Is a Novel Fluoroscopic Intraoperative Reference System Superior to Conventional Management for Distal Radius Fracture Reduction? A Propensity-matched Comparative Study

BACKGROUND

Preoperative planning is generally performed to simulate the process of reduction as well as to determine the size and placement of implants in patients undergoing distal radius fracture surgery. We previously described a three-dimensional (3D) digital preoperative planning system for the osteosynthesis of distal radius fractures, and we have developed a novel intraoperative referencing system that superimposes preoperative planning (such as plate position and length) onto fluoroscopic images during surgery; however, its efficacy has not been evaluated compared with conventional planning and surgery.

QUESTIONS/PURPOSES

Does use of a novel intraoperative referencing system result in (1) better Mayo wrist scores at 3 and 6 months after surgery and (2) less loss of reduction in terms of ulnar variance, palmar tilt, and radial inclination on plain radiographs taken 1 week, 3 months, and 6 months after surgery compared with conventional preoperative planning?

METHODS

Between April 2014 and October 2021, we treated 294 patients with open reduction and volar plate fixation for distal radius fractures. Of 294 patients, 65% (191) underwent surgery using either conventional preoperative planning or a novel intraoperative referencing system. The remaining patients were excluded because they were younger than 18 years, they had some missing medical records related to the clinical outcomes, or they had a previous history of upper extremity injuries. During that time, we generally treated fractures with volar plates when there was: more than 2 mm of stepoff/gap in the articular surface, a dorsal tilt more than 15°, radial inclination less than 15°, or radial shortening more than 5 mm. Generally, we used a flexor carpi radialis approach. In some patients who had dorsal fragments, we added a dorsal approach. At that time, we were developing the new intraoperative referencing system, so it was not used consistently. To arrive at a fair assessment, we opted to perform propensity matching based on age, gender, and AO fracture type. During the period in question, 36% (69 of 191) of patients with distal radius fractures who received a volar plate were treated using our novel intraoperative referencing system, and 64% (122 of 191) had surgery using conventional preoperative planning (control group). Of those, 91% (63 of 69) of patients who were treated with the intraoperative referencing system and 89% (108 of 122) of those in the control group were available for follow-up with all imaging and Mayo wrist scores at least 6 months after surgery. After propensity matching, that left us with two groups of 39 patients, who were well matched in terms of age and fracture type; these were the study groups. We also tried to match them according to gender, but there were fewer patients in the intraoperative referencing group, and the percentage of women for each group differed: 70% (44 of 63) in the intraoperative referencing group and 76% (82 of 108) in the control group. Also, there were fewer men with C3 fractures in the control group. Therefore, 64% (25 of 39) of patients in the intraoperative referencing group were women and 77% (30 of 39) of patients in the control group were women. In the intraoperative referencing group, our novel intraoperative referencing system was used in combination with the 3D digital preoperative planning system for preoperative planning. In the control group, preoperative planning was performed manually in a conventional manner using tracing paper and implant templates or using a digital template. We compared the groups in terms of operative duration, the radiation dose used in surgery, and Mayo wrist scores at 3 and 6 months after surgery. We also compared the groups in terms of loss of reduction on ulnar variance, palmar tilt, and radial inclination on plain radiographs taken 3 months and 6 months after surgery. We considered the plain radiograph taken 1 week after surgery as a baseline. Each item was compared between the image fusion and control groups using a Welch t - test.

RESULTS

Mayo wrist scores were no different between the intraoperative referencing system and the control group at 3 months (71 ± 7 versus 72 ± 11, mean difference 1 [95% CI -3.7 to 5.7]; p = 0.07) or at 6 months after surgery (76 ± 6 versus 79 ± 11, mean difference 3 [95% CI -3.5 to 7.9]; p = 0.12). There were no differences in surgical duration or radiation doses between the intraoperative referencing and control groups. We found only a small advantage in favor of the intraoperative referencing system in terms of loss of reduction on ulnar variance (3 months after surgery: 0.2 ± 0.4 mm versus 0.6 ± 0.7 mm, mean difference 0.4 mm [95% CI 0.15 to 0.69]; p = 0.003, 6 months after surgery: 0.4 ± 0.6 mm versus 0.8 ± 0.8 mm, mean difference 0.4 mm [95% CI 0.05 to 0.73]; p = 0.02 for the intraoperative referencing system and the control group, respectively). This difference in radial shortening was so small that it was not likely to have been clinically important.

CONCLUSION

We found no clinically important advantages from the use of our novel intraoperative referencing system except a slight improvement in ulnar variance. Therefore, we recommend against its use in everyday practice at this time. However, future improvements may lead to better clinical outcomes, so we plan further investigations.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Effects of 5-fluorouracil Co-administration on Blood Pressure in Patients Maintained on Antihypertensives: a Retrospective Case Series

This study aimed to investigate the possible drug-drug interactions (DDIs) of 5-FU with antihypertensives metabolised by CYP3A4 and 2C9, using blood pressure (BP) as a pharmacodynamic (PD) parameter. Patients who received 5-FU in combination with antihypertensives metabolised by CYP3A4 or 2C9, specifically, a) amlodipine, nifedipine, or amlodipine + nifedipine, b) candesartan or valsartan, or c) amlodipine + candesartan, amlodipine + losartan, or nifedipine + valsartan, (Group A, n = 20) were identified. Patients who received 5-FU with WF and antihypertensives, specifically, a) amlodipine or b) amlodipine + telmisartan, amlodipine + candesartan, or amlodipine + valsartan, (Group B, n = 5) or 5-FU alone (Group C, n = 25) were also identified and analysed as a comparator and control group, respectively. Regarding the peak BP levels during chemotherapy, there was a significant increase in both SBP (P < 0.0002 and 0.0013) and DBP (P = 0.0243 and 0.0032) in Groups A and C, respectively (Tukey-Kramer test). In contrast, although SBP also increased in Group B during chemotherapy, the change was not statistically significant and there was a decrease in DBP. The significant increase in SBP can be attributed to chemotherapy-induced hypertension by 5-FU or other drugs in the chemotherapeutic regimens. However, when comparing the lowest BP levels during chemotherapy, there was a decrease in SBP and DBP in all groups from the baseline values. The median time to peak and lowest BP was at least 2 weeks and 3 weeks, respectively, for all groups, suggesting that a BP lowering effect was observed following the offset of the initial chemotherapy-induced hypertension. At least 1 month after 5-FU chemotherapy, the SBP and DBP returned to baseline values in all groups. Since Group B also showed a significant increase in PT-INR, possibly demonstrating 5-FU inhibition of CYP activity and, consequently, of WF metabolism, it is likely that 5-FU also inhibited the metabolism of the antihypertensive drugs. The findings suggest possible DDIs between 5-FU and antihypertensives metabolised by CYP3A4.

Analysis of COVID-19 mRNA Vaccine-induced Mouth Ulcers Using the Japanese Adverse Drug Event Report Database

There are case reports of mouth ulcers caused by the coronavirus disease 2019 (COVID-19) messenger ribonucleic acid (mRNA) vaccine; however, the actual number and characteristics of cases are unknown. Therefore, we examined this issue using the Japanese Adverse Drug Event Report (JADER), a large Japanese database. We calculated the reported odds ratio (ROR) of drugs that may be specifically associated with mouth ulcers and assumed that a signal was present if the lower limit of the calculated ROR's 95% confidence interval (CI) was > 1. In addition, the time to symptom onset after administration of the COVID-19 mRNA and influenza HA vaccines was investigated. We found that the JADER database contained 4,661 mouth ulcer cases between April 2004 and March 2022. The COVID-19 mRNA vaccine was the eighth most common causative drug for mouth ulcers, with 204 reported cases. The ROR was 1.6 (95% CI, 1.4-1.9) and a signal was detected. There were 172 mouthulcer cases associated with the Pfizer-BioNTech's COVID-19 mRNA vaccine, 76.2% of which were female. The outcome was no unrecovered cases with the influenza HA vaccine, whereas the COVID-19 mRNA vaccine showed unrecovered cases (Pfizer-BioNTech: 12.2%, Moderna: 11.1%). The median time-to-onset of the mouth ulcers was two days for the COVID-19 mRNA vaccine and one day for the influenza HA vaccine, indicating that mouth ulcers caused by the COVID-19 mRNA vaccine were delayed adverse events. In this study, the COVID-19 mRNA vaccine was shown to cause mouth ulcers in a Japanese population.

Impact of respiratory bacterial infections on mortality in Japanese patients with COVID-19: a retrospective cohort study

BACKGROUND

Although cases of respiratory bacterial infections associated with coronavirus disease 2019 (COVID-19) have often been reported, their impact on the clinical course remains unclear. Herein, we evaluated and analyzed the complication rates of bacterial infections, causative organisms, patient backgrounds, and clinical outcome in Japanese patients with COVID-19.

METHODS

We performed a retrospective cohort study that included inpatients with COVID-19 from multiple centers participating in the Japan COVID-19 Taskforce (April 2020 to May 2021) and obtained demographic, epidemiological, and microbiological results and the clinical course and analyzed the cases of COVID-19 complicated by respiratory bacterial infections.

RESULTS

Of the 1,863 patients with COVID-19 included in the analysis, 140 (7.5%) had respiratory bacterial infections. Community-acquired co-infection at COVID-19 diagnosis was uncommon (55/1,863, 3.0%) and was mainly caused by Staphylococcus aureus, Klebsiella pneumoniae and Streptococcus pneumoniae. Hospital-acquired bacterial secondary infections, mostly caused by Staphylococcus aureus, Pseudomonas aeruginosa, and Stenotrophomonas maltophilia, were diagnosed in 86 patients (4.6%). Severity-associated comorbidities were frequently observed in hospital-acquired secondary infection cases, including hypertension, diabetes, and chronic kidney disease. The study results suggest that the neutrophil-lymphocyte ratio (> 5.28) may be useful in diagnosing complications of respiratory bacterial infections. COVID-19 patients with community-acquired or hospital-acquired secondary infections had significantly increased mortality.

CONCLUSIONS

Respiratory bacterial co-infections and secondary infections are uncommon in patients with COVID-19 but may worsen outcomes. Assessment of bacterial complications is important in hospitalized patients with COVID-19, and the study findings are meaningful for the appropriate use of antimicrobial agents and management strategies.

Correlations between 3D preoperative planning and postoperative reduction in the osteosynthesis of distal humeral fractures

BACKGROUND

Three-dimensional preoperative planning has been applied to the osteosynthesis of distal humerus fractures. The present study investigated the correlations between 3D preoperative planning and postoperative reduction for the osteosynthesis of distal humerus fractures using 3D parameters.

METHODS

Twenty-three elbows of 23 distal humerus fracture patients who underwent osteosynthesis with three-dimensional preoperative planning were evaluated. 3D images of the distal humerus were created after taking preoperative CT scans of the injured elbow. Fracture reduction, implant selection, and placement simulations were performed based on 3D images. Postoperative CT images were taken 1 month after surgery. Correlations were evaluated with preoperative plans and postoperative 3D images. The longitudinal axis and coordinates of the humerus were defined on the 3D images. The coronal angle (CA) was defined as the angle formed by the long axis and the line connecting the medial and lateral margins of the trochlea of the humerus on a coronal plane image. The sagittal angle (SA) was defined as the angle formed by the long axis and the line connecting the top of the lateral epicondyle and the center of the humeral capitellum on a sagittal plane image. The axial angle (AA) was defined as the angle between the sagittal plane and the line connecting the medial and lateral margins behind the trochlea of the humerus. The intraclass correlation coefficients (ICC) of each measurement value were assessed between preoperative planning and postoperative images.

RESULTS

Preoperative planning and postoperative measurement values were CA: 85.6 ± 5.9°/85.8 ± 5.9°, SA: 140.9 ± 8.5°/139.4 ± 7.9°, and AA: 84.0 ± 3.1°/82.6 ± 4.9°, respectively. ICCs were CA: 0.75 (P < 0.01), SA: 0.78 (P < 0.01), and AA: 0.34 (P < 0.05), respectively.

CONCLUSIONS

The 3D preoperative planning of distal humeral fractures achieved the good correlations of coronal and sagittal angles, but the relatively poor correlation of the axial angle. This may be attributed to an inability to assess the rotation angle during surgery. We propose the measurement indices shown in the present study as a three-dimensional evaluation index for distal humerus fractures.

TRIAL REGISTRATION

Registered as NCT04349319 at ClinicalTrials.gov.

Potential Relationships between the Median Nerve Cross-Sectional Area and Physical Characteristics in Unilateral Symptomatic Carpal Tunnel Syndrome Patients

Background: The present study investigated the relationships between the median nerve cross-sectional area (CSA) and physical characteristics in patients with unilateral symptomatic carpal tunnel syndrome (CTS). Methods: Height, weight, body mass index (BMI), disease duration, results of electrodiagnostic testing (EDX), and median nerve CSA at the level of the wrist crease were recorded in 81 patients with CTS who presented with symptoms on only one side. Correlation coefficients between median nerve CSA and physical characteristics, disease duration, and results of EDX were analyzed. Results: Median nerve CSA at the wrist crease (mm2) was significantly larger on the symptomatic side (14.1 ± 3.8) than on the asymptomatic side (11.5 ± 2.9). Median nerve CSA correlated with body weight (correlation coefficient = 0.39) and BMI (correlation coefficient = 0.44) on the asymptomatic side, but not on the symptomatic side. These correlations were slightly stronger in females (correlation coefficient = 0.46) than in males (correlation coefficient = 0.40). No correlations between median nerve CSA and disease duration and the results of EDX were observed in both sides. Conclusions: In patients with unilateral symptomatic CTS, median nerve CSA correlated with BMI only on the asymptomatic side. The present results suggest that the relationship between median nerve CSA and BMI in CTS is significant until symptom onset but may be masked by edema and pseudoneuroma after its onset. A higher BMI is associated with a larger CSA of the median nerve, which may be a risk factor for the development of CTS.

Comparison of 3D Bone Position Estimation Using QR Code and Metal Bead Markers

To improve the accuracy of a 3D bone position estimation system that displays 3D images in response to changes in the position of fluoroscopic images, modified markers using quick response (QR) codes were developed. The aims of this study were to assess the accuracy of the estimated bone position on 3D images with reference to QR code markers on fluoroscopic images and to compare its accuracy with metal bead markers. Bone positions were estimated from reference points on a fluoroscopic image compared with those on a 3D image. The positional relationships of QR code and metal bead markers on the fluoroscopic image were compared with those on the 3D image in order to establish whether a 3D image may be drawn by tracking positional changes in radius models. Differences were investigated by comparing the distance between markers on the fluoroscopic image and that on the 3D image, which was projected on the monitor. The error ratio, which was defined as the difference in the measurement between the fluoroscopic and 3D images divided by the fluoroscopic measurement, was compared between QR code and metal bead markers. Error ratios for the QR code markers were 5.0 ± 2.0%, 6.4 ± 7.6%, and 1.0 ± 0.8% in the anterior–posterior view, ulnar side lateral view, and posterior–anterior view, respectively. Error ratios for the metal bead markers were 1.3 ± 1.7%, 13.8 ± 14.5%, and 4.7 ± 5.7% in the anterior–posterior view, ulnar side lateral view, and posterior–anterior view, respectively. The error ratio for the metal bead markers was smaller in the initial position (p < 0.01). However, the error ratios for the QR code markers were smaller in the lateral position and the posterior–anterior position (p < 0.05). In QR code marker tracking, tracking was successful even with discontinuous images. The accuracy of a 3D bone position estimation was increased by using the QR code marker system. QR code marker tracking facilitates real-time comparisons of dynamic changes in preoperative 3D and intraoperative fluoroscopic images.

Utility of 5-aminolaevulinic acid fluorescence-guided endoscopic biopsy for malignant mesothelioma in a cat and dog

Malignant mesothelioma (MM) is uncommon in cats and dogs and can be challenging to diagnose. Adequate tissue sampling is required for superior diagnostic accuracy. Protoporphyrin IX, a metabolite of 5-aminolaevulinic acid (5-ALA), is a photosensitiser for photodynamic diagnosis (PDD). To the best of our knowledge, no study has reported the use of 5-ALA-PDD to detect MM in veterinary medicine. The present study describes the use of 5-ALA-PDD for MM diagnosis in a cat and dog, as well as the effectiveness of intracavitary chemotherapy. We evaluated the use of PDD with 5-ALA hydrochloride (5-ALA-PDD) in two cases of MM. A 12-year-old cat presented with a 1-month history of respiratory distress, and a 9-year-old dog presented with a 3-month history of mild abdominal distention. We endoscopically biopsied lesions in both the cases using 5-ALA-PDD. Histopathological examination revealed mesothelioma, and immunohistochemical staining was positive for calretinin. Both patients were treated with carboplatin. The cat died of respiratory failure. Although, the dog's condition improved 21 days after the first chemotherapeutic drug administration, the dog died on day 684 owing to cardiac-related issues. 5-ALA-PDD is thus, safe and feasible for the diagnosis of MM in veterinary medicine.

Computer-Aided Assessment of Three-Dimensional Standard Bone Morphology of the Distal Radius

The present study attempted to define the three-dimensional (3D) locations of reference points and standard measures of the distal radius of a normal wrist joint. One hundred wrists from 50 males and 50 females who matched the age distribution (19−95 years old, mean: 56.0 years old) were evaluated. Computed tomography (CT) images of normal wrist joints acquired for comparison with the affected side were used. The absence of a previous history and complaints in the unaffected wrist was confirmed in an interview and with medical records. Three-dimensional images of the distal radius were reconstructed using the data obtained from CT scans. The site at which the major axis of the radial diaphysis contacted the distal radius joint surface was defined as the origin. The 3D coordinates of reference points for the radial styloid process (1), sigmoid notch volar edge (2), and sigmoid notch dorsal edge (3) as well as the barycenter for the joint surface and joint surface area were evaluated. A slope of the line connecting coordinates 1−2 in the coronal plane was evaluated as the 3D radial inclination (3DRI) and that connecting coordinates 2−3 in the sagittal plane as the 3D palmar tilt (3DPT). Each measurement value was compared between males and females. The positions of each reference point from the origin were as follows: (1) 14.2 ± 1.3/12.6 ± 1.1 mm for the distal-palmar-radial position; (2) 19.3 ± 1.3/16.9 ± 1.3 mm for the proximal-palmar-ulnar position; (3) 15.6 ± 1.4/14.1 ± 0.9 mm for the proximal-dorsal-ulnar position; and (barycenter) 4.1 ± 0.7/3.7 ± 0.7 mm for the proximal-volar-ulnar position for males and females, respectively. The areas of the radius articular surface were 429.0 ± 67.9/347.6 ± 44.6 mm2 for males and females, respectively. The 3DRI and 3DPT were 24.2 ± 4.0/25.7 ± 3.1° and 10.9 ± 5.1/13.2 ± 4.4° for males and females, respectively. Significant differences were observed in all measurement values between males and females (p < 0.01). The reference points and measured values obtained in the present study will serve as criteria for identifying the dislocation direction and reduction conditions of distal radius fractures in 3D images.

Clinical Relevance of Ultrasonographic and Electrophysiological Findings of the Median Nerve in Unilateral Carpal Tunnel Syndrome Patients

Few studies have compared the unaffected and affected sides in the same carpal tunnel syndrome (CTS) patients using ultrasonography and electrophysiological tests. We focused on unilateral idiopathic CTS patients to investigate whether clinical test results differ between the unaffected and affected sides. The bilateral wrist joints of 61 unilateral idiopathic CTS patients were evaluated. The median nerve cross-sectional area of ultrasound image, and latencies of the compound muscle action potential (CMAP) and sensory nerve action potential (SNAP) were measured. The values obtained were compared between the affected and unaffected sides. The diagnostic accuracies of each parameter were assessed, and cut-off values were defined. Significant differences were observed in all parameters between the affected and unaffected sides (p < 0.01). Area under the curve (AUC) values were 0.74, 0.88, and 0.73 for the cross-sectional area, CMAP distal latency, and SNAP distal latency, respectively. Cut-off values were 11.9 mm2, 5.1 ms, and 3.1 ms for the cross-sectional area, CMAP distal latency, and SNAP distal latency, respectively. The most reliable parameter that reflected clinical symptoms was the distal latency of CMAP. Cut-off values for each parameter are considered to be an index for the onset of the clinical symptoms of CTS.

Occurrence of voriconazole-induced cutaneous squamous cell carcinoma in Japan: data mining from different national pharmacovigilance databases

Long-term voriconazole use may increase the risk of cutaneous squamous cell carcinoma (cSCC), especially in immunocompromised patients. However, relatively little is known regarding voriconazole-induced cSCC in Japan. Thus, the purpose of this study was to evaluate the association between voriconazole use and cSCC in Japan using different national pharmacovigilance databases. First, using the Japanese Adverse Drug Event Report (JADER) database, we evaluated the association between voriconazole use and cSCC in Japan. Second, using the U. S. Food and Drug Administration Adverse Event Reporting System (FAERS) database, we examined regional differences in the occurrence of voriconazole-induced cSCC between Japan and other countries. We calculated reporting odds ratios (RORs) as disproportionality analysis to evaluate voriconazole-induced cSCC. In this study, cases in which one or more of "Bowen's disease", "Carcinoma in situ of skin", "Keratoacanthoma", "Squamous cell carcinoma in skin", or "Squamous cell carcinoma" were reported as adverse events were considered to be cSCC cases. The analysis based on the JADER database showed an association between voriconazole use and cSCC in Japan, with a ROR (95% confidence interval) of 35.37 (25.60-48.87). Further, the analysis based on the FAERS database revealed that signals were detected in Japan as well as in Western countries and Australia. This study is the first in which the association between voriconazole use and cSCC in Japan is assessed using national pharmacovigilance databases. Healthcare providers need to be fully aware of the potential for cSCC development owing to voriconazole use and in all countries, including Japan, ensure careful follow-up of patients' skin.

Scaphoid nonunion with DISI deformity treated in a two-stage operation with the Ilizarov mini fixator: A case report

Scaphoid nonunion causes humpback deformity and dorsal intercalated segment instability (DISI) deformity due to dorsal rotation of the proximal scaphoid fragment. In the treatment of scaphoid nonunion, it is important to not only achieve bone union, but also to improve DISI deformity and carpal bone alignment in order to attenuate pain, increase the range of motion, and prevent the development of osteoarthritis.

We encountered a case of DISI deformity caused by the long-term neglect of scaphoid nonunion that was treated in a two-stage operation with the Ilizarov mini fixator. A 28-year-old male had been injured during a soccer game 10 years ago. Although he had wrist pain, he did not visit a hospital. This led to chronic scaphoid nonunion with DISI deformity. Since 10 years had passed from the initial injury, DISI deformity was considered to be difficult to correct using a single stage procedure. Therefore, a two-stage operation was performed. The Ilizarov mini fixator was used to gradually correct DISI deformity in the first stage, and screw fixation with bone grafting was performed in the second stage.

Difficulties are associated with achieving good clinical results in cases of long-term scaphoid nonunion. In cases of DISI deformity, it is important to correct the alignment of lunate dorsiflexion and the distal carpal row as well as achieve bone union. Although the Ilizarov external fixator has been used for scaphoid nonunion, it has not yet been applied to scaphoid nonunion with DISI deformity. The Ilizarov mini fixator may be useful to correct long-term deformities, and good results were obtained in the present case. It represents an option for the treatment of scaphoid nonunion with DISI deformity.

An Experimental Study of a 3D Bone Position Estimation System Based on Fluoroscopic Images

To compare a 3D preoperative planning image and fluoroscopic image, a 3D bone position estimation system that displays 3D images in response to changes in the position of fluoroscopic images was developed. The objective of the present study was to evaluate the accuracy of the estimated position of 3D bone images with reference to fluoroscopic images. Bone positions were estimated from reference points on a fluoroscopic image compared with those on a 3D image. The four reference markers positional relationships on the fluoroscopic image were compared with those on the 3D image to evaluate whether a 3D image may be drawn by tracking positional changes in the radius model. Intra-class correlations coefficients for reference marker distances between the fluoroscopic image and 3D image were 0.98–0.99. Average differences between measured values on the fluoroscopic image and 3D bone image for each marker corresponding to the direction of the bone model were 1.1 ± 0.7 mm, 2.4 ± 1.8 mm, 1.4 ± 0.8 mm, and 2.0 ± 1.6 mm in the anterior-posterior view, ulnar side lateral view, posterior-anterior view, and radial side lateral view, respectively. Marker positions were more accurate in the anterior-posterior and posterior-anterior views than in the radial and ulnar side lateral views. This system helps in real-time comparison of dynamic changes in preoperative 3D and intraoperative fluoroscopy images.

The whole blood transcriptional regulation landscape in 465 COVID-19 infected samples from Japan COVID-19 Task Force

Coronavirus disease 2019 (COVID-19) is a recently-emerged infectious disease that has caused millions of deaths, where comprehensive understanding of disease mechanisms is still unestablished. In particular, studies of gene expression dynamics and regulation landscape in COVID-19 infected individuals are limited. Here, we report on a thorough analysis of whole blood RNA-seq data from 465 genotyped samples from the Japan COVID-19 Task Force, including 359 severe and 106 non-severe COVID-19 cases. We discover 1169 putative causal expression quantitative trait loci (eQTLs) including 34 possible colocalizations with biobank fine-mapping results of hematopoietic traits in a Japanese population, 1549 putative causal splice QTLs (sQTLs; e.g. two independent sQTLs at TOR1AIP1), as well as biologically interpretable trans-eQTL examples (e.g., REST and STING1), all fine-mapped at single variant resolution. We perform differential gene expression analysis to elucidate 198 genes with increased expression in severe COVID-19 cases and enriched for innate immune-related functions. Finally, we evaluate the limited but non-zero effect of COVID-19 phenotype on eQTL discovery, and highlight the presence of COVID-19 severity-interaction eQTLs (ieQTLs; e.g., CLEC4C and MYBL2). Our study provides a comprehensive catalog of whole blood regulatory variants in Japanese, as well as a reference for transcriptional landscapes in response to COVID-19 infection.

Genetic mechanisms influencing COVID-19 susceptibility are not well understood. Here, the authors analyzed whole blood RNA-seq data of 465 Japanese individuals with COVID-19, highlighting thousands of fine-mapped variants affecting expression and splicing of genes, as well as the presence of COVID-19 severity-interaction eQTLs.

Application of force-monitor ultrasonography to assess distal radioulnar joint instability in patients with triangular fibrocartilage complex injury

Introduction

In this study, we evaluated the differences and measurement accuracy in the force-displacement relationship of the distal radioulnar joint (DRUJ) between patients with triangular fibrocartilage complex (TFCC) injury and healthy controls using force-monitor ultrasonography.

Methods

This study included 11 TFCC injury patients and 22 healthy controls. We evaluated differences in the force-displacement relationship of the DRUJ in these patients using force-monitor ultrasonography. Cyclic compression was applied to the dorsal surface of the ulnar head. Distance between the dorsal surface of the distal radius and ulnar head at the DRUJ level was measured in the initial and pressed-down positions. Changes in radioulnar displacement, applied force, and displacement-to-force ratio were measured. Furthermore, we compared the parameters between the affected and unaffected wrists and between TFCC injury patients and controls.

Results

The radioulnar displacement and displacement-to-force ratio were significantly larger in the affected wrists than in the unaffected wrists (P = 0.003 and P = 0.02). The affected/unaffected side ratio of radioulnar displacement and displacement-to-force ratio were significantly larger in the TFCC injury patients than in the controls (P = 0.003 and P = 0.02). The area under the curve was 0.82 for the affected/unaffected ratio of the radioulnar displacement. The optimal cutoff value indicated by the receiver-operating characteristic curve for the affected/unaffected ratio of the radioulnar displacement was 1.71; the sensitivity and specificity were 82% and 86%, respectively.

Conclusions

Assessing the DRUJ instability with force-monitor ultrasonography may help identify TFCC-injured wrists.

POS0841 HIGH-INTENSITY INDUCTION THERAPY COMBINING TOFACITINIB, RITUXIMAB, AND PLASMAPHERESIS IN RAPIDLY PROGRESSIVE INTERSTITIAL LUNG DISEASE ASSOCIATED WITH ANTI-MDA5 ANTIBODY POSITIVE DERMATOMYOSITIS

Background

Rapidly progressive interstitial lung disease (RP-ILD) associated with anti-melanoma differentiation-associated protein 5 (MDA5) autoantibody (Ab) -positive dermatomyositis (DM) is one of the most life-threatening autoimmune conditions. The clinical course is very rapid, leading to death within three months after the onset of symptoms. Although triple therapy which consists of corticosteroids, cyclophosphamide, and tacrolimus has been considered as standard therapy and additional treatments including plasma exchange (PE) and rituximab (RTX) have been reported, the survival rate of patients with poor prognostic factors is still poor even if all of these treatments were applied. Recently, there exist increasing evidences regarding the efficacy of tofacitinib (TOF) in refractory DM. We have treated anti-MDA5Ab-positive RP-ILD with multiple poor prognostic factors with high-intensity induction therapy which combined triple therapy, PE, RTX, and TOF.

Objectives

This study aimed to investigate the therapeutic efficacy of high-intensity induction therapy for patients with anti-MDA5Ab-positive RP-ILD with multiple poor prognostic factors.

Methods

31 patients who were diagnosed with anti-MDA5Ab-positive DM during 2014 to 2021 in our institution were included in this study. The clinical characteristics for poor prognosis were retrospectively analyzed, and the outcomes of high-intensity induction therapy were analyzed for the survival and adverse events.

Results

17 cases were treated before the introduction of TOF. Although triple therapy with RTX, PE, or intravenous immunoglobulin (IVIG) were used, eight out of 10 RP-ILD cases with a ferritin level >400 ng/mL (range, 402.5-5,831; mean, 2,342 ± 2,069) died in median 2.5 months. Poor prognosis was predicted by followings; elevated levels of serum ferritin, lactate dehydrogenase, transaminases, creatinine phosphokinase, and C-reactive protein; decrease in platelets, serum albumin, and oxygen saturation; use of oxygen; higher age; shorter disease duration to admission. The addition of RTX and PE was not enough to control RP-ILD in anti-MDA5Ab positive DM, and prevention of the initial exacerbation of ILD following induction therapy was considered to be important. Based on these observations, high-intensity induction therapy was consisted as follows; triple therapy with decreasing the dose of methylprednisolone by half from 1g to 1 mg/kg, liposteroid to suppress macrophage activity, TOF, PE, and RTX. High-intensity induction therapy was applied in eight patients (ferritin levels; range, 412.2-7,095 ng/mL; mean, 3,558±3,152 ng/mL) with multiple poor prognostic factors described above. Although deaths at two months and eight months due to ILD were observed, significant improvement of survival was documented (Figure 1). Two patients in whom RTX was not initially administered, exacerbation of ILD was observed one month later, which prompted the use of RTX. Several adverse events were observed in high-intensity induction therapy. The most common events were reactivation of cytomegalovirus, meanwhile herpes zoster was not documented. Sustained leukocytopenia and thrombocytopenia were observed in three patients, and two patients developed thrombotic microangiopathy which led to the discontinuation of tacrolimus. Fungal infections in lung were also documented. These adverse events were controllable.

Figure 1.

Conclusion

Significant improvement of survival was observed in patients treated with high-intensity induction therapy. Meanwhile, stratification of patients for poor prognosis would be important.

References

None

Disclosure of Interests

None declared

OP0062 EFFICACY AND SAFETY OF ADALIMUMAB WITH LOW AND HIGH DOSE-METHOTREXATE IN PATIENTS WITH RHEUMATOID ARTHRITIS WITH INADEQUATE RESPONSE TO METHOTREXATE: THE RANDOMISED CONTROLLED MIRACLE STUDY

Background

Rheumatoid arthritis (RA) is a chronic inflammatory autoimmune disease that causes not only joint pain but also bone destruction resulting in impairment of quality of life. Tumor necrosis factor inhibitors have improved prognosis of patients with rheumatoid arthritis dramatically, especially in combination with methotrexate, however, the optimal dose of the concomitant methotrexate is unclear.

Objectives

To evaluate the efficacy and safety of adalimumab in combination with reduced dose of methotrexate in patients with early RA with inadequate response to methotrexate.

Methods

The MIRACLE study was a multinational, randomized, open-label study in patients with RA with inadequate response to methotrexate conducted in Asia. It compared low dose and high dose methotrexate upon starting adalimumab. Methotrexate-naive patients with RA with a disease duration of less than two years started methotrexate at 6 to 8 mg/week and increased it to the maximum tolerable dose by week 12. Patients who have not achieved remission according to simplified disease activity index (SDAI) despite methotrexate ≥ 10 mg/week at week 24 were randomised to the maximum tolerable dose of methotrexate group (10 to 25 mg/week) or the reduced dose group (6 to 8 mg/week) and started to receive subcutaneous adalimumab 40 mg every other week. The primary endpoint was non-inferiority in the achievement of SDAI remission at week 48 in the reduced dose group compared with the maximum tolerable dose group with a non-inferiority margin of -15% based on two-sided 90% confidence interval. (NCT03505008)

Results

A total of 300 patients were enrolled in the study. Among them, 291 started methotrexate and were included in the analysis. The mean age was 57.7±15.2 years, female was 74.6%, and the mean disease duration from the diagnosis of RA was 21.1±56.2 days. Anti-CCP antibody was positive in 211 (73.0%) and the mean SDAI at study enrollment was 26.5±12.4. At week 24, with the mean dose of methotrexate of 12.6±2.9 mg/week, 108 patients (37.1%) achieved remission according to SDAI and continued MTX monotherapy. 134 patients (46.0%) were randomised and started adalimumab with 68 patients in the maximum tolerable dose group and 66 patients in the reduced dose group. At week 48, the remission achievement rates were 38.4 % and 44.8 %, respectively, with the adjusted risk difference of the reduced dose group to the maximum tolerable dose group of 6.4% (-7.0% to 19.8%, 90% CI), which met the criterion for noninferiority. No significant difference was found in health assessment questionnaire disability index ≤0.5 (59.1% vs 62.0%, respectively, p=0.72) and in radiological remission rates (Δmodified total Sharp score ≤0.5, 66.3% vs 62.0 %, respectively, p=0.59). Adverse drug reactions tended to be more frequent in the maximum tolerable dose group than in the reduced dose group (22.1% vs 9.1%, respectively, p=0.06).

Conclusion

The MIRACLE randomised study demonstrated that, in patients with inadequate response to methotrexate, the efficacy of adalimumab with reduced dose of concomitant methotrexate was not inferior to that with maximum tolerable dose of methotrexate with better safety profile.

Disclosure of Interests

Hiroya Tamai Speakers bureau: Eisai, Grant/research support from: Eisai, Kei Ikeda Speakers bureau: AbbVie, Eisai, Eli Lilly, Novartis, Gilead, Asahi-Kasei, Grant/research support from: Mitsubishi-Tanabe, Toshiaki Miyamoto: None declared, Hiroaki Taguchi: None declared, Chang-Fu Kuo: None declared, Kichul Shin: None declared, Shintaro Hirata Speakers bureau: AbbVie, Asahi-Kasei, Astellas, Ayumi, Bristol Myers Squibb, Celgene, Chugai, Eisai, Eli Lilly, Gilead, Glaxo SmithKline, Janssen, Kyorin, Novartis, Pfizer, Sanofi, Tanabe-Mitsubishi, UCB, Paid instructor for: AbbVie, Mitsubishi-Tanabe, Consultant of: AbbVie, Astellas, Bristol Myers Squibb, Eisai, Gilead, Ily Lilly, Grant/research support from: AbbVie, Asahi-Kasei, Eisai, Otsuka, Sanofi, Shionogi, Chugai, Pfizer, Tanabe-Mitsubishi, Eli Lilly, UCB, yutaka okano: None declared, Shinji Sato Speakers bureau: AbbVie, Eisai, Grant/research support from: AbbVie, Eisai, Hidekata Yasuoka Speakers bureau: AbbVie, Asahi Kasei Pharma, Astellas, Daiichi-Sankyo, Eisai, Kissei, Takeda, Mitsubishi-Tanabe, Chugai, Novartis, Eli Lilly, Pfizer, Janssen, Sanofi, Teijin, Boehringer-Ingelheim, Bayer, Glaxo Smith Kline, Paid instructor for: AbbVie, Consultant of: AbbVie, Asahi Kasei, Grant/research support from: Mitsubishi-Tanabe, Takeda, Daiichi-Sankyo, Chugai, Bristol-Myers, MSD, Astellas, In Ah Choi Speakers bureau: Abbvie, Eisai, Sung-Hwan Park: None declared, Meng-Yu Weng Paid instructor for: Novartis, Eli Lilly, ChuGai, Abbvie, Consultant of: Abbvie, Masataka Kuwana Speakers bureau: Astellas, Asahi Kasei Pharma, Boehringer-Ingelheim, Chugai, Eisai, Janssen, Mochida, Nippon Shinyaku, Ono Pharmaceuticals, Pfizer, Mitsubishi-Tanabe, Consultant of: Boehringer-Ingelheim, Kissei, Mochida, Grant/research support from: AbbVie, Asahi Kasei Pharma, Boehringer-Ingelheim, Chugai, Eisai, MBL, Nippon Shinyaku, Ono Pharmaceuticals, Mitsubishi-Tanabe, Yun Jong Lee Grant/research support from: Yuhan, Tomonori Ishii Speakers bureau: Chugai, Mitsubishi-Tanabe, Glaxo Smith Kline, Pfizer, Eli Lilly, Janssen, AbbVie, Eisai, Astellas, Jinhyun Kim: None declared, Hideto Kameda Speakers bureau: AbbVie, Pfizer, Consultant of: AbbVie, Grant/research support from: AbbVie, Eisai, Toshihisa Kojima Speakers bureau: AbbVie, Pfizer, Eisai, Grant/research support from: AbbVie, Han Joo Baek: None declared, Ping-Ning Hsu: None declared, Chun-Ming Huang Paid instructor for: Abbvie, Pfizer, Tien-Tsai Cheng Paid instructor for: Abbvie, Grant/research support from: Abbvie, Wan-Yu Sung: None declared, Takehiro Taninaga Shareholder of: Eisai.co.,Ltd., Employee of: Eisai.co.,Ltd., Masahiko Mori Shareholder of: Eisai.co.,Ltd., Employee of: Eisai.co.,Ltd., Hideaki Miyagishi Shareholder of: Eisai.co.,Ltd., Employee of: Eisai.co.,Ltd., Yasunori Sato Speakers bureau: Eisai Co., Ltd. Kowa Company, Ltd., Consultant of: MOCHIDA PHARMACEUTICAL CO., LTD, Tsutomu Takeuchi Speakers bureau: Astellas, AbbVie, Ayumi, Bristol Myers Squibb, Chugai, Daiichi-Sankyo, Eisai, Eli Lilly, Gilead, Glaxo Smith Kline, Janssen, Mitsubishi-Tanabe, Nippon-kayaku, Novartis, Pfizer, Sanofi, UCB, Grant/research support from: Asahi Kasei, AbbVie, Ayumi, Boehringer-Ingelheim, Chugai, Eisai, Eli Lilly, Mitsubishi-Tanabe, Sanofi, UCB, Yuko Kaneko Speakers bureau: Asahi Kasei, Astellas, Ayumi, Bristol Myers Squibb, Chugai, Eisai, Elli Lilly, Mitsubishi-Tanabe, Novartis, UCB, Grant/research support from: AbbVie, Chugai, Eisai, Mitsubishi-Tanabe, UCB.

Utility of the Berlin Initiative Study-1 equation for the prediction of serum vancomycin concentration in elderly patients aged 75 years and older

Accurate assessment of renal function is essential for determining serum vancomycin (VCM) concentration. Creatinine clearance (Ccr)-calculated using the Cockcroft and Gault (CG) equation-can be used to evaluate renal function for determining VCM dosage. However, Ccr-based evaluation may not be an accurate representation of the renal function in the elderly. Herein, we examine the effectiveness of estimated glomerular filtration rate (eGFR) calculated using the Berlin Initiative Study-1 (BIS1) equation, for predicting the serum VCM concentration. Herein, we retrospectively analyzed patients (aged ≥ 75 years) who had received VCM. Serum VCM concentration was predicted based on Ccr and eGFR. eGFR was calculated using the Japanese equation for eGFR (eGFR_JAP), Modification of Diet in Renal Disease (MDRD) equation (eGFR_MDRD), chronic kidney disease epidemiology collaboration (CKD-EPI) equation (eGFR_CKD-EPI), and BIS1 equation (eGFR_BIS1). The predicted serum VCM concentration was compared with the measured values. Prediction bias, accuracy, and precision were evaluated by calculating the mean prediction error (ME), mean absolute prediction error (MAE), and root mean squared prediction error (RMSE). Our results showed that the ME between the measured and the predicted values calculated using Ccr and each eGFR was the largest and smallest when calculated based on Ccr and eGFR_MDRD, respectively. MAE and RMSE were the largest and smallest when calculated based on Ccr and eGFR_BIS1, respectively. A significant difference was observed in the MAE associated with eGFR_JAP, eGFR_MDRD, and eGFR_CKD-EPI compared to that associated with eGFR_BIS1. In conclusion, our results suggest that the BIS1 equation might be useful for determining the VCM dosage in the elderly.

Preoperative Predictions of Distal Screw Length for the Osteosynthesis of Distal Radius Fractures

Background: The objective of this study was to clarify whether anteroposterior dimension of the radius along the screw axis of a fixed angle volar locking plate (VLP) can be predicted from the width of the radius on the VLP. Methods: Sixty-nine wrists in 68 patients with distal radius fractures that underwent fixation with a fixed angle VLPs were evaluated. All patients underwent pre- and postoperative computed tomographic scans of the distal radius. The transverse width of the radius was measured at the position of the third screw hole from the proximal edge. The anteroposterior dimension of the radius (R) was measured along the axes of the distal screws. The distal row screw holes were defined as R1, R2, R3, and R4 from the radial to the ulnar side. Correlation analysis between the width and the anteroposterior dimension, and single regression analysis were performed for each screw hole. The correlations amongst the R values for the different distal row screws were also assessed. Results: The correlation coefficients between the transverse width and anteroposterior dimensions were 0.54, 0.58, 0.55, and 0.42 for R1, R2, R3, and R4 respectively (p < 0.05). The regression equations were R1 = 0.49W + 7.99, R2 = 0.47W + 11.8, R3 = 0.52W + 10.8, and R4 = 0.41W + 11.5 respectively. The correlation coefficients among anteroposterior dimensions were 0.85, 0.64, 0.59, 0.70, 0.61, and 0.80 for R1/R2, R1/R3, R1/R4, R2/R3, R2/R4, and R3/R4 respectively (p < 0.01). Conclusions: There were significant correlations in the anteroposterior dimensions amongst the distal row screw lengths. The regression equations used in this study may be helpful to predict the length of distal row screw and prevent complications due to inappropriate screw choices. Level of Evidence: Level III (Therapeutic).

Effects of mechanical stress and deficiency of dihydrotestosterone or 17β-estradiol on Temporomandibular Joint Osteoarthritis in mice

OBJECTIVE

To observe and analyze the interaction between excessive mechanical stress (MS) and decreased sex hormones on Temporomandibular Joint Osteoarthritis (TMJ-OA), and to discover TMJ-OA disease susceptibility genes by molecular biological analysis to elucidate part of the mechanism of TMJ-OA onset.

DESIGN

For experimental groups, orchiectomy (ORX) or ovariectomy (OVX) was performed on sexually mature 8-week-old mice. A metal plate was attached to the posterior surface of the maxillary incisors to apply excessive MS on mandibular condyles. Male mice were divided into control, ORX, MS, and ORX + MS groups, while female mice were divided into control, OVX, MS, and OVX + MS groups. Mandibular condyles were evaluated by histology and molecular biology.

RESULTS

Histomorphometric analysis of the TMJ in ORX + MS and OVX + MS groups revealed the thinnest chondrocyte layers, highest modified Mankin scores, and significant increases in the number of osteoclasts. Gene expression analysis indicated upregulation of Angptl7 and Car1 genes in the mandibular condyles of mice subjected to the combined effects of excessive MS and reduced sex hormones. In vitro analysis suggested that cartilage-like cells overexpressing Angptl7 enhanced calcification, and osteoblast-like cells overexpression Car1 suppressed cell proliferation and calcification.

CONCLUSIONS

A severe TMJ-OA mouse model was successfully developed by applying excessive MS on the mandibular condyle of male and female mice with reduced sex hormones. Disease-susceptibility genes Angptl7 and Car1 were newly discovered in the experimental groups, suggesting their involvement in the onset mechanism of TMJ-OA.

Assessment of distal radioulnar joint stability in healthy subjects: Changes with dominant hand, sex, and age

This study aimed to elucidate the differences in distal radioulnar stability in dominant/nondominant hand, sex, and age. Bilateral wrists of 60 healthy subjects were evaluated using force-monitoring ultrasonography. This apparatus was developed to apply cyclic compression and measure applied force to displacement during an ultrasound exam. The transducer was placed on the dorsal side of the distal radioulnar joint, and the center of the ulnar head was displayed on the monitor. The distance between the dorsal surface of the distal radius and the ulnar head was measured at an initial and at a pressed-down position. The radioulnar displacement, applied force to displacement, and displacement-to-force ratio were evaluated. The results were compared between the dominant and nondominant hands, and between males and females, and among different age groups. There were no significant differences in the parameters between the dominant and nondominant hands. The applied force to displacement was significantly greater in the male group compared with the female group. There were significant effects for the different age groups in all parameters (displacement: F = 3.67, p = .008; applied-force: F = 3.08, p = .019; displacement-to-force ratio: F = 4.66, p = .002). Our results indicated that the stability of distal radioulnar joint differed depending on age and sex. Age and sex should be considered when assessing distal radioulnar joint stability.

An image fusion system for corrective osteotomy of distal radius malunion

Background

To provide surgical support for corrective osteotomy, we developed an image fusion system for three-dimensional (3D) preoperative planning and fluoroscopy. To assess the utility of this image fusion system, we evaluated the reproducibility of preoperative planning for corrective osteotomy of dorsally angulated distal radius malunion using the system and compared reproducibility without using the system.

Methods

Ten wrists from 10 distal radius malunion patients who underwent corrective osteotomy were evaluated. 3D preoperative planning and the image fusion system were used for the image fusion group (n = 5). Only 3D preoperative planning was used for the control group (n = 5). 3D preoperative planning was performed for both groups in order to assess reduction, placement, and the choice of implants. In the image fusion group, the outline of the planned image was displayed on a monitor and overlapped with fluoroscopy images during surgery. Reproducibility was evaluated using preoperative plan and postoperative 3D images. Images were compared with the 3D coordinates of the radial styloid process (1), the volar and dorsal edges of the sigmoid notch (2) (3), and the barycentric coordinates of the three reference points. The reproducibility of the preoperative plan was evaluated by the distance of the coordinates between the plan and postoperative images for the reference points.

Results

The distances between preoperative planning and postoperative reduction in the image fusion group were 2.1 ± 1.1 mm, 1.8 ± 0.7 mm, 1.9 ± 0.9 mm, and 1.4 ± 0.7 mm for reference points (1), (2), (3), and the barycenter, respectively. The distances between preoperative planning and postoperative reduction in the control group were 3.7 ± 1.0 mm, 2.8 ± 2.0 mm, 1.7 ± 0.8 mm, and 1.8 ± 1.2 mm for reference points (1), (2), (3), and the barycenter, respectively. The difference in reference point (1) was significantly smaller in the image fusion group than in the control group (P < 0.05).

Conclusion

Corrective osteotomy using an image fusion system will become a new surgical support method for fracture malunion.

Trial registration Registered as NCT03764501 at ClinicalTrials.gov.

AB0253 COMPARISON OF PHARMACODYNAMICS OF METHOTREXATE AS METHOTREXATE-POLYGLUTAMATES CONCENTRATIONS IN RHEUMATOID ARTHRITIS; INTERIM DATA EVALUATION OF MIRACLE STUDY CONDUCTED IN JAPAN, KOREA AND TAIWAN

Background:

Methotrexate (MTX) is the first-line therapy for rheumatoid arthritis (RA). The concentrations of MTX-polyglutamates (PG) in erythrocytes, an active form of MTX, are useful markers for the optimal usage of MTX in patients with RA. The concentrations of MTX-PG have been reported to be different between Japanese and Caucasians. However, the difference among Asian ethnicity remains unclear.

Objectives:

To examine MTX-PG concentrations in association with MTX dose during the first 24 weeks after the initiation of MTX for newly diagnosed RA patients in Japan, Korea and Taiwan.

Methods:

MIRACLE study is a multicenter, open-label, randomized, 48 weeks interventional study conducted in Japan, Korea and Taiwan to evaluate non-inferiority of low dose to high dose of MTX as an add-on therapy to adalimumab in 300 patients with RA who do not achieve remission after 24 weeks MTX monotherapy in stipulated dosage. In the first 24 weeks, MTX was started at 6 to 8 mg/week for newly diagnosed RA patients, and promptly escalated to the maximum tolerable dose in 12 weeks in principle. This interim data evaluation was intended to investigate the differences among countries in the relationship between MTX dose, safety and MTX-PG concentrations in erythrocytes during the first 24 weeks. The efficacy of the treatment is not included at this point.

Results:

A total of 166 patients (106 in Japan, 35 in Korea, 25 in Taiwan) were included in this interim data. The age at treatment initiation was 57.2 years old on average and female was 79.5%. The time course changes in total and individual MTX-PG levels differed in the three countries. At 24 weeks, whereas the mean total MTX-PG concentrations were comparable (112.9 nmol/L in Japan, 104.4 nmol/L in Korea, and 115.7 nmol/L in Taiwan) with a dose of MTX of 12.3 mg/week, 14.1 mg/week, and 12.2 mg/week, respectively, the individual MTX-PG concentrations were different. The MTX-PG1 and MTX-PG2 concentrations were lower in Korea than Japan and Taiwan whereas MTX-PG3, MTX-PG4 and MTX-PG5 concentrations were the highest in Korea.

Conclusion:

The distribution of short-chain and long-chain MTX-PG concentrations were various among Asian countries despite similar dose of MTX administration: NCT03505008.

Disclosure of Interests:

Hiroya Tamai: None declared, Yuko Kaneko Speakers bureau: AbbVie, Astellas, Ayumi, Bristol–Myers Squibb, Chugai, Eisai, Eli Lilly, Hisamitsu, Jansen, Kissei, Kirin, Pfizer, Sanofi, Takeda, Tanabe-Mitsubishi, and UCB., Grant/research support from: Sanofi, Hideto Kameda Speakers bureau: AbbVie, Pfizer, Consultant of: AbbVie, Grant/research support from: AbbVie, Eisai, Masataka Kuwana Speakers bureau: Astellas, Asahi Kasei Pharma, Boehringer- Ingelheim, Chugai, Eisai, Janssen, Mochida, Nippon Shinyaku, Ono Pharmaceuticals, Pfizer, Mitsubishi-Tanabe, Consultant of: Corbus, Grant/research support from: AbbVie, Asahi Kasei Pharma, Boehringer- Ingelheim, Chugai, Eisai, MBL, Nippon Shinyaku, Ono Pharmaceuticals, Mitsubishi-Tanabe, Yutaka Okano: None declared, Tomonori Ishii Speakers bureau: Chugai, Mitsubishi- Tanabe, Glaxo Smith Kline, Pfizer, Eli Lilly, Janssen, AbbVie, Eisai, Astellas, Kei Ikeda Speakers bureau: AbbVie, Eli Lilly, Novartis, Mitsubishi-Tanabe, Eisai, BMS, Grant/research support from: Mitsubishi-Tanabe, Hiroaki Taguchi: None declared, Shinji Sato: None declared, Toshiaki Miyamoto: None declared, Shintaro Hirata Speakers bureau: AbbVie, Asahi Kasei Pharma, Astellas, Ayumi, Bristol Myers Squibb, Chugai, Eisai, Eli Lilly, Janssen, Glaxo Smith Kline, Kissei, Pfizer, Sanofi, Mitsubishi- Tanabe, UCB, Paid instructor for: AbbVie, Mitsubishi- Tanabe, Consultant of: AbbVie, Eisai, Gilead, Grant/research support from: AbbVie, Chugai, Mitsubishi-Tanabe, UCB, Hidekata Yasuoka Speakers bureau: AbbVie, Asahi Kasei Pharma, Astellas, Daiichi- Sankyo, Eisai, Kissei, Takeda, Mitsubishi- Tanabe, Chugai, Novartis, Eli Lilly, Pfizer, Janssen, Sanofi, Teijin, Boehringer- Ingelheim, Bayer, Glaxo Smith Kline, Paid instructor for: AbbVie, Consultant of: AbbVie, Asahi Kasei, Grant/research support from: Mitsubishi-Tanabe, Takeda, Daiichi-Sankyo, Chugai, Bristol-Myers, MSD, Astellas, Toshihisa Kojima Speakers bureau: AbbVie, Pfizer, Eisai, Grant/research support from: AbbVie, Sung-Hwan Park: None declared, Kichul Shin: None declared, Han Joo Baek: None declared, Yun Jong Lee Grant/research support from: research fund, In Ah Choi Speakers bureau: Abbvie, Eizai, Grant/research support from: Abbvie, Eizai, Jinhyun Kim: None declared, Ping-Ning Hsu: None declared, Chang-Fu Kuo: None declared, Chun-Ming Huang Paid instructor for: AbbVie, Pfizer, Meng-Yu Weng Consultant of: AbbVie, Wan-Yu Sung: None declared, Wen-Chan Tsai: None declared, Tien-Tsai Cheng Paid instructor for: AbbVie, Grant/research support from: AbbVie, Takehiro Taninaga Shareholder of: Eisai Co., Ltd., Employee of: Eisai Co., Ltd., Masahiko Mori Shareholder of: Eisai Co., Ltd., Employee of: Eisai Co., Ltd., Hideaki Miyagishi Employee of: Eisai Co., Ltd., Yasunori Sato: None declared, Tsutomu Takeuchi Speakers bureau: Astellas, Abbvie, Daiichi Sankyo, Ayumi, Eisai, GlaxoSmithKline, Mitsubishi Tanabe, Chugai, Novartis, Eli Lilly, Pfizer, Bristol Myers Squibb, Janssen, UCB, TaishoToyama, Sanofi–Aventis, Nipponkayaku, Taiho, Gilead, Boehringer Ingelheim, Grant/research support from: Asahikasei, Astellas, Abbvie, Daiichi Sankyo, Ayumi, Eisai, Takeda, Mitsubishi Tanabe, Chugai, Eli Lilly, UCB, Sanofi–Aventis, Nipponkayaku, Boehringer Ingelheim

Evaluation of eustachian tube function using a portable device

The present paper investigates a portable eustachian-tube-function testing device by sonotubometry based on pure-tone sound transmission via the eustachian tube (ET). The measured results obtained by the proposed method were validated through comparison with the existing testing technique based on broadband sound inspection. The measurement results for the ET opening time (T_open) and the sound pressure difference in the ear canal between open and closed ETs (ΔL) obtained using pure-tone sounds with tonal frequency components of 7.0 and 9.5 kHz generally agreed with the results obtained by the existing technique with broadband testing sound.

AB0249 SAFETY OF BARICITINIB IN JAPANESE PATIENTS WITH RHEUMATOID ARTHRITIS (RA): THE 2020 INTERIM REPORT FROM ALL-CASE POST MARKETING SURVEILLANCE IN CLINICAL PRACTICE

Background:

An all-case post marketing surveillance (PMS) of baricitinib (Bari), that started in Sep 2017, collects safety and effectiveness for the first 24 wks of treatment and continues to collect serious adverse events (SAEs) for 3 yrs.

Objectives:

To evaluate Bari safety in RA patients (pt) in clinical practice.

Methods:

We report pt baseline demographics and adverse events (AEs) up to 24 wks for pts whose case report files for 24-wk data were completed as of Jun 2020.

Results:

Data from 3445 pts were analyzed (females=80%, mean age=64yr, mean RA duration 12yr). Bari dose regimen was as follows: 4mg, 60%, 2mg, 27%, 4mg→2mg, 5%, 2mg→4mg, 5%, and others, 2%. Concomitant use of MTX and glucocorticoid was 65% and 48%, respectively. 74% continued treatment for 24 wks. AE and SAE were recognized in 887 (26%) and 122 pts (4%), respectively. 6 pts died of pneumonia, aspiration pneumonia, bacterial pneumonia, cerebral infarction/ILD/aspiration pneumonia, adenocarcinoma, and colorectal cancer. Major AEs were as follows: herpes zoster=3%, liver dysfunction=3%, serious infection=1%, anemia=1%, hyperlipidemia=1%, malignancy=0.3%, interstitial pneumonia=0.2%, MACE=0.1%, and VTE=0.1%.

Conclusion:

Data do not show new safety concerns and encourage guideline-compliant use of Bari.

Disclosure of Interests:

Takao Fujii Speakers bureau: Chugai Pharmaceutical Co. Ltd.; Eisai Co. Ltd; Eli Lilly Japan K.K.; Janssen Pharmaceutical K.K.; Ono Pharmaceutical Co. Ltd., Consultant of: Asahikasei Pharma Corp, Grant/research support from: Asahikasei Pharma Corp; AbbVie Japan GK; Chugai Pharmaceutical Co. Ltd., Eisai Co. Ltd; Eli Lilly Japan K.K.; Mitsubishi-Tanabe Pharma Co.; Ono Pharmaceutical Co., Ltd., Tatsuya Atsumi Speakers bureau: AbbVie Japan GK; Astellas Pharma Inc.; Bristol-Myers Squibb Co. Ltd; Chugai Pharmaceutical Co. Ltd.; Daiichi Sankyo Co. Ltd.; Eisai Co. Ltd.; Eli Lilly Japan K.K.; Mitsubishi Tanabe Pharma Co.; Pfizer Japan Inc.; Takeda Pharmaceutical Co. Ltd., UCB Japan Co. Ltd., Consultant of: AbbVie Japan GK; AstraZeneca plc.; Boehringer Ingelheim Co. Ltd.; Medical & Biological Laboratories Co. Ltd.; Novartis Pharma K.K.; Ono Pharmaceutical Co. Ltd.; Pfizer Japan Inc., Grant/research support from: Astellas Pharma Inc., Alexion Inc.; Chugai Pharmaceutical Co. Ltd., Daiichi Sankyo Co. Ltd., Mitsubishi Tanabe Pharma Co., Otsuka Pharmaceutical Co., Ltd.

Pfizer Japan Inc.; Takeda Pharmaceutical Co. Ltd., Nami Okamoto Speakers bureau: AbbVie Japan GK; Asahikasei Pharma Co.; AYUMI Pharmaceutical Co.

Eisai Co. Ltd; Bristol-Myers Squibb Co. Ltd.; Eli Lilly Japan K.K.; Mitsubishi-Tanabe Pharma Co.; Pfizer Japan Inc.

Sanofi K.K.; Chugai Pharmaceutical Co. Ltd.; Novartis Pharma Co.; Teijin Pharma Ltd.; Torii Pharmaceutical Co., Ltd., Nobunori Takahashi Speakers bureau: AbbVie Japan GK; Eisai Co. Ltd.; Mitsubishi Tanabe Pharma Co.; Pfizer Japan Inc.; Chugai Pharmaceutical Co., Ltd.; Eli Lilly Japan K.K.; Janssen Pharmaceutical K.K.; UCB Japan Co. Ltd.; Astellas Pharma Inc.; Bristol Myers Squibb Co. Ltd., Grant/research support from: Bristol Myers Squibb Co. Ltd., Naoto Tamura Speakers bureau: AbbVie Japan GK; Bristol Myers Squibb Co. Ltd.; Chugai Pharmaceutical Co. Ltd.; Eisai Co. Ltd.; Eli Lilly Japan K.K.; Glaxo Smith Kline K.K.; Janssen Pharmaceutical K.K.; Mitsubishi-Tanabe Pharma Co.; Novartis Pharma Co., Atsuo Nakajima: None declared, Ayako Nakajima Speakers bureau: AbbVie Japan GK; Actelion Pharmaceuticals Japan Ltd., Asahi Kasei Pharma Co., Astellas Pharma Inc., Ayumi Pharmaceutical Co., Bristol Myers Squibb Co., Ltd.,Chugai Pharmaceutical Co., Ltd., Eisai Co., Ltd., Eli Lilly Japan K.K., Glaxo Smith Kline K.K., Hisamitsu Pharmaceutical Co. Inc., Kyorin Pharmaceutical Co. Ltd., Mitsubishi Tanabe Pharma Co., Otsuka Pharmaceutical Co. Ltd., Pfizer Japan Inc., Teijin Pharma Ltd., Grant/research support from: Chugai Pharmaceutical Co., Ltd., Mitsubishi Tanabe Pharma Co., Pfizer Japan Inc., Hiroaki Matsuno Speakers bureau: Chugai Pharmaceutical Co., Ltd., Daiichi Sankyo Co., Ltd., Eli Lilly Japan K.K., Consultant of: Mochida Pharmaceutical Co., Ltd., Grant/research support from: Astellas Pharma Inc., Eli Lilly Japan K.K.; Janssen Pharmaceutical K.K, Naoto Tsujimoto Shareholder of: Eli Lilly, Employee of: Eli Lilly Japan K.K., Atsushi Nishikawa Shareholder of: Eli Lilly, Employee of: Eli Lilly Japan K.K., Taeko Ishii Shareholder of: Eli Lilly, Employee of: Eli Lilly Japan K.K., Tsutomu Takeuchi Speakers bureau: AbbVie Japan GK, Ayumi Pharmaceutical Co., Bristol Myers Squibb Co., Ltd., Chugai Pharmaceutical Co, Ltd. Daiichi Sankyo Co., Ltd. Eisai Co., Ltd. Eli Lilly Japan K.K.; Gilead Sciences, Inc. Janssen Pharmaceutical K.K.; Mitsubishi-Tanabe Pharma Co.; Novartis Pharma Co.; Pfizer Japan Inc.; Sanofi K.K.; UCB Japan Co., Ltd., Consultant of: AbbVie Japan GK, Astellas Pharma, Inc.; Chugai Pharmaceutical Co, Ltd.; Eli Lilly Japan K.K.; Eisai Co., Ltd.; Gilead Sciences, Inc.; Janssen Pharmaceutical K.K.; Mitsubishi-Tanabe Pharma Corp., Pfizer Japan Inc., Grant/research support from: AbbVie Japan GK, Asahikasei Pharma Corp., Chugai Pharmaceutical Co, Ltd., DNA Chip Research Inc.; Eisai Co., Ltd., Eli Lilly Japan K.K.; Mitsubishi-Tanabe Pharma Corp., UCB Japan Co., Ltd., Masataka Kuwana Speakers bureau: AbbVie Japan GK, Astellas Pharma Inc., Asahi Kasei Pharma Co., Boehringer-Ingelheim, Chugai Pharmaceutical Co., Ltd., Eisai Co., Ltd., Janssen Pharmaceutical K.K., Medical &Biological Laboratories Co., Ltd.; Mitsubishi Tanabe Pharma Co.; Mochida Pharmaceutical Co., Ltd., Nippon Shinyaku Co., Ltd.; Ono Pharmaceutical Co., Ltd.; Pfizer Japan Inc., Consultant of: Boehringer-Ingelheim, Chugai Pharmaceutical Co., Ltd., Corbus Pharmaceuticals Holdings, Inc.; Medical &Biological Laboratories Co., Ltd.; Mochida Pharmaceutical Co., Ltd., Grant/research support from: Boehringer-Ingelheim, Chugai Pharmaceutical Co., Ltd., Eisai Co., Ltd., Medical &Biological Laboratories Co., Ltd; Mitsubishi Tanabe Pharma Co., Ono Pharmaceutical Co., Ltd., Michiaki Takagi Speakers bureau: Yes, but sponsored lectures without COI in the academic meetings, only.

Computer-Aided Assessment of Displacement and Reduction of Distal Radius Fractures

This study aims to investigate displacements and reductions of distal radius fractures using measurement indices based on the computer-aided three-dimensional (3D) radius shape model. Fifty-two distal radius fracture patients who underwent osteosynthesis were evaluated with pre- and post-operative distal radius 3D images. In the 3D images, three reference points, i.e., the radial styloid process (1), sigmoid notch volar, and dorsal edge (2) (3) were marked. The three-dimensional coordinates of each reference point and the barycentric coordinates of the plane connecting the three reference points were evaluated. The distance and direction moved, due to the reductions for each reference point, were (1) 12.1 ± 8.1 mm in the ulnar-palmar-distal direction, (2) 7.5 ± 4.1 mm in the ulnar-palmar-proximal direction, and (3) 8.2 ± 4.7 mm in the ulnar-palmar-distal direction relative to the preoperative position. The barycentric coordinate moved 8.4 ± 5.3 mm in the ulnar-palmar-distal direction compared to the preoperative position. This analyzing method will be helpful to understand the three-dimensional direction and the extent of displacements in distal radius fractures.

The feasible maintenance dose of corticosteroid in Takayasu arteritis in the era of biologic therapy

Objective: Although biologic agents are used in Takayasu arteritis (TAK), corticosteroids are still the mainstay of treatment. This study aimed to investigate the feasible maintenance dose of prednisolone (PSL) in the biologic therapy era.Method: We enrolled 93 patients with TAK who satisfied the criteria of the American College of Rheumatology and visited our department from 2008 to 2018. The clinical characteristics and PSL dose of the patients were retrospectively evaluated.Results: The mean ± sd maintenance dose of PSL was 5.0 ± 3.0 mg/day. In patients having TAK for > 20 years, PSL discontinuation and drug-free status were achieved in 27.2% and 18%, respectively. Although tapering the PSL dose to 10 mg/day was achieved within 12 months, tapering to 5 mg/day required 10 years. Relapse significantly interfered with the PSL dose reduction. The clinical characteristics of patients with relapse included a lower rate of combination therapy using immunosuppressants. Moreover, biologics were used in > 60% of patients with relapse. Tapering of PSL was significantly possible in patients receiving biologics and additional relapse was observed in 6.3% and 50% of patients with and without biologics, respectively. Such PSL-sparing effect enabled the reduction of the median PSL dose from 10 to 5 mg/day. Steroid discontinuation was achieved in some patients.Conclusions: The use of biologics significantly reduced the PSL dose in relapsed patients. A PSL dose of ≤ 5 mg/day is a feasible target for TAK, especially when biologic agents are used. Nevertheless, corticosteroid discontinuation may also be the target in some patients.

Bilateral Osteochondritis Dissecans of the Talar Posterior Calcaneal Articular Surface in a Professional Soccer Player: A Case Report

Introduction

Preferred sites of osteochondritis dissecans (OCD) are the distal femur and humerus, and the dome of the talus. We report a rare case of a professional soccer player with bilateral OCD of the talar posterior calcaneal articular surface.

Case Report

The left talus showed a loose but not displaced fragment, and pain was relieved with 3 months of conservative treatment. The right had two loose fragments that were displaced from their beds in the talar posterior calcaneal articular surface. The loose bodies were surgically excised. The player remains symptom free 4 years after the operation and participates in professional games. Thus, although OCD of the talar posterior calcaneal articular surface remains a relatively uncommon injury, we suggest that treatment methods tailored to the OCD stage as per Berndt and Harty classification may be successful. The exact causes and establishment of a treatment protocol in these cases will depend on the investigation of future cases.

Conclusion

Since this case of OCD of the talar posterior calcaneal articular surface was bilateral, we hypothesized that it may have been caused by microtrauma in the sense of repetitive, excessive compression of the subchondral bone, or by a vascular etiology.

Three-dimensional evaluations of preoperative planning reproducibility for the osteosynthesis of distal radius fractures

BACKGROUND

Three-dimensional preoperative planning was applied for the osteosynthesis of distal radius fractures. The objective of this study was to evaluate the reproducibility of three-dimensional preoperative planning for the osteosynthesis of distal radius fractures with three-dimensional reference points.

METHODS

Sixty-three wrists of 63 distal radius fracture patients who underwent osteosynthesis with three-dimensional preoperative planning were evaluated. After taking preoperative CT scans of the injured wrists, 3D images of the distal radius were created. Fracture reduction, implants choices, and placements simulation were performed based on the 3D images. One month after the surgery, postoperative CT images were taken. The reproducibility was evaluated with preoperative plan and postoperative 3D images. The images were compared with the three-dimensional coordinates of radial styloid process, volar and dorsal edges of sigmoid notch, and the barycentric coordinates of the three reference points. The reproducibility of the preoperative plan was evaluated by the distance of the coordinates between the plan and postoperative images for the reference points. The reproducibility of radial inclination and volar tilt on three-dimensional images were evaluated by intra-class correlation coefficient (ICC).

RESULTS

The distances between the preoperative plan and the postoperative reduction for each reference point were (1) 2.1±1.3 mm, (2) 1.9±1.2 mm, and (3) 1.9±1.2 mm, respectively. The distance between the preoperative plan and postoperative reduction for the barycentric coordinate was 1.3±0.8 mm. ICCs were 0.54 and 0.54 for the volar tilt and radial inclination, respectively (P<0.01).

CONCLUSIONS

Three-dimensional preoperative planning for the osteosynthesis of distal radius fracture was reproducible with an error of about 2 mm for each reference point and the correlations of reduction shapes were moderate. The analysis method and reference points may be helpful to understand the accuracy of reductions for the three-dimensional preoperative planning in the osteosynthesis of distal radius fractures.

TRIAL REGISTRATION

Registered as NCT02909647 at ClinicalTrials.gov.

Human Leukocyte Antigen (HLA) Class I Susceptible Alleles Against COVID-19 Increase Both Infection and Severity Rate

Introduction

Each country's difference in the severity rate of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) may be explained by the difference in human leukocyte antigen (HLA) class I molecules, which affects the reactivity of cytotoxic T lymphocyte (CTL).

Methods

To clarify the relationship between HLA class I and the severity rate, the binding repertoires of each HLA class I allele to SARS-CoV-2 peptides and the allele frequencies of HLA-A, -B, and -A/B haplotypes in each country were quoted.

Results

HLA-A1 and the number of deaths per million population (severity rate) in each country had an exponential approximation correlation with correlation coefficient R=0.4879. In addition, the correlation between the infected cases per million (infection rate) and the severity rate was linearly approximated, with R=0.7422. Weak HLA-A alleles with a repertoire of under 300 also had an exponential approximation correlation with the severity rate (R=0.5972), whereas there was a linear approximation with the infection rate (R=0.6808). Weak HLA-B alleles of 30 repertoires or less had no correlation with the severity rate (R=-0.1530). The weak HLA-A/B haplotype has a stronger effect on the severity rate than the weak HLA-A alone. Therefore, the simple HLA class I susceptibility index was calculated, and a strong correlation (R=0.7388) of an exponential approximation with the severity rate was obtained.

Conclusions

HLA class I susceptible alleles against COVID-19 increase both infection and severity rate. The weak HLA-A is a major factor of severity rate, whereas the weak -B alone has no correlation. However, the weak HLA-A/B haplotype has a stronger effect on the severity rate than the weak -A alone.

Bilateral atypical ulnar fractures occurring after long-term treatment with bisphosphonate for 7 years and with teriparatide for 2 years: a case report

Most atypical fractures associated with the long-term treatment with bisphosphonates (BP) commonly develop in the femoral shaft or subtrochanteric region. We report a rare case of bilateral atypical ulnar fractures in an 86-year-old woman with osteoporosis who finished the treatment with teriparatide for 2 years after long-term treatment with BP. She slid down from an approximately 30-cm-tall seat and slightly contused her left elbow. Plain radiography revealed that both ulnae had a noncomminuted short oblique fracture with cortical thickening and sclerosis at the fracture site. Based on the clinical and radiological findings, she was diagnosed with bilateral atypical ulnar fractures. The fracture of the left ulna was completely displaced and treated surgically. On the other hand, since the right ulna was an incomplete fracture, it was treated conservatively. During surgery, drilling with Kirschner wire and curettage were performed in the osteosclerotic lesion, and an autologous cancellous bone graft was inserted from the ipsilateral olecranon. Bone union was achieved in both fractures at 1 year after surgery. There have been no reports regarding the development of atypical ulnar fractures occurring after the long-term treatment with BP and 2-year use of teriparatide, and the treatment strategies of such fractures have not been established. If teriparatide cannot be used after occurring atypical fractures, the use of low-intensity pulsed ultrasound (LIPUS) and subsequent treatment for osteoporosis are recommended for the bone union. In addition, the treatment of the osteosclerotic lesion and rigid internal fixation are required in surgery.

Correction to: Bilateral atypical ulnar fractures occurring after long-term treatment with bisphosphonate for 7 years and with teriparatide for 2 years: a case report

The original version of this article, published on 10 September 2020 contained a mistake.

Development of three-dimensional preoperative planning system for the osteosynthesis of distal humerus fractures

BACKGROUND

To reproduce anatomical reduction and appropriate implant placement/choices during osteosynthesis for elbow fractures, we developed a 3D preoperative planning system. To assess the utility of 3D digital preoperative planning for the osteosynthesis of distal humerus fractures, we evaluated the reproducibility of implant reduction shapes and placements in patients with distal humerus fractures.

METHODS

Twelve patients with distal humerus fractures who underwent osteosynthesis using 3D preoperative planning were evaluated. Reduction shapes were evaluated by the angle between the diaphysis axis and a line connecting the vertices of the medial epicondyle and the lateral epicondyle (epicondyle angle), and the angle between the diaphysis axis and the articular surface (joint angle) in the coronal plane, and the distance between the anterior diaphysis and the anterior articular surface in the sagittal plane (anterior distance) based on 3D images of the distal humerus. In addition, the implant positions were evaluated by the positions of the proximal and posterior edge of the plate, and the angle of the plate to the epicondyle line. The reproducibility was evaluated by intra-class correlation coefficients of the parameters between pre- and postoperative images.

RESULTS

The intra-class correlation coefficients were 0.545, 0.802, and 0.372 for the epicondyle angle, joint angle, and anterior distance, respectively. The differences in the measurements between the preoperative plan and postoperative reduction were 2.1 ± 2.1 degrees, 2.3 ± 1.8 degrees, and 2.8 ± 2.0 mm, for the epicondyle angle, joint angle, and anterior distance, respectively. The intra-class correlation coefficients were 0.983, 0.661, and 0.653 for the proximal and posterior plate positions, and the angle to the epicondyle, respectively. The differences in the measurements between the preoperative plan and postoperative reduction were 3.3 ± 2.1 mm, 2.7 ± 1.7 mm and 9.7 ± 9.8 degrees, for the plate positions of proximal and posterior edge, and the angle of the plate to the epicondyle line, respectively. There were significant correlations for the epicondyle angle, joint angle, and plate positions.

CONCLUSIONS

3D preoperative planning for osteosynthesis of distal humerus fracture was reproducible for the reduction shape of the coronal view and the plate positions. It may be helpful for acquiring practical images of osteosynthesis in distal humerus fractures.

LEVEL OF EVIDENCE

Level III, a case-control study.

OP0249 LONG-TERM EXTENSION RESULTS OF RISE-SSC, A RANDOMIZED TRIAL OF RIOCIGUAT IN PATIENTS WITH EARLY DIFFUSE CUTANEOUS SYSTEMIC SCLEROSIS (DCSSC)

Background:

RISE-SSc (NCT02283762) was a multicenter Phase IIb trial of riociguat in pts with early (duration ≤18 months) dcSSc and modified Rodnan skin score (mRSS) 10−22 units. Pts were randomized double-blind to placebo or riociguat 0.5–2.5 mg t.i.d. for 52 weeks. The primary endpoint, mRSS change from baseline to Week (Wk) 52, did not reach statistical significance (p=0.08, riociguat vs placebo), but there were favorable trends in some other outcomes.

Objectives:

To present open-label long-term extension (LTE) results of RISE-SSc.

Methods:

Pts who completed Wk 52 of double-blind therapy could enter LTE on riociguat. Endpoints included mRSS, adverse events (AEs), and serious AEs (SAEs).

Results:

Of 60 pts randomized to riociguat and 61 to placebo, 42 (riociguat−riociguat group) and 45 (former placebo group), respectively, entered LTE. At LTE start, mean±SD mRSS was 16.4±3.2 and 16.3±4.2 units, and mean disease duration was 8.9±7.8 and 8.9±5.8 months, in the riociguat−riociguat and former placebo groups, respectively. Other demographics/disease characteristics were also comparable. Median duration of riociguat treatment was 1092 d in riociguat−riociguat pts and 649 d in former placebo pts. Throughout the study, mRSS decreased in both groups (Figure 1). From Wk 52 to last visit, mRSS fell by −3.02±5.51 in riociguat−riociguat patients and −3.96±5.43 in former placebo pts. Rates of mRSS regression (decrease by >5 units and ≥25% from Wk 52 to last visit) and of % declines in mRSS were similar in the two groups (Figure 2). mRSS progression (increase by >5 units and ≥25% from Wk 52 to last visit) occurred in 1 pt (2%) in each group. During the entire study, rescue therapy agents were used in 15 (36%) riociguat−riociguat pts and 17 (38%) former placebo pts. AEs were reported from Wk 52 to last visit in 82 pts (94%): 40 (95%) riociguat−riociguat and 42 (93%) former placebo. Most common AEs overall: nasopharyngitis (24%), gastroesophageal reflux disease (17%), diarrhea (15%), and hypotension (14%). AEs of special interest (dizziness, postural dizziness, or hypotension) occurred in 5 riociguat−riociguat pts (12%) and 4 former placebo pts (9%). SAEs were reported in 21 (24%) pts: 10 (24%) riociguat−riociguat pts and 11 (24%) former placebo pts, with no SAE reported in >1 patient, no SAEs of special interest, and no deaths.

Conclusion:

During LTE riociguat treatment, mRSS decreased in both groups from Wk 52 onwards and mRSS progression was uncommon. Riociguat had acceptable safety, similar to the main study, with no new safety signal.

Acknowledgments:

RISE-SSc was jointly funded by Bayer AG and Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc., Kenilworth, NJ, USA.

Disclosure of Interests:

Dinesh Khanna Shareholder of: Eicos, Grant/research support from: NIH NIAID, NIH NIAMS, Consultant of: Acceleron, Actelion, Bayer, BMS, Boehringer-Ingelheim, Corbus, Galapagos, Genentech/Roche, GSK, Mitsubishi Tanabi, Sanofi-Aventis/Genzyme, UCB Pharma, Janet Pope Grant/research support from: AbbVie, Bristol-Myers Squibb, Eli Lilly & Company, Merck, Roche, Seattle Genetics, UCB, Consultant of: AbbVie, Actelion, Amgen, Bayer, Boehringer Ingelheim, Bristol-Myers Squibb, Eicos Sciences, Eli Lilly & Company, Emerald, Gilead Sciences, Inc., Janssen, Merck, Novartis, Pfizer, Roche, Sandoz, Sanofi, UCB, Speakers bureau: UCB, Marco Matucci-Cerinic Grant/research support from: Actelion, MSD, Bristol-Myers Squibb, Speakers bureau: Acetelion, Lilly, Boehringer Ingelheim, Masataka Kuwana Grant/research support from: Acetelion, Consultant of: Acetelion, Bayer, Chugai, Corbus Pharmaceuticals, CSL Behring and Reata Pharmaceuticals. He was a member of the SENSCIS trial Steering Committee (Boehringer Ingelheim), Christopher Denton Grant/research support from: GlaxoSmithKline, CSL Behring, and Inventiva, Consultant of: Medscape, Roche-Genentech, Actelion, GlaxoSmithKline, Sanofi Aventis, Inventiva, CSL Behring, Boehringer Ingelheim, Corbus Pharmaceuticals, Acceleron, Curzion and Bayer, Yannick Allanore Grant/research support from: BMS, Inventiva, Roche, Sanofi, Consultant of: Actelion, Bayer AG, BMS, BI, Melanie Wosnitza Employee of: Bayer AG, Marie-Elise Truchetet: None declared, Gabriella Szücs: None declared, Wendy Stevens: None declared, Viginia Steen Grant/research support from: The associated affiliation has received grants/research from Boehringer Ingelheim, Corbus Pharmaceuticals, CSL Behring, Eicos, Galapagos, Immune Tolerance Network, Reata, Consultant of: Virginia Steen has acted as a consultant for Boehringer Ingelheim, Corbus, CSL Behring, Eicos, Forbius, Chiara Stagnaro: None declared, Vanessa Smith Grant/research support from: The affiliated company received grants from Research Foundation - Flanders (FWO), Belgian Fund for Scientific Research in Rheumatic diseases (FWRO), Boehringer Ingelheim Pharma GmbH & Co and Janssen-Cilag NV, Consultant of: Boehringer-Ingelheim Pharma GmbH & Co, Speakers bureau: Actelion Pharmaceuticals Ltd, Boehringer-Ingelheim Pharma GmbH & Co and UCB Biopharma Sprl, Richard Silver: None declared, Elena Schiopu: None declared, Valeria Riccieri: None declared, Frank Kramer Employee of: Bayer AG, Sindhu Johnson Grant/research support from: Boehringer Ingelheim, Corbus Pharmaceuticals, GlaxoSmithKline, Roche, Merck, Bayer, Consultant of: Boehringer Ingelheim, Ikaria, Osamu Ishikawa: None declared, Tomonori Ishii: None declared, Eric Hachlla: None declared, Ellen De Langhe Consultant of: member of advisory board for Boehringer, László Czirják Consultant of: Actelion, BI, Roche-Genentech, Lilly, Medac, Novartis, Pfizer, Bayer AG, Radim Bečvář Consultant of: Actelion, Roche, Tatsuya Atsumi Grant/research support from: Eli Lily Japan K.K., Alexion Pharmaceuticals, Inc., Bristol-Myers Squibb Co., AbbVie Inc., Daiichi Sankyo Co., Ltd., Pfizer Inc., Chugai Pharmaceutical Co., Ltd., Mitsubishi Tanabe Pharma Co., Astellas Pharma Inc., Consultant of: Gilead Sciences, Inc., Eli Lilly Japan K.K., UCB Japan Co. Ltd., AbbVie Inc., Daiichi Sankyo Co., Ltd., Pfizer Inc., Chugai Pharmaceutical Co., Ltd., Speakers bureau: Eli Lilly Japan K.K., UCB Japan Co. Ltd., Bristol-Myers Squibb Co., AbbVie Inc., Eisai Co. Ltd., Otsuka Pharmaceutical Co., Ltd., Daiichi Sankyo Co., Ltd., Pfizer Inc., Chugai Pharmaceutical Co., Ltd., Mitsubishi Tanabe Pharma Co., Takeda Pharmaceutical Co., Ltd., Astellas Pharma Inc., Oliver Distler Grant/research support from: Grants/Research support from Actelion, Bayer, Boehringer Ingelheim, Competitive Drug Development International Ltd. and Mitsubishi Tanabe; he also holds the issued Patent on mir-29 for the treatment of systemic sclerosis (US8247389, EP2331143)., Consultant of: Consultancy fees from Actelion, Acceleron Pharma, AnaMar, Bayer, Baecon Discovery, Blade Therapeutics, Boehringer, CSL Behring, Catenion, ChemomAb, Curzion Pharmaceuticals, Ergonex, Galapagos NV, GSK, Glenmark Pharmaceuticals, Inventiva, Italfarmaco, iQvia, medac, Medscape, Mitsubishi Tanabe Pharma, MSD, Roche, Sanofi and UCB, Speakers bureau: Speaker fees from Actelion, Bayer, Boehringer Ingelheim, Medscape, Pfizer and Roche

FRI0575 BIOMARKER ANALYSIS FROM THE RISE-SSC STUDY OF RIOCIGUAT IN EARLY DIFFUSE CUTANEOUS SYSTEMIC SCLEROSIS (DCSSC)

Background:

RISE-SSc (NCT02283762) was a multicenter, double-blind, Phase IIb study of riociguat in early dcSSc. Primary endpoint was change in mRSS from baseline to Wk 52.

Objectives:

Exploratory, descriptive analyses of riociguat target engagement and effects on disease biomarkers in RISE-SSc and their relationship with effects on the primary endpoint. All biomarker p-values are for information only.

Methods:

Pts with dcSSc (duration ≤18 mo; modified Rodnan skin score [mRSS] 10–22 units) were randomized to riociguat 0.5−2.5 mg tid (n=60) or placebo (n=61). Biomarkers of target engagement (cGMP), inflammation and/or vascular/endothelial function (e.g. high-sensitivity C-reactive protein [hsCRP], soluble platelet endothelial cell adhesion molecule 1 [sPECAM-1], soluble E-selectin, chemokine ligand 4 [CXCL-4]), and fibrosis (e.g. alpha-smooth muscle cell actin [alphaSMA], pro-collagen mRNA expression) were measured in plasma, serum, and skin biopsies at baseline and Wk 14.

Results:

Mean±SD change from baseline in mRSS was –2.09±5.66 (n=57) with riociguat and –0.77±8.24 (n=52) with placebo (p=0.08). From baseline to Wk 14, plasma cGMP rose by mean (SD) 94% (78%) (n=52) with riociguat and 10% (39%) (n=52) with placebo (nominal p<0.001). Serum sPECAM-1 and CXCL-4 fell with riociguat vs placebo; changes in hsCRP or E-selectin differed little between groups (Fig 1). Pts with higher baseline sPECAM-1 showed larger mRSS reductions with riociguat vs placebo than pts with lower levels (nominal interaction p=0.004). In baseline skin biopsies, 34% and 31% of pts in the riociguat and placebo groups, respectively, had no alphaSMA-positive cells; other pts had +ve cells (alphaSMA counts 0.1–99.5, median 2.5), a potential indicator of higher disease activity. Pts with +ve baseline alphaSMA counts showed a reduction of mRSS with riociguat vs placebo (Fig 2). Skin collagen mRNA expression biomarkers in skin biopsies showed no differences between groups.

Conclusion:

Primary study endpoint (change in mRSS) was not met. Plasma cGMP rose with riociguat, confirming engagement with the NO-sGC-cGMP pathway. Serum sPECAM-1 (marker of endothelial activation) and CXCL-4 (marker of progressive SSc) fell with riociguat; hsCRP and E-selectin did not. Some serum and skin biomarkers of higher disease activity at baseline were associated with a greater effect of riociguat on skin fibrosis.

Acknowledgments:

RISE-SSc was jointly funded by Bayer AG and Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc., Kenilworth, NJ, USA.

Disclosure of Interests:

Oliver Distler Grant/research support from: Grants/Research support from Actelion, Bayer, Boehringer Ingelheim, Competitive Drug Development International Ltd. and Mitsubishi Tanabe; he also holds the issued Patent on mir-29 for the treatment of systemic sclerosis (US8247389, EP2331143)., Consultant of: Consultancy fees from Actelion, Acceleron Pharma, AnaMar, Bayer, Baecon Discovery, Blade Therapeutics, Boehringer, CSL Behring, Catenion, ChemomAb, Curzion Pharmaceuticals, Ergonex, Galapagos NV, GSK, Glenmark Pharmaceuticals, Inventiva, Italfarmaco, iQvia, medac, Medscape, Mitsubishi Tanabe Pharma, MSD, Roche, Sanofi and UCB, Speakers bureau: Speaker fees from Actelion, Bayer, Boehringer Ingelheim, Medscape, Pfizer and Roche, Frank Kramer Employee of: Bayer AG, Josef Höfler Employee of: Josef Höfler is an employee of Staburo GmbH, Munich, Germany, contracted by Bayer AG to perform the biomarker analyses, Mercedeh Ghadessi Employee of: Bayer AG, Peter Sandner Employee of: Bayer AG, Yannick Allanore Grant/research support from: BMS, Inventiva, Roche, Sanofi, Consultant of: Actelion, Bayer AG, BMS, BI, Christopher Denton Grant/research support from: GlaxoSmithKline, CSL Behring, and Inventiva, Consultant of: Medscape, Roche-Genentech, Actelion, GlaxoSmithKline, Sanofi Aventis, Inventiva, CSL Behring, Boehringer Ingelheim, Corbus Pharmaceuticals, Acceleron, Curzion and Bayer, Masataka Kuwana Grant/research support from: Acetelion, Consultant of: Acetelion, Bayer, Chugai, Corbus Pharmaceuticals, CSL Behring and Reata Pharmaceuticals. He was a member of the SENSCIS trial Steering Committee (Boehringer Ingelheim), Marco Matucci-Cerinic Grant/research support from: Actelion, MSD, Bristol-Myers Squibb, Speakers bureau: Acetelion, Lilly, Boehringer Ingelheim, Janet Pope Grant/research support from: AbbVie, Bristol-Myers Squibb, Eli Lilly & Company, Merck, Roche, Seattle Genetics, UCB, Consultant of: AbbVie, Actelion, Amgen, Bayer, Boehringer Ingelheim, Bristol-Myers Squibb, Eicos Sciences, Eli Lilly & Company, Emerald, Gilead Sciences, Inc., Janssen, Merck, Novartis, Pfizer, Roche, Sandoz, Sanofi, UCB, Speakers bureau: UCB, Tatsuya Atsumi Grant/research support from: Eli Lily Japan K.K., Alexion Pharmaceuticals, Inc., Bristol-Myers Squibb Co., AbbVie Inc., Daiichi Sankyo Co., Ltd., Pfizer Inc., Chugai Pharmaceutical Co., Ltd., Mitsubishi Tanabe Pharma Co., Astellas Pharma Inc., Consultant of: Gilead Sciences, Inc., Eli Lilly Japan K.K., UCB Japan Co. Ltd., AbbVie Inc., Daiichi Sankyo Co., Ltd., Pfizer Inc., Chugai Pharmaceutical Co., Ltd., Speakers bureau: Eli Lilly Japan K.K., UCB Japan Co. Ltd., Bristol-Myers Squibb Co., AbbVie Inc., Eisai Co. Ltd., Otsuka Pharmaceutical Co., Ltd., Daiichi Sankyo Co., Ltd., Pfizer Inc., Chugai Pharmaceutical Co., Ltd., Mitsubishi Tanabe Pharma Co., Takeda Pharmaceutical Co., Ltd., Astellas Pharma Inc., Radim Bečvář Consultant of: Actelion, Roche, László Czirják Consultant of: Actelion, BI, Roche-Genentech, Lilly, Medac, Novartis, Pfizer, Bayer AG, Ellen De Langhe Consultant of: member of advisory board for Boehringer, Eric Hachlla: None declared, Tomonori Ishii: None declared, Osamu Ishikawa: None declared, Sindhu Johnson Grant/research support from: Boehringer Ingelheim, Corbus Pharmaceuticals, GlaxoSmithKline, Roche, Merck, Bayer, Consultant of: Boehringer Ingelheim, Ikaria, Kaisa Laapas Employee of: Partly in-sourced to Bayer, Valeria Riccieri: None declared, Elena Schiopu: None declared, Richard Silver: None declared, Vanessa Smith Grant/research support from: The affiliated company received grants from Research Foundation - Flanders (FWO), Belgian Fund for Scientific Research in Rheumatic diseases (FWRO), Boehringer Ingelheim Pharma GmbH & Co and Janssen-Cilag NV, Consultant of: Boehringer-Ingelheim Pharma GmbH & Co, Speakers bureau: Actelion Pharmaceuticals Ltd, Boehringer-Ingelheim Pharma GmbH & Co and UCB Biopharma Sprl, Chiara Stagnaro: None declared, Viginia Steen Grant/research support from: The associated affiliation has received grants/research from Boehringer Ingelheim, Corbus Pharmaceuticals, CSL Behring, Eicos, Galapagos, Immune Tolerance Network, Reata, Consultant of: Virginia Steen has acted as a consultant for Boehringer Ingelheim, Corbus, CSL Behring, Eicos, Forbius, Wendy Stevens: None declared, Gabriella Szücs: None declared, Marie-Elise Truchetet: None declared, Melanie Wosnitza Employee of: Bayer AG, Dinesh Khanna Shareholder of: Eicos Sciences, Inc./Civi Biopharma, Inc., Grant/research support from: Dr Khanna was supported by NIH/NIAMS K24AR063120, Consultant of: Acceleron, Actelion, Bayer, Boehringer Ingelheim, Bristol-Myers Squibb, Corbus Pharmaceuticals, Horizon Therapeutic, Galapagos, Roche/Genentech, GlaxoSmithKline, Mitsubishi Tanabe, Sanofi-Aventis/Genzyme, UCB

FRI0189 ENDOTHELIAL PROTEIN C RECEPTOR AND SCAVENGER RECEPTOR CLASS B TYPE 1 NEGATIVELY REGULATE ENDOTHELIAL ACTIVATION AND REPRESENT NOVEL AUTOANTIGENS IN TAKAYASU ARTERITIS

Background:

Takayasu arteritis (TAK) is a chronic granulomatous vasculitis and affects large vessels in young female. It has been recognized that high numbers of patients with TAK possessed autoantibodies against vascular endothelium, which are called anti-endothelial cell antibodies (AECAs). Although their target antigens had not been identified for a long time, we utilized an expression cloning system for specific identification of cell-surface antigens and successufully identified endothelial protein C receptor (EPCR) and scavenger receptor class B type 1 (SR-BI) as major novel autoantigens in TAK. It was possible that identified novel autoantibodies were utilized for clinical application and elucidating pathomechanisms of TAK.

Objectives:

To reveal the clinical impact and pathogenic potential of novel autoantibodies in TAK

Methods:

Three hundred twenty-five patients with autoimmune diseases were enrolled: 80, TAK; 10, giant cell arteritis (GCA); and 235, other autoimmune diseases. The expressions of EPCR and SR-BI were examined in the aortic tissue from several diseases by immunohistochemistry. The presence of novel autoantibodies was measured in TAK and other autoimmune diseases. Clinical characteristics of patients with these autoantibodies were evaluated in TAK. To investigate the pathogenetic potential of these novel autoantibodies, vascular endothelial cells from umbilical vein, aortic artery, and pulmonary artery were examined for the endothelial cell activation. The effects of the novel autoantibodies upon the differentiation of immune cells were also evaluated.

Results:

In non-inflammatory aortic tissue, the expressions of EPCR and SR-BI were observed in the endothelium of vasa vasorum. Their expressions in the endothelium were augumented in TAK tissue. Novel autoantibodies against EPCR or SR-BI were detected in 34.6 % or 36.5 % of cases, respectively in TAK, and overlap was obsereved only in two cases, indicating their exclusive nature. These autoantibodies were specific for TAK among autoimmune rheumatic diseases, and they were not detected in patients with GCA with cranial involvement, suggesting different pathomechanisms among these diseases. The clinical characteristics of patients with anti-EPCR autoantibodies included high prevalence of stroke and ulcerative colitis. Surprisingly, anti-EPCR autoantibodies were also detected in patients with primary ulcerative colitis, suggesting their common pathomechanisms with TAK. Serial measurement of these novel autoantibodies revealed their correlation with disease activity of TAK. In machanistic studies, EPCR and SR-BI functioned as negative regulators of endothelial activation and chemokine production. EPCR further functioned in human T cells and ameliorated Th17 differentiation. Autoantibodies against EPCR and SR-BI blocked the functions of their targets, thereby promoting pro-inflammatory phenotype.

Conclusion:

EPCR and SR-BI are preferentially expressed in the endothelium of vaso vasorum and upregulated in TAK tissue. Autoantibodies against EPCR or SR-BI are specific for TAK among autoimmune rheumatic conditions and detected in about 70 % of TAK, suggesting their usefulness for the diagnosis, subclassification, and monitoring of TAK. Autoantibodies inhibit the resolution of activated immune responses and thus would lead to the chronic vascular inflammation.

References:

[1]Shirai T et al. Arthritis Res Ther 2012;14:R157.

[2]Shirai T et al. Clin Dev Immunol 2013;2013:453058.

[3]Shirai T et al. J Neuroinflammation. 2013;10:128

Disclosure of Interests:

None declared

0147 Dynamic Alterations in Functional Connectivity Between Sleep- and Wake-Promoting Regions of the Human Brain at the Sleep Onset Period

Introduction

The sleep onset period, involving so-called stage N1 sleep largely, is characterized by a reduction in the amount of alpha activity compared to wakefulness. Various kinds of physiological and psychological changes are also apparent, such as slow eye movements, changes in muscle tonus, and the hypnagogic dream-like mentation. These phenomena are thought to be the reflection of dynamic alterations in the brain during the transition period, however, details of these changes have still been uncovered.

Methods

We aimed to investigate a dynamic shift in the brain connectivity at sleep onset using the method of EEG-fMRI simultaneous recording. Twenty-three healthy subjects participated. EEG/fMRI were recorded simultaneously during an hour’s nap in a 3T-MRI scanner and real-time monitoring of EEG was performed. To record the transition period between multiple times, an experimenter inside a scanner room touched a subject’s foot for inducing arousal when a shift to NREM sleep stage 1 was observed. EEG data were scored according to the AASM criteria. Based on sleep stages defined by polysomnographic findings, we investigated alterations in functional connectivity of sleep- and wake- promoting regions within the hypothalamus and other areas including the thalamus.

Results

Posterior alpha power showed significant positive correlation with BOLD signals in the anterior and medial dorsal thalamus. Connectivity between the thalamus and cortical regions reduced sharply in the descent to sleep stage. Meanwhile, BOLD signals of the sleep- and wake- promoting regions within the hypothalamus fluctuated with certain temporal lags from fluctuations of alpha rhythm at sleep onset.

Conclusion

Present findings provide preliminary evidence of dynamics of wake- and sleep- promoting regions in the human brain in vivo. Our data also support the hypothesis that reduced thalamocortical connectivity which limits the capacity to integrate information is associated with the transition of consciousness at sleep onset.

Support

None

Search for Electron Antineutrino Appearance in a Long-Baseline Muon Antineutrino Beam

Electron antineutrino appearance is measured by the T2K experiment in an accelerator-produced antineutrino beam, using additional neutrino beam operation to constrain parameters of the Pontecorvo-Maki-Nakagawa-Sakata (PMNS) mixing matrix. T2K observes 15 candidate electron antineutrino events with a background expectation of 9.3 events. Including information from the kinematic distribution of observed events, the hypothesis of no electron antineutrino appearance is disfavored with a significance of 2.40σ and no discrepancy between data and PMNS predictions is found. A complementary analysis that introduces an additional free parameter which allows non-PMNS values of electron neutrino and antineutrino appearance also finds no discrepancy between data and PMNS predictions.

Radiographic characteristics of wrists in idiopathic carpal tunnel syndrome patients

Background

To determine the radiographic characteristics of wrists in idiopathic carpal tunnel syndrome patients, we compared the radiographic parameters of the wrists between carpal tunnel syndrome patients and non-symptomatic controls.

Methods

We evaluated radiographic parameters of 94 wrists of 62 idiopathic carpal tunnel syndrome patients and 94 asymptomatic wrists of 94 controls. Carpal tunnel syndrome was diagnosed by clinical findings and nerve conduction studies. The lack of symptoms was confirmed with the medical records and interviews for the controls. X-ray images of the postero-anterior and lateral views of the wrist were taken. Using the obtained X-ray images, the indices of radial inclination, volar tilt, ulnar variance, and transverse and antero-posterior diameters of the wrists were measured. Two raters independently performed the measurement. One rater measured without information of clinical symptoms. Inter-rater reliabilities for each parameter were evaluated by the intra-class correlation coefficients. The averages of the measurements of two raters were compared between the carpal tunnel syndrome patients and the controls.

Results

The intra-class correlation coefficients were 0.58 for radial inclination, 0.77 for ulnar variance, 0.99 for transverse diameter, 0.60 for volar tilt, and 0.91 for antero-posterior diameter. Statistically significant correlations were found for all parameters (P < 0.01). The ulnar variance was significantly larger in the carpal tunnel syndrome patients compared to the controls (1.7 +/− 1.8 mm and 0.8 +/− 1.5 mm for the patients and controls, respectively P < 0.01). There were no significant differences in the other parameters.

Conclusions

Significant differences in the ulnar variance were observed between carpal tunnel syndrome patients and controls. This suggests that the imbalance of radioulnar bone length is one of the risk factors to develop carpal tunnel syndrome. The positive ulnar variance may be an index that needs attention to the development of carpal tunnel syndrome.

Level of evidence

level III, a case control study.

Postoperative diagnostic potentials of median nerve strain and applied pressure measurement after carpal tunnel release

Bakground

The objective of this study is to investigate the prognostic values of median nerve strain and applied pressure measurement for the assessment of clinical recovery after carpal tunnel release.

Methods

Forty-five wrists, from 45 idiopathic carpal tunnel syndrome patients who treated with open carpal tunnel release, were evaluated by ultrasound. Median nerve strain, pressure applied to the skin, and ratio of pressure-strain were measured at the proximal part of the carpal tunnel. In addition, distal latencies in the motor and sensory nerve conductions studies and cross-sectional area of median nerve were measured. The parameters were compared before and after the open carpal tunnel release. According to patient recovery, the receiver operating characteristic curves were generated to evaluate the prognostic values of the parameters. The areas under the receiver operating characteristic curves were compared among parameters.

Results

There was a significant increase in the median nerve strain, and significant decreases in the pressure applied to the skin and ratio of pressure-strain after carpal tunnel release (P < 0.01). There were significant decreases in the distal latencies and the cross-sectional area after carpal tunnel release (P < 0.01). The areas under the curves were 0.689, 0.773, 0.811, 0.668, 0.637, and 0.562 for the pressure, strain, pressure-strain ratio, motor latency, sensory latency, and area, respectively.

Conclusions

The results suggest that elasticity of the median nerve and pressure around the nerve recover quickly after carpal tunnel release. Pressure-strain ratio was the most reliable parameter to reflect clinical recovery. The measurement of strain and applied pressure can be useful indicators to evaluate effectiveness of the carpal tunnel release.

Trial registration

Registered as NCT04027998 at ClinicalTrials.gov. Retrospectively registered on July 22, 2019.

Utility of an image fusion system for 3D preoperative planning and fluoroscopy in the osteosynthesis of distal radius fractures

Background

Recently, computerized virtual surgery planning has been increasingly applied in various orthopedic procedures. In this study, we developed an image fusion system for 3D preoperative planning and fluoroscopy for the osteosynthesis. To assess the utility of image fusion system, we evaluated the reproducibility of preoperative planning in the osteosynthesis of distal radius fractures with using the image fusion system, and compared with the reproducibility of the patients without using the image fusion system.

Methods

Forty-two wrists of 42 distal radius fracture patients who underwent osteosynthesis using volar locking plates were evaluated. The patients were divided into two groups. Image fusion group utilized three-dimensional (3D) preoperative planning and image fusion system. Control group utilized only 3D preoperative planning. In both groups, 3D preoperative planning was performed in order to determine reduction, placement, and choice of implants. In the image fusion group, the outline of planned image was displayed on a monitor overlapping with fluoroscopy images during surgery. Reductions were evaluated by volar tilt and radial inclination of 3D images. Plate positions were evaluated with distance to joint surface, plate center axis position, and inclination relative to the radius axis. Screw choices were recorded for the plan and actual choices for each screw hole. Differences in the parameters between pre- and postoperative images were evaluated. Differences in reduction shape, plate positions, and screw choices were compared between groups.

Results

The differences in the distance from plate to joint surface were significantly smaller in the image fusion group compared to the control group (P < 0.01). The differences in the distal screw choices were significantly smaller in the image fusion group compared to the control group (P < 0.01).

Conclusions

The image fusion system was useful to reproduce the planned plate position and distal screw choices in the osteosynthesis of distal radius fractures.

Trial registration

ClinicalTrials.gov, NCT03764501

Reliability of Quantitative Assessment of Distal Radioulnar Joint Stability With Force-Monitor Ultrasonography

The purpose of this study was to evaluate the reliability of ultrasound assessment of the displacement-force relationships for distal radioulnar joint (DRUJ) stability. Non-dominant wrists of 10 healthy male subjects were evaluated by force-monitor ultrasonography. This apparatus was developed to apply cyclic compression to the wrist with pre-determined transducer displacement conditions in the range of 0.1-3.0 mm. The subject's wrist was placed on the table with the forearm in the pronated position. The transducer was placed on the dorsal surface of the distal radius and ulna, perpendicular to the long axis of the forearm. The center of the ulnar head was at the DRUJ level. The distance between the dorsal surface of the distal radius and the ulnar head was measured at an initial and a pressed-down position. Changes in radioulnar displacement, force to the wrist and the displacement/force ratio were evaluated. The measurements were performed independently by two raters. The intra-class correlation coefficients (ICCs) for the radioulnar displacement were 0.76, 0.68, and 0.93, in the 1.0, 2.0, and 3.0 mm transducer displacement conditions, respectively. The ICCs for the force to the wrist were 0.18, 0.67, and 0.34, in different transducer displacement conditions, respectively. The ICCs for the displacement/force ratios were 0.68, 0.67, and 0.97, in different transducer displacement conditions, respectively. The highest ICC for the radioulnar displacement and the displacement/force ratio was observed in the 3.0 mm displacement condition. This assessment of displacement-force relationships may be useful to quantify DRUJ stability. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 37:2053-2060, 2019.

A Comparison of Radiographic Outcomes between 3D Preoperative Planning and Conventional Planning in the Osteosynthesis of Distal Radius Fractures

Background: To assess the usefulness of three-dimensional (3D) digital pre-operative planning, we compared the radiographic parameters of the distal radius from 3D planning and conventional planning after osteosynthesis of distal radius fractures. We hypothesized that the use of 3D digital planning may improve radiographic outcomes for reduction and decrease the risk of correction loss. Methods: Sixty wrists of 60 distal radius fracture patients were randomly divided into two groups according to the order of hospital visits. Thirty wrists were treated with 3D preoperative planning as the plan group. Another thirty wrists were treated with conventional preoperative planning as the control group. Both groups were treated with volar locking plates. In the plan group, 3D digital preoperative planning and a surgical simulation were performed in order to determine the reduction and placement of the implants in addition to the plate/screw size prior to surgery. In the control group, conventional preoperative planning was performed. Ulnar variance, volar tilt, and radial inclination were measured at one week, three and six months after surgery. Difference of the measurement of radiographic parameters between operated and healthy side wrists were compared between plan and control groups at one week after surgery. Loss of corrections for radiographic parameters were compared between plan and control groups. Results: The differences between the operated and healthy side wrists were significantly smaller in the plan group compared to the control group for the volar tilt and radial inclination (p < 0.05).The loss of corrections for ulnar variance and volar tilt were significantly smaller in the plan group compared to the control group at six months after surgery (p < 0.05). Conclusions: 3D preoperative planning offers better reduction accuracy and reduces correction loss in the osteosynthesis of distal radius fractures.

Delayed lupus nephritis in the course of systemic lupus erythematosus is associated with a poorer treatment response: a multicentre, retrospective cohort study in Japan

Objective

The objective of this study was to investigate possible differences in treatment responses between two categories for the onset of lupus nephritis.

Methods

We performed a multicentre, retrospective cohort study of class III–V lupus nephritis patients diagnosed between 1997 and 2014. The renal responses to initial induction therapy were compared between patients who developed lupus nephritis within one year from diagnosis of systemic lupus erythematosus (early (E-) LN) and the remainder (delayed (D-) LN) using the Kaplan–Meier method. We determined the predictors of renal response as well as renal flares and long-term renal outcomes using multivariate Cox regression analyses.

Results

A total of 107 E-LN and 70 D-LN patients were followed up for a median of 10.2 years. Log-rank tests showed a lower cumulative incidence of complete response in D-LN compared with E-LN patients. Multivariate analysis identified D-LN (hazard ratio (HR) 0.48, 95% confidence interval (CI) 0.33–0.70), nephrotic syndrome at baseline, and a chronicity index greater than 2 as negative predictors of complete response. D-LN patients were more likely to experience renal flares. D-LN (HR 2.54, 95% CI 1.10–5.83) and decreased renal function were significant predictors of chronic kidney disease at baseline.

Conclusion

D-LN was a predictor of poorer treatment outcomes, in addition to renal histology and severity of nephritis at lupus nephritis onset.