Supplementary Appendix

Transcription

1 Supplementary Appendix This appendix has been provided by the authors to give readers additional information about their work. Supplement to: Boehm BO, Rosinger S, Belyi D, Dietrich JW. The parathyroid as a target for radiation damage. N Engl J Med 2011;365:676-8.

2 Manuscript ID: R2 The parathyroid is a target for radiation damage Bernhard O. Boehm et al. Supplementary Information Clinical and biochemical work-up. Liquidators Liquidators were exposed to ionized radiation at the Chernobyl accident and were extensively re-examined 14 years after the Chernobyl accident (N=61; male 58 probands). These probands were among the most severely exposed to high doses of beta-particles and gamma-radiation 1. Whole-body exposure was in the range between Gy. ARS severity level classification was applied as described in Mettler 2 and coworkers and Belyi 3 and coworkers. : Clinical examination was performed on a yearly basis until the year Healthy Controls Healthy normal controls (N=688; male 652 control probands) were recruited from an age and sex-matched population based cohort in Germany 14 years after the Chernobyl accident and classified as a non-radiation exposed background population. The time period of the blood sampling in controls and the liquidators was the same. Study probands provided written informed consent for the study. High-resolution ultrasound examination of the thyroid Thyroid nodules were defined by using high-resolution ultrasound, 7.5-MHz transducer (Aloka 630, Japan). Number of affected probands with a single or multiple nodules was recorded. The prevalence of single nodules and/or multiple thyroid nodules was not different in the group of liquidators versus the controls. Biochemical work-up

3 Bio-intact PTH was measured by a chemiluminescence immunoassay (Nichols Institute Diagnostics). Ionized calcium levels were determined using standard automated techniques and equilibrated at ph OH vitamin D and 1,25-OH vitamin D levels were determined using radioimmunoassays (IBL International, Hamburg, Germany). Total testosterone levels were measured using a RIA test system (T; DSL-4000 ACTIVE Testosterone Radioimmunoassay, DSL GmbH Germany; intraassay coefficients of variation (CVs) were %). For healthy adult men, the normal range for testosterone was ng/ml. All samples were collected at the same time, between 07:00 and 9:00 a.m. Categorization to primary hyperparathyroidism (phpt) included presence of an elevated intact PTH, elevated ionized calcium or ionized calcium in the upper range of the normal and high-normal or elevated 1,25-OH vitamin D as a function of PTH. The classification also included lack of 25-vitamin D (< 10 ng/ml) as well as an impaired kidney function using glomerular filtration rate according to MDRD2 formula 4. References 1. Boehm BO, Steinert M, Dietrich JW, et al. Thyroid examination in highly radiationexposed workers after the Chernobyl accident. Eur J Endocrinol 2009;160: Mettler FA, Gus'kova AK, Gusev I. Health effects in those with acute radiation sickness from the Chernobyl accident. Health Physics 2007;93: Belyi D.A., Khomenko V.I., Bebeshko V.G. Emergency preparedness of Research Center for Radiation Medicine and its hospital to admit and treat the patients with signs of acute radiation sickness. Radiat Prot Dosimetry 2009;134: Lin J, Knight EL, Hogan ML, Singh AK. A comparison of prediction equations for estimating glomerular filtration rate in adults without kidney disease. J Am Soc Nephrol. 2003;14: Erratum in: J Am Soc Nephrol. 2005;16:2814.

4 Statistics Levels of PTH, ionized calcium and vitamin D metabolites were compared with respect to group, gender and ARS stage with two-way ANOVA. Post-hoc testing and correction for alpha error accumulation in the setting of multiple testing were performed with Tukey s honest significance difference test (Tukey-Kramer method) and a Benjamini-Hochberg procedure. Survival data and frequency of phpt in dependency of ARS stage, gender and duration of radiation exposure were investigated with multiple logistic regression. Spearman's rank correlation was used in order to investigate the relation between duration of radiation exposure and levels of ionized Ca (ica), PTH, vitamin D metabolites, and thyroid autoantibody titers. Epidemiological data and frequency outcomes were compared with Pearson s Chi-squared test with Yates continuity correction. All statistical tests were performed with custom S scripts that were executed in the statistical environment R References 1. R Development Core Team. R: A Language and Environment for Statistical Computing. In Vienna, Austria: R Foundation for Statistical Computing; Epidemiological comparisons 1. Prevalence based estimation of phpt risk

5 1.1 Comparison with population prevalence in Sweden 1 : Liquidators Population 1 phpt No phpt X-squared = 20.8, df = 1, p-value = 5.1e-06. RR: 23.0 (95% CI: 3.3 to 159.2) OR: 30.1 (95% CI: 4.1 to 221.0). 1.2 Comparison with population prevalence estimation in USA 2 : Liquidators Population 2 phpt 15 1 No phpt X-squared = 216.0, df = 1, p-value < 2.2e-16. RR: (95% CI: 33.0 to ) OR: (95% CI: 42.1 to ). 2. Incidence based estimation: 2.1 Comparison with lower bound of population incidence estimation in USA 3 : Liquidators Population 3 phpt Persons at risk X-squared = 664.5, df = 1, p-value < 2.2e-16. RR: 51.0 (95% CI: 32.1 to 81.3) OR: 63.4 (95% CI: 35.7 to 112.5). Population incidence figure expressed as 14-year incidence. 2.2 Comparison with upper bound of population incidence estimation in USA 3 : Liquidators Population 3 phpt Persons at risk X-squared = 436.2, df = 1, p-value < 2.2e-16

6 RR: 33.8 (95% CI: 21.3 to 53.5) OR: 41.8 (95% CI: 23.6 to 74.0). Population incidence figure expressed as 14-year incidence. References 1. Palmer M, Jakobsson S, Akerstrom G, Ljunghall S. Prevalence of hypercalcaemia in a health survey: a 14-year follow-up study of serum calcium values. European journal of clinical investigation 1988;18: Boonstra CE, Jackson CE. Serum calcium survey for hyperparathyroidism: results in 50,000 clinic patients. American journal of clinical pathology 1971;55: Melton LJ, 3rd. Epidemiology of primary hyperparathyroidism. J Bone Miner Res 1991;6 Suppl 2:S25-30; discussion S1-2.