria for gout. On univariate analysis, as compared with normo-uricemic patients, hyperuricemic patients were more often male (72.6% vs. 39.1%, p = 1.6x10-06), had higher BMI (30.9 vs. 28.7 kg/m2, p = 0.015) and had more comorbidities (Charlson Comorbidity Index: 2.6 vs. 1.8, p = 0.005). In hyperuricemic versus normo-uricemic patients, PsA started at an older age (47.5 vs 43 years, p = 0.016); PsA was more polyarticular (56.2% vs 41.9%, p = 0.049) than axial (9.6% vs 22.8%, p = 0.019) and more destructive (52.8% vs. 37.4%, p = 0.032). Median uricemia was higher in patients with destructive than non-destructive PsA (321 vs 288.8 μmol/l, p = 0.0038), and hyperuricemia was more frequent with than without joint destruction (37.6% vs 25.8%, p = 0.047). The multivariate analysis confirmed hyperuricemia associated with peripheral joint involvement (OR 2.98, p = 0.025) and less good response to PsA treatment (OR 0.35, p = 0.024).

Figure 1.

Description of normo- and hyperuricemic psoriatic arthritis

CRF: moderate to severe chronic renal failure. MACEs: major adverse cardiovascular events. HBP: high blood pressure. MetS: metabolic syndrome. PsA: psoriatic arthritis

Conclusion:

Patients with hyperuricemic PsA have less good response to PsA treatment than those with normo-uricemia and more peripheral and destructive joint damage. Recognition of PsA in which hyperuricemia would play an aggravating role could modify the management. This would justify a diagnostic reassessment in case of doubt, the possible introduction of hypouricemic treatment and the careful use of NSAIDs in the context of multiple morbidities.

References:

[1]Felten R, Duret P-M, Gottenberg J-E, Spielmann L, Messer L. At the crossroads of gout and psoriatic arthritis: « psout ». Clin Rheumatol. Febr 2020.

Acknowledgements:

We thank all participating patients. We also thank the medical secretaries for their help with the ICD-10 extraction, and Dr Thomas Lavaux for helping with serum urate tests at Strasbourg University Hospital.

Disclosure of Interests:

None declared

A clinical review of the t:slim X2 insulin pump

Insulin pumps are commonly used for intensive insulin therapy to treat type 1 diabetes in adults and youth. Insulin pump technologies have advanced dramatically in the last several years to integrate with continuous glucose monitors (CGM) and incorporate control algorithms. These control algorithms automate some insulin delivery in response to the glucose information received from the CGM to reduce the occurrence of hypoglycemia and hyperglycemia and improve overall glycemic control. The t:slim X2 insulin pump system became commercially available in 2016. It is an innovative insulin pump technology that can be updated remotely by the user to install new software onto the pump device as new technologies become available. Currently, the t:slim X2 pairs with the Dexcom G6 CGM and there are two advanced software options available: Basal-IQ, which is a predictive low glucose suspend (PLGS) technology, and Control-IQ, which is a Hybrid Closed Loop (HCL) technology. This paper will describe the different types of advanced insulin pump technologies, review how the t:slim X2 insulin pump works, and summarize the clinical studies leading to FDA approval and commercialization of the Basal-IQ and Control-IQ technologies.

Identical and Nonidentical Twins: Risk and Factors Involved in Development of Islet Autoimmunity and Type 1 Diabetes

OBJECTIVE

There are variable reports of risk of concordance for progression to islet autoantibodies and type 1 diabetes in identical twins after one twin is diagnosed. We examined development of positive autoantibodies and type 1 diabetes and the effects of genetic factors and common environment on autoantibody positivity in identical twins, nonidentical twins, and full siblings.

RESEARCH DESIGN AND METHODS

Subjects from the TrialNet Pathway to Prevention Study (N = 48,026) were screened from 2004 to 2015 for islet autoantibodies (GAD antibody [GADA], insulinoma-associated antigen 2 [IA-2A], and autoantibodies against insulin [IAA]). Of these subjects, 17,226 (157 identical twins, 283 nonidentical twins, and 16,786 full siblings) were followed for autoantibody positivity or type 1 diabetes for a median of 2.1 years.

RESULTS

At screening, identical twins were more likely to have positive GADA, IA-2A, and IAA than nonidentical twins or full siblings (all P < 0.0001). Younger age, male sex, and genetic factors were significant factors for expression of IA-2A, IAA, one or more positive autoantibodies, and two or more positive autoantibodies (all P ≤ 0.03). Initially autoantibody-positive identical twins had a 69% risk of diabetes by 3 years compared with 1.5% for initially autoantibody-negative identical twins. In nonidentical twins, type 1 diabetes risk by 3 years was 72% for initially multiple autoantibody-positive, 13% for single autoantibody-positive, and 0% for initially autoantibody-negative nonidentical twins. Full siblings had a 3-year type 1 diabetes risk of 47% for multiple autoantibody-positive, 12% for single autoantibody-positive, and 0.5% for initially autoantibody-negative subjects.

CONCLUSIONS

Risk of type 1 diabetes at 3 years is high for initially multiple and single autoantibody-positive identical twins and multiple autoantibody-positive nonidentical twins. Genetic predisposition, age, and male sex are significant risk factors for development of positive autoantibodies in twins.

A Type 1 Diabetes Genetic Risk Score Predicts Progression of Islet Autoimmunity and Development of Type 1 Diabetes in Individuals at Risk

OBJECTIVE

We tested the ability of a type 1 diabetes (T1D) genetic risk score (GRS) to predict progression of islet autoimmunity and T1D in at-risk individuals.

RESEARCH DESIGN AND METHODS

We studied the 1,244 TrialNet Pathway to Prevention study participants (T1D patients' relatives without diabetes and with one or more positive autoantibodies) who were genotyped with Illumina ImmunoChip (median [range] age at initial autoantibody determination 11.1 years [1.2-51.8], 48% male, 80.5% non-Hispanic white, median follow-up 5.4 years). Of 291 participants with a single positive autoantibody at screening, 157 converted to multiple autoantibody positivity and 55 developed diabetes. Of 953 participants with multiple positive autoantibodies at screening, 419 developed diabetes. We calculated the T1D GRS from 30 T1D-associated single nucleotide polymorphisms. We used multivariable Cox regression models, time-dependent receiver operating characteristic curves, and area under the curve (AUC) measures to evaluate prognostic utility of T1D GRS, age, sex, Diabetes Prevention Trial-Type 1 (DPT-1) Risk Score, positive autoantibody number or type, HLA DR3/DR4-DQ8 status, and race/ethnicity. We used recursive partitioning analyses to identify cut points in continuous variables.

RESULTS

Higher T1D GRS significantly increased the rate of progression to T1D adjusting for DPT-1 Risk Score, age, number of positive autoantibodies, sex, and ethnicity (hazard ratio [HR] 1.29 for a 0.05 increase, 95% CI 1.06-1.6; P = 0.011). Progression to T1D was best predicted by a combined model with GRS, number of positive autoantibodies, DPT-1 Risk Score, and age (7-year time-integrated AUC = 0.79, 5-year AUC = 0.73). Higher GRS was significantly associated with increased progression rate from single to multiple positive autoantibodies after adjusting for age, autoantibody type, ethnicity, and sex (HR 2.27 for GRS >0.295, 95% CI 1.47-3.51; P = 0.0002).

CONCLUSIONS

The T1D GRS independently predicts progression to T1D and improves prediction along T1D stages in autoantibody-positive relatives.

Fully Closed-Loop Multiple Model Probabilistic Predictive Controller Artificial Pancreas Performance in Adolescents and Adults in a Supervised Hotel Setting

BACKGROUND

Initial Food and Drug Administration-approved artificial pancreas (AP) systems will be hybrid closed-loop systems that require prandial meal announcements and will not eliminate the burden of premeal insulin dosing. Multiple model probabilistic predictive control (MMPPC) is a fully closed-loop system that uses probabilistic estimation of meals to allow for automated meal detection. In this study, we describe the safety and performance of the MMPPC system with announced and unannounced meals in a supervised hotel setting.

RESEARCH DESIGN AND METHODS

The Android phone-based AP system with remote monitoring was tested for 72 h in six adults and four adolescents across three clinical sites with daily exercise and meal challenges involving both three announced (manual bolus by patient) and six unannounced (no bolus by patient) meals. Safety criteria were predefined. Controller aggressiveness was adapted daily based on prior hypoglycemic events.

RESULTS

Mean 24-h continuous glucose monitor (CGM) was 157.4 ± 14.4 mg/dL, with 63.6 ± 9.2% of readings between 70 and 180 mg/dL, 2.9 ± 2.3% of readings <70 mg/dL, and 9.0 ± 3.9% of readings >250 mg/dL. Moderate hyperglycemia was relatively common with 24.6 ± 6.2% of readings between 180 and 250 mg/dL, primarily within 3 h after a meal. Overnight mean CGM was 139.6 ± 27.6 mg/dL, with 77.9 ± 16.4% between 70 and 180 mg/dL, 3.0 ± 4.5% <70 mg/dL, 17.1 ± 14.9% between 180 and 250 mg/dL, and 2.0 ± 4.5%> 250 mg/dL. Postprandial hyperglycemia was more common for unannounced meals compared with announced meals (4-h postmeal CGM 197.8 ± 44.1 vs. 140.6 ± 35.0 mg/dL; P < 0.001). No participants met safety stopping criteria.

CONCLUSIONS

MMPPC was safe in a supervised setting despite meal and exercise challenges. Further studies are needed in a less supervised environment.

Ketone production in children with type 1 diabetes, ages 4-14 years, with and without nocturnal insulin pump suspension

OBJECTIVE

To compare the frequency of elevated morning blood ketone levels according to age in 4-14 year olds with type 1 diabetes following overnight use of an automated low glucose insulin suspension system, or following control nights when the system was not used.

RESEARCH DESIGN AND METHODS

For 28 children ages 4-9 years and 54 youth ages 10-14 years, elevation of morning blood ketone levels was assessed using the Precision Xtra Ketone meter following 1155 and 2345 nights, respectively. Repeated measures logistic regression models were used to compare age groups for blood ketone level elevation following control nights (system not activated) and following intervention nights with and without insulin suspension.

RESULTS

Elevated morning blood ketones (≥0.6 mmol/L) were present following 10% of 580 control nights in the 4-9 year olds compared with 2% of 1162 control nights in 10-14 year olds (P < 0.001). Likewise, the frequency was greater following intervention nights in the younger age group (13% of 575 nights vs 2% of 1183 nights, P < 0.001). A longer duration of pump suspension resulted in a higher percentage of mornings with elevated blood ketones in the younger age group (P = 0.002), but not in the older age group (P = 0.63). The presence of elevated morning ketone levels did not progress to ketoacidosis in any subject.

CONCLUSIONS

Elevated morning blood ketones are more common in younger children with type 1 diabetes with or without nocturnal insulin suspension. Care providers need to be aware of the differences in ketogenesis in younger age children relative to various clinical situations.

Automated hybrid closed-loop control with a proportional-integral-derivative based system in adolescents and adults with type 1 diabetes: individualizing settings for optimal performance

BACKGROUND

Automated insulin delivery systems, utilizing a control algorithm to dose insulin based upon subcutaneous continuous glucose sensor values and insulin pump therapy, will soon be available for commercial use. The objective of this study was to determine the preliminary safety and efficacy of initialization parameters with the Medtronic hybrid closed-loop controller by comparing percentage of time in range, 70-180 mg/dL (3.9-10 mmol/L), mean glucose values, as well as percentage of time above and below target range between sensor-augmented pump therapy and hybrid closed-loop, in adults and adolescents with type 1 diabetes.

METHODS

We studied an initial cohort of 9 adults followed by a second cohort of 15 adolescents, using the Medtronic hybrid closed-loop system with the proportional-integral-derivative with insulin feed-back (PID-IFB) algorithm. Hybrid closed-loop was tested in supervised hotel-based studies over 4-5 days.

RESULTS

The overall mean percentage of time in range (70-180 mg/dL, 3.9-10 mmol/L) during hybrid closed-loop was 71.8% in the adult cohort and 69.8% in the adolescent cohort. The overall percentage of time spent under 70 mg/dL (3.9 mmol/L) was 2.0% in the adult cohort and 2.5% in the adolescent cohort. Mean glucose values were 152 mg/dL (8.4 mmol/L) in the adult cohort and 153 mg/dL (8.5 mmol/L) in the adolescent cohort.

CONCLUSIONS

Closed-loop control using the Medtronic hybrid closed-loop system enables adaptive, real-time basal rate modulation. Initializing hybrid closed-loop in clinical practice will involve individualizing initiation parameters to optimize overall glucose control.

Efficacy of an Overnight Predictive Low-Glucose Suspend System in Relation to Hypoglycemia Risk Factors in Youth and Adults With Type 1 Diabetes

BACKGROUND

We developed a system to suspend insulin pump delivery overnight when the glucose trend predicts hypoglycemia. This predictive low-glucose suspend (PLGS) system substantially reduces nocturnal hypoglycemia without an increase in morning ketosis. Evaluation of hypoglycemia risk factors that could potentially influence the efficacy of the system remains critical for understanding possible problems with the system and identifying patients that may have the greatest benefit when using the system.

METHODS

The at-home randomized trial consisted of 127 study participants with hemoglobin A1c (A1C) of ≤8.5% (mmol/mol) for patients aged 4-14 years and ≤8.0% for patient aged 15-45 years. Factors assessed included age, gender, A1C, diabetes duration, daily percentage basal insulin, total daily dose of insulin (units/kg-day), bedtime BG, bedtime snack, insulin on board, continuous glucose monitor (CGM) rate of change (ROC), day of the week, time system activated, daytime exercise intensity, and daytime CGM-measured hypoglycemia.

RESULTS

The PLGS system was effective in preventing hypoglycemia for each factor subgroup. There was no evidence that the PLGS system was more or less effective in preventing hypoglycemia in any one subgroup compared with the other subgroups based on that factor. In addition, the effect of the system on overnight hyperglycemia did not differ in subgroups.

CONCLUSIONS

The PLGS system tested in this study effectively reduced hypoglycemia without a meaningful increase in hyperglycemia across a variety of factors.

Duration of Infusion Set Survival in Lipohypertrophy Versus Nonlipohypertrophied Tissue in Patients with Type 1 Diabetes

BACKGROUND

Improved insulin infusion set survival and faster insulin action are important issues for pump users and for the development of an artificial pancreas. The current recommendation is to change infusion sets every 3 days. Our objectives were to determine the effect of lipohypertrophy (LH) on infusion set survival and continuous glucose monitoring glucose levels.

RESEARCH DESIGN AND METHODS

In this multicenter crossover trial, we recruited 20 subjects (age 28.1 ± 9.0 years) with type 1 diabetes (duration 17.5 ± 8.8 years) and an area of lipohypertrophied tissue >3 cm. Subjects alternated weekly wearing a Teflon infusion set in an area of either LH or non-LH for 4 weeks. Sets were changed after (a) failure or (b) surviving 7 days of use.

RESULTS

The least-squares mean duration of infusion set survival for sets that lasted <7 days in lipohypertrophied tissue was 4.31 days compared with 4.12 days in nonlipohypertrophied tissue (P = 0.71). The average duration of set survival for individual subjects ranged from 2.2 to 7.0 days. Infusion sets in lipohypertrophied tissue failed due to hyperglycemia in 35% of subjects compared with 23% in nonlipohypertrophied tissue (P = 0.22). Both lipohypertrophied and nonlipohypertrophied tissues displayed a general increase in mean daily glucose after the third day of infusion set wear, but daily mean glucose did not differ by tissue type (P > 0.38 on each day).

CONCLUSION

LH did not significantly affect infusion set survival or mean glucose. Achieving optimal infusion set performance requires research into factors affecting set survival. Additionally, the recommendation for duration of set change may need to be individualized.

Factors associated with nocturnal hypoglycemia in at-risk adolescents and young adults with type 1 diabetes

BACKGROUND

Hypoglycemia remains an impediment to good glycemic control, with nocturnal hypoglycemia being particularly dangerous. Information on major contributors to nocturnal hypoglycemia remains critical for understanding and mitigating risk.

MATERIALS AND METHODS

Continuous glucose monitoring (CGM) data for 855 nights were studied, generated by 45 subjects 15-45 years of age with hemoglobin A1c (HbA1c) levels of ≤8.0% who participated in a larger randomized study. Factors assessed for potential association with nocturnal hypoglycemia (CGM measurement of <60 mg/dL for ≥30 min) included bedtime blood glucose (BG), exercise intensity, bedtime snack, insulin on board, day of the week, previous daytime hypoglycemia, age, gender, HbA1c level, diabetes duration, daily basal insulin, and daily insulin dose.

RESULTS

Hypoglycemia occurred during 221 of 885 (25%) nights and was more frequent with younger age (P<0.001), lower HbA1c levels (P=0.006), medium/high-intensity exercise during the preceding day (P=0.003), and the occurrence of antecedent daytime hypoglycemia (P=0.001). There was a trend for lower bedtime BG levels to be associated with more frequent nocturnal hypoglycemia (P=0.10). Bedtime snack, before bedtime insulin bolus, weekend versus weekday, gender, and daily basal and bolus insulin were not associated with nocturnal hypoglycemia.

CONCLUSIONS

Awareness that HbA1c level, exercise, bedtime BG level, and daytime hypoglycemia are all modifiable factors associated with nocturnal hypoglycemia may help patients and providers decrease the risk of hypoglycemia at night. Risk for nocturnal hypoglycemia increased in a linear fashion across the range of variables, with no clear-cut thresholds to guide clinicians or patients for any particular night.

Preventing post-exercise nocturnal hypoglycemia in children with type 1 diabetes

OBJECTIVE

To determine the effects of reducing overnight basal insulin or a bedtime dose of terbutaline on nocturnal blood glucose (BG) nadir and hypoglycemia after exercise in children with type 1 diabetes mellitus.

STUDY DESIGN

Sixteen youth (mean age 13.3 years) on insulin pumps were studied overnight on 3 occasions after a 60-minute exercise session with BG measurements every 30 minutes. Admissions were randomized to bedtime treatment with oral terbutaline 2.5 mg, 20% basal rate insulin reduction for 6 hours, or no treatment.

RESULTS

Mean overnight nadir BG was 188 mg/dL after terbutaline and 172 mg/dL with basal rate reduction compared with 127 mg/dL on the control night (P = .002 and .042, respectively). Terbutaline eliminated nocturnal hypoglycemia but resulted in significantly more hyperglycemia (≥250 mg/dL) when compared with the control visit (P < .0001). The basal rate reduction resulted in fewer BG readings <80 and <70 mg/dL but more readings ≥250 mg/dL when compared with the control visit.

CONCLUSIONS

A basal insulin rate reduction was safe and effective in raising post-exercise nocturnal BG nadir and in reducing hypoglycemia in children with type 1 diabetes mellitus. Although effective at preventing hypoglycemia, a 2.5-mg dose of terbutaline was associated with hyperglycemia.

Timing of meal insulin boluses to achieve optimal postprandial glycemic control in patients with type 1 diabetes

OBJECTIVE

This study determined the optimal timing of insulin bolus administration in relation to meal consumption in adolescents and adults with type 1 diabetes.

STUDY DESIGN AND METHODS

Twenty-three subjects participated in this crossover study consisting of three treatment arms: delivering an insulin glulisine bolus by insulin pump 20 min prior to a meal ("PRE"), immediately before the meal ("START"), and 20 min after meal initiation ("POST"). Blood glucose levels were measured every 30 min for a total of 240 min post-meal initiation. Mean blood glucose levels at 1 and 2 h after meal initiation, blood glucose area under the curve (AUC), and maximum blood glucose levels were analyzed.

RESULTS

At both 60 and 120 min after meal initiation, the PRE arm showed significantly lower glycemic excursions than the START arm (P = 0.0029 and 0.0294, respectively) and the POST arm (P = 0.001 and 0.0408, respectively). Glycemic AUC was significantly less in the PRE arm versus both the START and POST arms (159.5 +/- 58.9 mg/dL vs. 187.0 +/- 43.1 mg/dL [P = 0.0297] and 184.5 +/- 33.2 mg/dL [P = 0.0463], respectively). Peak blood glucose levels were significantly lower in the PRE arm compared to the START arm (P = 0.0039) and the POST arm (P = 0.0027).

CONCLUSIONS

A bolus of rapid-acting insulin 20 min prior to a meal results in significantly better postprandial glucose control than when the meal insulin bolus is given just prior to the meal or 20 min after meal initiation.

Educating families on real time continuous glucose monitoring: the DirecNet navigator pilot study experience

PURPOSE

The purpose of this article is to describe the process of educating families and children with type 1 diabetes on real time continuous glucose monitoring (RT-CGM) and to note the similarities and differences of training patients using continuous subcutaneous insulin infusion (CSII) versus multiple daily injections (MDI).

METHODS

A total of 30 CSII participants and 27 MDI participants were educated using the Navigator RT-CGM in a clinical trial. Time spent with families for visits and calls was tracked and compared between patient groups. The Diabetes Research in Children Network (DirecNet) educators were surveyed to assess the most crucial, time intensive, and difficult educational concepts related to CGM.

RESULTS

Of the 27 MDI families, an average of 9.6 hours was spent on protocol-prescribed visits and calls (not measured in CSII) and 2 hours on participant-initiated contacts over 3 months. MDI families required an average of 5.4 more phone contacts over 3 months than CSII families. According to the DirecNet educators, lag time and calibrations were the most crucial teaching concepts for successful RT-CGM use. The most time was spent on teaching technical aspects, troubleshooting, and insulin dosing. The most unanticipated difficulties were skin problems including irritation and the sensor not adhering well.

CONCLUSION

Educators who teach RT-CGM should emphasize lag time and calibration techniques, technical device training, and sensor insertion. Follow-up focus should include insulin dosing adjustments and skin issues. The time and effort required to introduce RT-CGM provided an opportunity for the diabetes educators to reemphasize good diabetes care practices and promote self-awareness and autonomy to patients and families.

Genetic mapping of a mouse modifier gene that can prevent ALS onset

Mutations in the cytoplasmic Cu/Zn superoxide dismutase (SOD1) gene on human chromosome 21q22.1 cause 10-20% of familial amyotrophic lateral sclerosis (ALS) cases. The expression of the ALS phenotype in mice carrying the murine G86R SOD1 mutation is highly dependent upon the mouse genetic background. This is similar to the phenotypic variation observed in ALS patients containing identical SOD1 mutations. In the FVB/N background, mice expressing mG86R SOD1 develop an ALS phenotype at approximately 100 days. However, when these mice were bred into a mixed background of C57Bl6/129Sv, the onset of the ALS phenotype was delayed (143 days to >2 years). Using 129 polymorphic autosomal markers in a whole genome scan, we have identified a major genetic modifier locus with a maximum lod score of 5.07 on mouse chromosome 13 between D13mit36 and D13mit76. This 5- to 8-cM interval contains the spinal muscular atrophy (SMA)-associated gene Smn (survival motor neuron) and seven copies of Naip (neuronal apoptosis inhibitory protein), suggesting a potential link between SMA and ALS.

Early detection of cervical cancer among Native American women: a qualitative supplement to a quantitative study

The North Carolina Native American Cervical Cancer Prevention Project was a 5-year (1989-1995) National Cancer Institute-funded, community-based, early detection of cervical cancer intervention implemented among two Native American tribes in North Carolina: the eastern band of the Cherokee Indians and the Lumbee. The initial quantitative analysis of the intervention showed modest effects and found that the intervention had different effects in the two communities. Due to the equivocal findings, a retrospective qualitative study was conducted. The qualitative study found that two types of factors influenced the intervention's results. The first were project and intervention characteristics, and the second were community and cultural factors over which the project had no control. The community and cultural factors took two forms: enhancers, which contributed to greater intervention effect, and attenuators, which created barriers to success. Examples of each factor are presented, and implications for cervical cancer detection among Native American women are discussed.

A longitudinal study predicting patterns of cigarette smoking in late childhood

Early initiation of cigarette smoking so strongly predicts future smoking that several investigators have advocated delaying the age of initiation as a prevention strategy. To complement retrospective studies of early initiation, this study assessed prospectively patterns of smoking behavior in a sample of 401 children who were surveyed in the fifth, sixth, and seventh grades. The principal findings were (1) modeling of smoking by parents and friends is sufficient to influence children to initiate smoking, particularly when children also have low behavioral self-control, and (2) when modeling occurs in combination with poor adjustment to school, low parental monitoring, easy access to cigarettes, and other risk attributes, early initiators are significantly more likely to continue smoking. The results suggest that delaying initiation of smoking without also modifying child attributes and socialization factors that predict early initiation and persistent smoking is unlikely to reduce the proportion of children who become habitual smokers.

Linkage mapping of the retinoic acid receptor-gamma gene to porcine chromosome 5

The porcine retinoic acid receptor-gamma gene (RARG) has been mapped by restriction fragment length polymorphism analysis to porcine chromosome 5. The placement of RARG distal to the diacylglycerol kinase gene increases the length of the existing map (PiGMaP) and adds a fifth type-I marker to this sparsely mapped chromosome. This augments the homology of pig chromosome 5 and human chromosome 12 established by previous comparative mapping.

Cystic fibrosis mutation screening in healthy men with reduced sperm quality

The majority of men with cystic fibrosis (CF) are infertile due to a bilateral congenital absence of the vas deferens (CBAVD). However, clinically affected CF patients present a spectrum of genital phenotypes ranging from normal fertility to severely impaired spermatogenesis and CBAVD. Recently, it has become apparent that CF can manifest itself as isolated CBAVD in the absence of other clinical symptoms. The present study was undertaken to test the possible involvement of the CF gene in the aetiology of male infertility other than CBAVD. Semen specimens from 127 unrelated healthy males with various diagnoses of reduced sperm quality were screened for a panel of 13 mutations in the cystic fibrosis transmembrane conductance regulator (CFTR) gene. Fourteen of 80 (17.5%) healthy men with infertility due to reduced sperm quality and 3 of 21 (14.3%) men with azoospermia had at least one CF mutation (one azoospermic male was a compound heterozygote). The frequency of mutations in our sample of infertile males was significantly higher than the expected CF carrier frequency in the local population (P = 0.00139). No mutations were found in a control group of 26 individuals with normal semen parameters. This increased frequency of CF mutations in healthy men with reduced sperm quality and in men with azoospermia without CBAVD suggests that the CFTR protein may be involved in the process of spermatogenesis or sperm maturation apart from playing a critical role in the development of the epididymal glands and the vas deferens.

MHC class II compatibility in aborted fetuses and term infants of couples with recurrent spontaneous abortion

Maternal-fetal histocompatibility for alleles at HLA class II loci, HLA-DQA1 and HLA-DQB1, was examined in 40 abortuses and 31 liveborn children of 68 couples with a history of idiopathic recurrent spontaneous abortion (RSAB) who underwent leukocyte immunization prior to the index pregnancy. Significantly more couples with RSAB shared two HLA-DQA1 alleles as compared with fertile control couples (0.18 vs. 0.03, respectively; P = 0.031). There were no differences in HLA sharing between couples with RSAB who experienced a repeat abortion in the index pregnancy as compared with couples with RSAB who were delivered of a liveborn child. Non-significant deficits of abortuses who were compatible for alleles at the HLA-DQA1 (6 observed vs. 8.5 expected; P = 0.225) and the HLA-DQB1 (7 observed vs. 9.2 expected; P = 0.254) loci were observed. A significant deficit of HLA-DQA1 compatible liveborn children was observed (1 observed vs. 5.5 expected; P = 0.0069). The overall deficit of HLA-DQA1 compatible fetuses (7 observed vs. 14.0 expected; P = 0.0018) after approximately 8 weeks gestation suggests that HLA-DQA1 compatible fetuses may be aborted early in pregnancy, prior to the time when fetal tissue can be recovered for genetic studies.