Improvement of mammary gland health in 81 'sentinel herds' in England and Scotland between 2012 and 2021

BACKGROUND

Achieving a reduction in mastitis in dairy cows is a common industry goal, but there is no recent peer-reviewed record of progress in the UK.

METHODS

A convenience sample of 125 herds in England and Scotland was recruited based on the quality of records in 2016, willingness to participate and representative geographical distribution. Individual cow somatic cell counts and clinical mastitis data from 2012 to 2021 were summarised annually, and temporal changes were analysed. Eighty-one herds had sufficient data for comparison between 2012 and 2021, for one or more parameters.

RESULTS

Over this period, the median incidence rate of clinical mastitis decreased from 40.0 to 21.0 cases per 100 cows per year (p < 0.001), with improvement in both lactation and dry period indicators. Lactation new infection rate calculated from individual cow somatic cell counts fell from 8.75% to 5.95% (p < 0.001), dry period new infection rate fell from 16.8% to 14.1% (p < 0.05) and proportion of cows over 200,000 cells/mL fell from 20.0% to 14.3% (p < 0.001).

LIMITATIONS

Data were necessarily from herds with good records and do not provide absolute values for the industry.

CONCLUSION

The findings reflect good progress over a 10-year period in a cohort of well-recorded herds and align with other national datasets.

The use of machine learning to predict somatic cell count status in dairy cows post-calving

Udder health remains a priority for the global dairy industry to reduce pain, economic losses, and antibiotic usage. The dry period is a critical time for the prevention of new intra-mammary infections and it provides a point for curing existing intra-mammary infections. Given the wealth of udder health data commonly generated through routine milk recording and the importance of udder health to the productivity and longevity of individual cows, an opportunity exists to extract greater value from cow-level data to undertake risk-based decision-making. The aim of this research was to construct a machine learning model, using routinely collected farm data, to make probabilistic predictions at drying off for an individual cow's risk of a raised somatic cell count (hence intra-mammary infection) post-calving. Anonymized data were obtained as a large convenience sample from 108 UK dairy herds that undertook regular milk recording. The outcome measure evaluated was the presence of a raised somatic cell count in the 30 days post-calving in this observational study. Using a 56-farm training dataset, machine learning analysis was performed using the extreme gradient boosting decision tree algorithm, XGBoost. External validation was undertaken on a separate 28-farm test dataset. Statistical assessment to evaluate model performance using the external dataset returned calibration plots, a Scaled Brier Score of 0.095, and a Mean Absolute Calibration Error of 0.009. Test dataset model calibration performance indicated that the probability of a raised somatic cell count post-calving was well differentiated across probabilities to allow an end user to apply group-level risk decisions. Herd-level new intra-mammary infection rate during the dry period was a key driver of the probability that a cow had a raised SCC post-calving, highlighting the importance of optimizing environmental hygiene conditions. In conclusion, this research has determined that probabilistic classification of the risk of a raised SCC in the 30 days post-calving is achievable with a high degree of certainty, using routinely collected data. These predicted probabilities provide the opportunity for farmers to undertake risk decision-making by grouping cows based on their probabilities and optimizing management strategies for individual cows immediately after calving, according to their likelihood of intra-mammary infection.

Emerging Roles for Artificial Intelligence in Heart Failure Imaging

Artificial intelligence (AI) applications are expanding in cardiac imaging. AI research has shown promise in workflow optimization, disease diagnosis, and integration of clinical and imaging data to predict patient outcomes. The diagnostic and prognostic paradigm of heart failure is heavily reliant on cardiac imaging. As AI becomes increasingly validated and integrated into clinical practice, AI influence on heart failure management will grow. This review discusses areas of current research and potential clinical applications in AI as applied to heart failure cardiac imaging.

A comprehensive study of skeletal muscle imaging in FHL1-related reducing body myopathy

OBJECTIVE

FHL1-related reducing body myopathy is an ultra-rare, X-linked dominant myopathy. In this cross-sectional study, we characterize skeletal muscle ultrasound, muscle MRI, and cardiac MRI findings in FHL1-related reducing body myopathy patients.

METHODS

Seventeen patients (11 male, mean age 35.4, range 12-76 years) from nine independent families with FHL1-related reducing body myopathy underwent clinical evaluation, muscle ultrasound (n = 11/17), and lower extremity muscle MRI (n = 14/17), including Dixon MRI (n = 6/17). Muscle ultrasound echogenicity was graded using a modified Heckmatt scale. T1 and STIR axial images of the lower extremity muscles were evaluated for pattern and distribution of abnormalities. Quantitative analysis of intramuscular fat fraction was performed using the Dixon MRI images. Cardiac studies included electrocardiogram (n = 15/17), echocardiogram (n = 17/17), and cardiac MRI (n = 6/17). Cardiac muscle function, T1 maps, T2-weighted black blood images, and late gadolinium enhancement patterns were analyzed.

RESULTS

Muscle ultrasound showed a distinct pattern of increased echointensity in skeletal muscles with a nonuniform, multifocal, and "geographical" distribution, selectively involving the deeper fascicles of muscles such as biceps and tibialis anterior. Lower extremity muscle MRI showed relative sparing of gluteus maximus, rectus femoris, gracilis, and lateral gastrocnemius muscles and an asymmetric and multifocal, "geographical" pattern of T1 hyperintensity within affected muscles. Cardiac studies revealed mild and nonspecific abnormalities on electrocardiogram and echocardiogram with unremarkable cardiac MRI studies.

INTERPRETATION

Skeletal muscle ultrasound and muscle MRI reflect the multifocal aggregate formation in muscle in FHL1-related reducing body myopathy and are practical and informative tools that can aid in diagnosis and monitoring of disease progression.

Associations between Johne's disease and fertility in UK dairy herds

The objective of this observational study was to quantify associations between Mycobacterium avium subspecies paratuberculosis (MAP) antibody status and a variety of fertility outcomes, in UK dairy cattle. Longitudinal milk recording, fertility and MAP antibody enzyme-linked immunosorbent assay (ELISA) milk test data were collated retrospectively from 121,762 lactations in 78 herds. Datasets were structured into appropriate units to suit outcomes and enable temporal association between current and future MAP status, and fertility measures. Current MAP status was categorised according to most recent status within 180 days, with time-related future MAP status assigned based on MAP antibody ELISA milk test data for each cow. Multilevel multivariable logistic regression models were used to evaluate associations between MAP status and 21-day pregnancy and submission rate and conception risk. Posterior predictions and cross-validation techniques were used to assess model fit and check model building assumptions. A negative association was found between risk of insemination (Odds Ratio [OR], 0.78; 95% Credible Interval [CI], 0.66-0.92) and conception occurring (OR, 0.65; CI, 0.5-0.84) and transition from negative to non-negative MAP test status in the next 30-90 days. A positive association was observed between risk of insemination (OR, 1.34; CI, 1.16-1.52) and conception occurring (OR, 1.26; CI, 1.11-1.43) and transition from negative to non-negative MAP test status in the next 90-180 days. Current positive MAP test status was negatively and positively associated with insemination (OR, 0.59; CI, 0.49-0.70) and conception risk (OR, 1.12; CI, 0.96-1.30), respectively. Herd managers will have had access to test results, declaring cows with past recent or multiple positive MAP antibody ELISA results not to be bred, negatively influencing insemination risk. Overall, these results demonstrate the temporal association between a positive MAP antibody ELISA result and dairy cow fertility outcomes, with particular variability prior to a positive MAP antibody ELISA result.

Atherosclerosis Imaging Quantitative Computed Tomography (AI-QCT) to guide referral to invasive coronary angiography in the randomized controlled CONSERVE trial

AIMS

We compared diagnostic performance, costs, and association with major adverse cardiovascular events (MACE) of clinical coronary computed tomography angiography (CCTA) interpretation versus semiautomated approach that use artificial intelligence and machine learning for atherosclerosis imaging-quantitative computed tomography (AI-QCT) for patients being referred for nonemergent invasive coronary angiography (ICA).

METHODS

CCTA data from individuals enrolled into the randomized controlled Computed Tomographic Angiography for Selective Cardiac Catheterization trial for an American College of Cardiology (ACC)/American Heart Association (AHA) guideline indication for ICA were analyzed. Site interpretation of CCTAs were compared to those analyzed by a cloud-based software (Cleerly, Inc.) that performs AI-QCT for stenosis determination, coronary vascular measurements and quantification and characterization of atherosclerotic plaque. CCTA interpretation and AI-QCT guided findings were related to MACE at 1-year follow-up.

RESULTS

Seven hundred forty-seven stable patients (60 ± 12.2 years, 49% women) were included. Using AI-QCT, 9% of patients had no CAD compared with 34% for clinical CCTA interpretation. Application of AI-QCT to identify obstructive coronary stenosis at the ≥50% and ≥70% threshold would have reduced ICA by 87% and 95%, respectively. Clinical outcomes for patients without AI-QCT-identified obstructive stenosis was excellent; for 78% of patients with maximum stenosis < 50%, no cardiovascular death or acute myocardial infarction occurred. When applying an AI-QCT referral management approach to avoid ICA in patients with <50% or <70% stenosis, overall costs were reduced by 26% and 34%, respectively.

CONCLUSIONS

In stable patients referred for ACC/AHA guideline-indicated nonemergent ICA, application of artificial intelligence and machine learning for AI-QCT can significantly reduce ICA rates and costs with no change in 1-year MACE.

Potential of ESBL-producing Escherichia coli selection in bovine feces after intramammary administration of first generation cephalosporins using in vitro experiments

Selection and spread of Extended Spectrum Beta-Lactamase (ESBL) -producing Enterobacteriaceae within animal production systems and potential spillover to humans is a major concern. Intramammary treatment of dairy cows with first-generation cephalosporins is a common practice and potentially selects for ESBL-producing Enterobacteriaceae, although it is unknown whether this really occurs in the bovine fecal environment. We aimed to study the potential effects of intramammary application of cephapirin (CP) and cefalonium (CL) to select for ESBL-producing Escherichia coli in the intestinal content of treated dairy cows and in manure slurry, using in vitro competition experiments with ESBL and non-ESBL E. coli isolates. No selection of ESBL-producing E. coli was observed at or below concentrations of 0.8 µg/ml and 4.0 µg/ml in bovine feces for CP and CL, respectively, and at or below 8.0 µg/ml and 4.0 µg/ml, respectively, in manure slurry. We calculated that the maximum concentration of CP and CL after intramammary treatment with commercial products will not exceed 0.29 µg/ml in feces and 0.03 µg/ml in manure slurry. Therefore, the results of this study did not find evidence supporting the selection of ESBL-producing E. coli in bovine feces or in manure slurry after intramammary use of commercial CP or CL-containing products.

Comparative performance of composite measures from two phase III clinical trials of ixekizumab in psoriatic arthritis

Background/objective

The aim of this study was to evaluate relative performance of composite measures in psoriatic arthritis and assess the impact of structural damage and functional disability on outcomes during ixekizumab treatment.

Methods

Data from SPIRIT-P1 and SPIRIT-P2 were analysed to evaluate the effect of ixekizumab on achievement of low disease activity (LDA) and remission with the minimal disease activity (MDA) and very low disease activity (VLDA) composite, Disease Activity index for Psoriatic Arthritis (DAPSA), Psoriatic Arthritis Disease Activity Score, GRAppa Composite ScorE and modified Composite Psoriatic Disease Activity Index (mCPDAI). Performance was compared by quantifying residual symptom burden and the impact of structural damage and functional disability.

Results

Significantly more ixekizumab-treated patients achieved treatment targets at week 24 versus placebo assessed with all composites. More patients achieved targets assessed by mCPDAI and DAPSA than other composites. Residual disease activity was similar between composites, but residual high patient-reported outcomes (PROs) and functional disability were more frequent when assessed with mCPDAI and DAPSA. Achievement of treatment targets was reduced by high baseline levels of structural damage and functional disability.

Conclusion

Residual disease activity was similar in patients achieving treatment targets assessed with all composites, but residual high PROs and functional disability were more common when assessed with mCPDAI and DAPSA, most likely due to the absence/attenuated functional assessment in these composites. High baseline levels of structural damage and functional disability attenuated response rates with all composites, affecting MDA/VLDA most prominently; LDA may be the most appropriate target in these patients.

Trial registration number

NCT01695239.

Cardiovascular Imaging in Pregnancy: Valvulopathy, Hypertrophic Cardiomyopathy, and Aortopathy

Pregnancy is associated with profound hemodynamic changes that are particularly impactful in patients with underlying cardiovascular disease. Management of pregnant women with cardiovascular disease requires careful evaluation that considers the well-being of both the woman and the developing fetus. Clinical assessment begins before pregnancy and continues throughout gestation into the post-partum period and is supplemented by cardiac imaging. This review discusses the role of imaging, specifically echocardiography, cardiac MRI, and cardiac CT, in pregnant women with valvular diseases, hypertrophic cardiomyopathy, and aortic pathology.

OA34 Post-hoc analysis of spinal MRI SPARCC inflammation scores in patients with radiographic axial spondyloarthritis treated with ixekizumab: results from the COAST-V study at week 16

Background/Aims

Ixekizumab, an interleukin-17A inhibitor, has demonstrated efficacy in radiographic axial spondyloarthritis (r-axSpA) irrespective of baseline local inflammation as measured by spinal magnetic resonance imaging (MRI) Spondyloarthritis Research Consortium of Canada (SPARCC) inflammation scores. This post-hoc analysis assessed the efficacy of ixekizumab in patients with r-axSpA categorized by MRI SPARCC score at baseline and 16-week change from baseline (CFB).

Methods

COAST-V (NCT02696785) was a phase 3, randomized, controlled trial enrolling patients with active r-axSpA naïve to biologic disease-modifying antirheumatic drugs, randomized 1:1:1:1 to 80-mg ixekizumab every 2 weeks, 80-mg ixekizumab every 4 weeks (Q4W), adalimumab, or placebo for the 16-week blinded treatment period. Three categories were defined according to spinal MRI SPARCC inflammation score at baseline and CFB (based on published minimally important change): 1) low baseline (baseline SPARCC score &lt;5.0 points), 2) low responder (baseline SPARCC score ≥5.0 points and CFB &lt;5.0 points), 3) high responder (baseline SPARCC score ≥5.0 points and CFB ≥5.0 points). Proportions of patients achieving Assessment in SpondyloArthritis international Society 40% (ASAS40), Ankylosing Spondylitis Disease Activity Score (ASDAS) &lt;2.1, and BASDAI (Bath Ankylosing Spondylitis Disease Activity Index) 50 were determined. Means at baseline and week-16 least squares means of CFBs were calculated for ASDAS, BASDAI, Spinal Pain, Bath Ankylosing Spondylitis Functional Index (BASFI), and 36-item Short Form Health Survey Physical Component Summary (SF-36 PCS). Non-responder imputation and modified baseline observation carried forward were used for missing week-16 data in discrete and continuous variables, respectively.

Results

Of 78 patients receiving ixekizumab Q4W, 35 (44.9%), 11 (14.1%), and 32 (41.0%), were MRI SPARCC low baseline, low responders, and high responders, respectively. Similar proportions of ixekizumab-treated patients in all categories achieved ASAS40, ASDAS&lt;2.1, and BASDAI50 week-16 responses; week-16 improvements in other efficacy endpoints were broadly similar, with high responders showing greater improvements in ASAS40 and ASDAS CFB (Table). In adalimumab-treated patients, week-16 improvements were less pronounced in the low baseline and low responder categories.

Conclusion

Patients with r-axSpA receiving ixekizumab Q4W showed broadly similar reduction in the signs and symptoms of r-axSpA irrespective of their spinal MRI SPARCC inflammation score category at week 16.

Disclosure

H. Marzo-Ortega: Honoraria; Abbvie, Celgene, Eli Lilly and Company, Janssen, Novartis, Pfizer, Takeda, UCB, Biogen. Grants/research support; Janssen, Novartis. W. Tsai: Consultancies; Abbvie, Pfizer, Roche. H. Kameda: Consultancies; Abbvie, Asahikasei Pharma, Bristol-Myers Squibb, Eisai, Eli Lilly and Company, Janssen, Mitsubishi Tanabe Pharma, Novartis, Chugai, Pfizer. Member of speakers’ bureau; Abbvie, Asahikasei Pharma, Bristol-Myers Squibb, Eisai, Eli Lilly and Company, Janssen, Mitsubishi Tanabe Pharma, Novartis, Chugai, Pfizer. A. Konomi: Shareholder/stock ownership; Eli Lilly and Company. Other; Employment - Eli Lilly and Company. A.J. Bradley: Shareholder/stock ownership; Eli Lilly and Company. Other; Employment - Eli Lilly and Company. K. Ng: Shareholder/stock ownership; Eli Lilly and Company. Other; Employment - Eli Lilly and Company. Y. Schymura: Shareholder/stock ownership; Eli Lilly and Company. Other; Employment - Eli Lilly and Company. S. Liu-Leage: Shareholder/stock ownership; Eli Lilly and Company. Other; Employment - Eli Lilly and Company. W.P. Maksymowych: Corporate appointments; CARE Arthritis Limited. Consultancies; Abbvie, Boehringer Ingelheim, Celgene, Eli Lilly and Company, Galapagos, Janssen, Novartis, Pfizer, UCB. Member of speakers’ bureau; Abbvie, Janssen, Novartis, Pfizer, UCB. Grants/research support; Abbvie, Novartis, Pfizer, UCB. M. Østergaard: Consultancies; Abbvie, Bristol-Myers Squibb, Boehringer Ingelheim, Celgene, Eli Lilly and Company, Hospira, Janssen, Merck, Novartis, Novo, Orion, Pfizer, Regeneron, Roche, UCB. Member of speakers’ bureau; Abbvie, Bristol-Myers Squibb, Boehringer Ingelheim, Celgene, Eli Lilly and Company, Hospira, Janssen, Merck, Novartis, Novo, Orion, Pfizer, Regeneron, Roche, UCB. Grants/research support; Abbvie, Celgene, Centocor, Merck, Novartis.

Artificial Intelligence Advancements in the Cardiovascular Imaging of Coronary Atherosclerosis

Coronary artery disease is a leading cause of death worldwide. There has been a myriad of advancements in the field of cardiovascular imaging to aid in diagnosis, treatment, and prevention of coronary artery disease. The application of artificial intelligence in medicine, particularly in cardiovascular medicine has erupted in the past decade. This article serves to highlight the highest yield articles within cardiovascular imaging with an emphasis on coronary CT angiography methods for % stenosis evaluation and atherosclerosis quantification for the general cardiologist. The paper finally discusses the evolving paradigm of implementation of artificial intelligence in real world practice.

The relationship between physical activity, BMI, circadian rhythm, and sleep with cognition in bipolar disorder

BACKGROUND

Cognitive deficits affect a significant proportion of patients with bipolar disorder (BD). Problems with sustained attention have been found independent of mood state and the causes are unclear. We aimed to investigate whether physical parameters such as activity levels, sleep, and body mass index (BMI) may be contributing factors.

METHODS

Forty-six patients with BD and 42 controls completed a battery of neuropsychological tests and wore a triaxial accelerometer for 21 days which collected information on physical activity, sleep, and circadian rhythm. Ex-Gaussian analyses were used to characterise reaction time distributions. We used hierarchical regression analyses to examine whether physical activity, BMI, circadian rhythm, and sleep predicted variance in the performance of cognitive tasks.

RESULTS

Neither physical activity, BMI, nor circadian rhythm predicted significant variance on any of the cognitive tasks. However, the presence of a sleep abnormality significantly predicted a higher intra-individual variability of the reaction time distributions on the Attention Network Task.

CONCLUSIONS

This study suggests that there is an association between sleep abnormalities and cognition in BD, with little or no relationship with physical activity, BMI, and circadian rhythm.

Bedding system influences lying behaviour in dairy cows

BACKGROUND

The nature and depth of bedding material have an important influence on cow lying behaviour and comfort. Increasing use of recycled manure solids (RMS) as bedding led to an investigation of the influence of this material on cow lying behaviour.

METHODS

Leg mounted accelerometers were used to estimate daily lying time and number and duration of lying bouts in four groups of 40 cows. Each group spent two 2-week periods on each of four bedding systems: deep sand, deep RMS, sawdust on mattresses and RMS on mattresses.

RESULTS

Total daily lying times were significantly shorter on both RMS treatments than on sawdust. Number of lying bouts per day was greater on sawdust than any other treatment, while lying bouts were 2.6 min longer on deep RMS and 9.3 min longer on sand, than on sawdust.

CONCLUSIONS

Greater depth and apparent softness of bedding material does not necessarily result in longer total daily lying times. RMS may have some characteristics that reduce its attraction as a bedding material for cows. The influence of bedding system on number and duration of lying bouts and the resulting total lying time appear complex.

Ixekizumab Demonstrates Consistent Efficacy Versus Adalimumab in Biologic Disease-Modifying Anti-rheumatic Drug-Naïve Psoriatic Arthritis Patients Regardless of Psoriasis Severity: 52-Week Post Hoc Results from SPIRIT-H2H

Introduction

Ixekizumab, a selective interleukin-17A antagonist, was compared with adalimumab in the SPIRIT-H2H study (NCT03151551) in patients with psoriatic arthritis (PsA) and concomitant psoriasis. This post hoc analysis reports outcomes to week 52 in patients from SPIRIT-H2H, stratified by baseline psoriasis severity.

Methods

SPIRIT-H2H was a 52-week, multicenter, randomized, open-label, rater-blinded, parallel-group study of biologic disease-modifying antirheumatic drug (DMARD)-naïve patients (N = 566) with PsA and active psoriasis (≥ 3% body surface area involvement). Patients were randomized to ixekizumab or adalimumab (1:1) with stratification by baseline concomitant use of conventional synthetic DMARDs and psoriasis severity (with/without moderate-to-severe psoriasis). Patients received on-label dosing according to psoriasis severity. The primary endpoint was the proportion of patients simultaneously achieving ≥ 50% improvement in American College of Rheumatology criteria (ACR50) and 100% improvement in Psoriasis Area Severity Index (PASI100) at week 24. Secondary endpoints included musculoskeletal, disease activity (defined by composite indices), skin and nail, quality of life and safety outcomes. In this post hoc analysis, primary and secondary endpoints of SPIRIT-H2H were analyzed by baseline psoriasis severity.

Results

A greater proportion of patients achieved the combined endpoint of ACR50 + PASI100 and PASI100 with ixekizumab compared with adalimumab at weeks 24 and 52, regardless of baseline psoriasis severity. ACR response rates were similar for ixekizumab and adalimumab across both patient subgroups. For musculoskeletal outcomes, similar efficacy was seen for ixekizumab and adalimumab, but ixekizumab showed greater responses for skin outcomes regardless of psoriasis severity. The safety profiles of ixekizumab and adalimumab were consistent between subgroups.

Conclusions

Regardless of baseline psoriasis severity, ixekizumab demonstrated greater efficacy than adalimumab with respect to simultaneous achievement of ACR50 + PASI100, and showed consistent and sustained efficacy across PsA-related domains. It also demonstrated higher response rates for skin outcomes. These subgroup analyses highlight the efficacy of ixekizumab in patients with PsA irrespective of the severity of concomitant psoriasis.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40744-021-00388-8.

Mass spectrometry and machine learning for the accurate diagnosis of benzylpenicillin and multidrug resistance of Staphylococcus aureus in bovine mastitis

Staphylococcus aureus is a serious human and animal pathogen threat exhibiting extraordinary capacity for acquiring new antibiotic resistance traits in the pathogen population worldwide. The development of fast, affordable and effective diagnostic solutions capable of discriminating between antibiotic-resistant and susceptible S. aureus strains would be of huge benefit for effective disease detection and treatment. Here we develop a diagnostics solution that uses Matrix-Assisted Laser Desorption/Ionisation-Time of Flight Mass Spectrometry (MALDI-TOF) and machine learning, to identify signature profiles of antibiotic resistance to either multidrug or benzylpenicillin in S. aureus isolates. Using ten different supervised learning techniques, we have analysed a set of 82 S. aureus isolates collected from 67 cows diagnosed with bovine mastitis across 24 farms. For the multidrug phenotyping analysis, LDA, linear SVM, RBF SVM, logistic regression, naïve Bayes, MLP neural network and QDA had Cohen's kappa values over 85.00%. For the benzylpenicillin phenotyping analysis, RBF SVM, MLP neural network, naïve Bayes, logistic regression, linear SVM, QDA, LDA, and random forests had Cohen's kappa values over 85.00%. For the benzylpenicillin the diagnostic systems achieved up to (mean result ± standard deviation over 30 runs on the test set): accuracy = 97.54% ± 1.91%, sensitivity = 99.93% ± 0.25%, specificity = 95.04% ± 3.83%, and Cohen's kappa = 95.04% ± 3.83%. Moreover, the diagnostic platform complemented by a protein-protein network and 3D structural protein information framework allowed the identification of five molecular determinants underlying the susceptible and resistant profiles. Four proteins were able to classify multidrug-resistant and susceptible strains with 96.81% ± 0.43% accuracy. Five proteins, including the previous four, were able to classify benzylpenicillin resistant and susceptible strains with 97.54% ± 1.91% accuracy. Our approach may open up new avenues for the development of a fast, affordable and effective day-to-day diagnostic solution, which would offer new opportunities for targeting resistant bacteria.

Randomized controlled field trial comparing quarter and cow level selective dry cow treatment using the California Mastitis Test

Selective use of antibiotic dry cow treatment can be implemented at the cow or quarter level, with the latter having the potential to further reduce antibiotic use. Our objective was to compare these 2 approaches in 6 herds in the United Kingdom in which environmental mastitis predominated. Eight hundred seven cows were enrolled and categorized as having a high cell count (n = 401) or low cell count (n = 406) in the last 3 mo of lactation and clinical mastitis history. All quarters of all enrolled cows received an internal teat sealant. Within each category, cows were randomly allocated to 1 of 3 groups; in one group antibiotic treatment was allocated at cow level (i.e., all 4 quarters received antibiotic), whereas in the 2 remaining groups antibiotic treatment was allocated at quarter level, based on California Mastitis Test (CMT) findings. Two different thresholds, score 1 and 2, were used to determine likely infection status. Quarter milk samples were collected at dry off and postcalving for bacteriological culture and somatic cell count (SCC). Cows were monitored for clinical mastitis from dry off until 100 d in milk. Cow level SCC and milk yield data were collated from farm records. Within each category, the 2 quarter level treatment groups were compared with cow level treatment at dry off. Leaving quarters untreated with intramammary antibiotic in cows in the high cell count group, with a CMT <2 or <1, reduced antibiotic use by 55% and 31%, respectively, and resulted in no difference in the odds of being infected with any pathogen postcalving, but was associated with a higher SCC at the first test day. Intramammary antibiotic treatment of quarters with a CMT ≥1 in cows in the low cell count category at dry off was not associated with any reduction in the odds of being infected with a major pathogen postcalving but was associated with a decrease in the odds of being infected with a minor mastitis pathogen postcalving. The use of antibiotics in quarters of cows categorized as low cell count at dry off, increased the proportion of quarters treated with antibiotic from 0% at cow level to 31% (CMT ≥ 1) and 12% (CMT ≥ 2) at quarter level, only resulting in a reduction in SCC of around 20,000 cells/mL at the first test day, if all quarters with CMT score ≥1 were treated with antibiotic. No differences in clinical mastitis incidence and milk yield in the first 100 d in milk were detected between any of the treatment groups. These study findings support selective quarter level dry off treatment only in cows with cow level SCC >200,000 cells/mL at dry off.

P195 Efficacy of ixekizumab versus adalimumab in psoriatic arthritis (PsA) patients with and without moderate-to-severe psoriasis: 52-week results from a multicentre, randomised open-label study

Background/Aims 

Ixekizumab (IXE), is approved for of active PsA, moderate-to-severe psoriasis (PsO), and radiographic/non-radiographic axial SpA treatment in adults. Efficacy of IXE was compared to adalimumab (ADA) in patients (pts) with PsA and concomitant PsO in SPIRIT-H2H (NCT03151551). We report results at week (wk) 24 and 52 from subgroup analysis based on baseline PsO severity.

Methods 

SPIRIT-H2H was a 52-wk, multicenter, randomized, open-label, rater-blinded, parallel-group study of biologic DMARD-naïve pts (N = 566) with PsA and active PsO (≥3% body surface area). Pts were randomized (stratified by concomitant use of conventional synthetic DMARDs and PsO severity) to IXE or ADA. Pts received on label dosing according to PsO severity. We report efficacy outcomes at wk 24 and 52 for subgroup analysis of patients with/without moderate-to-severe PsO at baseline. The primary endpoint was the proportion of pts simultaneously achieving ACR50 and PASI PASI100 at wk 24. Additional post-hoc analysis was performed for other endpoints. Logistic regression models were performed with treatment, baseline PsO severity and treatment-by-baseline PsO severity interaction as independent variables. Differences in the proportion of responders were assessed using Fisher’s exact test.

Results 

At baseline, 49/283 IXE-treated pts and 51/282 ADA-treated pts had moderate-to-severe PsO. A greater proportion of IXE-treated pts achieved the combined endpoint of ACR50+PASI100, and PASI100 compared to ADA at wk 24 and 52, regardless of baseline PsO severity (Table). Similar efficacy was observed on joints for IXE and ADA across subgroups. Faster improvement was observed for IXE vs. ADA in minimal disease activity (MDA) and Disease Activity in Psoriatic Arthritis (DAPSA) remission regardless of PsO severity, and very low disease activity (VLDA) in pts with moderate-to-severe PsO. Table. Other efficacy outcomes by subgroup based on PsO severity at baseline P195 Table 1:Proportion of pts, n/N (%)Week 24Week 52With moderate- to-severe PsOWithout moderate- to-severe PsOWith moderate- to-severe PsOWithout moderate- to-severe PsOIXEADAIXEADAIXEADAIXEADAACR50 + PASI10040.8*†17.635.030.338.8*17.639.3*28.1ACR5059.254.948.745.055.162.748.746.8PASI10059.2*†27.560.3*51.159.2***25.565.4***45.0ACR2037/49 (75.5)40/51 (78.4)158/234 (67.5)164/231 (71.0)36/49 (73.5)41/51 (80.4)161/234 (68.8)153/231 (66.2)ACR7021/49 (42.9)17/51 (33.3)69/234 (29.5)56/231 (24.2)21/49 (42.9)20/51 (39.2)79/234 (33.8)76/231 (32.9)PASI7544/49 (89.8)38/51 (74.5)183/234 (78.2)*157/231 (68.0)42/49 (85.7)41/51 (80.4)180/234 (76.9)*153/231 (66.2)PASI9041/49 (83.7)**30/51 (58.8)162/234 (69.2)**128/231 (55.4)40/49 (81.6)**31/51 (60.8)166/234 (70.9)***122/231 (52.8)MDA57.139.245.7*34.651.045.146.639.8VLDA32.7**9.814.110.426.519.622.618.6DAPSA LDA/Rem73.564.759.059.371.472.559.455.4DAPSA Rem38.821.623.917.336.739.228.625.5SPARCC enthesitis18/29 (62.1)†25/36 (69.4)89/160 (55.6)**52/134 (38.8)16/29 (55.2)22/36 (61.1)91/160 (56.9)*60/134 (44.8)LEI=015/25 (60.0)18/28 (64.3)80/134 (59.7)63/118 (53.4)14/25 (56.0)18/28 (64.3)84/134 (62.7)65/118 (55.1)LDI-B=09/9 (100.0)19/19 (100.0)28/33 (84.8)35/39 (89.7)8/9 (88.9)18/19 (94.7)27/33 (81.8)29/39 (74.4)NAPSI=028/37 (75.7)*†21/41 (51.2)83/154 (53.9)67/136 (49.3)29/37 (78.4)28/41 (68.3)100/154 (64.9)76/136 (55.9)DLQI (0,1)29/49 (59.2)*†17/51 (33.3)145/234 (62.0)129/231 (55.8)27/49 (55.1)19/51 (37.3)140/234 (59.8)118/231 (51.1)HAQ-DI MCID ≥0.3534/45 (75.6)37/45 (82.2)134/207 (64.7)129/209 (61.7)33/45 (73.3)35/45 (77.8)135/207 (65.2)129/209 (61.7)*p ≤ 0.05,**p ≤ 0.01,***p ≤ 0.001 vs. ADA. P-values from Fisher''s exact test. †Interaction p ≤ 0.10. Other efficacy outcome assessed in a post-hoc analysis.Patients with moderate-to-severe PsO (PASI ≥12, sPGA ≥3, BSA involvement ≥10%) received either IXE (160 mg at week 0, then 80 mg Q2W to week 12 and Q4W thereafter) or ADA (80 mg at week 0 then 40 mg Q2W). Patients without moderate-to-severe PsO received either IXE (160 mg at week 0, then 80 mg Q4W) or ADA (40 mg Q2W).ACR20/70, ≥20%/≥50%/≥70% improvement in American College of Rheumatology criteria; ADA, adalimumab; BSA, body surface area; DLQI (0,1), DAPSA, Disease Activity in PSoriatic Arthritis; Dermatology Life Quality Index 0 or 1; HAQ-DI MCID ≥0.35, Health Assessment Questionnaire-Disability Index minimal clinically important difference of ≥ 0.35 points; IXE, ixekizumab; LDA, low disease activity; LDI-B=0, complete resolution in Leeds Dactylitis Index-Basic; LEI=0, complete resolution in Leeds Enthesitis Index; MDA, Minimal disease activity (18 entheseal points); n, number of patients in each subgroup; N, number of patients in the analysis population; NAPSI=0, complete resolution in Nail Psoriasis Severity Index; PASI, Psoriasis Area and Severity Index; PASI75/90/, ≥75%/≥90% improvement in PASI; PsA, psoriatic arthritis; PsO, psoriasis; pts, patients; Q2W, every 2 weeks; Q4W, every 4 weeks; SPARCC, Spondyloarthritis Research Consortium of Canada criteria; sPGA, static Physician’s Global Assessment; VLDA, very low disease activity (18 entheseal points).

Conclusion 

In pts with active PsA, a significantly higher proportion of IXE-treated pts achieved the combined ACR50+PASI100 endpoint, and PASI100 at wk 52 vs. ADA, regardless of baseline PsO severity. ACR50 response at wk 24 and 52 was not influenced by IXE dosing. Faster improvements in MDA and DAPSA remission were observed with IXE than with ADA. These results were consistent with the overall SPIRIT-H2H population.

Disclosure 

L. Kristensen: Consultancies; LE. Kristensen is a consultant for Amgen, Biogen, Bristol-Myers Squibb, Celgene, Eli Lilly and Company, Forward Pharma, Janssen, Merck and Co., Novartis, Pfizer, UCB. M. Okada: Consultancies; M. Okada is a consultant for Eli Lilly and Company. Member of speakers’ bureau; M. Okada is on the speaker’s bureau of: Santen Pharmaceutical, Mitsubishi Tanabe Pharma, Pfizer, Abbott Japan. W. Tillett: Honoraria; W. Tillett has received grants/speaker fees and/or honoraria from Abbvie, Celgene, Eli Lilly, Janssen, Novartis, Pfizer, and UCB. S. Liu Leage: Shareholder/stock ownership; S.L. League is a shareholder and employee of Eli Lilly and Company. C. El Baou: Shareholder/stock ownership; C. El Baou is a shareholder and employee of Eli Lilly and Company. A.J. Bradley: Shareholder/stock ownership; A. Bradley is a shareholder and employee of Eli Lilly and Company. G. Meszaros: Shareholder/stock ownership; G. Meszaros is a shareholder and employee of Eli Lilly and Company. K. de Vlam: Consultancies; K. de Vlam is a consultant for Celgene, Eli Lilly and Company, Galapagos NV, Novartis, Pfizer, and UCB Pharma. Grants/research support; K. de Vlam has received grant/research support from Celgene.

P172 Quality of life improvements in patients with PsA who achieve remission or low disease activity targets: results from two clinical trials of ixekizumab at three years of treatment

Background/Aims 

Treatment guidelines suggest a treat-to-target strategy using remission or low disease activity (LDA) targets in psoriatic arthritis (PsA). For patients with PsA, target achievement is associated with significantly improved quality of life (QoL). This analysis examined physical function and QoL improvements in PsA patients achieving remission or LDA targets at 3 years (156 weeks) of treatment with ixekizumab, a high-affinity monoclonal antibody selectively targeting interleukin-17A.

Methods 

This study used integrated data from 2 double-blind, randomized phase 3 clinical trials (SPIRIT-P1, NCT01695239; SPIRIT-P2, NCT02349295) of ixekizumab-treated PsA patients who entered the extension period (N = 410). QoL outcome measures included HAQ-Disability Index (HAQ-DI), 36-Item Short-Form Health Survey Physical Component Score (SF-36 PCS), and the 5-level EQ-5D Visual Analogue Scale (EQ-5D-5L VAS). Remission or LDA targets included minimal disease activity (MDA), very low disease activity (VLDA), Disease Activity in Psoriatic Arthritis (DAPSA) remission, DAPSA LDA, Psoriatic Arthritis Disease Activity Score (PASDAS) LDA, and PASDAS VLDA. The response rate (%) of patients achieving minimal clinically important differences (MCID RR) for measures with defined MCID and changes from baseline (CFB) for EQ-5D-5L VAS were observed. QoL improvements by remission or LDA target response status were assessed; significance was calculated by Fisher’s exact test for MCID RR and one-way analysis of variance for CFB. Missing data were imputed by non-responder imputation and modified baseline observation carried forward for binary and continuous measures, respectively.

Results 

At 3 years of treatment, the percentage of responders was 34.6% (n/N=142/410), 16.1% (n/N=66/410), 48.8% (n/N=200/410), 23.4% (n/N=96/410), 40.5% (n/N=166/410), and 20.7% (n/N=85/410) for MDA, VLDA, DAPSA LDA, DAPSA remission, PASDAS LDA, and PASDAS VLDA, respectively. Achievement of VLDA, DAPSA remission, and PASDAS VLDA were significantly associated with the most QoL improvement, more than achievement of MDA, DAPSA LDA, and PASDAS LDA, which were significantly associated with more QoL improvement than target nonachievement (Table). P172 Table 1:Association of Patients Achieving Remission or Low Disease Activity Targets with Incremental QoL Improvement at 3 Years.(1) Did not achieve MDA or VLDA(2) MDA but not VLDA(3) Achieved VLDAHAQ-DI MCID RRResponse, % (n/N)16.3 (40/246)83.1 (54/65)94.4 (51/54)Difference vs. (1), % (95% CI)–66.8 (56.6, 77.0) ‡78.2 (70.5, 85.8) ‡Difference vs. (2), % (95% CI)––11.4 (0.39, 22.3)SF-36 PCS MCID RRResponse, % (n/N)27.2 (73/268)80.3 (61/76)86.4 (57/66)Difference vs. (1), % (95% CI)–53.0 (42.6, 63.4) ‡59.1 (49.3, 69.0) ‡Difference vs. (2), % (95% CI)––6.1 (-6.1, 18.3)EQ-5D-5L VAS CFBNx2617463Mean (SD)7.5 (21.1)17.2 (22.7)28.0 (22.1)Mean Difference vs. (1), (95% CI)–9.7 (4.2, 15.3) ‡20.5 (14.7, 26.4) ‡Mean Difference vs. (2), (95% CI)––10.8 (3.3, 18.3)†(1) Did not achieve DAPSA LDA or DAPSA remission(2) DAPSA LDA but not remission(3) Achieved DAPSA remissionHAQ-DI MCID RRResponse, % (n/N)8.9 (17/191)60.4 (55/91)88.0 (73/83)Difference vs. (1), % (95% CI)–51.5 (40.7, 62.4) ‡79.1 (71.0, 87.1) ‡Difference vs. (2), % (95% CI)––27.5 (15.3, 39.8) ‡SF-36 PCS MCID RRResponse, % (n/N)15.2 (32/210)72.1 (75/104)87.5 (84/96)Difference vs. (1), % (95% CI)–56.9 (47.0, 66.8) ‡72.3 (64.1, 80.5) ‡Difference vs. (2), % (95% CI)––15.4 (4.5, 26.3) †EQ-5D-5L VAS CFBNx20510192Mean (SD)5.6 (20.8)15.9 (21.1)24.4 (23.5)Mean Difference vs. (1), (95% CI)–10.4 (5.4, 15.3) ‡18.8 (13.5, 24.1) ‡Mean Difference vs. (2), (95% CI)––8.4 (2.1, 14.7)†(1) Did not achieve PASDAS LDA or VLDA(2) PASDAS LDA but not VLDA(3) Achieved PASDAS VLDAHAQ-DI MCID RRResponse, % (n/N)15.3 (34/223)63.2 (43/68)91.9 (68/74)Difference vs. (1), % (95% CI)–48.0 (35.6, 60.4) ‡76.7 (68.8, 84.5) ‡Difference vs. (2), % (95% CI)––29.7 (15.6, 41.7) ‡SF-36 PCS MCID RRResponse, % (n/N)22.1 (54/244)75.3 (61/81)89.4 (76/85)Difference vs. (1), % (95% CI)–53.2 (42.4, 63.9) ‡67.3 (58.9, 75.6) ‡Difference vs. (2), % (95% CI)––14.1 (2.7, 25.6)*EQ-5D-5L VAS CFBNx2387882Mean (SD)6.2 (21.1)15.8 (19.9)27.7 (22.8Mean Difference vs. (1), (95% CI)–9.5 (4.2, 14.9) ‡21.5 (16.1, 26.9) ‡Mean Difference vs. (2), (95% CI)––11.9 (5.3, 18.6) ‡Negative changes from baseline indicate improvement in HAQ-DI. Positive changes from baseline indicate improvement in SF-36 PCS and EQ-5D-5L VAS. The MCID for HAQ-DI is defined as a CFB ≤-0.35. The MCID for SF-36 PCS is defined as a CFB ≥2.5. DAPSA LDA refers to a DAPSA score &gt;4 but ≤14; DAPSA remission refers to a DAPSA score ≤4. PASDAS LDA refers to a PASDAS score &gt;1.9 but ≤3.2; PASDAS VLDA refers to a PASDAS score ≤1.9.EQ-5D-5L VAS is measured on a scale of 1-100. Missing data were imputed by NRI for MCID (HAQ-DI and SF-36 PCS) and mBOCF for CFB (EQ-5D-5L VAS). P values were calculated by Fisher’s exact test for MCID RR (HAQ-DI and SF-36) and one-way ANOVA for CFB (EQ-5D);*p &lt; 0.05;†p &lt; 0.01;‡p &lt; 0.001. ANOVA=analysis of variance; CFB= change from baseline; CI=confidence interval; DAPSA=Disease Activity in Psoriatic Arthritis; EQ-5D-5L VAS=5-Level EQ-5D Visual Analog Scale; HAQ-DI= Health Assessment Questionnaire-Disability Index; MCID RR=minimal clinically important difference response rate (%); LDA=low disease activity; mBOFC=modified baseline observation carried forward; MDA=minimal disease activity; n=number of patients achieving QoL measure; N=number of patients in subgroup; NRI=non-responder imputation; Nx=number of patients with non-missing data; PASDAS=Psoriatic Arthritis Disease Activity Score; QoL=quality of life; SD=standard deviation; SF-36 PCS=36-Item Short-Form Health Survey Physical Component Score; VLDA=very low disease activity.

Conclusion 

Significant associations between remission or LDA target achievement and QoL improvements were present at 3 years of ixekizumab treatment. Numerical improvements in HAQ-DI and SF-36 PCS appear greater in patients achieving the lowest targets; achieving the lowest targets shows incremental QoL benefits compared to achieving LDA.

Disclosure 

L.C. Coates: Consultancies; Laura Coates has received honoraria, grant/research support or consulting fees from AbbVie, Amgen, Boehringer-Ingelheim, BMS, Celgene, Eli Lilly, Janssen, MSD, Novartis, Pfizer, Sun Pharma, and UCB. Honoraria; Laura Coates has received honoraria, grant/research support or consulting fees from AbbVie, Amgen, Boehringer-Ingelheim, BMS, Celgene, Eli Lilly, Janssen, MSD, Novartis, Pfizer, Sun Pharma, and UCB. Member of speakers’ bureau; Laura Coates is a member of a speakers' bureau for AbbVie, Amgen, Biogen, BMS, Celgene, Eli Lilly, Janssen, Medac, Novartis, Pfizer, Sun Pharma, and UCB. Grants/research support; Laura Coates has received honoraria, grant/research support or consulting fees from AbbVie, Amgen, Boehringer-Ingelheim, BMS, Celgene, Eli Lilly, Janssen, MSD, Novartis, Pfizer, Sun Pharma, and UCB. J. Birt: Other; Julie Birt is an employee and shareholder of Eli Lilly and Company. A. Kronbergs: Other; Andris Kronbergs is an employee and shareholder of Eli Lilly and Company. R. Bolce: Other; Rebecca Bolce is an employee and shareholder of Eli Lilly and Company. A.J. Bradley: Other; Andrew J. Bradley is an employee and shareholder of Eli Lilly and Company. S. Park: Other; So Young Park is an employee and shareholder of Eli Lilly and Company. P.S. Helliwell: Consultancies; Philip Helliwell has received honoraria/consultation fees paid to university from Eli Lilly and Pfizer and paid to self from Celgene, Janssen, and Eli Lilly. Honoraria; Philip Helliwell has received honoraria/consultation fees paid to university from Eli Lilly and Pfizer and paid to self from Celgene, Janssen, and Eli Lilly. Grants/research support; Philip Helliwell has received grants and research support paid to charity by Novartis.

P178 The impact of peripheral articular manifestations on the efficacy of ixekizumab in patients with radiographic axial spondyloarthritis

Background/Aims 

Axial spondyloarthritis (axSpA) is characterised by chronic inflammation of the axial skeleton and is commonly associated with peripheral articular manifestations (PA), which further increases disease burden. Ixekizumab (IXE), a high-affinity monoclonal antibody that selectively targets IL-17A, is approved for treating both nonradiographic and radiographic (r-) forms of axSpA. We explored the efficacy of IXE in patients with raxSpA with (PA+) and without (PA−) PA at baseline.

Methods 

Week 16 data from two Phase 3, randomized, double-blind, placebo (PBO)-controlled trials, with patients who fulfilled the Assessment of Spondylo-Arthritis International Society (ASAS) criteria for r-axSpA and were either biologic-naïve (COAST-V, NCT02696785) or TNFi-experienced (COAST-W, NCT02696798), were analysed. Patients were randomly assigned 1:1:1:1 to subcutaneous PBO, 80 mg IXE every 4 (Q4W) or 2 (Q2W) weeks (80 mg or 160 mg starting dose, assigned 1:1) or 40 mg adalimumab (ADA) Q2W in COAST-V or 1:1:1 in COAST-W. We present a post-hoc analysis of data from COAST-V and -W and an integrated dataset, with patients categorized by baseline PA status. Presence of PA was defined as a 44-joint swollen joint count (SJC) ≥1 or a 46-joint tender joint count (TJC) ≥1. Efficacy and health-related quality of life (HRQoL) outcomes were analysed at week 16.

Results 

Data from 656 patients (COAST-V: N = 146 PA−/194 PA+; COAST-W: N = 93 PA−/223 PA+) were analyzed. At baseline, PA+ patients had a higher mean age, more enthesitis (higher Spondyloarthritis Research Consortium of Canada [SPARCC] scores), and higher disease activity (higher CRP levels, Ankylosing Spondylitis Disease Activity Score [ASDAS] and BASDAI). ASAS40, ASDAS &lt;2.1, and BASDAI50 responder rates (Table, section a) were all significantly higher for both IXE dose regimens versus PBO in both PA− and PA+ patients in the integrated dataset and numerically higher in the separate datasets. Furthermore, short-form-36 physical component summary (Table, section b) showed significantly greater improvements from baseline in both IXE groups vs PBO in the separate and integrated datasets, regardless of baseline PA status.

Conclusion 

IXE led to significant improvements versus PBO in all efficacy and HRQoL endpoints at Week 16 in the integrated dataset, irrespective of PA manifestations at baseline. P178 Table 1:a) Responder rates at Week 16 for the intent-to-treat population, number (%)No peripheral articular manifestations at baselinePeripheral articular manifestations at baselinePBOADAQ2WIEQ4WIXEQ2WPBOADAQ2WIXEQ4WIXEQ2WIntegrated datasetaN=71N/AN=63N=66N=119N/AN=132N=115ASAS4011.5N/A29 (46.0)‡28 (42.4)‡18 (15.1)N/A39 (29.5)†45 (39.1)‡ASDAS &lt;2.18 (11.3)N/A24 (38.1)‡23 (34.8)†8 (6.7)N/A31 (23.5)‡28 (24.3)‡BASDAI5010 (14.1)N/A21 (33.3)*26 (39.4)†15 (12.6)N/A38 (28.8)‡33 (28.7)†COAST-VbN=34N=39N=35N=38N=52N=51N=46N=45ASAS408 (23.5)17 (43.6)18 (51.4)*18 (47.4)8 (15.4)15 (29.4)21 (45.7)†25 (55.6)‡ASDAS &lt;2.17 (20.6)18 (46.2)*14 (40.0)17 (44.7)*4 (7.7)16 (31.4)†21 (45.7)†18 (40.0)‡BASDAI507 (20.6)16 (41.0)13 (37.1)16 (42.1)8 (15.4)13 (25.5)21 (45.7)†20 (44.4)†COAST-WbN=37N/AN=28N=28N=67N/AN=86N=70ASAS403 (8.1)N/A11 (39.3)†10 (35.7)*10 (35.7)*N/A18 (20.9)20 (28.6)ASDAS &lt;2.11 (2.7)N/A10 (35.7)‡6 (21.4)*4 (6.0)N/A10 (11.6)10 (14.3)BASDAI503 (8.1)N/A8 (28.6)*10 (35.7)*7 (10.4)N/A17 (19.8)13 (18.6)Non-responder imputation was used for missing responses.P-values vs. PBO (aCochran-Mantel-Haenszel test, adjusted by study;bFisher’s exact test):*P&lt;0.05,†P&lt;0.01,‡P&lt;0.001.b) Change from baseline in SF-36 PCS scores at Week 16 for the intent-to-treat population, LSM (SE)No peripheral articular manifestations at baselinePeripheral articular manifestations at baselinePBOADAQ2WIXEQ4WIXEQ2WPBOADAQ2WIXEQ4WIXEQ2WIntegrated dataseta1.6 (0.90)N/A7.2 (0.95)‡6.1 (0.92)‡3.8 (0.69)N/A7.7 (0.67)‡8.2 (0.71)‡COAST-Vb2.3 (1.15)7.0 (1.10)†6.9 (1.13)†6.4 (1.07)*4.6 (1.00)6.9 (1.01)8.3 (1.07)*9.3 (1.10)†COAST-Wc0.64 (1.57)N/A7.1 (1.75)†5.4 (1.72)*1.9 (0.96)N/A6.4 (0.85)‡6.3 (0.97)‡P-values vs. PBO (MMRM analysis with treatment,a,b,c study,a baseline value,a,b,c visit,a,b,c baseline value-by-visit,a,b,c treatment-by-visit interaction,a,b,c geographic region,b,c baseline CRP status,b,c and number of prior TNF inhibitorsc included as fixed factors):*P &lt; 0.05,†P &lt; 0.01,‡P &lt; 0.001.ADAQ2W = adalimumab every 2 weeks; ASAS = Assessment of Spondyloarthritis International Society criteria; ASDAS = ankylosing spondylitis disease activity score; BASDAI = Bath Ankylosing Spondylitis Disease Activity Index; CRP = c reactive protein; IXEQ2W = ixekizumab every 2 weeks; IXEQ4W = ixekizumab every 4 weeks; MMRM = mixed-effects model of repeated measures; N/A = not applicable; PBO = placebo; PCS = physical component summary; SE = standard error; SF-36 = short-form-36; TNF = tumour necrosis factor.

Disclosure 

R. Sengupta: None. P. Bird: Grants/research support; Pfizer, Eli Lilly, Gilead, Abbvie, Novartis. D. Aletaha: Consultancies; Abbvie, Amgen, Celgene, Eli Lilly, Medac, Merck, Novartis, Pfizer, Roche, Sandoz, Sanofi, Genzyme. Grants/research support; Abbvie, Novartis, Roche. M. Magrey: Consultancies; Novartis, Pfizer, Eli Lilly, Abbvie, UCB. Other; Clinical trials with: Abbvie and UCB. Y. Kadono: Member of speakers’ bureau; Abbie, Lilly, Novartis. E. Soriano: Consultancies; Abbvie, Eli Lilly, GlaxoSmithKline, Novartis, Pfizer, Sandoz. Member of speakers’ bureau; Abbvie, Amber, Bristol-Myers Squibb, Eli Lilly, Novartis, Pfizer, Roche, UCB. Grants/research support; Abbvie, Eli Lilly, GlaxoSmithKline, Novartis, Pfizer, Sandoz, UCB. A.J. Bradley: Shareholder/stock ownership; Eli Lilly. Other; Employee of Eli Lilly and Company. S. Liu-Leage: Shareholder/stock ownership; Eli Lilly. Other; Employee of Eli Lilly and Company. Y. Schymura: Other; Employee of Eli Lilly and Company. M.J. Nissen: Corporate appointments; Abbvie, Celgene, Lilly, Novartis, Pfizer. Member of speakers’ bureau; Abbvie, Celgene, Novartis, Pfizer. Other; Member of EuroSpA (supported by Novartis).

Cardiothoracic imaging findings of Proteus syndrome

In this work, we sought to delineate the prevalence of cardiothoracic imaging findings of Proteus syndrome in a large cohort at our institution. Of 53 individuals with a confirmed diagnosis of Proteus syndrome at our institution from 10/2001 to 10/2019, 38 individuals (men, n = 23; average age = 24 years) underwent cardiothoracic imaging (routine chest CT, CT pulmonary angiography and/or cardiac MRI). All studies were retrospectively and independently reviewed by two fellowship-trained cardiothoracic readers. Disagreements were resolved by consensus. Differences between variables were analyzed via parametric and nonparametric tests based on the normality of the distribution. The cardiothoracic findings of Proteus syndrome were diverse, but several were much more common and included: scoliosis from bony overgrowth (94%), pulmonary venous dilation (62%), band-like areas of lung scarring (56%), and hyperlucent lung parenchyma (50%). In addition, of 20 individuals who underwent cardiac MRI, 9/20 (45%) had intramyocardial fat, mostly involving the endocardial surface of the left ventricular septal wall. There was no statistically significant difference among the functional cardiac parameters between individuals with and without intramyocardial fat. Only one individual with intramyocardial fat had mildly decreased function (LVEF = 53%), while all others had normal ejection fraction.

Routes to diagnosis and missed opportunities in the detection of renal cancer

AIM

To determine the proportion of renal cancers for which incidental detection was the route to diagnosis, the characteristics of tumours identified in this way, and the frequency with which opportunities to make this diagnosis were missed.

MATERIALS AND METHODS

Consecutive patients with renal cancers treated at Royal Cornwall Hospitals NHS Trust (April 2011 and July 2018 inclusive) were identified from the Trust's cancer registry database, and a retrospective review of the imaging and electronic case notes was undertaken. Mann-Whitney U-tests for comparison of patient age and tumour size at diagnosis, and chi-squared tests for comparing cell type distribution and grade were performed. Logistic regression was then used to identify the characteristics of patients in whom a renal tumour was missed initially.

RESULTS

Of 327 patients, 194 (63%) presented incidentally, and 133 (37%) symptomatically. Incidentally detected cancers were found in younger patients, (median of 65 years versus 69 p=0.01) and were smaller at presentation (median of 5.5 versus 7.2 cm, p<0.00001). Thirty-six different reporters missed opportunities to diagnose renal cancer in 50 (16%) patients on 78 occasions, 28 lesions (35%) being missed more than once. Thirty were imaged incompletely; four were visible only on a single image and three on a scout view at magnetic resonance imaging.

CONCLUSION

The commonest route to diagnosis of renal cancer is by incidental detection of a mass. In 16% of patients in whom renal cancer is diagnosed, there is at least one prior examination on which the lesion is visible at an earlier date. The clinical impact of these missed diagnostic opportunities remains uncertain.

P281 52-Week efficacy and safety of ixekizumab in r-axSpA/AS patients naïve to biologic treatments or with prior inadequate response/intolerance to tumor necrosis factor inhibitors

Background

Radiographic axial spondylitis (r-axSpA), or ankylosing spondylitis (AS), is a chronic inflammatory disease of the axial skeleton associated with serious pain, stiffness and limited flexibility, impairing quality of life. Two clinical trials demonstrated efficacy and safety of ixekizumab (IXE), a humanised anti-IL-17 IgG4 antibody, in r-axSpA/AS patients naïve to biologics, or with prior inadequate response/intolerance to tumor necrosis factor inhibitors (TNFi) over 16 weeks. This study assessed the treatment effect over 52 weeks. Additionally, the influence of baseline inflammation, measured by C-reactive protein (CRP) and/or spinal MRI on ASAS40 response at week 16 was investigated.

Methods

Data from two Phase 3, randomised, double-blind, placebo (PBO)-controlled trials, with patients who fulfilled the Assessment of Spondylo-Arthritis International Society (ASAS) criteria for AS and were either biologic-naïve (COAST-V, NCT02696785) or TNFi-experienced (COAST-W, NCT02696798), were analysed. We compared the proportion of patients achieving ASAS20/40, a 50% improvement of baseline Bath Ankylosing Spondylitis Disease Activity Index (BASDAI50) and assessed the change in spinal pain. Missing data was handled by using non-responder imputation for ASAS20/40 and BASDAI50 response rates and modified Baseline Observation Carried Forward (mBOCF) for spinal pain change from baseline. To investigate the influence of baseline inflammation on the efficacy, we examined the ASAS40 response at week 16 by baseline CRP (normal; ≤5 or elevated; &gt;5 mg/L) and/or MRI Spondyloarthritis Research Consortium of Canada (SPARCC) spine score (&lt;2 or ≥ 2) using an integrated COAST-V/W dataset.

Results

At week 16, significantly more IXE than PBO-treated patients achieved ASAS20/40 and BASDAI50 and a decrease in spinal pain. Decreases in disease activity were maintained through week 52 (Table 1). These outcomes occurred in both biologic-naïve and TNFi-experienced patients. Safety outcomes were consistent with previous IXE studies. At week 16, in the integrated dataset, significantly more IXE than PBO-treated patients achieved ASAS40 response regardless of baseline CRP or MRI spine SPARCC score.

Conclusion

Through week 52, treatment with IXE resulted in sustained efficacy in biologic-naïve and TNFi-experienced AS patients with no unexpected safety signals. Furthermore, at week 16, IXE demonstrated efficacy (ASAS40) irrespective of baseline CRP levels or spinal MRI score.

Disclosures

K. Gaffney: Consultancies; Abbvie, Eli Lilly, UCB, Novartis. Member of speakers’ bureau; Eli Lilly, UCB, Novartis. Grants/research support; Abbvie, Pfizer. D. Aletaha: Member of speakers’ bureau; Abbvie, Amgen, Celgene, Eli Lilly, Medac, Merck, Novartis, Pfizer, Roche, Sandoz, Sanofi, Sanofi/Genzyme. Grants/research support; Abbvie, Novartis, Roche. A.J. Bradley: Corporate appointments; Eli Lilly employee. Shareholder/stock ownership; Eli Lilly. M.H. Nassab: Corporate appointments; Eli Lilly employee. S. Liu Leage: Corporate appointments; Eli Lilly employee. R. Micheroli: None.

P276 Comparative effects of ixekizumab (IXE) vs adalimumab (ADA) across PsA patients defined by baseline characteristics: week 24 outcomes from SPIRIT-H2H

Background

Comparisons of PsA treatment options to guide physicians are limited. When conventional treatment is insufficient, the recommendations is a biological agent, most frequently tumour necrosis factor (TNF)-inhibitors. IXE, an IL-17A antagonist biologic, showed superiority over TNF-inhibitor ADA for the simultaneous achievement of ACR50 and PASI100, and PASI100 alone in the SPIRIT-H2H trial at week 24. We analysed differences in efficacy outcomes between IXE and ADA by subgroups based on baseline clinical characteristics.

Methods

We conducted post-hoc analysis of data from SPIRIT-H2H (NCT03151551), a 52-week, multicentre, open-label, blinded assessor study patients with active PsA (defined as swollen joint count ≥3 and tender joint count ≥3), with a body surface area (BSA) ≥3% and insufficient response to ≥ 1 conventional synthetic disease-modifying anti-rheumatic drugs (csDMARDs) and naïve to biologic (b)-DMARDs. Patients were randomised 1:1 to IXE or ADA, while presence/absence of moderate-to-severe psoriasis (defined as PASI ≥12, static Physician Global Assessment ≥3 and BSA ≥10%) determined on-label dosing. Subgroups were defined by baseline enthesitis, dactylitis, fingernail psoriasis (presence/absence), BSA (&lt;10%, ≥10%) and CRP (≤6 mg/L,&gt;6 mg/L). A Fisher’s exact test was used for between group comparisons of efficacy outcome measures at 24 weeks (PASI90, ACR50/70, and minimal disease activity [MDA]). Missing data were overcome by non-responder imputation.

Results

At week 24, IXE and ADA demonstrated comparable efficacy in ACR50 response rates across all subgroups. ACR70 response in patients with fingernail psoriasis was significantly greater with IXE-treated vs ADA (p = 0.02) (table). PASI90 response with baseline enthesitis (p &lt; 0.001), without dactylitis (p &lt; 0.001), with fingernail psoriasis (p &lt; 0.001), CRP (≤6 mg/L, p = 0.003; &gt;6 mg/L, p = 0.036) and BSA (&lt;10%, p = 0.010; ≥10%, p = 0.003) was significantly greater in IXE vs ADA (table). Significantly more IXE-treated patients vs ADA achieved MDA with baseline enthesitis (p = 0.002), without dactylitis (p = 0.015), with fingernail psoriasis (p &lt; 0.001), CRP ≤6 mg/L (p = 0.046) and BSA ≥10% (p = 0.01) (table). A limitation is that this analysis was completed post-hoc, not controlled for multiplicity, and patients were not stratified by baseline disease characteristics.

Conclusion

IXE and ADA are associated with comparable efficacy and associated with a greater effect in certain subgroups. Results will aid clinicians when making treatment choices.

Disclosures

H. Tahir: Consultancies; Novartis, Eli-Lilly, Abbvie. A.J. Bradley: Shareholder/stock ownership; Eli Lilly. Other; Full time employee of Eli Lilly. M.H. Nassab: Other; Full time employee of Eli Lilly. B. Möller: None. J.S. Smolen: Consultancies; AbbVie, Amgen, Astra-Zeneca, Astro, BMS, Celgene, Celltrion, Chugai, Eli Lilly, Gilead, ILTOO, Janssen, Medimmune, MSD, Novartis- Sandoz, Pfizer, Roche, Samsung, Sanofi-Aventis, UCB. Grants/research support; AbbVie, Eli Lilly, Novartis, Pfizer, Roche. C. Sapin: Shareholder/stock ownership; Eli Lilly. Other; Full time employee of Eli Lilly. C.F. Dionello: Consultancies; Novartis, Lilly, Janssen, Abbvie. Honoraria; Novartis, Lilly, Janssen, Abbvie, Roche, Pfizer. G. Meszaros: Shareholder/stock ownership; Eli Lilly. Other; Full time employee of Eli Lilly.

O23 Ixekizumab (IXE) vs. adalimumab (ADA) for the treatment of PSA: 52-week efficacy and safety outcomes

Background

With multiple biologic disease-modifying anti-rheumatic drugs (bDMARDs) available, comparisons are important for treatment decisions. At week 24 of the SPIRIT H2H study in patients with active PSA, IXE showed superiority to ADA for the simultaneous achievement of ACR50 and PASI100. Here we report the 52-week efficacy outcomes including individual ACR components and in subgroups +/- concomitant methotrexate (MTX).

Methods

SPIRIT H2H (NCT03151551) was a 52-week, multicentre, open-label, blinded-assessor study of bDMARD naïve patients with active PSA (defined as swollen joint count ≥3/68, and tender joint count ≥3/66), with a body surface area (BSA) ≥3% and inadequate response to conventional synthetic (cs)-DMARDs. Patients were randomised 1:1 to IXE or ADA stratified by concomitant csDMARD use and the presence of moderate-to-severe psoriasis (defined as Psoriasis Area and Severity Index [PASI] ≥12 combined with a static Physician Global Assessment ≥3 and BSA ≥10%). Patients received approved label dosing of assigned treatment dependent on presence/absence of moderate-to-severe psoriasis. Primary outcome was achievement of simultaneous ACR50 + PASI100; secondary outcomes were achievement of PASI100, ACR20/50/70 and changes in individual ACR component scores. Data were analysed using logistic regression with non-responder imputation for missing data.

Results

Baseline characteristics were balanced across treatment groups. At week 52, a significantly larger percentage of IXE- vs. ADA-treated patients achieved simultaneous ACR50 + PASI100 and PASI100, consistent with 24-week results (table). IXE performed at least as well as ADA at week 52 for all other outcomes (table). With/without MTX, IXE efficacy was consistent at week 52 across ACR20/50/70 with a significantly greater achievement of simultaneous ACR50 + PASI100 and ACR70 (table). IXE- versus ADA-treatment resulted in comparable changes from baseline for each individual ACR component at week 52. Safety was consistent with previous reports.

Conclusion

In patients with PSA, treatment with IXE versus ADA resulted in a significantly greater achievement of simultaneous skin and joint improvement at week 52, consistent with week 24 results. At week 52 consistent efficacy was shown for IXE when used with/without MTX.

Disclosures

C.J. Edwards: Consultancies; Celltrion, Abbvie, Samsung. Honoraria; Abbvie, BMS, Biogen, Chugai, Fresenius, Gilead, Janssen, Lilly, Pfizer, Roche, Samsung, UCB. Member of speakers’ bureau; Abbvie, BMS, Biogen, Chugai, Fresenius, Gilead, Janssen, Lilly, Pfizer, Roche, Samsung, UCB. Grants/research support; Pfizer, Biogen, Abbvie. A.J. Bradley: Shareholder/stock ownership; Eli Lilly. Other; Full time employee of Eli Lilly. M.H. Nassab: Other; Full time employee of Eli Lilly. B. Möller: None. K.P. Machold: Honoraria; Arsanis, Astro, Baxter, BMS, Celgene, Eli-Lilly, MSD, Pfizer, Roche, Novartis, Sandoz. Member of speakers’ bureau; MSD, Pfizer, BMS, Janssen-Cilag, Sandoz, Novartis, Eli-Lilly. Grants/research support; AbbVie, BMS, Eli-Lilly, Novartis, MSD, Pfizer, Sanofi-Aventis, UCB. C. Sapin: Shareholder/stock ownership; Eli Lilly. Other; Full time employee of Eli Lilly. R. Ranza: Consultancies; Abbvie, Novartis, Lilly, Pfizer, Janssen. Member of speakers’ bureau; Abbvie, Novartis, Lilly, Pfizer, Janssen. Grants/research support; Abbvie, Novartis, Pfizer, Janssen. S.L. Leage: Other; Full time employee of Eli Lilly.

The association between sleep and cognitive abnormalities in bipolar disorder

BACKGROUND

Bipolar disorder (BD) is associated with attentional and processing abnormalities. Such abnormalities are also seen in healthy subjects with sleep disruption. We hypothesised cognitive abnormalities in BD patients would be worse in those with objectively verified sleep abnormalities.

METHODS

Forty-six BD patients and 42 controls had comprehensive sleep/circadian rhythm assessment over 21 days alongside mood questionnaires. Cognitive function was assessed with a range of tasks including Psychomotor Vigilance Test (PVT), Attention Network Task (ANT) and Digit Symbol Substitution Test (DSST). BD participants with normal and abnormal sleep were compared with age- and sex-matched controls.

RESULTS

BD patients had longer response times and made more lapses (responses >500 ms) than controls on the PVT (both p < 0.001). However, patients with normal sleep patterns did not differ from controls while those with sleep abnormalities did (p < 0.001). An identical pattern of effects were seen with the ANT response times, with the abnormality in bipolar abnormal sleepers related to the executive attentional network. Similarly, patients made fewer correct responses on the DSST compared with the controls (p < 0.001). Bipolar normal sleepers did not differ while those with abnormal sleep did (p < 0.001). All these differences were seen in bipolar abnormal sleepers who were euthymic (p < 0.01) and across the main abnormal sleep phenotypes.

CONCLUSIONS

We confirm impairment in attention and processing speed in BD. Rather than sleep abnormalities exacerbating such dysfunction, the impairments were confined to bipolar abnormal sleepers, consistent with sleep disturbance being the main driver of cognitive dysfunction.

Evaluation of an incidental cardiac finding in a patient with bronchitis

Clinical introduction

A 63-year-old man with HIV presented with 1 month of dyspnoea and productive cough without orthopnoea. He was afebrile with normal blood pressure, borderline tachycardia and mild pulmonary wheezing. He had exertional hypoxia requiring 4 L per minute of oxygen. No murmurs, jugular venous distention or lower extremity oedema was noted. Clinical evaluation included transthoracic echocardiography (TTE), which showed mild left ventricular hypertrophy with normal size and systolic function. The right ventricle was normal. There was mild aortic insufficiency; other valves were normal. An abnormality was incidentally seen at the aortic root.

The patient was treated for bronchitis and chronic obstructive pulmonary disease exacerbation, while further evaluation of the incidental aortic root finding was performed with transoesophageal echocardiography (TEE) and cardiac MRI (CMR).

Question

What is the most likely diagnosis for this finding?

Barriers to living donor kidney transplantation in the United Kingdom: a national observational study

Background. Living donor kidney transplantation (LDKT) provides more timely access to transplantation and better clinical outcomes than deceased donor kidney transplantation (DDKT). This study investigated disparities in the utilization of LDKT in the UK.

Methods. A total of 2055 adults undergoing kidney transplantation between November 2011 and March 2013 were prospectively recruited from all 23 UK transplant centres as part of the Access to Transplantation and Transplant Outcome Measures (ATTOM) study. Recipient variables independently associated with receipt of LDKT versus DDKT were identified.

Results. Of the 2055 patients, 807 (39.3%) received LDKT and 1248 (60.7%) received DDKT. Multivariable modelling demonstrated a significant reduction in the likelihood of LDKT for older age {odds ratio [OR] 0.11 [95% confidence interval (CI) 0.08–0.17], P < 0.0001 for 65–75 years versus 18–34 years}; Asian ethnicity [OR 0.55 (95% CI 0.39–0.77), P = 0.0006 versus White]; Black ethnicity [OR 0.64 (95% CI 0.42–0.99), P = 0.047 versus White]; divorced, separated or widowed [OR 0.63 (95% CI 0.46–0.88), P = 0.030 versus married]; no qualifications [OR 0.55 (95% CI 0.42–0.74), P < 0.0001 versus higher education qualifications]; no car ownership [OR 0.51 (95% CI 0.37–0.72), P = 0.0001] and no home ownership [OR 0.65 (95% CI 0.85–0.79), P = 0.002]. The odds of LDKT varied significantly between countries in the UK.

Conclusions. Among patients undergoing kidney transplantation in the UK, there are significant age, ethnic, socio-economic and geographic disparities in the utilization of LDKT. Further work is needed to explore the potential for targeted interventions to improve equity in living donor transplantation.

The impact of dairy cows' bedding material and its microbial content on the quality and safety of milk - A cross sectional study of UK farms

The introduction of bedding dairy cows on recycled manure solids (RMS) in the UK led to concern by competent authorities that there could be an increased, unacceptable risk to animal and human health. A cross-sectional study was designed to evaluate the microbial content of different bedding materials, when used by dairy cows, and its impact on the microbial content of milk. Data were collected from farms bedding lactating cows on sand (n=41), sawdust (n=44) and RMS (n=40). The mean duration of RMS use prior to sampling was 13months. Total bacterial count, and counts of Streptococcus/Enterococcus spp., Staphylococcus spp., Bacillus cereus, thermophilic, thermoduric and psychrotrophic bacteria were determined in used bedding and milk. Samples were evaluated for the presence/absence of Listeria monocytogenes, Salmonella spp. and Yersinia enterocolitica. Data on milking practices were collected to investigate their potential to reduce microbial transfer from bedding to milk. There were substantial differences in bacterial counts both within and between bedding materials. However, there were no significant differences between bedding groups in counts in milk for any of the organisms studied, and no significant correlations between bacterial load in used bedding and milk. Fore-milking was associated with a reduced total bacterial count in milk. Dipping teats with disinfectant and drying, prior to milking, was associated with lower numbers of Streptococcus/Enterococcus spp. in milk. Disinfecting clusters between milking different cows was associated with a reduction in thermophilic and psychrotrophic counts in milk. This study did not provide evidence that use of RMS bedding increased the risk of presence of Y. enterocolitica, Salmonella spp. or L. monocytogenes in milk. However, the strength of this conclusion should be tempered by the relatively small number of farms on which Y. enterocolitica and Salmonella spp. were isolated. It is concluded that, despite the higher bacterial load of RMS, its use as bedding for lactating dairy cows need not be associated with a higher bacterial load in milk than the use of sand or sawdust. However, this finding must be interpreted in the light of the relatively recent introduction of RMS as a bedding material on the farms studied. Teat preparation provides a control point for the potential transfer of microorganisms from bedding to milk. The detection of zoonotic pathogens in a small proportion of milk samples, independent of bedding type, indicates that pasteurisation of milk prior to human consumption remains an important control measure.

Factors affecting the cost-effectiveness of on-farm culture prior to the treatment of clinical mastitis in dairy cows

The objective of this study was to use probabilistic sensitivity analysis to evaluate the cost-effectiveness of using an on-farm culture (OFC) approach to the treatment of clinical mastitis in dairy cows and compare this to a ‘standard’ treatment approach. A specific aim was to identify the herd circumstances under which an OFC approach would be most likely to be cost-effective. A stochastic Monte Carlo model was developed to simulate 5000 cases of clinical mastitis at the cow level and to calculate the associated costs simultaneously when treated according to 2 different treatment protocols; i) a 'conventional' approach (3 tubes of intramammary antibiotic) and ii) an OFC programme, whereby cows are treated according to the results of OFC. Model parameters were taken from recent peer reviewed literature on the use of OFC prior to treatment of clinical mastitis. Spearman rank correlation coefficients were used to evaluate the relationships between model input values and the estimated difference in cost between the standard and OFC treatment protocols. The simulation analyses revealed that both the difference in the bacteriological cure rate due to a delay in treatment when using OFC and the proportion of Gram-positive cases that occur on a dairy unit would have a fundamental impact on whether OFC would be cost-effective. The results of this study illustrated that an OFC approach for the treatment of clinical mastitis would probably not be cost-effective in many circumstances, in particular, not those in which Gram-positive pathogens were responsible for more than 20% of all clinical cases. The results highlight an ethical dilemma surrounding reduced use of antimicrobials for clinical mastitis since it may be associated with financial losses and poorer cow welfare in many instances.

Sleep and circadian rhythm disturbance in bipolar disorder

BACKGROUND

Subjective reports of insomnia and hypersomnia are common in bipolar disorder (BD). It is unclear to what extent these relate to underlying circadian rhythm disturbance (CRD). In this study we aimed to objectively assess sleep and circadian rhythm in a cohort of patients with BD compared to matched controls.

METHOD

Forty-six patients with BD and 42 controls had comprehensive sleep/circadian rhythm assessment with respiratory sleep studies, prolonged accelerometry over 3 weeks, sleep questionnaires and diaries, melatonin levels, alongside mood, psychosocial functioning and quality of life (QoL) questionnaires.

RESULTS

Twenty-three (50%) patients with BD had abnormal sleep, of whom 12 (52%) had CRD and 29% had obstructive sleep apnoea. Patients with abnormal sleep had lower 24-h melatonin secretion compared to controls and patients with normal sleep. Abnormal sleep/CRD in BD was associated with impaired functioning and worse QoL.

CONCLUSIONS

BD is associated with high rates of abnormal sleep and CRD. The association between these disorders, mood and functioning, and the direction of causality, warrants further investigation.

A Bayesian micro-simulation to evaluate the cost-effectiveness of interventions for mastitis control during the dry period in UK dairy herds

Importance of the dry period with respect to mastitis control is now well established although the precise interventions that reduce the risk of acquiring intramammary infections during this time are not clearly understood. There are very few intervention studies that have measured the clinical efficacy of specific mastitis interventions within a cost-effectiveness framework so there remains a large degree of uncertainty about the impact of a specific intervention and its costeffectiveness. The aim of this study was to use a Bayesian framework to investigate the cost-effectiveness of mastitis controls during the dry period. Data were assimilated from 77 UK dairy farms that participated in a British national mastitis control programme during 2009-2012 in which the majority of intramammary infections were acquired during the dry period. The data consisted of clinical mastitis (CM) and somatic cell count (SCC) records, herd management practices and details of interventions that were implemented by the farmer as part of the control plan. The outcomes used to measure the effectiveness of the interventions were i) changes in the incidence rate of clinical mastitis during the first 30days after calving and ii) the rate at which cows gained new infections during the dry period (measured by SCC changes across the dry period from <200,000cells/ml to >200,000cells/ml). A Bayesian one-step microsimulation model was constructed such that posterior predictions from the model incorporated uncertainty in all parameters. The incremental net benefit was calculated across 10,000 Markov chain Monte Carlo iterations, to estimate the cost-benefit (and associated uncertainty) of each mastitis intervention. Interventions identified as being cost-effective in most circumstances included selecting dry-cow therapy at the cow level, dry-cow rations formulated by a qualified nutritionist, use of individual calving pens, first milking cows within 24h of calving and spreading bedding evenly in dry-cow yards. The results of this study highlighted the efficacy of specific mastitis interventions in UK conditions which, when incorporated into a costeffectiveness framework, can be used to optimize decision making in mastitis control. This intervention study provides an example of how an intuitive and clinically useful Bayesian approach can be used to form the basis of an on-farm decision support tool.

Invited review: Opportunities for genetic improvement of metabolic diseases

Metabolic disorders are disturbances to one or more of the metabolic processes in dairy cattle. Dysfunction of any of these processes is associated with the manifestation of metabolic diseases or disorders. In this review, data recording, incidences, genetic parameters, predictors, and status of genetic evaluations were examined for (1) ketosis, (2) displaced abomasum, (3) milk fever, and (4) tetany, as these are the most prevalent metabolic diseases where published genetic parameters are available. The reported incidences of clinical cases of metabolic disorders are generally low (less than 10% of cows are recorded as having a metabolic disease per herd per year or parity/lactation). Heritability estimates are also low and are typically less than 5%. Genetic correlations between metabolic traits are mainly positive, indicating that selection to improve one of these diseases is likely to have a positive effect on the others. Furthermore, there may also be opportunities to select for general disease resistance in terms of metabolic stability. Although there is inconsistency in published genetic correlation estimates between milk yield and metabolic traits, selection for milk yield may be expected to lead to a deterioration in metabolic disorders. Under-recording and difficulty in diagnosing subclinical cases are among the reasons why interest is growing in using easily measurable predictors of metabolic diseases, either recorded on-farm by using sensors and milk tests or off-farm using data collected from routine milk recording. Some countries have already initiated genetic evaluations of metabolic disease traits and currently most of these use clinical observations of disease. However, there are opportunities to use clinical diseases in addition to predictor traits and genomic information to strengthen genetic evaluations for metabolic health in the future.

Current management practices and interventions prioritised as part of a nationwide mastitis control plan

The objectives of this study were to report performance and management data taken from a sample of UK dairy farms that have participated in the Agriculture and Horticulture Development Board Dairy Mastitis Control Plan (DMCP) and to identify important mastitis prevention practices that are not currently widely implemented. A total of 234 UK dairy herds were included in the study from which farm management and udder health data were collected. Herds were grouped according to their mastitis epidemiology and could be classed as (i) environmental dry period (EDP) (i.e. environmental pathogen with majority of infections being acquired during the dry period), (ii) environmental lactation (EL), (iii) contagious dry period (CDP) or (iv) contagious lactation (CL). The results of this study showed that many mastitis-related management practices that are generally considered to be important were not widely performed. A better understanding of those practices not widely adopted by UK dairy farmers at present may aid practitioners in identifying and overcoming potential barriers to improved mastitis control.

Recycling manure as cow bedding: Potential benefits and risks for UK dairy farms

Material obtained from physical separation of slurry (recycled manure solids; RMS) has been used as bedding for dairy cows in dry climates in the US since the 1970s. Relatively recently, the technical ability to produce drier material has led to adoption of the practice in Europe under different climatic conditions. This review collates the evidence available on benefits and risks of using RMS bedding on dairy farms, with a European context in mind. There was less evidence than expected for anecdotal claims of improved cow comfort. Among animal health risks, only udder health has received appreciable attention. There are some circumstantial reports of difficulties of maintaining udder health on RMS, but no large scale or long term studies of effects on clinical and subclinical mastitis have been published. Existing reports do not give consistent evidence of inevitable problems, nor is there any information on clinical implications for other diseases. The scientific basis for guidelines on management of RMS bedding is limited. Decisions on optimum treatment and management may present conflicts between controls of different groups of organisms. There is no information on the influence that such 'recycling' of manure may have on pathogen virulence. The possibility of influence on genetic material conveying antimicrobial resistance is a concern, but little understood. Should UK or other non-US farmers adopt RMS, they are advised to do so with caution, apply the required strategies for risk mitigation, maintain strict hygiene of bed management and milking practices and closely monitor the effects on herd health.

Accuracy of preoperative CT T staging of renal cell carcinoma: which features predict advanced stage?

AIMS

To characterise CT findings in renal cell carcinoma (RCC), and establish which features are associated with higher clinical T stage disease, and to evaluate patterns of discrepancy between radiological and pathological staging of RCC.

MATERIALS AND METHODS

Preoperative CT studies of 92 patients with 94 pathologically proven RCCs were retrospectively reviewed. CT stage was compared with pathological stage using the American Joint Committee on Cancer (AJCC), 7(th) edition (2010). The presence or absence of tumour necrosis, perinephric fat standing, thickening of Gerota's fascia, collateral vessels were noted, and correlated with pT stage. The sensitivity, specificity, and positive (PPV) and negative predictive values (NPV) for predicting pT stage ≥pT3a were derived separately for different predictors using cross-tabulations.

RESULTS

Twenty-four lesions were pathological stage T1a, 21 were T1b, seven were T2a, 25 were T3a, 11 were T3b, four were T3c, and two were T4. There were no stage T2b. Sixty-three (67%) patients had necrosis, 27 (29%) thickening of Gerota's fascia (1 T1a), 25 had collateral vessels (0 T1a), 28 (30%) had fat stranding of <2 mm, 20 (21%) of 2-5mm and one (1%) of >5 mm. For pT stage ≥pT3a, the presence of perinephric fat stranding had a sensitivity, specificity, PPV and NPV of 74%, 65%, 63%, and 76%, respectively. Presence of tumour necrosis had a sensitivity, specificity, PPV, and NPV of 81%, 44%, 54%, and 72%, respectively. Thickening of Gerota's fascia had a sensitivity, specificity, PPV, and NPV of 52%, 90%, 81% and 70%, respectively; and enlarged collateral vessels had a sensitivity, specificity, PPV, and NPV value of 52%, 94%, 88%, and 71% respectively.

CONCLUSION

The presence of perinephric stranding and tumour necrosis were not reliable signs for pT stage >T3a. Thickening of Gerota's fascia and the presence of collateral vessels in the peri- or paranephric fat had 90% and 94% specificity, with 82% and 88% PPV, respectively, for the presence of tumour stage for pT stage >T3a. These are considered reliable signs of locally advanced renal cancer.

Dairy herd mastitis and reproduction: using simulation to aid interpretation of results from discrete time survival analysis

Probabilistic sensitivity analysis (PSA) is a simulation-based technique for evaluating the relative importance of different inputs to a complex process model. It is commonly employed in decision analysis and for evaluation of the potential impact of uncertainty in research findings on clinical practice, but has a wide variety of other possible applications. In this example, it was used to evaluate the association between herd-level udder health and reproductive performance in dairy herds. Although several recent studies have found relatively large associations between mastitis and fertility at the level of individual inseminations or lactations, the current study demonstrated that herd-level intramammary infection status is highly unlikely to have a clinically significant impact on the overall reproductive performance of a dairy herd under typical conditions. For example, a large increase in incidence rate of clinical mastitis (from 92 to 131 cases per 100 cows per year) would be expected to increase a herd's modified FERTEX score (a cost-based measure of overall reproductive performance) by just £4.50(1) per cow per year. The herd's background level of submission rate (proportion of eligible cows served every 21 days) and pregnancy risk (proportion of inseminations leading to a pregnancy) correlated strongly with overall reproductive performance and explained a large proportion of the between-herd variation in performance. PSA proved to be a highly useful technique to aid understanding of results from a complex statistical model, and has great potential for a wide variety of applications within the field of veterinary science.

Cortisol awakening response and spatial working memory in man: a U-shaped relationship

OBJECTIVE

The association between hypothalamic-pituitary-adrenal (HPA)-axis function and cognition has long been investigated. An inverted U-shaped relationship has been described between various measures of HPA-axis function and neuropsychological performance in animals and man. Work with glucocorticoid receptor manipulation has corroborated these findings, with particular effects observed in relation to spatial working memory (SWM). As HPA-axis dysfunction is frequently found in patients with psychiatric illness, research in this area has potential implications for the treatment of the commonly observed cognitive impairment in such disorders. Here, we present the results of a pilot study examining the relationship between cortisol awakening response (CAR) and cognitive functions known to be susceptible to HPA-axis manipulation.

METHODS

Nineteen healthy male volunteers were recruited, and their CAR and performance in a task of SWM were assessed.

RESULTS

A highly significant quadratic relationship was observed between the CAR and SWM error rate (R(2)=0.63, p=0.001).

CONCLUSION

We provide novel evidence supporting the existence of an inverted U-shaped relationship between corticosteroid levels and cognitive function in humans.

Does adding noradrenaline reuptake inhibition to selective serotonin reuptake inhibition improve efficacy in patients with depression? A systematic review of meta-analyses and large randomised pragmatic trials

Selective serotonin reuptake inhibitors (SSRIs) are recommended as first-line pharmacological treatment for depression and are the most commonly prescribed class of antidepressants. However, there is substantial evidence that noradrenaline has a role in the pathogenesis and treatment of depression. This review aims to examine the evidence of including noradrenaline reuptake inhibition with serotonin reuptake inhibition with respect to increasing efficacy in the treatment of depression. Evidence from meta-analysis of randomised controlled trials (RCTs) and randomised pragmatic trials was found in support of greater efficacy of the serotonin noradrenaline reuptake inhibitors (SNRIs), venlafaxine and duloxetine, in moderate to severe depression compared to SSRIs but no evidence was found for superiority of milnacipran. There is sufficient current evidence that demonstrates an increase in efficacy, when noradrenaline reuptake is added to serotonin (5-HT) reuptake, to suggest that patients with severe depression or those who have failed to reach remission with a SSRI may benefit from treatment with a SNRI. However, as these conclusions are drawn from the evidence derived from meta-analyses and pragmatic trials, large adequately powered RCTs using optimal dosing regimens and clinically relevant outcome measures in severe depression and SSRI treatment failures are still required to confirm these findings.

Sleep disturbance in mental health problems and neurodegenerative disease

Sleep has been described as being of the brain, by the brain, and for the brain. This fundamental neurobiological behavior is controlled by homeostatic and circadian (24-hour) processes and is vital for normal brain function. This review will outline the normal sleep-wake cycle, the changes that occur during aging, and the specific patterns of sleep disturbance that occur in association with both mental health disorders and neurodegenerative disorders. The role of primary sleep disorders such as insomnia, obstructive sleep apnea, and REM sleep behavior disorder as potential causes or risk factors for particular mental health or neurodegenerative problems will also be discussed.

The influence of reproductive hormones on the torpor patterns of the marsupial Sminthopsis macroura: bet-hedging in an unpredictable environment

Seasonal cycles of reproduction are common in many mammals and these are combined with the necessary energy budgeting for thermoregulatory challenges. Many mammals meet the challenge of changing environmental temperatures in winter by using torpor, a controlled reduction in body temperature and metabolic rate. We aimed to determine the effects of photoperiod and reproductive hormones on the seasonal cycles of reproduction and torpor use in a marsupial that commences reproduction in winter, the stripe-faced dunnart, Sminthopsis macroura. Males and females were placed under LD 14:10 and natural reproductive hormones blocked by either flutamide (males) or mifepristone (females) or tamoxifen (females). Reproductive parameters, metabolic rate and torpor variables were determined. The same animals were then placed under LD 10:14 and given testosterone (males) or progesterone (females) or oestrogen (females). Reproductive parameters, metabolic rate and torpor variables were measured. Body mass and tail widths (fattening indicator) in males were significantly affected by testosterone, and the effects were reversed by hormone blockers. Reproductive parameters were unaffected. Resting metabolic rate and ability to use torpor were not affected by treatment in males, however torpor characteristics, especially torpor bout duration, were affected by presence of testosterone in males. In females, body mass was unaffected by hormone presence, although tail widths were affected. Disruption of reproductive cycles occurred with hormone blockers in females, however, resting metabolic rate was not affected, and only presence of progesterone affected torpor characteristics in females. Our results differ from those found for rodents, where presence of testosterone abolishes the use of torpor in males, and oestrogen inhibits torpor use in females. Our study suggests that, in this mammal, metabolic responses to the presence or absence of reproductive hormones differs between males and females, and there is no absolute endocrinologically-driven reproductive season demarcated from the torpor season.

Non-elective percutaneous nephrostomy (PCN) service in a tertiary uroradiology centre: can radiologists and urologists agree on timing?

AIM

To assess agreement between uroradiologists and urologists with regards to the timing of non-elective percutaneous nephrostomy (PCN) catheter insertion, and whether any delay produced unacceptable complications.

MATERIALS AND METHODS

Standardized data collection forms detailing patient demographics, indications for PCN catheter insertion, blood results, procedural details, and immediate complications were completed by uroradiologists. At the time of referral, patients were stratified by both radiologists and urologists into three groups as follows: group 1 = PCN within 6 h; group 2 = PCN between 6 and 24 h; and group 3 = PCN between 24 and 48 h.

RESULTS

One hundred and eighteen non-elective PCN catheter insertions were performed over 2 years. Radiologists stratified 12 patients (10.2%) into group 1, 65 (55.1%) patients into group 2, and 41 (34.7%) patients into group 3. Urologists stratified 14 (11.9%) patients into group 1, 68 (57.6%) patients into group 2, and 36 (30.5%) patients into group 3. There was good agreement between radiologist and urologists (κ = 0.865) on stratification in all but nine (7.6%) cases. Ninety-four point one percent of PCN catheters were inserted within the timeframe stratified by radiologists and urologists, or sooner. Sepsis was associated with a shortened timeframe. Elevated international normalized ratio (INR; >1.5) resulted in an increased timeframe. A major complication rate of 3% is within recommended limits. Fourteen percent of PCN catheter insertions were inserted outside normal working hours. Urgency stratification has decreased the number of cases performed out of hours.

CONCLUSION

Radiologists and urologists had good agreement on stratification with an acceptable major complication rate of 3%.