POS0873 PERSISTENT INFLAMMATION IN SYSTEMIC SCLEROSIS IS STRONGLY ASSOCIATED WITH SEVERE DISEASE AND MORTALITY: AN ANALYSIS FROM THE EUSTAR DATABASE

Background

Systemic sclerosis (SSc) is a heterogeneous autoimmune disease, with a high disease-related mortality and morbidity. A subset of patients show elevated CRP levels (20-35%), which has been reported as inflammatory SSc. Preliminary data suggest that this subset is characterized by a severe phenotype.

Objectives

To analyse the phenotype and the survival of inflammatory compared with non-inflammatory SSc patient subsets.

Methods

Data from 8571 SSc patients with available CRP measurement from the EUSTAR cohort were analysed. Exclusion criteria included acute infection, missing follow-up and tocilizumab treatment. Patients with a CRP ≥5mg/l at ≥80% of visits were stratified as persistent inflammatory and as non-inflammatory if CRP was ≥5 mg/l at <20% of visits (as described previously (1)). As a sensitivity analysis, patients were defined as inflammatory and non-inflammatory based on a single CRP measurement at baseline only (CRP ≥5 or <5mg/l, respectively). We compared baseline characteristics using Chi-square and non-parametric Kruskal–Wallis tests as appropriate. Kaplan Meier curves with log-rank tests were used to estimate time from baseline to death or censoring, and Cox regression to compare mortality risks adjusted for time from diagnosis to baseline.

Results

Out of 2883 patients with more than two visits, 404 (14%) showed persistent inflammation and 1032 (36%) a non-inflammatory phenotype. Out of 5619 patients with more than one visit, 1830 (33%) were stratified as inflammatory as defined by as single CRP measurement at baseline and 3789 (67%) as non-inflammatory. With both definitions, the inflammatory subset revealed a more severe phenotype than non-inflammatory patients, including more frequent diffuse-cutaneous disease, anti-Scl-70 autoantibodies, pulmonary fibrosis, pulmonary hypertension, higher modified Rodnan skin score, and lower forced vital capacity and diffusing capacity for carbon monoxide. Patients with persistent inflammation had a strongly increased risk of all-cause mortality (HR 7.1 [95%CI 3.7 to 13.5], p<0.001) compared to non-inflammatory patients, whereas this association was weaker when based on a single CRP measurement (HR 2.6 [95%CI 2.1 to 3.2], p<0.001).

Conclusion

The severe phenotype and decreased survival of the inflammatory SSc subset, which was most prominent in patients with persistently elevated CRP levels, suggest a distinct disease subset. Therefore both, the need for more regular monitoring of inflammatory parameters and implications for immune-modulating treatment, needs to be carefully analysed.

References

[1]Mitev, A., et al., Inflammatory stays inflammatory: a subgroup of systemic sclerosis characterized by high morbidity and inflammatory resistance to cyclophosphamide. Arthritis Res Ther, 2019. 21(1): p. 262. PMID: 31791379

Figure 1.

Overall mortality from baseline onward a. by persistent inflammatory phenotype, b. by inflammatory phenotype at baseline

Disclosure of Interests

Adela-Cristina Sarbu: None declared, Sabina Guler: None declared, Odile Stadler: None declared, Yannick Allanore: None declared, Vera Bernardino: None declared, Jörg H.W. Distler: None declared, Armando Gabrielli: None declared, Anna-Maria Hoffmann-Vold: None declared, Marco Matucci-Cerinic: None declared, Ulf Müller-Ladner: None declared, Vera Ortiz-Santamaria: None declared, Simona Rednic: None declared, Valeria Riccieri: None declared, Vanessa Smith: None declared, Susanne Ullman: None declared, Ulrich Walker: None declared, Thomas Geiser: None declared, Oliver Distler: None declared, Britta Maurer Speakers bureau: Boehringer-Ingelheim, Consultant of: Novartis, Boehringer Ingelheim, Janssen-Cilag, Grant/research support from: AbbVie, Protagen, Novartis Biomedical Research, Florian Kollert Shareholder of: Roche, Consultant of: BMS, Actelion, Boehringer-Ingelheim, Pfizer, Grant/research support from: Roche, Gilead, Pfizer, Employee of: Roche

Clinical prediction of 5-year survival in systemic sclerosis: validation of a simple prognostic model in EUSTAR centres

OBJECTIVE

Systemic sclerosis (SSc) is associated with a significant reduction in life expectancy. A simple prognostic model to predict 5-year survival in SSc was developed in 1999 in 280 patients, but it has not been validated in other patients. The predictions of a prognostic model are usually less accurate in other patients, especially from other centres or countries. A study was undertaken to validate the prognostic model to predict 5-year survival in SSc in other centres throughout Europe.

METHODS

A European multicentre cohort of patients with SSc diagnosed before 2002 was established. Patients with SSc according to the preliminary American College of Rheumatology classification criteria were eligible for the study when they were followed for at least 5 years or shorter if they died. The primary outcome was 5-year survival after diagnosis of SSc. The predefined prognostic model uses the following baseline variables: age, gender, presence of urine protein, erythrocyte sedimentation rate (ESR) and carbon monoxide diffusing capacity (DLCO).

RESULTS

Data were available for 1049 patients, 119 (11%) of whom died within 5 years after diagnosis. Of the patients, 85% were female, the mean (SD) age at diagnosis was 50 (14) years and 30% were classified as having diffuse cutaneous SSc. The prognostic model with age (OR 1.03), male gender (OR 1.93), urine protein (OR 2.29), elevated ESR (1.89) and low DLCO (OR 1.94) had an area under the receiver operating characteristic curve of 0.78. Death occurred in 12 (2.2%) of 509 patients with no risk factors, 45 (13%) of 349 patients with one risk factor, 55 (33%) of 168 patients with two risk factors and 7 (30%) of 23 patients with three risk factors.

CONCLUSION

A simple prognostic model using three disease factors to predict 5-year survival at diagnosis in SSc showed reasonable performance upon validation in a European multicentre study.

Absence of high‐affinity calreticulin autoantibodies in patients with systemic rheumatic diseases and coeliac disease

Calreticulin has been reported to be an autoantigen in various autoimmune connective tissue diseases and in coeliac disease. Previous studies have used incubation buffers with low salt and low detergent concentrations (low stringency conditions) with serum albumin or other proteins as a blocking agent. Using these conditions we found a relatively high level of non-specific binding in many sera. Antibodies to proteins that are used as blocking reagents in ELISA (bovine serum albumin (BSA), ovalbumin, skimmed milk powder) are frequently present in sera, and these may cause false-positive results. Moreover, the low isoelectric point of calreticulin and its chaperone properties may give rise to false-positive results under low stringency conditions. We report that the use of a simple buffer without protein (50 mM Tris, pH 7.5, 1% Tween 20, 0.3 M NaCl) removes most of the problems with unwanted binding (high stringency conditions). Using the high stringency conditions, we screened sera from 107 patients with systemic lupus erythematosus, sera from patients with other systemic autoimmune diseases and from children with coeliac disease for the presence of high-affinity calreticulin autoantibodies by immunoblotting and ELISA. None of the sera contained high-affinity calreticulin antibodies. It is concluded that calreticulin is not a common autoantigen in patients with autoimmune connective tissue diseases or coeliac disease.

A randomized controlled trial of R-salbutamol for topical treatment of discoid lupus erythematosus

BACKGROUND

In a recent open pilot trial, R-salbutamol sulphate, a well-known molecule with anti-inflammatory effects, was tested successfully on patients with therapy-resistant discoid lupus erythematosus (DLE).

OBJECTIVES

To compare the efficacy and safety of R-salbutamol cream 0.5% vs. placebo on DLE lesions in a multicentre, double-blinded, randomized, placebo-controlled phase II trial.

METHODS

Thirty-seven patients with at least one newly developed DLE lesion were randomized - 19 to the R-salbutamol cream 0.5% and 18 to placebo - and treated twice daily for 8 weeks. Efficacy was evaluated through scores of erythema, scaling/hypertrophy and induration as well as pain and itching; general improvement scored by the investigator and global improvement scored by patients' assessment were also evaluated.

RESULTS

The mean area under the curve of improvement for scaling/hypertrophy, pain, itching and global patient assessment was significantly better for the actively treated patients as compared with placebo (scaling/hypertrophy, P = 0.0262; pain, P = 0.0238; itching, P = 0.0135; global patient assessment, P = 0.045). Moreover, the percentage of patients without induration was significantly higher in the active group compared with the placebo group (P = 0.013), and a statistically significantly greater decrease in the size of the lesional area was also seen in the overall analysis of the R-salbutamol-treated patients (P = 0.0197). No serious adverse events were reported.

CONCLUSIONS

Application of R-salbutamol cream 0.5% was safe and well tolerated. Statistically significant effects were seen on scaling/hypertrophy, induration, pain and itching as well as patient global assessment, suggesting that R-salbutamol could be a promising new topical therapy alternative for DLE.

High serum levels of YKL-40 in patients with systemic sclerosis are associated with pulmonary involvement

OBJECTIVES

YKL-40, a growth factor of connective tissue cells, is elevated in sera from patients with diseases characterized by inflammation, tissue remodelling, or fibrosis. The aim of the study was to determine serum YKL-40 levels in patients with systemic sclerosis (SSc) and to explore any possible clinical and prognostic associations.

METHODS

YKL-40 was measured in sera from 88 patients with SSc (26 with diffuse and 62 with limited skin involvement) and in sera from 88 matched healthy controls. Immunohistochemical staining for YKL-40 antigen was performed in a biopsy from a patient with pulmonary SSc.

RESULTS

Serum YKL-40 levels of the SSc patients were significantly higher than those of the controls (p<0.00001). Patients with pulmonary fibrosis by chest X-ray, obstructive ventilatory pattern, reduced diffusing capacity (DLco), and digital joint deformity due to skin retraction had significantly higher serum YKL-40 compared with patients without these findings. Patients with elevated serum YKL-40 had shorter survival times than patients with normal serum YKL-40 (p = 0.0005), although this was not independent of age and pulmonary function. YKL-40 protein expression was found in inflammatory cells in fibrosing pulmonary tissue from a patient with SSc.

CONCLUSIONS

Serum YKL-40 is elevated in patients with SSc with pulmonary involvement.

Viscoelastic properties and flexibility of the human muscle-tendon unit in benign joint hypermobility syndrome

OBJECTIVE

To examine the passive energy absorption of the hamstring muscle-tendon unit in 9 women with benign joint hypermobility syndrome (BJHS) and 9 age and sex matched controls.

METHODS

Resistance to stretch was measured as knee flexion moment (N.m) with an isokinetic dynamometer during passive knee extension. The angle that induced a stretch sensation without pain was the maximal stretch angle. Force, angle, angular velocity (0.09 rad/s), and electromyograph were simultaneously and continuously recorded during the stretch. Hamstring cross sectional area was obtained with magnetic resonance imaging.

RESULTS

Forearm skin extensibility was greater for BJHS (3.6+/-0.5 cm) than for controls (1.3+/-0.2 cm) (p < 0.01). Similarly, the Beighton score was greater for BJHS (6.6+/-0.8) than for controls (0.4+/-0.2) (p < 0.001). Maximal stretch angle was greater for BJHS (delta1.35+/-0.07 rad) compared to controls (delta0.98+/-0.05 rad) (p < 0.001), and the corresponding peak moment was also greater for BJHS (1.3+/-0.4 Nm/cm2) than for controls (0.6+/-0.1 Nm/cm2) (p < 0.01). For a given mutual angle the passive energy absorption was the same for both groups, but at the maximal stretch angle the total area-normalized energy was greater for BJHS (0.36+/-0.04 J/cm2) than for controls (0.18+/-0.28 J/cm2) (p < 0.001).

CONCLUSION

The lack of difference in passive energy absorption for a given mutual stretch angle suggests that passive properties of the muscle-tendon unit of BJHS are similar to those of controls. However, the greater maximal stretch angle and corresponding peak moment in BJHS suggests a greater subjective tolerance to passive stretch. That is, increased flexibility in BJHS is not a function of altered passive properties of the muscle-tendon complex. It remains unknown if the enhanced tolerance to passive tension plays a role in the development of musculoskeletal ailment.

Influence of clinical features, serum antinuclear antibodies, and lung function on survival of patients with systemic sclerosis

OBJECTIVE

To evaluate the independent contribution of several clinical and laboratory variables to the mortality of a cohort of Danish patients with systemic sclerosis (SSc).

METHODS

A cohort of 174 patients with incident SSc was retrospectively identified using clinical charts and study records of all new patients with SSc. Disease onset was defined as the time of onset of cutaneous sclerosis. Vital status and causes of death were determined at the end of the observation period. Data on clinical status and pulmonary function were obtained. Antitopoisomerase I (anti-topo I), anticentromere, anti-U1-RNP, anti-U3-RNP, anti-Th-RNP, and anti-RNA polymerase (anti-RNAP) antibodies were determined by means of double immunodiffusion, immunofluorescence, hemagglutination technique, radioactively labelled antisense riboprobes, and ELISA, respectively.

RESULTS

Patients were followed for a mean period of 13.3 yrs; 16 died of an SSc related condition and 50 of other causes. Pulmonary fibrosis, DLCO reduction < 40% of the expected, diffuse cutaneous involvement, SSc nephropathy, cardiac disease, and anti-topo I and anti-RNAP antibody were related to decreased survival due to SSc. Variables that entered a Cox regression model of SSc related mortality were right heart failure (RR 12.4, 95% CI 2.5-60), diffuse SSc (RR 7.8, 95% CI 1.8-35), SSc nephropathy (RR 6.1, 95% CI 1.8-21), and DLCO < 40% (RR 4.8, 95% CI 1.1-20). The relative risk of developing right heart failure and diffuse SSc given the presence of anti-RNAP antibody was 14 (p = 0.0001) and 1.9 (p = 0.01), respectively. The corresponding figures for anti-topo I antibody were 4.6 (p = 0.02) and 2.0 (p = 0.01).

CONCLUSION

SSc related mortality was associated with right heart failure and diffuse SSc, both of which were also associated with the presence of anti-topo I and anti-RNAP antibody. The prognostic value of these autoantibodies may lie in the early course of the disease when specific morbidity has not yet evolved.

Determination of autoantibodies to annexin XI in systemic autoimmune diseases

Annexin XI, a calcyclin-associated protein, has been shown to be identical to a 56,000 Da antigen recognized by antibodies found in sera from patients suffering from systemic autoimmune diseases. In this work hexahistidine-tagged recombinant annexin XI (His6- rAnn XI) was used as antigen in ELISA experiments for determination of autoantibodies to annexin XI in sera of patients with systemic rheumatic autoimmune diseases. Immunoblotting with HeLa cell extract and with His6-rAnn XI as antigen was used for confirmation of positive ELISA results. We found eleven anti-annexin XI positive sera (3.9%) out of 282 sera from patients with systemic rheumatic diseases. The highest number of annexin XI positive sera were found in primary antiphospholipid syndrome (3/17), and in subacute lupus erythematosus (1/6), while lower frequencies of positive sera were found in patients with systemic sclerosis (5/137), rheumatoid arthritis (1/21), and systemic lupus erythematosus (1/58). Sera from healthy donors and patients with chronic infections were negative, except for one Salmonella typhimurium antibody positive serum. Autoantibodies to annexin XI were found to relate to thrombosis, but not to other clinical or laboratory features. A relation between antibodies to annexins and thrombosis has so far only been known for annexin V.

Prognostic value of renal biopsy and clinical variables in patients with lupus nephritis and normal serum creatinine

OBJECTIVE

To evaluate factors with possible influence on the renal outcome in patients with lupus nephritis but without chronic renal insufficiency (CRI).

METHODS

Renal biopsies from 94 patients were re-assessed with regard to WHO class, activity, chronicity and tubulointerstitial indices without knowledge of clinical features. The outcome parameters were CRI defined as irreversibly increased serum creatinine and renal end stage disease.

RESULTS

The risk ratios (RR) of developing CRI were 2.6 for active urinary sediment, 3.1 for hyaline thrombi and 7.3 for glomerular leukocyte exudation. The RR of renal end stage disease was 5.0 when the duration of renal disease exceeded one year at the time of biopsy and 4.3 when biopsy disclosed a class IV lesion. Glomerular sclerosis was also associated to renal end stage disease.

CONCLUSION

Early renal biopsy and the abovementioned signs of active renal disease carry prognostic information that may have significant therapeutic implications.

Computation of pattern invariance in brain-like structures

A fundamental capacity of the perceptual systems and the brain in general is to deal with the novel and the unexpected. In vision, we can effortlessly recognize a familiar object under novel viewing conditions, or recognize a new object as a member of a familiar class, such as a house, a face, or a car. This ability to generalize and deal efficiently with novel stimuli has long been considered a challenging example of brain-like computation that proved extremely difficult to replicate in artificial systems. In this paper we present an approach to generalization and invariant recognition. We focus our discussion on the problem of invariance to position in the visual field, but also sketch how similar principles could apply to other domains.The approach is based on the use of a large repertoire of partial generalizations that are built upon past experience. In the case of shift invariance, visual patterns are described as the conjunction of multiple overlapping image fragments. The invariance to the more primitive fragments is built into the system by past experience. Shift invariance of complex shapes is obtained from the invariance of their constituent fragments. We study by simulations aspects of this shift invariance method and then consider its extensions to invariant perception and classification by brain-like structures.

Twisted collagen fibrils in acrocyanosis

Essential acrocyanosis (EA) present as a dusky discoloration of the hands as the sole symptom without any other abnormal results from laboratory investigation. Previously, the authors have found twisted collagen fibrils (TCF) in the normal skin of an EA patient. This study was intended to evaluate the significance of TCF in EA. Thirteen patients showing dusky discoloration were randomly selected and studied for TCF in normal skin by routine electron microscopy. TCF were found in 10 of 13 patients; 3 patients with only the discoloration (EA), 3 with the mild symptoms which were supposed to be Ehlers-Danlos syndrome (EDS), 1 with definite symptoms of EDS, 1 with Raynaud's disease and 2 with hyperglobulinemia. TCF were the ultrastructural sign for inherited malformation of collagen fibrils. EA was probably elucidated as a vascular disorder in TCF-carrying people. EA could be included in the disease category of EDS but it seems unreasonable to force EA patients into one of the subtypes of EDS. For pathogenesis, the inherited dysfunction in the hypertrophic pericytes of the subpapillary vascular plexus was presumed.

[Scleroderma--systemic sclerosis. Serology, lung function and survival]

Patients with systemic sclerosis (SSc) were studied with regard to the presence of antinuclear antibodies (ANA) and their clinical correlates (n = 230), pulmonary function (n = 176), and mortality and causes of death (n = 344). ANA were found in 85%. Anti-centromere antibodies were found in 34%, anti-Scl-70 antibodies in 13% and anti-U1-RNP antibodies in 6.5%. These serological groups were associated with limited SSc, diffuse SSc, and myositis/arthritis, respectively. The most prevalent finding at first lung function test was isolated reduction of diffusion capacity (47%). Further deterioration of diffusion capacity was related to the presence of anti-centromere antibodies and increased sedimentation rate. The standardized mortality rate (SMR) was 2.9, higher in young patients (SMR = 13) and patients with diffuse SSc (SMR = 4.5).

Mortality and causes of death of 513 Danish patients with systemic lupus erythematosus

A multicentre cohort of 513 clinic attenders with systemic lupus erythematosus (SLE) was retrospectively identified, representing 4185 patient-years of follow-up. Expected numbers of death were calculated by means of age- and sex-specific mortality rates of the general Danish population. The observed number of deaths was 122. The survival rates were 97%, 91%, 76%, 64% and 53% after 1, 5, 10, 15, and 20 years respectively. The overall mortality rate was 2.9% per year (95% CI 2.4-3.5), and the standardized mortality rate (SMR) was 4.6 (95% CI 3.8-5.5). The causes of death included active SLE (n = 19), end stage organ failure due to SLE (n = 16), infections (n = 25), malignancy (n = 9), cardiovascular disease (n = 32), and other causes (n = 21). SLE was directly related to one third of the excess mortality. In conclusion, SLE patients in the present cohort had a 4.6-fold increased mortality compared with the general population and half of the deaths were caused by SLE manifestations or infections, especially in young patients during the early period of the disease.

A multicentre study of 513 Danish patients with systemic lupus erythematosus. II. Disease mortality and clinical factors of prognostic value

In this Danish multicentre study, predictive clinical factors of mortality and survival were calculated for 513 patients with systemic lupus erythematosus (SLE), 122 of whom died within a mean observation period of 8.2 years equalling a mortality rate of 2.9% per year. Survival rates were 97%, 91%, 76% and 64% after 1, 5, 10 and 15 years, respectively. The direct causes of death included SLE (n = 35), infections (n = 25), malignancy (n = 9), cardiovascular disease (n = 32) and other causes (n = 21). Uni- and multivariate analyses of survival and mortality were performed for all deaths and for SLE-related deaths. Azotaemia (one-fifth of the patients) was a strong predictor of increased overall and SLE-related mortality, but nephropathy per se (one-half of the patients) and large proteinuria (one-sixth of the patients) were unrelated to survival. Haemolytic anaemia had a significant negative influence on survival related to mortality caused by infections. Diffuse central nervous system disease and myocarditis were related to increased SLE-related mortality, whereas photosensitivity predicted a decreased mortality. Non-fatal infections and thrombotic events predicted a decreased overall survival. Since 1980 the mortality caused by SLE manifestations has decreased significantly.

A multicentre study of 513 Danish patients with systemic lupus erythematosus. I. Disease manifestations and analyses of clinical subsets

A Danish multicentre study was undertaken of the manifestations, infections, thrombotic events, survival and predictive factors of survival in 513 Danish patients with systemic lupus erythematosus (SLE) according to the 1982 classification criteria of the American College of Rheumatology. The mean duration of follow-up was 8.2 years from diagnosis and 12.8 years from first symptom. This paper describes the most common clinical and laboratory manifestations and their relationship to sex and age at the time of onset and diagnosis. Cluster analysis revealed three clinically defined clusters at the time of disease onset. Cluster 1 (57% of patients) consisted of relatively elderly patients without nephropathy or malar rash, but with a high prevalence of discoid lesions. Cluster 2 (18%) consisted of patients with nephropathy, a third of whom also developed serositis and lymphopenia. The patients of the third cluster (25%) all had malar rash and half were photosensitive. Follow-up showed that the patients of cluster 2 developed azotaemia, large proteinuria, arterial hypertension and myositis significantly more often than did the rest of the patients, but the mortality was not increased. The risk of developing renal end-stage disease was highest in men with early-onset disease.

Oral iloprost in Raynaud's phenomenon secondary to systemic sclerosis: a multicentre, placebo-controlled, dose-comparison study

OBJECTIVE

To identify the optimal dose of oral iloprost on the basis of efficacy and tolerability in patients with Raynaud's phenomenon secondary to systemic sclerosis.

DESIGN

Multicentre, randomized, parallel-group comparison of two different doses of oral iloprost and placebo.

SETTING

European university hospitals.

PATIENTS

A total of 103 patients with Raynaud's phenomenon secondary to systemic sclerosis.

INTERVENTION

Patients received one of three treatments for 6 weeks: placebo, oral iloprost 50 microg or oral iloprost 100 microg. Each treatment was taken twice daily, giving total daily doses of iloprost of 100 and 200 microg.

MEASUREMENTS

The frequency, total daily duration and severity of Raynaud's attacks were recorded in a specially designed patient diary; physician's global assessment and adverse events were recorded at visits to the clinic. Analysis was performed on an intention-to-treat population.

RESULTS

A total of 103 patients were recruited, 89 completed the assessments throughout the treatment period and 82 completed an additional 6 weeks of follow-up after treatment. Thirty-five patients received placebo, 33 received iloprost 50 microg and 35 received iloprost 100 microg. The mean percentage reductions in the frequency, total daily duration and severity of Raynaud's attacks were numerically greater in the iloprost groups at the end of treatment and at the end of follow-up. At the end of treatment (6 weeks), there were significant treatment differences in the total daily duration of attacks (P = 0.03), but not in the severity (P = 0.07) or the frequency of attacks (P = 0.37). At the end of follow-up (12 weeks), there were significant treatment differences in the total daily duration of attacks (P = 0.001) and in the severity of attacks (P = 0.007), but not in the frequency of attacks (P = 0.07). Percentages of patients improved at the end of treatment as assessed by the physician were 44% placebo, 57% iloprost 50 microg and 64% iloprost 100 microg (not significant). Side-effects were reported by 80% of patients on placebo, 85% on oral iloprost 50 microg and 97% on oral iloprost 100 microg. Premature discontinuations of treatment in each group were 9, 30 and 51%, respectively, with 6, 27 and 51% being due to adverse events.

CONCLUSION

The results on the daily duration of Raynaud's attacks suggest that both 50 and 100 microg oral iloprost twice daily may be effective in the treatment of Raynaud's phenomenon secondary to systemic sclerosis. The 50 microg iloprost dose was better tolerated in this patient group.

Mortality and causes of death of 344 Danish patients with systemic sclerosis (scleroderma)

OBJECTIVE

To determine survival, mortality and causes of death in Danish patients with systemic sclerosis (scleroderma), and to analyse how these parameters are influenced by demographic variables and the extent of skin involvement.

METHODS

A cohort of 344 patients with incident systemic sclerosis (SSc) after 1 January 1960 was retrospectively identified, representing 3716 patient-years of follow-up. The vital status at the end of the study ultimo 1996 was established by reviewing the clinical charts and by contacting the Danish Central Person Register. The causes of death were based on information obtained from the hospital charts and the autopsy reports (80%) and death certificates (20%). The extent of skin sclerosis was described by means of a two-subset model (limited and diffuse involvement) and a three-subset model (digital, extremity and truncal involvement) in all patients. Expected numbers of deaths were calculated by means of age- and sex-specific mortality rates of the general Danish population.

RESULTS

Crude mortality rates were 6.5 and 3.9%/yr, respectively, in men and women. The standardized mortality ratio (SMR) was 2.9 (95% CI 2.5-3.4) and was not significantly influenced by sex or age at disease onset. Mortality rates were significantly increased in patients with diffuse skin sclerosis (SMR 4.5, 95% CI 3.5-5.7) and patients under the age of 35 yr (SMR 13, 95% CI 2.7-37). Of the 160 patients who died during the study, 41 deaths (26%) were SSc related, accounting for one-third of the excess mortality.

CONCLUSION

We found a significantly increased mortality in patients with SSc, particularly in the subset of patients with diffuse skin sclerosis and in young patients. The excess mortality was due to an increase in both the SSc-related mortality and the unrelated mortality. However, all other subsets also had a significantly increased risk of death, mainly due to an increased risk of death due to causes unrelated to SSc, cancer among others. The fact that the unrelated mortality in SSc was found to be 2-fold increased suggests that the excess mortality that was classified as unrelated should more appropriately be termed indirectly SSc related.

Three-dimensional object recognition based on the combination of views

Visual object recognition is complicated by the fact that the same 3D object can give rise to a large variety of projected images that depend on the viewing conditions, such as viewing direction, distance, and illumination. This paper describes a computational approach that uses combinations of a small number of object views to deal with the effects of viewing direction. The first part of the paper is an overview of the approach based on previous work. It is then shown that, in agreement with psychophysical evidence, the view-combination approach can use views of different class members rather than multiple views of a single object, to obtain class-based generalization. A number of extensions to the basic scheme are considered, including the use of non-linear combinations, using 3D versus 2D information, and the role of coarse classification on the way to precise identification. Finally, psychophysical and biological aspects of the view-combination approach are discussed. Compared with approaches that treat object recognition as a symbolic high-level activity, in the view-combination approach the emphasis is on processes that are simpler and pictorial in nature.

Clinical features and serum antinuclear antibodies in 230 Danish patients with systemic sclerosis

The objective was to investigate the relationship between the presence of different types of antinuclear antibodies (ANA) in patients with systemic sclerosis (SSc) and the presence of clinical features. Sera from 230 patients with SSc were tested for the presence of ANA, including anticentromere antibodies (ab), antitopoisomerase I ab, anti-U1 RNP ab and antinucleolar ab, including anti-Th RNP, anti-U3 RNP and anti-U17 RNP. Clinical features were registered prospectively in a clinical database. Eighty-two per cent of the patients were women. The median age was 58 yr (45-67, quartiles) and median age at disease onset was 44 (30-55) yr. ANA were found in 86% of the patients (anticentromere: 34%; antitopoisomerase I: 14%; anti-U1 RNP: 6.5%; antinucleolar total: 16%; anti-Th RNP: 2.2%; anti-U3 RNP: 3.5%; anti-U17 RNP: 0%). Anticentromere ab were found to be related to a high prevalence of calcinosis, telangiectasia, digital ulcers, acrosclerosis, primary biliary cirrhosis, isolated reduction of pulmonary diffusing capacity, and a low prevalence of radiological evidence of pulmonary fibrosis. Antitopoisomerase I ab were associated with a high prevalence of digital joint deformity, distal osteolysis, radiological signs of pulmonary fibrosis, a low prevalence of calcinosis and late onset of disease. Anti-U1 RNP ab were related to a high prevalence of arthritis and myositis, a low prevalence of calcinosis, and early disease onset. The presence of antinucleolar ab, including anti-U3 RNP and anti-Th RNP, was not significantly related to any particular clinical features in this study; possibly due to the small number of patients with these ab. The presence of anticentromere, antitopoisomerase I and anti-U1 RNP ab in the serum was also found to have previously described clinical correlations in a group of Danish SSc patients.

Elastic fibers in dermis of juvenile elastoma

To explore the ultrastructure of elastic fibers in juvenile elastoma, three patients (two without osteopoikilosis and one under examination of bones and joints) were studied by routine electron microscopy. In addition to normal elastic fibers, all the patients also exhibited alterations in elastic fibers. The altered ultrastructures showed lucent, homogenous matrix without peripheral microfibrils. The homogenous matrix were seen in various extensions from the small protrusions of the normal elastic fibers to the complete replacement of the entire fibers. Collagen fibrils occasionally showed twisted figures. Normal shapes of dermal glycosaminoglycans were increased in number. It seems likely that the lucent, homogenous matrix without peripheral microfibrils are the characteristic changes of elastic fibers in juvenile elastoma. The alteration could be nevoid in nature.

A longitudinal study of pulmonary function in Danish patients with systemic sclerosis

OBJECTIVE

To determine the types, prevalence and development of respiratory abnormalities in patients with systemic sclerosis (SSc), and to correlate the results with clinical and serological findings.

METHODS

176 patients with SSc observed longitudinally were retrospectively included in the study. The change per year of vital capacity (VC), forced expiratory volume in one second/vital capacity (FEV1/VC), diffusing capacity (DLco) and diffusing constant (Kco) of carbon monoxide from the first till the latest pulmonary function test were correlated to clinical and serological findings, including anti-centromere, anti-Scl-70, and antinucleolar antibodies.

RESULTS

An isolated reduction of DLco was seen in 47% and a restrictive ventilatory pattern in 25% of the patients. Restrictive ventilatory pattern correlated to pulmonary fibrosis, dyspnoea, a low prevalence (13%) of anti-centromere antibodies and a high prevalence of anti-Scl-70 antibodies (36%). Progression of DLco reduction was related to long disease duration, presence of anti-centromere antibodies and absence of treatment with penicillamine.

CONCLUSION

Pulmonary involvement is common in patients with SSc. The occurrence of different serological abnormalities in patients with restrictive disease and in patients with progressive isolated reduction of DLco, suggests that the two types of pulmonary damage may have different pathogeneses rather than being different stages in the progression of pulmonary damage.

Clinical evidence for hepatitis B transmission resulting from corneal transplantation

PURPOSE

Two cases of hepatitis B virus (HBV) infection after penetrating keratoplasty are presented.

METHODS

An extensive clinical and serologic investigation of these two transplant recipients was performed. In addition, the medical histories, autopsy reports, and specimens of blood from the two deceased corneal tissue donors were retrieved and studied.

RESULTS

Serum from both donors was positive for hepatitis B surface antigen; the clinical history and serologic testing of both recipients strongly suggest that the HBV infection in each case was acquired from donor corneal tissue.

CONCLUSION

To our knowledge, these are the first documented cases of HBV infection after corneal transplantation. Eye banks should continue to screen donors for HBV.

Low-level aspects of segmentation and recognition

This paper discusses two problems related to three-dimensional object recognition. The first is segmentation and the selection of a candidate object in the image, the second is the recognition of a three-dimensional object from different viewing positions. Regarding segmentation, it is shown how globally salient structures can be extracted from a contour image based on geometrical attributes, including smoothness and contour length. This computation is performed by a parallel network of locally connected neuron-like elements. With respect to the effect of viewing, it is shown how the problem can be overcome by using the linear combinations of a small number of two-dimensional object views. In both problems the emphasis is on methods that are relatively low level in nature. Segmentation is performed using a bottom -up process, driven by the geometry of image contours. Recognition is performed without using explicit three-dimensional models, but by the direct manipulation of two-dimensional images.

Follow-up of 151 patients with high-titer U1RNP antibodies

We performed a longitudinal follow-up study of clinical findings in 151 patients with high-titer antibodies against U1 ribonucleoprotein (U1RNP) as measured by haemagglutination. Formal connective tissue disease (CTD) diagnoses were assigned and diagnostic transitions analysed. One-hundred eighteen females and 33 males entered the study; the mean duration of follow-up was 7.1 years. Mean age at entry was 34.7 years; 73% of the patients had early disease (duration < 2 years). Fifty-six patients (37%) presented with a definite diagnosis, most often mixed connective tissue disease (MCTD, n = 40), followed by systemic lupus erythematosus (SLE, n = 11) and systemic sclerosis (SSc, n = 5). Of 84 patients (56%) presenting with nonspecific symptoms of possible, "undifferentiated" CTD, 58 developed MCTD, 4 SSc and 2 SLE. By the end of the follow-up period. 127 patients had developed a well-defined CTD; final diagnoses were: MCTD (n = 97), SLE (n = 18), SSc (n = 12). We conclude that CTD in the context of high-titer anti-U1RNP antibodies may be transitive and sequential in nature, although the diagnostic criteria for MCTD previously proposed by our group seem to delimit a clinically stable condition in most patients in this subgroup.

Generalization to novel images in upright and inverted faces

An image of a face depends not only on its shape, but also on the viewpoint, illumination conditions, and facial expression. A face recognition system must overcome the changes in face appearance induced by these factors. Two related questions were investigated: the capacity of the human visual system to generalize the recognition of faces to novel images, and the level at which this generalization occurs. This problem was approached by comparing the identification and generalization capacity for upright and inverted faces. For upright faces, remarkably good generalization to novel conditions was found. For inverted faces, the generalization to novel views was significantly worse for both new illumination and viewpoint, although the performance on the training images was similar to that on the upright condition. The results indicate that at least some of the processes that support generalization across viewpoint and illumination are neither universal (because subjects did not generalize as easily for inverted faces as for upright ones) nor strictly object specific (because in upright faces nearly perfect generalization was possible from a single view, by itself insufficient for building a complete object-specific model). It is proposed that generalization in face recognition occurs at an intermediate level that is applicable to a class of objects, and that at this level upright and inverted faces initially constitute distinct object classes.

Spatial context in recognition

In recognizing objects and scenes, partial recognition of objects or their parts can be used to guide the recognition of other objects. Here, the role of individual objects in the recognition of complete figures and the influence of contextual information on the identification of ambiguous objects were investigated. Configurations of objects that were placed in either proper or improper spatial relations were used, and response times and error rates in a recognition task were measured. Two main results were obtained. First, proper spatial relations among the objects of a scene decrease response times and error rates in the recognition of individual objects. Second, the presence of objects that have a unique interpretation improves the identification of ambiguous objects in the scene. Ambiguous objects were recognized faster and with fewer errors in the presence of clearly recognized objects compared with the same objects in isolation or in improper spatial relations. The implications of these findings for the organization of recognition memory are discussed.

Ulcerated haemangioma successfully treated with interferon alfa-2b and topical granulocyte-macrophage colony-stimulating factor

OBJECTIVE

We tested whether healing and regression could be promoted by granulocyte-macrophage colony-stimulating factor and interferon in a 6-month-old girl with an ulcerated haemangioma resistant to systemic steroid therapy.

METHODS

Interferon alfa-2b (Introna, Schering-Plough) was given subcutaneously once daily at a dose of 3 million units/m2 for 5.5 months and rhGM-CSF (Molgramostim, Leucomax; Sandoz/Schering-Plough) 3.33 units was applied on the wound surfaces once and concomitantly with the initiation of interferon therapy.

RESULTS

The ulcer healed completely within 1 month and the haemangioma almost totally regressed within 6 months.

CONCLUSION

Local application of rhGM-CSF appears to be effective in promoting ulcer healing in an ulcerated haemangioma otherwise responding to interferon treatment.

Sequence seeking and counter streams: a computational model for bidirectional information flow in the visual cortex

A computational model is proposed for some general aspects of information flow in the visual cortex. The basic process, called "sequence seeking," is a search for a sequence of mappings, or transformations, linking source and target patterns. The process has two main characteristics: it is bidirectional, bottom-up as well as top-down, and it explores in parallel a large number of alternative sequences. This operation is performed in a "counter streams" structure, in which multiple sequences are explored along two complementary pathways, an ascending and a descending one, seeking to meet. A biological embodiment of this model in cortical circuitry is proposed. The model serves to account for known aspects of cortical interconnections and to derive new predictions.

Fractionated epibulbar I-125 plaque radiotherapy for recurrent mucoepidermoid carcinoma of the bulbar conjunctiva

PURPOSE/METHODS

A patient with recurrent conjunctival mucoepidermoid carcinoma was treated successfully with surgical excision of the tumor and fractionated epibulbar I-125 plaque radiotherapy.

RESULTS/CONCLUSIONS

Local excision with fractionated epibulbar plaque radiotherapy is an effective means of eradication in select cases of recurrent mucoepidermoid carcinomas of the conjunctiva. This treatment may avoid more aggressive surgical treatment and preserve vision.

Screening for autoantibodies to the nucleolar U3- and Th(7-2) ribonucleoproteins in patients' sera using antisense riboprobes

In this study we report the detection of autoantibodies to the nucleolar U3- and Th(7-2) ribonucleoprotein (RNP) particles in sera from patients with connective tissue diseases. The method described employs radioactively labelled antisense U3- and Th RNA which are hybridized to immunoprecipitated U3- or Th RNA from a HeLa cell extract. Of the 66 sera that were screened with this method seven sera (11%) precipitated only Th RNP, 16 sera (24%) precipitated only U3 RNP and 4 sera (6%) precipitated both U3- and Th RNP. Both anti-U3 RNP and anti-Th RNP activity appeared to be mostly associated with scleroderma or scleroderma-associated diseases. Using this method we also showed that some of the Th RNP particles in a cell extract are associated with the La autoantigen. We conclude that for the identification of immunoprecipitated RNAs this method is very sensitive and provides unambiguous data.