The Regulation of Cell Therapy and Gene Therapy Products in Switzerland

This chapter describes the regulation of cell and gene therapy products (CGTPs) in Switzerland and its legal basis. The Swiss Agency for Therapeutic Products, Swissmedic, is the lead Regulatory Authority and its ATMP Division is responsible for the regulation of these products at the level of clinical trials and marketing authorization. CGTPs are regulated similarly to medicinal products. The legal basis is set by the Therapeutic Product Act, the Transplantation Act, the Human Research Act, and associated ordinances. The ATMP Division is involved in processes such as scientific advice meetings, presubmission advice meetings, pharmacovigilance, market surveillance, import/export approvals, manufacturing license approval, and inspections. In Switzerland, guidance documents relevant for cell and gene therapy provided by PIC/S, OECD, ICH, Ph.Eur., EMA, or FDA are considered. In order to harmonize requirements for CGTPs, the ATMP Division is in constant exchange of information with foreign Regulatory Authorities and part of working groups of ICH, IPRP, and Ph.Eur. As CGTPs are biologically and technically complex, a risk-based approach is applied on a case-by-case basis for the evaluation of clinical trial and marketing applications. A substantial part of this chapter will provide requirements with respect to the manufacturing and quality, nonclinical and clinical evaluation of CGTPs. Furthermore, information will be provided regarding the use of real-world evidence in evaluation of clinical long-term efficacy and safety in case of rare diseases where the numbers of patients are too small for statistically meaningful analysis during clinical trials. Finally, the chapter will provide information on a health technology assessment (HTA) program that was launched in 2015 in Switzerland by the federal authorities.

[Controlled trials on the efficacy of occupational therapy with elderly. Part I: Research question, search strategy and methodological quality of trials]

OBJECTIVE

To investigate how far controlled trials give evidence for the assumption that occupational therapy treatment improves or stabilises the competence, autonomy or satisfaction of elderly while performing every day activities.

METHOD

Clinical trials with randomised, quasi-experimental or crossover control group design and "occupational therapy" as the main subject were identified by an electronic search of the medline database. The criteria for the analysis were derived from the CONSORT-Statement and adapted for occupational therapy. They relate to the quality of sample, intervention, measurement and data analysis.

RESULTS

The 31 identified studies (RCT, n=23; quasi-experimental, n=2; crossover, n=6) were mainly conducted in Great Britain, USA and Canada, but not in Germany. They are heterogeneous regarding the characteristics and size of samples, the outcome variables and treatment approaches. They give evidence for a significant efficacy of occupational therapy with elderly, but also show some methodological shortcomings.

CONCLUSION

While on an international level the positive potential of occupational therapy for the elderly is evident, there is a strong need for further studies in Germany. Therefore a methodological harmonization and a co-operation with occupational therapy research and occupational science emerging currently in Europe are recommended.

Kontrollierte Studien zur Wirksamkeit von Ergotherapie bei �lteren

OBJECTIVE

To identify the evidence for the efficacy of occupational therapy on prioritized diseases and disabilities of the elderly.

METHOD

Reviews, meta-analyses and clinical trials with control group design regarding "occupational therapy" were identified by an electronic search of pubmed and reviewed based on the CONSORT-Statement. The study results were summarised in regard to diseases and commented considering further literature.

RESULTS

A total of 31 studies were identified: 10 on stroke, 6 on dementia, 5 on prevention of falls, growing loneliness or inactivity, 4 on need of nursing care, and 6 on other diseases or disabilities. There is evidence for a positive efficacy of occupational therapy on the level of several controlled trials or reviews.

CONCLUSION

Especially in Germany, further research specific to occupational therapy is needed in the fields of depression, diabetes mellitus and nursing care in the community.

Development of an in vitro model to study oxidative DNA damage in human coronary artery endothelial cells

The endothelial cell layer is a multifunctional barrier between the blood stream and the vascular wall. Reactive oxygen species can damage endothelial cells and may so potentiate atherosclerotic lesion formation. Therefore, we established an in vitro model for the qualitative and quantitative investigation of oxidative DNA damage and repair in human coronary arterial endothelial cells (CAEC). Oxidative DNA damage was induced by standardised treatment with 50-400 microM hydrogen peroxide (H(2)O(2)). The amount of DNA damage was quantified by determination of DNA single strand breaks (SSB) and alkali-labile sites in individual cells, using the alkaline single-cell gel electrophoresis assay--"comet assay". Significant DNA damage could be induced reproducibly in CAEC cells after exposure to 50 microM H(2)O(2) for 10 min. Additional treatment with catalase prevented DNA damage by H(2)O(2). The time needed for DNA repair depended on the initial grade of damage. After 30 min post-incubation at 37 degrees C, DNA damage was completely repaired in cells treated with 50 microM H(2)O(2). Cell samples initially damaged with H(2)O(2) concentrations between 100 microM and 400 microM were repaired after 60 min. This endothelial cell culture model allows experiments on oxidative DNA damage, alteration, and repair directly on the relevant target cells. Animals are used neither as direct objects of such experiments nor as cell or tissue donors.

[The Indicators of Rehab Status questionnaire version 3 (IRES-3) in 1818 rehabilitees with musculoskeletal Diseases]

OBJECTIVES

The revised version 3 of the questionnaire "Indicators of Reha Status" (IRES-3) was recently tested and introduced to the scientific community. The IRES-3 differs considerably from the previous version. It now comprises 16 multi-item scales that are combined to 6 dimensions and 3 single items that are combined to a 7th dimension. The aim of the study was to receive a further impression of the psychometric properties of the IRES-3 in a clinical population.

METHODS

1818 patients with musculoskeletal diseases from 10 rehabilitation hospitals completed the questionnaire at admission and at discharge. In addition to descriptive statistics (scale properties, internal consistency, sensitivity to change) logistic regression models were used to analyse the characteristics of patients in comparison to a random sample drawn from the general population.

RESULTS

From a psychometric point of view the scale properties are sound. The internal consistency of the multi-item scales ranges from Cronbach's alpha = 0.77 to 0.93. The sensitivity to change ranges from SRM = 0.03 to 1.00. All scales of the IRES-3 are able to discriminate between the clinical and the general population. In all scales the clinical population demonstrated a higher level of burden than the general population.

CONCLUSIONS

In our clinical population we were able to reproduce the measurement properties as reported by the authors of the IRES-3. The scales of the IRES-3 demonstrate good internal consistency and respond to change. A high discriminative validity of the instrument could be demonstrated. To further test the instrument the formation of dimensions by the authors of the IRES-3 has to be awaited.

Influence of operation duration on perioperative morbidity in revision total hip arthroplasty

This retrospective study investigated the impact of patient and procedure-related parameters on the complication rate following revision total hip arthroplasty. Complications included vessel and nerve damage, periprosthetic femoral fracture, wound infection, wound bleeding, prosthesis dislocations, thromboembolism, cardiac and pulmonary complications, and death. The influence of operation duration, gender, revision status, ASA classification, and type of fixation of the primary implant on the perioperative morbidity was investigated in a sample of 60 revision procedures (cemented stems, cemented or cementless cups). Odds ratio [OR] and 95% confidence interval [CI] were estimated with multiple regression models. Perioperative morbidity was significantly correlated to operation duration (OR = 1.03; CI: 1.00-1.05), but not to age (OR = 1.01; CI: 0.93-1.09), gender (OR = 2.66; CI: 0.50-14.05), revision status (OR = 2.34; CI: 0.54-10.05), ASA classification (OR = 1.24; CI: 0.30-5.18), or type of fixation of the primary implant (OR = 2.49; CI: 0.47-13.17) Duration of the revision operation appeared as a predictive parameter for perioperative morbidity in revision total hip arthroplasty in our study group.

Elements of fibromyalgia in an open population

OBJECTIVE

To examine the nosological concept of fibromyalgia in the general population.

METHODS

A postal survey of rheumatic pain and non-specific bodily complaints was sent to all 3174 German female residents of Bad Säckingen, Germany, aged 35 to 74 yr. A stratified random sample of 653 subjects was further examined in a clinical survey.

RESULTS

On the population level the point prevalence of chronic widespread pain was 13.5%. In the clinical survey, tender point count was associated not only with the extent of rheumatic pain, but also independently with the extent of bodily complaints. Subjects with no history of rheumatic pain but with non-specific bodily complaints had as many positive tender points as subjects without bodily complaints but with a history of rheumatic pain. Subjects could be identified who met the tender point criterion of the ACR without a history of widespread pain. Multivariate analyses demonstrated that some symptoms carry a risk for positive tender points (low physical mobility, pain, bodily complaints) and some for chronic widespread pain (poor health status, catastrophizing, emotional reactions, low energy level, sleep disturbances) that are independent of each other and of age.

CONCLUSIONS

The results do not only question the relevance and specificity of a history of widespread pain in diagnosing fibromyalgia, but also the concept of fibromyalgia as a distinct rheumatological disorder. The results support the concept of fibromyalgia as part of a wider spectrum of dysfunctional syndromes.

[Sociodemographic characteristics, risk factors and reproductive history in subjects with fibromyalgia--results of a population-based case-control study]

OBJECTIVES

According to recent studies, 1.3 to 4.8% of the population of Western industrialized nations suffer from fibromyalgia, with 80 to 90% of the affected persons being women. This preponderance of women, mostly in their reproductive years, suggests an association between fibromyalgia and sex hormones.

METHODS

Within the framework of a population-based cross-sectional study of 3174 female residents of Bad Säckingen aged 35 to 74 years a stratified random sample of 653 women was clinically examined and surveyed. Thirty-six of these women fulfilled the ACR criteria of fibromyalgia. Forty-four women suffered from chronic widespread pain without having fibromyalgia (chronic pain group); 408 had no chronic pain (controls).

RESULTS

Compared to the control group, subjects with fibromyalgia have a 3.6-fold risk, while compared to the chronic pain group, there is a 3.9-fold risk of having a lower social level. Subjects with fibromyalgia drink less alcohol than subjects from the chronic pain group and the control group. After adjusting for age, multivariate analyses demonstrated that, in comparison to controls, subjects with fibromyalgia have a significantly later menarche (OR=2.2 for >14 years) and had never been pregnant (OR=0.3). The comparison of the chronic pain group and controls did not demonstrate these associations.

CONCLUSIONS

The associations with a low social level, low alcohol intake, late menarche and rare pregnancies are specific for subjects with fibromyalgia. These factors distinguish subjects with fibromyalgia from subjects with other chronic pain conditions as well as from subjects with no chronic pain. The same hormonal factors responsible for a delayed menarche and a reduced fertility may be relevant in the development of fibromyalgia.

[The occupational therapy assessment: implementation in practice]

The "Ergotherapeutische Assessment" (EA, occupational therapy assessment instrument) is designed as a generic instrument assessing disabilities with consequences on everyday life. It is tested for its practicability and measurement properties and suitable for adult patients treated with occupational therapy. It can be used for routine documentation, as a result-indicator for data based quality management and in outcome research. The EA is integrated in an assessment network currently in development intended for occupational therapy, physiotherapy, speech therapy and, optionally, for further professions. The profession-specific approach should enhance the intrinsic motivation for self-evaluation and thus the learning organisation.

Reduction of post injury neointima formation due to 17beta-estradiol and phytoestrogen treatment is not influenced by the pure synthetic estrogen receptor antagonist ICI 182,780 in vitro

BACKGROUND

Animal and organ culture experiments have shown beneficial inhibitory estrogen effects on post injury neointima development. The purpose of this study was to investigate whether such estrogen effects are influenced by the estrogen receptor antagonist ICI 182,780. Different concentrations of 17beta-estradiol and the phytoestrogens genistein and daidzein were tested.

METHODS

Female New Zealand White rabbits were benumbed. In situ vascular injury of the thoracic and abdominal aorta was performed by a 3F Fogarty catheter. Segments of 5 mm were randomised and held in culture for 21 days. Three test series were performed: 1) control group--20 microM ICI--30 microM ICI--40 microM ICI. 2) control group--20 microM ICI--40 microM 17beta-estradiol--40 microM 17beta-estradiol + 20 microM ICI. 3) control group--20 microM ICI--40 microM daidzein--40 microM daidzein + 20 microM ICI--20 microM genistein--20 microM genistein + 20 microM ICI. After 21 days the neointima-media-ratio was evaluated.

RESULTS

1) Treatment with ICI 182,780 did not reduce neointima formation significantly (p = 0.05). 2) 40 microM 17beta-estradiol alone (p < 0.0001) and in combination with 20 microM ICI (p < 0.0001) reduced neointima formation significantly. 3) 20 microM genistein alone (p = 0.0083) and combined with 20 microM ICI (p = 0.0053) reduced neointima formation significantly. 40 microM daidzein did not have a significant (p = 0.0637) effect.

CONCLUSIONS

The estrogen receptor antagonist ICI 182,780 did not modulate the inhibitory estrogen effects on post injury neointima formation. These results do not support the idea that such effects are mediated by vascular estrogen receptors.

[Psychometric analyses of occupational therapy assessment]

PURPOSE

In German-speaking countries standardised assessments measuring the specific aspects of occupational therapy in adults are missing. The Occupational Therapy Assessment (OTA) was introduced by the authors during 2000 in the context of a field study regarding acceptance, practicability and the influence of the instrument on process quality. The purpose of this study was to test the psychometric properties of the OTA.

METHODS

: OTA was applied by 76 occupational therapists from 44 institutions to 833 consecutive patients. Additionally, the Mini Mental State Examination (MMSE) was applied. Patients completed established German instruments measuring functional capacity (Funktionsfragebogen Hannover - polyartikuläre Erkrankungen; FFbH-P), body complaints (Beschwerdenliste; BL) and general health (Indikatoren des Reha-Status; IRES). 59 randomly selected patients were assessed independently by two therapists. 42 randomly selected patients were assesses twice for test-retest reliability.

RESULTS

: For the domains 'activities of physical self-supply', 'activities of independent living', and the three domains 'consequences of sensomotor/neuropsychological/psychosocial functioning on everyday life' internal consistency (Cronbach alpha: 0.90-0.97), test-retest reliability (intraclass correlation coefficient: 0.93-0.99) and interrater reliability (kappa: 0.72-0.82) were high. Overall, the concurrent validity of the domains with corresponding scales or subscales of the MMSE, FFbH-P and IRES is satisfactory. In addition, the domains are sensitive to change.

CONCLUSION

: The OTA is a standardised assessment measuring the specific aspects of occupational therapy reliably, valid, sensitive to change and sufficiently comprehensive.

[Epidemiology in the study of human ecology - concept and evaluation of a seminar]

BACKGROUND

To assure proper methodology in medical studies epidemiology is the crucial profession. Medical students become acquainted with epidemiology within the course on human ecology. One year ago our department had the opportunity to assume the responsibility of this epidemiological seminar and to establish an activating teaching concept.

IMPLEMENTATION

In a two hour lecture, types of epidemiologic studies, their application, typical measures, strengths and limitations are illustrated on actual examples. The basic concepts of bias, confounding and causal inference are introduced. In a two hour seminar the students read and discuss primary literature on the question "Do allergic diseases increase?" in small groups. The students present the answers on provided questions in the plenum. The results are discussed together. METHOD OF EVALUATION: At the end of each seminar within the course students rate the structural and procedural quality by means of a questionnaire.

RESULTS

Compared to the former frontal teaching in epidemiology students rate the activating teaching concept significantly better in respect to lecturing style, discussion moderation, own contribution, contribution of others and course material. Comparison to the seminar "National health reporting system" (different subject, but same teaching concept and same instructor) yielded no significant differences, nor did the comparison between different instructors with the same teaching concept at the same seminar.

CONCLUSIONS

The structural and procedural quality of the activating teaching concept in epidemiology is rated significantly better than the former frontal teaching concept. This difference is based on conceptual differences and not on different instructors or different subjects.

[The social security system as a topic in medical education. Own experiences and description of student's contribution]

INTRODUCTION

The special subject "sociomedicine", as defined for medical students in "items to which the written examination in the second part of the medical examination can relate" has been taught by this department for 25 years as part of the course on medical ecology. There are 4 lectures (structure of the health care system; preventive care by doctors in the community and at the place of work; introduction to health economy; introduction to epidemiology) and the following seminars in small groups: social security systems; health insurance; excursion to a rehabilitation hospital; health reporting; epidemiology. The topics are presented and taught with emphasis on didactically useful and local examples.

METHODS

To ensure student participation "personal data" were introduced: Students give short reports on topics presented to them or they have to formulate questions to the topic of the seminar, questions or subjects to be dealt with. The questions concerning "social security systems" and "health insurance", collected over a 6 year period, were analyzed.

RESULTS

Initially, the subject "sociomedicine" is not much appreciated by the students. The analysis shows what students think when they are challenged. The spectrum of questions mainly reflects the discussion in the media: Finance and benefits predominate, also budget and misuse, especially with reference to old-age pension and health insurance. Questions related to specific medical functions as e. g. medical expert opinion, are less often raised. However, topics such as "expansion of preventive measures", "chip card and utilisation" and "unconventional methods" are often addressed. A special demand for personal advice is seen during small talk discussions in intermissions (health insurance).

CONCLUSION

The topics "medical expert opinion" and "comparison of public and private health insurance" have become positive knowledge required for the examination and for practising the medical profession. With these subjects as a starting point it appears easier for us to describe the relevant institutions and structures and the general principles of solidarity.

[Ergotherapy assessment: field study of acceptance, practicability and process quality]

There is need for comprehensive assessment of patients suitable for occupational therapy. The "Ergotherapeutische Assessment" (EA) occupational therapy assessment instrument has been developed recently by a group of experts in the field. Its main purpose is to significantly support occupational therapists in diagnostics, planning, communication and evaluation of therapeutic outcome. In a first step, EA was tested in a field study with regard to practicability, acceptance, and its effects on process quality. The EA was applied in 329 patients by 22 occupational therapists (office, institution) who had been specially trained (handbook, instruction session) prior to the study. In addition, participants had to answer standardized evaluation forms with respect to the general therapeutic success, relevant functional changes possibly not covered by the EA, and professional benefit in the areas under investigation. In summary, the value for practicability as described using a 10-point scale was 5.8, and 7.6 for acceptance. With regard to process quality, the ratings were 7.3 for diagnostic effect, 6.0 for definition of therapeutic aims, and 6.8 for improvement of communication between members of the rehabilitation team. The internal consistency of the five individual modules of the instrument as calculated by Cronbachs alpha was between 0.72 and 0.95. Changes considered relevant by the participants and not reflected by the instrument accounted for 9% only. The correlation coefficient for the evaluated general success of the patients and category changes found on the basis of EA severity ratings was 0.48.

[The North American Spine Society Lumbar Spine Outcome Assessment Instrument: translation and psychometric analysis of the German version in rehabilitation patients with chronic back pain]

The "Lumbar Spine Outcome Assessment Instrument", developed by the North American Spine Society (NASS), was translated into German. Its psychometric properties were tested in a group of rehabilitation patients with chronic, unspecific back pain, and in a comparison group of patients in cardiologic rehabilitation. With a Cronbach's alpha of 0.92, internal consistency was high. Principal component analysis revealed that the German version of the NASS instrument surveys the factors "back pain", "neurologic symptoms", and "impairments". A strong correlation with other measures of functional impairment (FFbH-R, IRES) indicates a high concurrent validity of the NASS instrument. After three weeks of inpatient rehabilitation, sensitivity to change could be demonstrated for the summary score of the instrument. This significant change was primarily due to moderate effects in the factor "back pain". In our study population, the factor "impairments" did not show a significant change. On the basis of these results, the German version of "The North American Spine Society Lumbar Spine Outcome Assessment Instrument" can be described as a reliable and valid instrument for measuring back pain, related neurologic symptoms, and back pain-induced impairments in rehabilitation patients. Because the factor "impairments" is not sensitive to change within three weeks of rehabilitation, the instrument is only partly suitable for measuring short-term outcome in rehabilitation patients. Further research is needed to determine if the instrument is useful for middle- and long-term outcome measurement in rehabilitation.

[Prevalence of low back pain in the population]

Studies on selected populations lead to biased estimates of the prevalence of back pain and associated factors. In order to obtain a valid picture of the prevalence of back pain this review article focuses on epidemiological studies in the general population. These studies can be divided into general health surveys and surveys with specific reference to back pain. General health surveys including questions on the prevalence of back pain have the greatest methodological differences because of different aims. Due to these different aims, different target populations and different methods these studies depict point prevalences between 0.8% and 41% and 1-year prevalences between 15% and 56%. These general health surveys are contrasted with epidemiological studies especially designed to evaluate the prevalence of back pain. In these studies the point prevalence ranges between 14% and 42% and the lifetime period prevalence between 51% and 84%. Depending on the study reviewed the highest prevalence is found at age 50 to 64. This prevalence pattern may be explained by several effects that are discussed in this article. Severe forms of back pain increase even in the higher age groups, especially in women. Beside this effect the reviewed articles show either no difference between men and women or only a slightly higher prevalence in women. The problems faced by epidemiological studies on back pain, resulting from different definitions of "the back", severity, chronicity and different methodology, are discussed in detail.

[Patient satisfaction in rehabilitation of musculoskeletal diseases--effect of patient characteristics, treatment, evaluation schedule and correlation with treatment outcome]

Within quality assurance in medical rehabilitation, patient satisfaction is viewed as one of the essential features. Patient satisfaction is expected to comprehensively cover structure, process and outcome quality. The aim of our study was to evaluate factors on which patient satisfaction with the rehabilitation measure depends. Sociodemographic factors, diagnosis at admission, characteristics of treatment, and the time of evaluation were considered. Furthermore, we examined whether four orthopedic-rheumatologic rehabilitation hospitals differ in respect of patient satisfaction and how patient satisfaction is associated with the result of treatment. Data collection was conducted in four German rehabilitation hospitals. Patient satisfaction was assessed in 1832 patients with an orthopedicrheumatologic disease as first diagnosis three months after discharge, using a postal questionnaire (Raspe et al. 1996). Additionally, 153 patients were assessed at the end of the rehabilitation measure. Besides the satisfaction with the treatment, its result was documented for 100 patients. For all sections of the questionnaire no or small differences could be demonstrated with respect to gender, age, education, and diagnosis. The questionnaire can differentiate between treating physicians and hospitals. The time of questioning had no influence. No relevant correlation existed between patient satisfaction and result of the treatment. The questionnaire assessing patient satisfaction can be applied with little expenditure. The acceptance is high. The questionnaire can assess the current status of many areas of rehabilitation practice, so that quality assurance measures could be introduced immediately. A comparison between hospitals is possible and reveals strengths and weaknesses. Thus, the questionnaire may be used as a quality assurance measure for hospitals and for health care providers. This tool may be used routinely for monitoring and for longitudinal evaluations.

[Biochemical changes in fibromyalgia]

Different changes in neurotransmitters were observed in patients with fibromyalgia. The aim of the study was to confirm the diagnosis fibromyalgia by determination of several of these substances. In 60 patients, who met the ACR classification criteria for fibromyalgia and in 20 sex and age matched controls the following estimations were made: serotonin (EIA), somatomedin C (RIA), calcitonin (RIA), prostaglandin E2 (EIA), oxytocin (RIA), ACTH (RIA), substance P (EIA), TSH (LIA), prolactin (LIA). In comparison to healthy controls, patients with fibromyalgia revealed significantly decreased levels of serotonin, somatomedin C, calcitonin, prostaglandin E2 and a significantly increased level of prolactin. No significant differences were found in the levels of ACTH, substance P and TSH. These results suggest that the diagnosis of fibromyalgia can be confirmed by various biochemical parameters, but further investigations must be carried out to value the diagnostic relevance of these findings.

Antineutrophil cytoplasmic antibodies (ANCA) in rheumatoid arthritis: a prospective study

To investigate a possible relationship between the presence of antineutrophil cytoplasmic antibodies (ANCA), rheumatoid factor (RF), antinuclear antibodies (ANA), complement, disease activity and disease severity, 111 clinically well-documented RA patients were studied prospectively for ANCA, RF, ANA, C-reactive protein (CRP), total haemolytic complement (CH50) and complement split product C3d. Disease activity and severity were also assessed clinically, as well as anamnestically, using the Hannover Activity of Daily Living Questionnaire, the functional Steinbrocker grades, and numeric and verbal rating scales. At a serum dilution of 1:50, 20% of the 111 sera showed predominantly an atypical perinuclear staining pattern. There was no correlation between ANCA positivity and serological markers, disease activity and disease severity. Regarding previous therapies with disease-modifying antirheumatic drugs, ANCA+ patients took sulphasalazine significantly more often than ANCA- patients.

IgA-alpha-1-antitrypsin complex in systemic lupus erythematosus: preliminary report

To investigate the role of the complex IgA-alpha-1-antitrypsin (IgA-AT) in systemic lupus erythematosus (SLE) and in mixed connective tissue disease (MCTD), and its possible relations to either activity of the disease or a treatment, we examined a concentration of IgA-AT complex in 65 SLE and 9 MCTD sera. Complex IgA-AT was evaluated using a double antibody enzyme-linked immunoassay (ELISA). Twenty nine patients with SLE (44.6%) and three patients with MCTD (33.3%) had increased serum IgA-AT levels. The mean values of IgA-AT complex in patients with SLE and MCTD were higher than in healthy controls. Among the SLE group, patients with current neurological manifestation were characterized by an increase in IgA-AT serum concentration (2.45 +/- 2.07 U vs. 0.78 +/- 0.70 U, P < 0.001). No relation was found between this complex and ESR level, C-reactive protein (CRP) concentration, or hemoglobin level. Ten SLE patients were treated with CTX intravenously. In this group of patients, IgA-AT complex level was found to be increased compared with patients without such a treatment (1.82 +/- 1.30 U vs. 0.80 +/- 0.67 U, P < 0.05). The present study provides two new observations. Firstly, IgA-AT complex is increased in SLE and MCTD compared with healthy controls, and secondly, patients with CNS involvement displayed a striking increased IgA-AT level.

Does the serum level of IgA-alpha-1-antitrypsin complex correlate with radiological progression in early rheumatoid arthritis? A 3-year follow-up study

We followed the levels of serum IgA-alpha-1-antitrypsin (IgA-AT) complex in 37 patients with early rheumatoid arthritis (RA) during the first 3 years of the disease. The changes in IgA-AT were correlated with a radiological damage score (DS) of the hands assessed according to Larsen. At the onset of the disease, the IgA-AT serum concentration was significantly higher as compared to the control group (0.72 +/- 0.22 U vs 0.29 +/- 0.14 U, P < 0.01). The level significantly decreased during the 3-year observation period. The DS was significantly higher after 3 years. However, this difference was due to changes in only 11 patients; in 26 patients the DS was almost unchanged. In the group of 11 patients with radiological progression, the level of IgA-AT either remained high or increased significantly (0.95 +/- 0.18 U at the onset, 0.97 +/- 0.25 U after 3 years), whereas we observed a decrease in IgA-AT in 26 patients without radiological progression (0.63 +/- 0.16 U at the onset of the disease, 0.45 +/- 0.10 U after 3 years, P < 0.01). Moreover, a relationship between changes in IgA-AT serum level and radiological progression was shown (r = 0.60, P < 0.01). Our studies suggested that the relationship between IgA-AT level and radiological progression of the disease should be considered. We cannot exclude the possibility that the constant high level of IgA-AT may cause worsening in bone erosions.

[Therapy of generalized tendomyopathy (fibromyalgia) caused by blocking 5-HT3 receptors]

In more than 40% of patients with fibromyalgia a marked influence on the pain in the skeletal system with a decrease of the tenderness at "tenderpoints" can be achieved by blocking the 5-HT3-receptors with ondansetron or tropisetron-hydrochloride. Physical complaints and vegetative signs also improve. It is discussed if patients not responding to therapy with ondansetron or tropisetron-hydrochloride have to be discriminated as a subgroup of fibromyalgia. More investigations are needed to confirm the described effects.

Immunological studies in patients with rheumatoid arthritis treated with methotrexate or cyclophosphamide

One-hundred-and-two-patients (pts) with rheumatoid arthritis (RA) were observed for 12 months. Forty-eight pts were treated with a weekly low-dose of methotrexate (MTX), 23 pts with cyclophosphamide (CTX) (eight pts with one single intravenous dose, and 15 pts orally with a single daily dose), and 31 pts with nonsteroidal antiinflammatory drugs (NSAID) only. In all individuals acute phase response, i.e., C-reactive protein (CRP) and alpha-1-acid glycoprotein (AGP) serum levels, and AGP microheterogeneity using affinoimmunoelectrophoresis with concanavalin A were evaluated. The phenotype of lymphocytes isolated from peripheral blood was characterized using immunofluorescence technique. Following treatment the increased level of CRP significantly decreased whereas AGP serum level remained unchanged. Among the patients, microheterogeneity of AGP expressed as reactivity coefficient (RC) was lower before treatment when compared with 17 controls (0.95 +/- 0.23 vs. 1.35 +/- 0.15, p < 0.01). After 12 months of MTX therapy AGP-RC rose significantly (1.19 +/- 0.13, p < 0.01). No changes were observed in AGP-RC levels in CTX and NSAID treated individuals. No significant differences were observed in the percentage of CD3+, CD4+, and CD8+ cells in all the patient groups, except in CTX intravenously treated patients. In this group of patients a decrease of CD4+ cells was noticed (60.1 +/- 11.5% and 43.8 +/- 12.5% before and after treatment respectively -p < 0.01). The percentage of CD19 positive cells decreased significantly during 12 months of treatment with MTX and CTX. The percentage of activated T cells (CD25+ cells and HLA-DR+ cells) remained unchanged in MTX treated patients and was reduced in both CTX groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Assessing health status after inpatient rehabilitation in rheumatoid arthritis

Evaluation of different therapy programmes, e.g. inpatient rehabilitation, in rheumatoid arthritis requires valid, reliable and sensitive instruments describing patient health status. Traditional measurements such as ESR, joint count or radiographic findings do not suffice for this purpose, particularly because they neglect the psychosocial dimensions of impairment. We report upon a questionnaire, MOPO scales, a German adaptation of the Arthritis Impact Measurement Scales. We found the questionnaire to be valid, reliable and sensitive to change. The main application of MOPO scales is in multidimensional measurement of patient health status and in detection and documentation of therapeutically induced change.