AB0509 AGREEMENT BETWEEN LABIAL BIOPSIES AND THE OMERACT GREY-SCALE ULTRASOUND SCORING SYSTEM FOR SALIVARY GLANDS IN A SINGLE-CENTER COHORT OF PATIENTS WITH SUSPECTED SJÖGREN’S SYNDROME

Background

Ultrasound is a promising non-invasive tool in the evaluation of the salivary glands for parenchymal changes related to Sjögrens Syndrome (SS). The OMERACT Ultrasound Grey-scale (GS) Scoring System for SS has been shown to have good sensitivity and excellent specificity for fulfilling the SS classification criteria, when a GS ≥2 in at least 1 gland was considered indicative of SS (1), however others have suggested pathology in at least 2 glands is required (2). Systematic use of ultrasound might reduce the need for labial biopsies if US findings are in agreement with biopsies.

Objectives

To assess the agreement between labial biopsy results and salivary gland ultrasound findings in patients suspected of SS.

Methods

Patients referred to our department with a suspicion of SS from 2017-2021, scheduled for a diagnostic labial biopsy were recruited. All underwent GS ultrasound of the parotid and submandibular glands bilaterally prior to clinical exam, Schirmer’s test, unstimulated salivary flow, blood samples including autoantibody analysis. Still images of the four glands were scored 0-3 using a previously developed ultrasound atlas (1) of the OMERACT ultrasound scoring system for SS (2,3). All biopsies were evaluated by a pathologist and focus score ≥1 was considered indicative of SS. Two different ultrasound scores for SS were tested: US-score ≥2 in at least 1 gland and US-score ≥2 in at least 2 glands. Descriptive statistics were used. In these analyses, we used labial biopsy as reference standard.

Results

103 patients were included and 44 were clinically diagnosed with SS of which 42 (95%) fulfilled the 2016 ACR/EULAR classification criteria and 33 (75%) had positive labial biopsy. Demographics are shown in Table 1.

Table 1.

Demographics

All patients, n=103Gender, n=females (%)89 (86)Age, mean ± SD55 ± 15.9Symptoms > 2 years, n=patients (%)51 (50)Symptoms < 2 years, ≥ 1 year, n= patients (%)28 (27)Symptoms < 1 year, n= patients (%)24 (23)Biopsy with focus score ≥ 1, n= patients (%)32 (31)US with ≥ 1 gland score ≥ 2, n=patients (%)36 (35)US with ≥2 glands score ≥ 2, n= patients (%)31 (30)SSA positive (%)39 (38)SSB positive (%)9 (9)ANA positive (%)42 (41)Sialometry positive (%)67 (65)Schirmer’s test positive (%)32 (31)

The sensitivity of ultrasound score ≥2 in at least 1 gland was 0.69 and the specificity 0.80. The positive predictive (PPV) and negative predictive values (NPV) were 0.61 and 0.85, respectively. Applying ultrasound score ≥2 in at least 2 glands did not improve specificity (0.83), PPV (0.61) or NPV (0.82) whereas sensitivity dropped to 0.59. The agreement between biopsies and ultrasound for SS is shown Figure 1.

Figure 1

Conclusion

In patients with suspected SS, we found good agreement between US of salivary glands and subsequent labial biopsy. US of salivary glands seems useful in the diagnosis and classification of SS, but labial biopsies may still be needed in select cases.

References

[1]Fana V et al. RMD Open. 2021;7(2):e001516.

[2]Jousse-Joulin S et al. Ann Rheum Dis. 2019;78(7):967-973.

[3]Finzel S et al. Rheumatology (Oxford). 2021 May 14;60(5):2169-2176.

Disclosure of Interests

Viktoria Fana: None declared, Nanna Surlemont Schmidt: None declared, Uffe Møller Døhn: None declared, Simon Krabbe: None declared, Lene Terslev Speakers bureau: Novartis, Pfizer, UCB, Janssen and GE

OP0149 RELIABILITY AND RESPONSIVENESS OF TWO OMERACT WHOLE-BODY MRI SCORES OF ENTHESEAL AND JOINT INFLAMMATION IN THE KNEE REGION IN SPONDYLOARTHRITIS

Background:

Inflammation in peripheral joints and entheses is common in spondyloarthritis (SpA). Whole-body magnetic resonance imaging (WB-MRI) allows assessment of the overall inflammatory status of arthritis patients including joints and entheses. The OMERACT MRI Whole-body scoring system for Inflammation in Peripheral joints and Entheses (MRI-WIPE) [1] has been developed and validated for the entire body assessment, including the knee, but not separately validated for the knee joint region. Detailed MRI scoring systems exist for heels, hands and feet, but although knee arthritis is a key cause of functional impairment, no detailed scoring system has been validated for inflammatory arthritides. The Knee Inflammation MRI Scoring System (KIMRISS) [2] was developed and validated in osteoarthritis and demonstrated good reliability.

Objectives:

To perform region-based development of whole-body MRI through validation of two knee region scoring systems in SpA.

Methods:

Assessment of inflammation was performed in the knee region on sagittal WB-MRIs using 2 scoring systems, MRI-WIPE and KIMRISS (Figure 1), in 4 iterative multi-reader exercises. In the final exercise, images (psoriatic arthritis, axial and peripheral SpA) were obtained before and after TNF-inhibitor.

Results:

In the final exercise (exercise 4), reliability was mostly good for experienced readers with the overall highest interreader agreement in the previous exercise (exercise 3). Median pairwise single measure intraclass correlation coefficients for osteitis and synovitis/effusion for status/change were 0.71/0.48 (WIPE osteitis), 0.48/0.77 (WIPE synovitis/effusion), 0.59/0.91 (KIMRISS osteitis) and 0.92/0.97 (KIMRISS synovitis/effusion) (Table 1). Wilcoxon signed-rank test showed significant change in synovitis/effusion for both methods and they correlated significantly regarding status in osteitis (0.92, p<0.001) and synovitis/effusion (0.89, p=0.001) and change in synovitis/effusion (0.89, p<0.001). Standardized response mean was 0.74 (WIPE synovitis/effusion) and 0.78 (KIMRISS synovitis/effusion).

Table 1.

MRI-WIPE knee and KIMRISS interreader reliability for OMERACT exercises 3 and 4

MRI-WIPE KneeKIMRISSOsteitisSynovitis/effusionOsteitisSynovitis/effusionVariablesNo. patientsType of scoreMean scoreICCMean scoreICCMean scoreICCMean scoreICCExercise 39 readers11Status3.6 (0-16)0.57 (-0.06-0.98)1.8 (0-4)0.47 (0.05-0.85)32.3 (1-224)0.87 (0.66-0.99)29.9 (11-60)0.34 (-0.62-0.87)11Change1.1 (-2-6)0.53 (0.03-0.90)0 (-2-1)0.32 (-0.13-0.76)27.7 (-9-131)0.58 (-0.30-0.96)-1.6 (-33-11)0.48 (-0.32-0.95)Exercise 33 readers11Status3.1 (0-16)0.83 (0.71-0.97)2.5 (0-5)0.59 (0.51-0.71)34.4 (0-233)0.89 (0.83-0.99)36.5 (16-78)0.59 (0.08-0.86)11Change0.9 (-3-6)0.72 (0.57-0.83)0 (-2-1)0.63 (0.49-0.76)19.3 (-23-86)0.46 (0.18-0.83)-1.8 (-45-17)0.89 (0.82-0.95)Exercise 49 readers10Change-0.25 (-4-5)0.38 (-0.35-0.94)-1.0 (-3-1)0.30 (-0.43-0.89)-0.45 (-37-65)0.26 (-0.86-0.97)-14.7 (-48-0.20)0.48 (-0.39-0.99)20Status2.9 (0-7)0.50 (-0.01-0.84)2.1 (0-4)0.44 (-0.21-0.79)15.2 (0-66)0.35 (-0.04-0.89)55.6 (1-122)0.54 (0.01-0.96)Exercise 43 readers10Change0.2 (-2-6)0.48 (0.16-0.66)-1.4 (-5-0)0.77 (0.70-0.82)5.8 (-27-111)0.92 (0.90-0.94)-20.7 (-65-28)0.97 (0.96-0.98)20Status2.3 (0-6)0.71 (0.60-0.80)2.7 (0-5)0.48 (0.42-0.57)11.4 (0-36)0.59 (0.39-0.71)69.4 (1-153)0.91 (0.87-0.93)

Sum scores are mean (range) of the patients scores. ICC values are mean (range). ICC is 2-way mixed model, single measure, by absolute agreement.

Conclusion:

MRI-WIPE and KIMRISS may both be useful as part of modular whole-body evaluation in clinical studies.

References:

[1]Krabbe S et al. J Rheum. 2019;46(9):1215-21

[2]Jaremko JL et al. RMD Open. 2017;3(1):e000355

Acknowledgements:

We thank CARE Aarthritis Limited (carearthritis.com) for help with setting up the web-based scoring interface, the scoring exercises, and the web-based meetings. We thank all who participated in the SIG (Special Interest Group) virtual OMERACT meeting 29 October 2020. HMO, GDM and PGC are supported in part by the National Institute for Health Research (NIHR) Leeds Biomedical Research Centre, United Kingdom. The views expressed in this study are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health.

Disclosure of Interests:

Marie Wetterslev: None declared, Walter P Maksymowych Speakers bureau: AbbVie, Janssen, Novartis, Pfizer and UCB, Consultant of: AbbVie, Boehringer Ingelheim, Celgene, Eli Lilly, Galapagos, Janssen, Novartis, Pfizer and UCB, Grant/research support from: AbbVie, Novartis, Pfizer and UCB, Robert G Lambert Consultant of: Parexel and Pfizer, Iris Eshed: None declared, Susanne Juhl Pedersen Speakers bureau: MSD, Pfizer, AbbVie, Novartis and UCB, Consultant of: AbbVie and Novartis, Grant/research support from: AbbVie, MSD, and Novartis, Maria Stoenoiu: None declared, Simon Krabbe: None declared, Paul Bird Speakers bureau: Janssen, Abbvie, UCB, Celgene, BMS, Novartis, Pfizer, Gilead, Eli-Lilly, Consultant of: Janssen, Abbvie, UCB, Celgene, BMS, Novartis, Pfizer, Gilead, Eli-Lilly, Violaine Foltz: None declared, Ashish Jacob Mathew: None declared, Frederique Gandjbakhch: None declared, Joel Paschke: None declared, Philippe Carron Speakers bureau: Pfizer, MSD, Novartis, BMS, AbbVie, UCB, Eli Lilly, Gilead and Celgene, Consultant of: Pfizer, MSD, Novartis, BMS, AbbVie, UCB, Eli Lilly, Gilead and Celgene, Grant/research support from: UCB, MSD and Pfizer, Gabriele De Marco: None declared, Helena Marzo-Ortega Speakers bureau: AbbVie, Celgene, Janssen, Lilly, Novartis, Pfizer, Takeda and UCB, Grant/research support from: Janssen and Novartis, Anna Enevold Fløistrup Poulsen: None declared, Jacob L Jaremko: None declared, Philip G Conaghan Speakers bureau: AbbVie, AstraZeneca, BMS, Eli Lilly, EMD Serono, Flexion Therapeutics, Galapagos, Gilead, Novartis, Pfizer and Stryker, Consultant of: AbbVie, AstraZeneca, BMS, Eli Lilly, EMD Serono, Flexion Therapeutics, Galapagos, Gilead, Novartis, Pfizer and Stryker, Mikkel Østergaard Speakers bureau: Abbvie, BMS, Boehringer-Ingelheim, Celgene, Eli-Lilly, Hospira, Janssen, Merck, Novartis, Pfizer, Regeneron, Roche, Sandoz, Sanofi and UCB, Consultant of: Abbvie, BMS, Boehringer-Ingelheim, Celgene, Eli-Lilly, Hospira, Janssen, Merck, Novartis, Pfizer, Regeneron, Roche, Sandoz, Sanofi and UCB, Grant/research support from: Abbvie, BMS, Boehringer-Ingelheim, Celgene, Eli-Lilly, Hospira, Janssen, Merck, Novartis, Pfizer, Regeneron, Roche, Sandoz, Sanofi and UCB

OP0252 ARTHRITIS AND ENTHESITIS IN THE HIP AND PELVIS REGION IN SPONDYLOARTHRITIS – VALIDATION OF TWO WHOLE-BODY MRI METHODS

Background:

Whole-body MRI (WB-MRI) allows assessment of the overall inflammation in arthritis patients, including joint and entheses. To enhance the use of WB-MRI in clinical trials, the OMERACT MRI in Arthritis Working Group developed the OMERACT MRI Whole-body score for Inflammation in Peripheral joints and Entheses in inflammatory arthritis (MRI-WIPE) [1]. This has been validated for the entire body, including the hip/pelvis region, but not for each individual region. More detailed scoring systems exist for heels, hands and feet but although hip arthritis is a key cause of functional impairment in spondyloarthritis (SpA), no detailed scoring system has been published for use in SpA. The Hip Inflammation Magnetic Resonance Imaging Scoring System (HIMRISS) was developed and validated in osteoarthritis showing good reliability.

Objectives:

To validate reliability, correlation and responsiveness of two WB-MRI scores for the hip/pelvis region in SpA.

Methods:

Inflammation in the hip/pelvis region was assessed on coronal WB-MRIs in 4 iterative multi-reader exercises using MRI-WIPE for the hip/pelvis region and HIMRISS (Figure 1). In final exercises, images (axial/peripheral SpA and psoriatic arthritis) were obtained before and after TNF-inhibitor.

Results:

In final exercises reliability was mostly good for the best calibrated readers. Median single-measure intraclass correlation coefficients were 0.58-0.65 (WIPE osteitis), 0.10-0.88 (HIMRISS osteitis), 0.38-0.72/0.52-0.60 (WIPE synovitis/effusion) and 0.68-0.89/0.78-0.85 (HIMRISS synovitis/effusion) (Table 1). The methods correlated significantly for status in osteitis (0.72, p=0.019) and for synovitis/effusion status (0.83, p=0.003) and change (0.73, p=0.017) (Table 1). In exercise 4 Wilcoxon signed-rank test showed significant change in osteitis between timepoints using WIPE hip/pelvis and SRM was large (1.23), while lower for WIPE synovitis/effusion and HIMRISS.

Table 1.

MRI-WIPE hip/pelvis and HIMRISS interreader reliability for OMERACT exercises 3-4

MRI-WIPE hip/pelvisHIMRISSOsteitisSynovitis/effusionOsteitisSynovitis/effusionVariablesNo. patients(cases)Type of scoreMeanscoreICCMeanscoreICCMeanscoreICCMeanscoreICCExercise 39 readers11Status2.3 (0-10)0.69 (0.23-0.93)1.4 (0-4)0.58 (-0.06-0.96)8.2 (1-60)0.84 (0.56-0.99)12.8 (3-25)0.52 (0.00-.91)11Change-0.2 (-1-1)NA-0.2 (-3-1)0.50 (0.10-0.87)-0.35 (-3-1)NA-1.8 (-17-10)0.50 (-0.05-0.89)Exercise 33 readers11Status1.8 (0-10)0.63 (0.46-0.93)1.7 (0-5)0.60 (0.34-0.80)6.6 (0-65)0.88 (0.77-0.94)12.8 (2-28)0.89 (0.87-0.91)11Change-0.12 (-1-1)NA-0.12 (-3-2)0.60 (0.48-0.83)-0.7 (-7-0)NA-1.6 (-21-8)0.78 (0.70-0.87)Exercise 49 readers10 (1-10)Status1.2 (0-4)0.21 (-0.39-0.91)1.1 (0-2)0.19 (-0.31-0.69)1.8 (0-6)0.07 (-0.17-0.83)16.4 (9-23)0.31 (0.00-0.89)10 (11-20)Status1.6 (0-6)0.51 (-0.08-0.99)1 (0-3)0.40 (-0.17-0.88)3.5 (1-8)0,08 (-0.21-0.95)11.2 (5-24)0.49 (0.00-0.94)10 11-20)Change-0.4 (-2-0)NA-0.39 (-2-0)0.22 (-0.68-0.83)-2.2 (-7-2)NA-5.2 (-18-0)0.57 (0.02-0.92)20 (1-20)Status1.4 (0-6)0.41 (-0.35-0.92)1.0 (0-3)0.27 (-0.07-0.75)2.7 (0-9)0.09 (-0.17-0.85)13.8 (5-25)0.45 (0.01-0.90)Exercise 43 readers10 (1-10)Status0.8 (0-4)0.29 (0.01-0.78)1.3 (0-2)-0.02 (-0.29-0.12)0.4 (0-2)-0.04 (-0.04-0.04)15.8 (5-26)0.73 (0.59-0.89)10 (11-20)Status1.8 (0-9)0.65 (0.52-0.76)1.2 (0-4)0.72 (0.62-0.81)1.7 (0-5)0.06 (-0.17-0.35)9.2 (2-26)0.68 (0.53-0.88)10 (11-20)Change-0.6 (-2-0)NA-0.5 (-3-1)0.52 (0.49-0.55)-0.2 (-2-1)NA-2.8 (-19-6)0.85 (0.82-0.88)20 (1-20)Status1.3 (0-9)0.58 (0.43-0.69)1.2 (0-4)0.38 (0.31-0.44)1.0 (0-5)0.10 (-0.09-0.33)12.5 (2-26)0.73 (0.69-0.77)

Sum scores and ICCs are mean (range). ICC is 2-way mixed, single measure, by absolute agreement.

Conclusion:

MRI-WIPE and HIMRISS may be useful tools in modular WB-MRI evaluation of hip/pelvis inflammation in clinical trials in SpA.

References:

[1]Krabbe S et al. J Rheum. 2019;46(9):1215-21

[2]Jaremko JL et al. J Rheum. 2019;46(9)1239-42

Acknowledgements:

We thank CARE Arthritis Limited (carearthritis.com) for help with setting up the web-based scoring interface, scoring exercises, and the web-based meetings. We acknowledge the contribution of SIG (Special Interest Group) participants at the virtual OMERACT meeting October 29, 2020. HMO, GDM and PGC are supported in part by the National Institute for Health Research (NIHR) Leeds Biomedical Research Centre, United Kingdom. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health.

Disclosure of Interests:

Marie Wetterslev: None declared, Robert G Lambert Consultant of: Parexel and Pfizer, Walter P Maksymowych Speakers bureau: AbbVie, Janssen, Novartis, Pfizer and UCB, Consultant of: AbbVie, Boehringer Ingelheim, Celgene, Eli Lilly, Galapagos, Janssen, Novartis, Pfizer and UCB, Grant/research support from: AbbVie, Novartis, Pfizer and UCB, Iris Eshed: None declared, Susanne Juhl Pedersen Speakers bureau: MSD, Pfizer, AbbVie, Novartis and UCB, Consultant of: AbbVie and Novartis, Grant/research support from: AbbVie, MSD, and Novartis, Paul Bird Speakers bureau: Janssen, Abbvie, UCB, Celgene, BMS, Novartis, Pfizer, Gilead, Eli-Lilly, Consultant of: Janssen, Abbvie, UCB, Celgene, BMS, Novartis, Pfizer, Gilead, Eli-Lilly, Maria Stoenoiu: None declared, Simon Krabbe: None declared, Ashish Jacob Mathew: None declared, Violaine Foltz: None declared, Frederique Gandjbakhch: None declared, Joel Paschke: None declared, Gabriele De Marco: None declared, Helena Marzo-Ortega Speakers bureau: AbbVie, Celgene, Janssen, Lilly, Novartis, Pfizer, Takeda and UCB, Grant/research support from: Janssen and Novartis, Philippe Carron Speakers bureau: Pfizer, MSD, Novartis, BMS, AbbVie, UCB, Eli Lilly, Gilead and Celgene, Consultant of: Pfizer, MSD, Novartis, BMS, AbbVie, UCB, Eli Lilly, Gilead and Celgene, Grant/research support from: UCB, MSD and Pfizer, Anna Enevold Fløistrup Poulsen: None declared, Jacob L Jaremko: None declared, Philip G Conaghan Speakers bureau: AbbVie, BMS, Eli Lilly, Flexion Therapeutics, Galapagos, Gilead, Novartis, Pfizer, Regeneron, Stryker, Consultant of: AbbVie, BMS, Eli Lilly, Flexion Therapeutics, Galapagos, Gilead, Novartis, Pfizer, Regeneron, Stryker, Mikkel Østergaard Speakers bureau: Abbvie, BMS, Boehringer-Ingelheim, Celgene, Eli-Lilly, Hospira, Janssen, Merck, Novartis, Pfizer, Regeneron, Roche, Sandoz, Sanofi and UCB, Consultant of: Abbvie, BMS, Boehringer-Ingelheim, Celgene, Eli-Lilly, Hospira, Janssen, Merck, Novartis, Pfizer, Regeneron, Roche, Sandoz, Sanofi and UCB, Grant/research support from: Abbvie, BMS, Boehringer-Ingelheim, Celgene, Eli-Lilly, Hospira, Janssen, Merck, Novartis, Pfizer, Regeneron, Roche, Sandoz, Sanofi and UCB

OP0018 A MULTICENTER RANDOMIZED STUDY IN EARLY RHEUMATOID ARTHRITIS TO COMPARE ACTIVE CONVENTIONAL THERAPY VERSUS THREE BIOLOGICAL TREATMENTS: 24 WEEK EFFICACY RESULTS OF THE NORD-STAR TRIAL

Background:

The optimal first-line treatment of patients (pts) with early rheumatoid arthritis (RA) is yet to be established.

Objectives:

The primary aim was to assess and compare the proportion of pts who achieved remission with active conventional therapy (ACT) and with three different biologic therapies after 24 wks. Secondary aims were to assess and compare other efficacy measures.

Methods:

The investigator-initiated NORD-STAR trial (NCT01491815) was conducted in the Nordic countries and Netherlands. In this multicenter, randomized, open-label, blinded-assessor study pts with treatment-naïve, early RA with DAS28>3.2, and positive RF or ACPA, or CRP >10mg/L were randomized 1:1:1:1. Methotrexate (25 mg/week after one month) was combined with: 1) (ACT): oral prednisolone (tapered quickly);or: sulphasalazine, hydroxychloroquine and mandatory intra-articular (IA) glucocorticoid (GC) injections in swollen joints <wk 20; 2) certolizumab 200 mg EOW SC (CZP); 3) abatacept 125 mg/wk SC (ABA); tocilizumab 162 mg/wk SC (TCZ). IA GC was allowed in all arms <wk 20. Primary outcome was clinical disease activity index remission (CDAI≤2.8) at wk 24. Secondary outcomes included CDAI remission over time and other remission criteria. Dichotomous outcomes were analyzed by adjusted logistic regression with non-responder imputation (NRI). Non-inferiority analyses had a pre-specified margin of 15%.

Results:

812 pts were randomized. Age was 54.3±14.7 yrs (mean±SD), 31.2% were male, DAS28 5.0±1.1, 74.9% were RF and 81.9% ACPA positive. Fig 1 shows the adjusted CDAI remission rates over time with 95% CI. Table shows crude remission and response rates and absolute differences in adjusted remission and response rates (superiority analysis). Differences in remission and response rates with CZP and TCZ, but not with ABA, remained within the pre-defined non-inferiority margin versus ACT, Fig 2.

Figure 1.

CDAI remission over time (adj. estimates with 95% CI)

Figure 2.

Non-inferiority analysis of protocol population. Estimated differences in CDAI remission rates between Arm 1 (active conventional therapy) and Arms 2, 3, and 4 (biologic arms) as reference with 95% confidence intervals, adjusted for gender, ACPA status, country, age, body-mass index and baseline DAS28-CRP. ABA, abatacept; CZP, certolizumab-pegol; MTX, methotrexate; TCZ, tocilizumab.

Conclusion:

High remission rates were found across all four treatment arms at 24 wks. Higher CDAI remission rate was observed for ABA versus ACT (+9%) and for CZP (+4%), but not for TCZ (-1%). With the predefined 15% margin, ACT was non-inferior to CZP and TCZ, but not to ABA. This underscores the efficacy of active conventional therapy based on MTX combined with glucocorticoids and may guide future treatment strategies for early RA.

Table.

Primary and key secondary outcomes at 24 weeks (ITT)

Active conventional therapy (ACT)Certolizumab+MTXAbatacept+MTXTocilizumab+MTXNo of pts (ITT)200203204188§Crude remission and response ratesCDAI remission42.0%47.8%52.5%41.0%ACR/EULAR Boolean remission34.0%38.4%37.3%31.4%DAS28 remission63.5%68.5%69.6%63.3%SDAI remission41.5%49.8%51.5%42.6%EULAR good response71.5%76.9%79.9%71.3%Difference (95% CI) in rates with Arm 1 as reference (adjusted)CDAI remissionRef4% (-5 to 13%)9% (0.1 to 19%)-1% (-10 to 9%)ACR/EULAR Boolean remissionRef4% (-6 to 13%)5% (-5 to 14%)-4% (-13 to 6%)DAS28 remissionRef3% (-6 to 11%)5% (-4 to 13%)-1% (-10 to 8%)SDAI remissionRef6% (-3 to 18%)9% (-0.3 to 18%)1% (-8 to 11%)EULAR good responseRef4% (-4 to 14%)8% (-2 to 18%)0.4% (-10 to 11%)

§17 patients allocated to Tocilizumab did not receive it due to its unavailability and were excluded from ITT.

Acknowledgments:

Manufacturers provided CZP and ABA.

Disclosure of Interests:

Merete L. Hetland Grant/research support from: BMS, MSD, AbbVie, Roche, Novartis, Biogen and Pfizer, Consultant of: Eli Lilly, Speakers bureau: Orion Pharma, Biogen, Pfizer, CellTrion, Merck and Samsung Bioepis, Espen A Haavardsholm Grant/research support from: AbbVie, UCB Pharma, Pfizer Inc, MSD Norway, Roche Norway, Consultant of: Pfizer, AbbVie, Janssen-Cilag, Gilead, UCB Pharma, Celgene, Lilly, Paid instructor for: UCB Pharma, Speakers bureau: Pfizer, AbbVie, UCB Pharma, Celgene, Lilly, Roche, MSD, Anna Rudin Consultant of: Astra/Zeneca, Dan Nordström Consultant of: Abbvie, Celgene, Lilly, Novartis, Pfizer, Roche and UCB., Speakers bureau: Abbvie, Celgene, Lilly, Novartis, Pfizer, Roche and UCB., Michael Nurmohamed Grant/research support from: Not related to this research, Consultant of: Not related to this research, Speakers bureau: Not related to this research, Björn Gudbjornsson Speakers bureau: Novartis and Amgen, Jon Lampa Speakers bureau: Pfizer, Janssen, Novartis, Kim Hørslev-Petersen: None declared, Till Uhlig Consultant of: Lilly, Pfizer, Speakers bureau: Grünenthal, Novartis, Gerdur Gröndal: None declared, Mikkel Ǿstergaard Grant/research support from: AbbVie, Bristol-Myers Squibb, Celgene, Merck, and Novartis, Consultant of: AbbVie, Bristol-Myers Squibb, Boehringer Ingelheim, Celgene, Eli Lilly, Hospira, Janssen, Merck, Novartis, Novo Nordisk, Orion, Pfizer, Regeneron, Roche, Sandoz, Sanofi, and UCB, Speakers bureau: AbbVie, Bristol-Myers Squibb, Boehringer Ingelheim, Celgene, Eli Lilly, Hospira, Janssen, Merck, Novartis, Novo Nordisk, Orion, Pfizer, Regeneron, Roche, Sandoz, Sanofi, and UCB, Marte Heiberg: None declared, Jos Twisk: None declared, Simon Krabbe: None declared, Kristina Lend: None declared, Inge Olsen: None declared, Joakim Lindqvist: None declared, Anna-Karin H Ekwall Consultant of: AbbVie, Pfizer, Kathrine L. Grøn Grant/research support from: BMS, Meliha C Kapetanovic: None declared, Francesca Faustini: None declared, Riitta Tuompo: None declared, Tove Lorenzen: None declared, Giovanni Cagnotto: None declared, Eva Baecklund: None declared, Oliver Hendricks Grant/research support from: Pfizer, MSD, Daisy Vedder: None declared, Tuulikki Sokka-Isler: None declared, Tomas Husmark: None declared, Maud-Kristine A Ljosa: None declared, Eli Brodin: None declared, Torkell Ellingsen: None declared, Annika Soderbergh: None declared, Milad Rizk Speakers bureau: AbbVie, Åsa Reckner: None declared, Per Larsson: None declared, Line Uhrenholt Speakers bureau: Abbvie, Eli Lilly and Novartis (not related to the submitted work), Søren Andreas Just: None declared, David Stevens: None declared, Trine Bay Laurberg Consultant of: UCB Pharma (Advisory Board), Gunnstein Bakland Consultant of: Novartis, UCB, Ronald van Vollenhoven Grant/research support from: BMS, GSK, Lilly, UCB, Pfizer, Roche, Consultant of: AbbVie, AstraZeneca, Biogen, Biotest, Celgene, Gilead, Janssen, Pfizer, Servier, UCB, Speakers bureau: AbbVie, Pfizer, UCB

SAT0549 A SEMI-QUANTITATIVE MRI SCORING SYSTEM FOR INFLAMMATION IN JOINTS AND ENTHESES IN THE LOWER EXTREMITIES DEMONSTRATES GOOD RELIABILITY AND VALIDITY: POST-HOC ANALYSIS OF DATA FROM THE CRESPA TRIAL

Background:

MRI allows an objective assessment of signs of inflammation in peripheral joints and entheses and is therefore of potential interest as outcome measure in trials. No knowledge exists on the reliability and validity of semi-quantitative MRI scores in the setting of peripheral spondyloarthritis (pSpA).

Objectives:

To describe the reliability of a semi-quantitative lower-extremity MRI scoring system, to investigate correlation with known measures of disease activity and ability to capture patients with improvement during treatment.

Methods:

In a post-hoc analysis, scores from 3 readers (LJ, MØ, SK) who independently assessed MRI images of pelvis (except sacroiliac joints), knees and ankles in the CRESPA trial blinded to chronology and all clinical data, were further analyzed. Entheses were scored 0-3 (none/mild/moderate/severe) for soft tissue inflammation (19 sites) and 0-3 for bone marrow edema (24 sites), joints were scored 0-3 for effusion/synovitis (10 sites) and 0-3 for bone marrow edema (22 sites). MRI score was defined as the sum of scores from all joints and entheses (i.e. all 75 sites). The CRESPA trial (NCT01426815) included 60 patients with early pSpA, defined as a symptom duration of <12 weeks. All patients fulfilled the Assessment of SpondyloArthritis international Society criteria for pSpA; data from 56 patients with available MRI images at baseline were included in this analysis, 46 had available MRI images at follow-up. Follow-up MRI was only performed if sustained clinical remission was reached. Reliability was assessed using two-way intra-class correlation coefficient (ICC) models by absolute agreement, single-measure (relevant when using scores from 1 reader) and average-measure (relevant when using averaged scores from 3 readers).

Results:

MRI scores at baseline were mean 7.2 (median 5, inter-quartile range 3 to 9, range 0 to 32). MRI change scores were mean −3.1 and (median −1, IQR −4 to 0, range −18 to 2). MRI status scores at baseline (n=56) had single measure ICC 0.78 (95% CI: 0.66-0.87) and average measure ICC 0.92 (0.85-0.95). MRI change scores (n=46) had single measure ICC 0.73 (0.57-0.84) average measure ICC 0.89 (0.80-0.94).

MRI status scores correlated significantly with CRP, ESR, swollen joint count and pain score.

Patients with PSpARC40 response (n=34) (≥40% improvement in disease activity according to the Peripheral SpA Response Criteria) had larger decreases in MRI scores compared to patients without PSpARC40 response (n=11), mean −3.4 vs. −1.0, p=0.03.

When using all MRI data from pelvis, knees and ankles combined, more patients could be identified to have improvement, as compared to only taking one of three parts into account.

MRI scores of pelvis, knees and feet combinedMRI scores of pelvis onlyMRI scores of knees onlyMRI scores of ankles onlyNumber of patients with improvement in MRI score > SDC15 (33%)9 (20%)12 (26%)14 (30%)Number of patients with improvement in MRI score ≥ 50%21 (46%)10 (22%)20 (43%)17 (37%)Net number of patients with improvement in MRI score*24 (52%)6 (13%)21 (46%)15 (33%)Number of patients with improvement in MRI score as assessed by 3 readers17 (37%)3 (7%)11 (24%)13 (28%)

*Patients with improvement minus patients with worsening.

Conclusion:

The semi-quantitative lower-extremity MRI score showed acceptable reliability and validity. The ability to capture response was best when combining information from all available areas that were imaged, i.e. both pelvis, knees and ankles.

*First authorship is shared between SK and TR.

Disclosure of Interests:

Simon Krabbe Grant/research support from: AbbVie, MSD, Novartis, Thomas Renson: None declared, Lennart Jans: None declared, Dirk Elewaut: None declared, Filip van den Bosch Consultant of: AbbVie, Celgene Corporation, Eli Lilly, Galapagos, Janssen, Novartis, Pfizer, and UCB, Speakers bureau: AbbVie, Celgene Corporation, Eli Lilly, Galapagos, Janssen, Novartis, Pfizer, and UCB, Philippe Carron: None declared, Mikkel Ǿstergaard Grant/research support from: AbbVie, Bristol-Myers Squibb, Celgene, Merck, and Novartis, Consultant of: AbbVie, Bristol-Myers Squibb, Boehringer Ingelheim, Celgene, Eli Lilly, Hospira, Janssen, Merck, Novartis, Novo Nordisk, Orion, Pfizer, Regeneron, Roche, Sandoz, Sanofi, and UCB, Speakers bureau: AbbVie, Bristol-Myers Squibb, Boehringer Ingelheim, Celgene, Eli Lilly, Hospira, Janssen, Merck, Novartis, Novo Nordisk, Orion, Pfizer, Regeneron, Roche, Sandoz, Sanofi, and UCB

Scoring magnetic resonance imaging (MRI) inflammation and structural lesions in sacroiliac joints of patients with axial spondyloarthritis: assessment of all MRI slices of the cartilaginous compartment versus standardized six or five slices

Objectives: The Spondyloarthritis Research Consortium of Canada (SPARCC) sacroiliac joint (SIJ) scoring system assesses six or five (6/5) semicoronal magnetic resonance imaging (MRI) slices for inflammation/structural lesions in patients with axial spondyloarthritis (axSpA). However, the cartilaginous SIJ compartment may be visible in a few additional slices. The objective was to investigate interreader reliability, sensitivity to change, and classification of MRI scans as positive or negative for various lesion types using an 'all slices' approach versus standard SPARCC scoring of 6/5 slices.Method: Fifty-three axSpA patients were treated with the tumour necrosis factor inhibitor golimumab and followed with serial MRI scans at weeks 0, 4, 16, and 52. The most anterior and posterior slices covering the cartilaginous compartment and the transitional slice were identified. Scores for inflammation, fat metaplasia, erosion, backfill, and ankylosis in the cartilaginous SIJ compartment were calculated for the 'all slices' approach and the 6/5 slices standard.Results: By the 'all slices' approach, three readers scored mean 7.2, 7.7, and 7.0 slices per MRI scan. Baseline and change scores for the various lesion types closely correlated between the two approaches (Pearson's rho ≥ 0.95). Inflammation score was median 13 (interquartile range 6-21, range 0-49) for 6/5 slices versus 14 (interquartile range 6-23, range 0-69) for all slices at baseline. Interreader reliability, sensitivity to change, and classification of MRI scans as positive or negative for various lesion types were similar.Conclusion: The standardized 6/5 slices approach showed no relevant differences from the 'all slices' approach and, therefore, is equally suited for monitoring purposes.

Extremely poor patient-reported outcomes are associated with lack of clinical response and decreased retention rate of tumour necrosis factor inhibitor treatment in patients with axial spondyloarthritis

OBJECTIVE

To investigate whether axial spondyloarthritis (axSpA) patients with extremely poor patient-reported outcomes (PROs) at start of first tumour necrosis factor inhibitor (TNFi) treatment have poorer treatment response and shorter treatment retention than other patients.

METHOD

This observational cohort study was based on the nationwide DANBIO registry. Patients with axSpA who started first TNFi during 2011-2016 were stratified according to baseline Bath Ankylosing Spondylitis Disease Activity Index (BASDAI ≥ 0.0 to ≤ 4.0, > 4.0 to ≤ 5.0, > 5.0 to ≤ 6.0, > 6.0 to ≤ 7.0, > 7.0 to ≤ 8.0, > 8.0 to ≤ 9.0, and > 9.0 to ≤ 10.0). An extremely poor BASDAI was defined as BASDAI > 9.0 to ≤ 10.0. Treatment responses after 6 months [≥ 50% improvement from baseline BASDAI (BASDAI50), ≥ 40% improvement in Assessment of SpondyloArthritis international Society (ASAS40) response, and ASAS partial remission] in patients with extremely poor PROs were compared with other patients by chi-squared tests, and retention rates by log-rank tests. Similar analyses were done for Bath Ankylosing Spondylitis Functional Index (BASFI), pain score, and patient global score.

RESULTS

The study included 1396 patients (median age 39 years, 60% men). Patients with extremely poor baseline BASDAI [63 patients (5%)] were more often women, ever smokers, and human leucocyte antigen-B27 negative, and had higher body mass index. Response rates were poorer in patients with extremely poor BASDAI vs remaining patients (BASDAI50 19% and 41%, respectively, p < 0.001; ASAS40 16% and 35%, p = 0.002; ASAS partial remission 6% and 22%, p < 0.001). Patients with extremely poor BASDAI had lower 1 year treatment retention (51% and 68%, p < 0.001). Largely similar results were found for patients with extremely poor BASFI, pain score, and patient global score.

CONCLUSION

Patients who reported an unusually large symptom burden at baseline had poor response rates and low retention rate. In such cases, competing causes of pain should carefully be taken into account when considering treatment with TNFi.

Investigation of a multi-biomarker disease activity score in rheumatoid arthritis by comparison with magnetic resonance imaging, computed tomography, ultrasonography, and radiography parameters of inflammation and damage

OBJECTIVES

To investigate the multi-biomarker disease activity (MBDA) score by comparison with imaging findings in an investigator-initiated rheumatoid arthritis (RA) trial (HURRAH trial, NCT00696059).

METHOD

Fifty-two patients with established RA initiated adalimumab treatment and had magnetic resonance imaging (MRI), ultrasonography (US), computed tomography (CT), and radiography performed at weeks 0, 26, and 52. Serum samples were analysed using MBDA score assays and associations between clinical measures, MBDA score, and imaging findings were investigated.

RESULTS

The MBDA score correlated significantly with MRI synovitis (rho = 0.65, p < 0.001), MRI bone marrow oedema (rho = 0.36, p = 0.044), and US power Doppler (PD) score at week 26 (rho = 0.35, p = 0.039) but not at week 0 or week 52. In the 15 patients who had achieved a Disease Activity Score based on C-reactive protein (DAS28-CRP) < 2.6 at week 26, MRI and/or US detected subclinical inflammation and 13 (87%) had a moderate/high MBDA score. For the cohort with available data, none of the four patients in MBDA remission (score ≤ 25) at week 26 had progression of imaging damage from baseline to week 52 whereas progression was observed in three out of nine (33%) and seven out of 21 (33%) patients with moderate (30-44) and high (> 44) MBDA scores, respectively.

CONCLUSIONS

In this cohort, the MBDA score correlated poorly with MRI/US inflammation. However, the MBDA score and MRI/US were generally concordant in showing signs of inflammation in most patients in clinical remission during anti-tumour necrosis factor (anti-TNF) therapy. MBDA scores were elevated in all patients with structural damage progression.

Health-related quality of life improves during one year of medical and surgical treatment in a European population-based inception cohort of patients with inflammatory bowel disease--an ECCO-EpiCom study

BACKGROUND & AIMS

Health-related quality of life (HRQoL) is impaired in patients with Inflammatory Bowel Disease (IBD). The aim was prospectively to assess and validate the pattern of HRQoL in an unselected, population-based inception cohort of IBD patients from Eastern and Western Europe.

METHODS

The EpiCom inception cohort consists of 1560 IBD patients from 31 European centres covering a background population of approximately 10.1 million. Patients answered the disease specific Short Inflammatory Bowel Disease Questionnaire (SIBDQ) and generic Short Form 12 (SF-12) questionnaire at diagnosis and after one year of follow-up.

RESULTS

In total, 1079 patients were included in this study. Crohn's disease (CD) patients mean SIBDQ scores improved from 45.3 to 55.3 in Eastern Europe and from 44.9 to 53.6 in Western Europe. SIBDQ scores for ulcerative colitis (UC) patients improved from 44.9 to 57.4 and from 48.8 to 55.7, respectively. UC patients needing surgery or biologicals had lower SIBDQ scores before and after compared to the rest, while biological therapy improved SIBDQ scores in CD. CD and UC patients in both regions improved all SF-12 scores. Only Eastern European UC patients achieved SF-12 summary scores equal to or above the normal population.

CONCLUSION

Medical and surgical treatment improved HRQoL during the first year of disease. The majority of IBD patients in both Eastern and Western Europe reported a positive perception of disease-specific but not generic HRQoL. Biological therapy improved HRQoL in CD patients, while UC patients in need of surgery or biological therapy experienced lower perceptions of HRQoL than the rest.

Health care and patients' education in a European inflammatory bowel disease inception cohort: an ECCO-EpiCom study

BACKGROUND AND AIMS

The EpiCom study and inception cohort was initiated in 2010 in 31 centers from 14 Western and 8 Eastern European countries, covering a 10.1million person background population. Our aim was to investigate whether there is a difference between Eastern and Western Europe in health care and education of patients with inflammatory bowel disease (IBD).

METHODS

A quality of care (QoC) questionnaire was developed in the EpiCom group consisting of 16 questions covering 5 items: time interval between the onset of symptoms and diagnosis, information, education, empathy and access to health care providers.

RESULTS

Of 1,515 patients, 947 (217 east/730 west) answered the QoC questionnaire. Only 23% of all patients had knowledge about IBD before diagnosis. In Eastern Europe, significantly more patients searched out information about IBD themselves (77% vs. 68%, p<0.05), the main source was the Internet (92% vs. 88% p=0.23). In Western Europe, significantly more patients were educated by nurses (19% vs. 1%, p<0.05), while in Eastern Europe, gastroenterologists were easier to contact (80% vs. 68%, p<0.05).

CONCLUSION

Health care differed significantly between Eastern and Western Europe in all items, but satisfaction rates were high in both geographic regions. Because of the low awareness and the rising incidence of IBD, general information should be the focus of patient organizations and medical societies. In Western Europe IBD nurses play a very important role in reducing the burden of patient management.

Environmental factors in a population-based inception cohort of inflammatory bowel disease patients in Europe--an ECCO-EpiCom study

BACKGROUND AND AIMS

The incidence of inflammatory bowel disease (IBD) is increasing in Eastern Europe possibly due to changes in environmental factors towards a more "westernised" standard of living. The aim of this study was to investigate differences in exposure to environmental factors prior to diagnosis in Eastern and Western European IBD patients.

METHODS

The EpiCom cohort is a population-based, prospective inception cohort of 1560 unselected IBD patients from 31 European countries covering a background population of 10.1 million. At the time of diagnosis patients were asked to complete an 87-item questionnaire concerning environmental factors.

RESULTS

A total of 1182 patients (76%) answered the questionnaire, 444 (38%) had Crohn's disease (CD), 627 (53%) ulcerative colitis (UC), and 111 (9%) IBD unclassified. No geographic differences regarding smoking status, caffeine intake, use of oral contraceptives, or number of first-degree relatives with IBD were found. Sugar intake was higher in CD and UC patients from Eastern Europe than in Western Europe while fibre intake was lower (p<0.01). Daily consumption of fast food as well as appendectomy before the age of 20 was more frequent in Eastern European than in Western European UC patients (p<0.01). Eastern European CD and UC patients had received more vaccinations and experienced fewer childhood infections than Western European patients (p<0.01).

CONCLUSIONS

In this European population-based inception cohort of unselected IBD patients, Eastern and Western European patients differed in environmental factors prior to diagnosis. Eastern European patients exhibited higher occurrences of suspected risk factors for IBD included in the Western lifestyle.

East-West gradient in the incidence of inflammatory bowel disease in Europe: the ECCO-EpiCom inception cohort

OBJECTIVE

The incidence of inflammatory bowel disease (IBD) is increasing in Eastern Europe. The reasons for these changes remain unknown. The aim of this study was to investigate whether an East-West gradient in the incidence of IBD in Europe exists.

DESIGN

A prospective, uniformly diagnosed, population based inception cohort of IBD patients in 31 centres from 14 Western and eight Eastern European countries covering a total background population of approximately 10.1 million people was created. One-third of the centres had previous experience with inception cohorts. Patients were entered into a low cost, web based epidemiological database, making participation possible regardless of socioeconomic status and prior experience.

RESULTS

1515 patients aged 15 years or older were included, of whom 535 (35%) were diagnosed with Crohn's disease (CD), 813 (54%) with ulcerative colitis (UC) and 167 (11%) with IBD unclassified (IBDU). The overall incidence rate ratios in all Western European centres were 1.9 (95% CI 1.5 to 2.4) for CD and 2.1 (95% CI 1.8 to 2.6) for UC compared with Eastern European centres. The median crude annual incidence rates per 100,000 in 2010 for CD were 6.5 (range 0-10.7) in Western European centres and 3.1 (range 0.4-11.5) in Eastern European centres, for UC 10.8 (range 2.9-31.5) and 4.1 (range 2.4-10.3), respectively, and for IBDU 1.9 (range 0-39.4) and 0 (range 0-1.2), respectively. In Western Europe, 92% of CD, 78% of UC and 74% of IBDU patients had a colonoscopy performed as the diagnostic procedure compared with 90%, 100% and 96%, respectively, in Eastern Europe. 8% of CD and 1% of UC patients in both regions underwent surgery within the first 3 months of the onset of disease. 7% of CD patients and 3% of UC patients from Western Europe received biological treatment as rescue therapy. Of all European CD patients, 20% received only 5-aminosalicylates as induction therapy.

CONCLUSIONS

An East-West gradient in IBD incidence exists in Europe. Among this inception cohort--including indolent and aggressive cases--international guidelines for diagnosis and initial treatment are not being followed uniformly by physicians.

East-West gradient in the incidence of inflammatory bowel disease in Europe: the ECCO-EpiCom inception cohort

OBJECTIVE

The incidence of inflammatory bowel disease (IBD) is increasing in Eastern Europe. The reasons for these changes remain unknown. The aim of this study was to investigate whether an East-West gradient in the incidence of IBD in Europe exists.

DESIGN

A prospective, uniformly diagnosed, population based inception cohort of IBD patients in 31 centres from 14 Western and eight Eastern European countries covering a total background population of approximately 10.1 million people was created. One-third of the centres had previous experience with inception cohorts. Patients were entered into a low cost, web based epidemiological database, making participation possible regardless of socioeconomic status and prior experience.

RESULTS

1515 patients aged 15 years or older were included, of whom 535 (35%) were diagnosed with Crohn's disease (CD), 813 (54%) with ulcerative colitis (UC) and 167 (11%) with IBD unclassified (IBDU). The overall incidence rate ratios in all Western European centres were 1.9 (95% CI 1.5 to 2.4) for CD and 2.1 (95% CI 1.8 to 2.6) for UC compared with Eastern European centres. The median crude annual incidence rates per 100,000 in 2010 for CD were 6.5 (range 0-10.7) in Western European centres and 3.1 (range 0.4-11.5) in Eastern European centres, for UC 10.8 (range 2.9-31.5) and 4.1 (range 2.4-10.3), respectively, and for IBDU 1.9 (range 0-39.4) and 0 (range 0-1.2), respectively. In Western Europe, 92% of CD, 78% of UC and 74% of IBDU patients had a colonoscopy performed as the diagnostic procedure compared with 90%, 100% and 96%, respectively, in Eastern Europe. 8% of CD and 1% of UC patients in both regions underwent surgery within the first 3 months of the onset of disease. 7% of CD patients and 3% of UC patients from Western Europe received biological treatment as rescue therapy. Of all European CD patients, 20% received only 5-aminosalicylates as induction therapy.

CONCLUSIONS

An East-West gradient in IBD incidence exists in Europe. Among this inception cohort--including indolent and aggressive cases--international guidelines for diagnosis and initial treatment are not being followed uniformly by physicians.

[Cataract--an initial symptom of diabetes mellitus in a 14-year old girl]

A 14-year-old girl presented with cataract as an initial sign of IDDM. Before the diagnosis of DM, she showed no acute symptoms, including ketoacidosis. Retrospectively, there had been faint signs of polyuria, polydipsia, and nycturia. Diabetic cataract is a rare complication in young diabetics and is usually associated with long-standing DM and poor metabolic control. Previous cases have a striking resemblance to our patient, thus suggesting that a small group of young diabetics have weak symptoms, but are nevertheless at great risk of developing diabetic complications.

[Iodine therapy for iodine deficiency goiter and autoimmune thyroiditis. A prospective study]

PROBLEM

There is epidemiological and clinical evidence that iodine may induce or promote the manifestation of autoimmune thyroiditis. For this reason it is important to know if substitution of alimentary iodine deficiency or iodine treatment of endemic goitre can cause formation of thyroid antibodies. On the other hand the practical importance of this phenomenon should be evaluated.

PATIENTS AND METHODS

During a prospective study we examined 209 patients with endemic non-toxic goitre and 53 healthy people. For treatment were used 200 micrograms iodine/d (n = 119), 500 micrograms iodine/d (n = 27), 1.5 mg iodine/week (n = 41), 150 micrograms iodine/d plus 75 to 100 micrograms T4/d (n = 26), 100 micrograms iodine plus 100 micrograms T4/d (n = 24). The observation took 1 year with a 3-month interval for check ups including clinical examination, ultrasound, TSH, T3, fT4, TPO- and thyreoglobuline antibodies and urinary iodine.

RESULTS

After 12 months 7.5% of iodine treated persons had produced antibodies, most of them at low levels. In healthy people we found increased antibody-levels in 3.8%, in patients with goitre in 9.0%, in patients with nodular goitres in 11.1%. 500 micrograms iodine caused the most antibody reaction in 14.8%. People treated with 200 micrograms iodine/d showed positive antibody levels in 5%. T4 seems to reduce antibody-reactions. Pathological antibody-levels were not found in patients with combined iodine/T4- and single-T4 therapy. Among the 22 primary pathological antibody levels only 4 increased further (18.2%). Three of them belonged to the group of 5 persons treated with 500 micrograms iodine/d. Primary high antibody values were normalized in 5 patients (22.7%). Hypothyroid disturbances were not found. Ultrasound did not show any alterations, and the reduction of thyroid volumes in antibody-positive patients was not affected. Median urinary iodine excretion during the observation-interval was 5.2 to 7.2 micrograms/dl.

CONCLUSIONS

Possible antibody reactions have no clinical importance at all. Individual cases must be observed. Low iodine doses should be preferred. Combined iodine/T4 treatment seems to have an advantage regarding immunological thyroidal reactions.

[Cryptorchism. Outcome of treatment and referral patterns in an unselected group of patients in a 3-year period]

The age of diagnosis and referral together with the efficacy of HCG treatment were studied retrospectively in 196 unselected cryptorchid patients seen over a period of three years. The median age of diagnosis was 2 years and 7 months, whereas the median age of referral was three years later. During the period of study, guidelines for referral and therapy were published in a nationwide journal and in the local region, and a slight but significant fall in age of referral was seen thereafter. The median age of treatment with HCG, 92 patients, was 6 years and 11 months, and median age of surgery, was 7 years and 7 months. The rate of success with HCG was for bilateral testes 41% and for unilateral testes 21%, giving an overall success rate of 30%. This result is lower than previously reported, which is most likely explained by a higher suprascrotal position of testes before treatment. Guidelines and recommendations for referral and therapy seem to influence the time of referral, which is, however, in this study not in accordance with the consensus of definitive treatment before the age of two years. Early diagnosis is recommended and should be followed by referral to a paediatric department with particular interest and knowledge about cryptorchidism.

[The effect of giving a copy of the discharge letter to parents]

The purpose of this study was to evaluate the effect of giving parents a copy of the discharge letter (DL) concerning the hospitalization of their child. Questionnaires were sent to parents, general practitioners (GP) and health visitors (HV). Sixty-one per cent of the parents and 64% of the GPs and HVs returned the questionnaires. Seventy-seven per cent of the responding parents had received the discharge letter within a week after the discharge, and 64% of the parents understood the DL without difficulties. The majority regarded it as an improvement of the service to the families.

Growth, growth hormone and final height after BMT. Possible recovery of irradiation-induced growth hormone insufficiency

The aim of the present study was to assess growth, final height, growth hormone (GH) secretion and growth factors after BMT including TBI in childhood. The median age of the 25 participants was 11.3 years at BMT, and a median of 7.5 years had elapsed since BMT. The median height standard deviation score (SDS) declined significantly from diagnosis until 4 years after BMT (n = 25, P = 0.015), and decreased 1.08 SDS from diagnosis until final height (n = 14, P = 0.030). Sitting height to standing height ratio was impaired, -0.64 SDS, P < 0.05. GH insufficiency was found in 32% at follow-up. Repeated assessments of GH production over the years indicated improvement in GH secretion in nine individuals. Evaluation of spontaneous 24-h GH secretion indicated a secretory pattern similar to controls, although the total amount of GH secreted was lower. Neither insulin-like growth factor-1 (IGF-1) nor IGF binding protein-3 (IGFBP-3) alone could be used as a marker of GH insufficiency. IGF-1 was low: -1.18 SDS; (P < 0.001). In conclusion, our study demonstrated the impact on growth, final height, body proportions, GH secretion and growth factors after BMT including TBI. We hypothesize that children who receive BMT at a younger age are more at risk of loss of final height and abnormal body proportions. Our data indicate that some improvement in GH production may occur over the years.

Serum insulin-like growth factor I (IGF-I) and IGF-binding protein 3 levels are increased in central precocious puberty: effects of two different treatment regimens with gonadotropin-releasing hormone agonists, without or in combination with an antiandrogen (cyproterone acetate)

Central precocious puberty (CPP) is characterized by early activation of the pituitary-gonadal axis, which leads to increased growth velocity and development of secondary sexual characteristics. It is generally believed that gonadal sex steroids stimulate pulsatile GH secretion, which, in turn, stimulates insulin-like growth factor I (IGF-I) and IGF-binding protein 3 (IGFBP-3) production. However, little is known about GH, IGF-I, and IGFBP-3 serum levels in children with precocious puberty. Treatment of CPP by GnRH agonists has become the treatment of choice. However, the effect of long term treatment with GnRH in combination with an antiandrogen (cyproterone acetate) to block the possible effect of adrenal androgens has not previously been evaluated. We, therefore, studied 40 patients with idiopathic CPP that were treated for 24 months with either GnRH analog (Buserelin) in combination with cyproterone acetate (Androcur; n = 23) or with long acting GnRH analog (Decapeptyl Depot; n = 17). We found that serum IGF-I levels were increased before treatment in both groups (mean +/- SE, 446 +/- 35 and 391 +/- 35 micrograms/L; P < 0.0001, respectively) compared to those in normal age-matched prepubertal children. Similarly, IGFBP-3 levels were significantly elevated (4675 +/- 209 and 4305 +/- 162 micrograms/L, respectively; P < 0.0001) in the two groups. Treatment with GnRH analog in combination with cyproterone acetate significantly decreased height velocity and serum IGF-I and IGFBP-3 levels to normal levels after 2 yr of treatment (P < 0.0001). Serum IGF-I levels remained unchanged during monthly im treatment with long acting GnRH analog, whereas IGFBP-3 levels significantly increased during the first year of this treatment despite unmeasurable estradiol levels. Thus, in both groups, the molar ratio between IGF-I and IGFBP-3 (i.e. free biologically active IGF-I) declined concomitantly with a decrease in growth velocity. Serum levels of IGF-I and IGFBP-3 (expressed as the SD score for bone age), but not those of estradiol, correlated with height velocity before and during treatment (r = 0.34; P < 0.0001 and r = 0.24; P = 0.003, respectively). Six of the patients with a subnormal GH response to clonidine had similar IGF-I and IGFBP-3 serum levels and growth velocity compared to the other 34 girls with CPP and a normal GH response.(ABSTRACT TRUNCATED AT 400 WORDS)

Immunohistochemical characterization of monoclonal antibodies directed against the TSH receptor

Monoclonal antibodies have been obtained by fusing mouse myeloma cells with spleen cells of mice immunized with crude thyroid membranes. Among the antibodies reactive with different thyroid antigenic components, three were found to specifically react with TSH receptor molecules. These antibodies displayed characteristic staining patterns on frozen sections of thyroid tissue from patients with various thyroid diseases upon identification of antibody binding by indirect peroxidase staining. No specific reactivity was detected with tissue from other human organs, such as pancreas, liver, fat, and muscle. The results demonstrate that the immunoperoxidase technique and the specificity of the monoclonal antibodies produced permitted the identification of cellular constituents that might be important antigens in autoimmune thyroid disease.

Concurrent uveoretinitis and pineocytoma in a child suggests a causal relationship

Uveoretinitis was observed in a 9-year-old girl 6 months prior to the clinical appearance of a pineal tumour. Surgical removal was not successful but biopsy revealed a parenchymal neoplasm with differentiated pinealocytes and absent mitotic activity. Some of the tumour cells contained S-antigen, rhodopsin, and serotonin. Systemic glucocorticoid therapy followed by radiation therapy caused considerable reduction in size of the tumour and a complete normalisation of all eye symptoms. This report demonstrates for the first time that a pineocytoma can occur together with uveoretinitis in humans. The latter resembles the experimentally induced autoimmune uveoretinitis described in animals. It is speculated that the retinitis might reflect an autoimmune response to S-antigen present in some tumour cells of the pineocytoma.

[Induction of spermatogenesis by pulsatile gonadotropin-releasing hormone treatment in hypogonadotropic hypogonadism]

A successful case of pulsatile GnRH treatment of a 31 years old male with hypogonadotropic hypogonadism is described. During therapy for six months the secretions of LH, FSH and testosterone were normalised and the testicular volume increased to normal adult size. The sperm count increased from 0.0 to 0.9 mill/ml. Subsequently the sexual partner became pregnant and delivered a normal female infant.

Fundamental voice frequency in female puberty measured with electroglottography during continuous speech as a secondary sex characteristic. A comparison between voice, pubertal stages, oestrogens and androgens

The change of fundamental voice frequency in continuous speech in female puberty was analysed in 47 girls by comparison of 2000 consecutive electroglottographic cycles in a reading situation. The results were compared with serum concentrations of androgens (dihydroepiandrosterone, delta-4-androstenedione, testosterone, and sex hormone binding globulin), oestrogens (oestradiol, oestrone, and oestronesulphate), and somatic puberty (weight, height, mamma stages, and pubic hair stages). Fundamental frequency in continuous speech was related only to oestrone r = -0.34, (P less than 0.05). But the tone range in continuous speech and the lowest tone in the phonetogram were found to be significantly correlated with many of the pubertal and hormone parameters. All these correlations could be explained by a common age-dependency. By multiple regression analysis different sets of variables for prediction of speaking fundamental frequency were found before and after menarche.

[Bone alkaline phosphatase as an activity parameter of acromegaly]

Serum levels of growth hormone (GH: arithmetic mean of three measurements eight hours apart), somatomedin C (SmC), alkaline phosphatase activity and the bone isoenzyme of alkaline phosphatase (as the liver/bone isoenzyme ratio) were measured in 26 patients with acromegaly (11 men and 15 women; mean age 45.5 [24-66] years), 18 in the active and eight in the nonactive phase of the disease. Activity was characterized by a raised (660 [330-1149] ng/ml), inactivity by a normal (186 [40-300] ng/ml) SmC concentration. All 18 patients with active acromegaly had an abnormally low liver/bone isoenzyme ratio (mean of 0.66 [0.01-1.28]). In seven of the eight patients with inactive acromegaly it was within normal limits. Thus measurement of bone alkaline phosphatase, which is significantly cheaper than that of SmC, is suitable for assessing activity.

Autoimmune involvement in Cushing syndrome due to primary adrenocortical nodular dysplasia

Cushing syndrome due to primary adrenocortical nodular dysplasia was diagnosed in two patients, aged 3 years 9 months and 9.5 years. Subsequently, adrenalectomy was performed and followed by steroid replacement. In both cases, the adrenals were normal or only slightly enlarged and showed adrenocortical nodular dysplasia histologically. Small lymphocytic infiltrates consisting of T-cells and class II MHC positive macrophages were present in adrenal specimens of both the patients. Samples of protein A sepharose purified serum immunoglobulins from both children stimulated adrenocortical DNA synthesis and cortisol production in cultured guinea-pig adrenal segments in vitro in a dose dependent fashion. Adrenal stimulating immunoglobulins were also demonstrated in serum specimens of both patients' mothers. However, none of them had overt signs of adrenal disease. Our data support the view that autoimmune mechanisms may be involved in primary adrenocortical nodular dysplasia.

Calcium homeostasis and mineralization in puberty

Calcium homoeostasis and bone mineralization have been the subject of many studies, but few have dealt with these aspects specifically in puberty. The main observations in our own studies - together with those in other recent reports - are summarized below. According to the aims of the present survey (Chapter 1) the results are grouped as follows: BLOOD MINERAL HOMOEOSTASIS AND ALKALINE PHOSPHATASE. The serum concentrations of calcium, total or ionized, remain remarkably constant throughout puberty, which probably reflects the important functions of the calcium ion. Serum phosphate, however, remain high in childhood, increase slightly with acceleration of growth and pubertal development and the levels then decrease toward adult values. Consequently, the pattern of the product of serum calcium and phosphate, essential for mineralization, follows that of phosphate. Serum magnesium does not change during puberty. The serum concentrations of alkaline phosphatase increase with acceleration in linear growth and pubertal development which has to be taken into consideration, in evaluation of changes in serum AP. Changes in osteoblastic activity, as expressed by AP (and BGP), are closely associated with changes in testosterone secretion with almost simultaneous increases in serum levels of both variables. It is further concluded that longitudinal study designs may add to the understanding of the growth process and rate of changes, whereas cross-sectional data are relevant to establish proper reference ranges. BONE MINERAL CONTENT. The use of photon absorptiometry in determining BMC is a precise, easy, atraumatic and reproducible method. It is shown that forearm BMC has a highly significant correlation to total body bone mineral also in the pubertal period of rapid growth. It should be noted that single measurements of BMC are of little diagnostic value in the presence of wide biological variation. A spurt in mineralization corresponding to that of height in puberty has been known since the development of the BMC technique. It is evident from our data that BMC and indices of body size are only significantly related after the start of the growth spurt. Significant increases of 25% in the BMC have been found in the year prior to PHV progressing with each PH stage. The mean time of maximal increase in forearm BMC occurred some 5 months later than that of testosterone and AP, and changes in these three variables are closely interrelated. The change in the serum concentrations of the two major adrenal androgens did not appear to be related to BMC.(ABSTRACT TRUNCATED AT 400 WORDS)

Testosterone regulates the haemoglobin concentration in male puberty

In a longitudinal study of male puberty 20 boys were examined every three months for at least two years. Haemoglobin concentration was determined and related to changes in serum testosterone concentrations. The data show a steep increase in serum testosterone during puberty (p less than 0.001) followed with a five months delay, by a significant increase in haemoglobin concentration (p less than 0.001). It is concluded that the steep increase in serum testosterone during puberty produces an acute stimulation of erythropoietin leading to an increase in erythrocyte production and thereby to a detectable increase in haemoglobin concentration a few months thereafter. The present study supports the idea that the selection of the relevant reference range for haemoglobin in boys should depend on the state of physical developments as expressed by serum testosterone.

Serum levels of vitamin D metabolites and testosterone in male puberty

We determined the serum concentrations of 25-hydroxyvitamin D, 1,25-dihydroxyvitamin D [1,25-(OH)2D], 24,25-(OH)2D, and 25,26-(OH)2D every third month in a 2-yr longitudinal study of 20 normal pubertal boys. Seasonal fluctuations and highly significant correlations with the hours of sunshine were found for 25-hydroxyvitamin D, 24,25-(OH)2D and 25,26-(OH)2D, whereas the serum concentrations of 1,25-(OH)2D were not related to sunshine duration. The boys were grouped according to the time at which the maximal increase in serum testosterone occurred, and the serum vitamin D metabolite levels were examined in relation to this point. No significant changes in the serum levels of the vitamin D metabolites were found. When compiling the data according to clinical evaluation of puberty estimated by pubic hair stages (PH1 to PH4), no significant changes in the serum levels of vitamin D metabolites were found. The present data indicate that the marked increase in serum testosterone in male puberty has no significant influence on circulating vitamin D metabolite levels.

Serum vitamin D metabolites are not related to growth rate, bone mineral content, or serum alkaline phosphatase in male puberty

Twenty boys were followed during their puberty for about 2 years with examinations every third month. At each examination we determined serum concentrations of 25OHD3, 1,25(OH)2D3, 24,25(OH)2D3, 25.26(OH)2D3, alkaline phosphatase (AP) and testosterone together with bone mineral content (BMC) at the distal forearm. Highly significant increases in both BMC (P less than 0.001), serum AP (P less than 0.001), and peak height velocity (PHV) followed the increase in serum testosterone. The boys were grouped according to time of maximal increase in BMC, AP, and PHV. The serum levels of the vitamin D metabolites were related to these points. No significant changes in any of the serum vitamin D metabolites were found. Thus vitamin D metabolism does not seem to be significantly influenced during the period of life when both the linear growth and bone mineralization is maximal.

Fundamental voice frequency measured by electroglottography during continuous speech. A new exact secondary sex characteristic in boys in puberty

The variation of fundamental voice frequency measured by the average of 2000 consecutive electroglottographic cycles in a reading situation has been examined in relation to pubertal development and androgens. Fundamental frequency among other parameters was related to height (r -0.82), pubic hair stage (r -0.87), testis volume (r -0.78), total testosterone (r -0.73) and serum hormone binding globulin (r 0.75). Single observations of fundamental frequency show a clear grouping of results under and over 200 Hz. Fundamental frequency of more than 200 Hz and serum testosterone of more than 10 nmol/l probably represent values for a boy in puberty. There seem to be comparable relations with other androgens and with serum hormone binding globulin.

Bone turnover in male puberty: a longitudinal study

In a longitudinal study of male puberty, 18 boys were examined every 3 months for at least 2 years. Serum bone Gla protein (BGP), a biochemical marker of bone formation, was determined and related to changes in serum testosterone (T), serum alkaline phosphatase (AP), serum calcitonin, and bone mineral content (BMC). The data demonstrate a steep increase in serum T during puberty (P less than 0.001), with an almost concomitant increase in serum BGP (P less than 0.001) and serum AP (P less than 0.001). Ten months after the maximal increase in serum T, the increase in BMC reached its maximum, whereas there was no significant change in the serum calcitonin. The data demonstrate that the steep increase in serum T during puberty, directly or indirectly, produces acute stimulation of bone formation (estimated from BGP and AP) followed by a highly significant increase in the integrated measurement of bone apposition (BMC).

Relationship between local and total bone mineral in normal pubertal boys

The bone mineral content of the distal forearm (BMC) using single-photon absorptiometry and total body bone mineral (TBBM) using dual-photon absorptiometry were determined in 19 normal boys at different pubertal stages. A highly significant correlation between BMC and TBBM was seen (r = 0.78, P less than 0.001) with a standard error of estimate (SEE) of 13%. Subgroups of early and late pubertal stages did not show any significant differences in the regression lines indicating an identical relationship between BMC and TBBM at various stages of pubertal development although great changes in bone mineral content take place. Due to high accuracy and reproducibility of both methods, which are non-invasive and harmless, measurement of BMC is suitable to estimate changes in total mineral content of the body. This may be of importance in various diseases with disturbance in growth and bone metabolism.

Longitudinal study of calcium metabolism in male puberty. II. Relationship between mineralization and serum testosterone

Height velocity, bone mineral content (BMC), serum concentrations of alkaline phosphatase (AP), testosterone, dehydroepiandrosterone (DHEA) and androstenedione (A-dione) were determined as a part of a longitudinal study of calcium metabolism in normal male puberty. The time of maximal increase (Tm) in concentrations was calculated for 20 boys from a curve-fitting analysis program. Highly significant correlations were found between Tm testosterone and Tm BMC (r = 0.73, p less than 0.001); Tm AP and Tm BMC (r = 0.68, p less than 0.001). The mean difference in time between Tm testosterone and Tm BMC was 4.7 months and between Tm AP and Tm testosterone 0.7 month. Our data indicate a very close relationship between testosterone, osteoblastic activity, and mineralization in normal male puberty, whereas the adrenal androgens do not seem to have a major influence on the mineralization at the male puberty growth spurt phase.

Longitudinal study of calcium metabolism in male puberty. I. Bone mineral content, and serum levels of alkaline phosphatase, phosphate and calcium

With the purpose of studying calcium metabolism at the growth spurt phase in puberty, bone mineral content (BMC) of the forearm, and serum concentrations of total alkaline phosphatase, phosphate, and calcium were determined in 36 boys every three months for about 2 years. BMC increased 35% throughout the study age period of 10.6 to 14.6 years, with a maximal rate between 12.8 and 13.8 years. In relation to growth velocity BMC rose steepest during the 12 months around peak height velocity (PHV) (p less than 0.001) and showed a progressive increase from 3 months before the first pubic hair stage (PH2) to PH4 (p less than 0.001). Serum alkaline phosphatase increased by a total of 55% throughout the age period with a diminished rate of increase from 13.5 to 14 years, around the PHV, and from PH3 to PH4.

Somatomedin A in male puberty. Variation with age, maturity, growth and androgens

Bioassayable somatomedin-A (SM-A) and serum concentrations of testosterone (T) and dehydroepiandrosterone (DHEA) were determined longitudinally in 26 normal boys during puberty. The mean trend of SM-A increased in relation to age, pubic hair development and peak height velocity (PHV) and significant correlations were observed with testicular volume, height velocity and T (all P less than 0.001) but not with DHEA. In relation to growth SM-A increased mainly during 12 to 6 months prior to PHV but no further increase was seen in the 6 months thereafter. Thus pubertal growth and development have to be taken into account in the evaluation of changes in bioassayable SM-A concentrations in boys.

Prevalence of antibodies to Epstein-Barr virus (EBV) in childhood and adolescence in Denmark

A seroepidemiologic survey on the prevalence of antibodies to Epstein-Barr virus (EBV) in Denmark was carried out. Sera from 518 children and 178 adults were investigated for IgG antibodies to the viral capsid antigen by an immunofluorescence assay. The proportion of subjects with antibodies increased from 15% at 1 yr to 60-65% in the 4-6 yr age group, was stationary at the age of 7-14, and then increased further progressively with age, to reach about 95% in late adulthood. Among preschool children a significantly higher prevalence rate was demonstrated in the lower socioeconomic stratum, as well as a somewhat higher prevalence rate in children attending day nurseries. The study indicates that infections with EBV have a rather early and widespread occurrence in this country compared with other developed areas.