Abrocitinib effect on patient-reported outcomes in patients with moderate-to-severe atopic dermatitis: Results from phase 3 studies, including the long-term extension JADE EXTEND study

BACKGROUND

Abrocitinib improved signs and symptoms of moderate-to-severe atopic dermatitis (AD) at Weeks 12 and 16 in phase 3 studies, with a manageable safety profile. Patient-reported outcomes with long-term abrocitinib treatment were not reported.

OBJECTIVE

To evaluate patient-reported outcomes with long-term abrocitinib treatment in patients with moderate-to-severe AD.

METHODS

JADE EXTEND (NCT03422822) is an ongoing, phase 3, long-term extension study that enrolled patients from previous abrocitinib AD trials. This analysis includes patients from the phase 3 trials JADE MONO-1 (NCT03349060), JADE MONO-2 (NCT03575871) and JADE COMPARE (NCT03720470) who completed the full treatment period of placebo or abrocitinib (200 or 100 mg once daily) and subsequently entered JADE EXTEND and were randomised to receive once-daily abrocitinib 200 or 100 mg. Patient-reported endpoints to Week 48 included the proportion of patients who achieved Dermatology Life Quality Index (DLQI) scores of 0/1 (no effect of AD on quality of life [QoL]) and a ≥4-point improvement in Patient-Oriented Eczema Measure (POEM) score (clinically meaningful improvement). Data cut-off: April 22, 2020.

RESULTS

Baseline DLQI mean scores were 15.4 and 15.3 in the abrocitinib 200- and 100-mg groups, respectively, which corresponded to a 'very large effect' on QoL; at Week 48, mean DLQI scores were lower with abrocitinib 200 mg (4.6; 'small effect' on QoL) and abrocitinib 100 mg (5.9; 'moderate effect' on QoL). Baseline POEM mean scores were 20.4 and 20.5 in the abrocitinib 200- and 100-mg groups, respectively; at Week 48, mean POEM scores were 8.2 and 11.0. Week 48 patient-reported responses with abrocitinib 200 mg and abrocitinib 100 mg were 44% and 34% for DLQI 0/1, and 90% and 77% for a ≥4-point reduction in POEM score.

CONCLUSION

In patients with moderate-to-severe AD, long-term abrocitinib treatment resulted in clinically meaningful improvement in patient-reported symptoms of AD, including QoL.

Vulnerable newborn types: analysis of subnational, population-based birth cohorts for 541 285 live births in 23 countries, 2000-2021

OBJECTIVE

To examine prevalence of novel newborn types among 541 285 live births in 23 countries from 2000 to 2021.

DESIGN

Descriptive multi-country secondary data analysis.

SETTING

Subnational, population-based birth cohort studies (n = 45) in 23 low- and middle-income countries (LMICs) spanning 2000-2021.

POPULATION

Liveborn infants.

METHODS

Subnational, population-based studies with high-quality birth outcome data from LMICs were invited to join the Vulnerable Newborn Measurement Collaboration. We defined distinct newborn types using gestational age (preterm [PT], term [T]), birthweight for gestational age using INTERGROWTH-21st standards (small for gestational age [SGA], appropriate for gestational age [AGA] or large for gestational age [LGA]), and birthweight (low birthweight, LBW [<2500 g], nonLBW) as ten types (using all three outcomes), six types (by excluding the birthweight categorisation), and four types (by collapsing the AGA and LGA categories). We defined small types as those with at least one classification of LBW, PT or SGA. We presented study characteristics, participant characteristics, data missingness, and prevalence of newborn types by region and study.

RESULTS

Among 541 285 live births, 476 939 (88.1%) had non-missing and plausible values for gestational age, birthweight and sex required to construct the newborn types. The median prevalences of ten types across studies were T+AGA+nonLBW (58.0%), T+LGA+nonLBW (3.3%), T+AGA+LBW (0.5%), T+SGA+nonLBW (14.2%), T+SGA+LBW (7.1%), PT+LGA+nonLBW (1.6%), PT+LGA+LBW (0.2%), PT+AGA+nonLBW (3.7%), PT+AGA+LBW (3.6%) and PT+SGA+LBW (1.0%). The median prevalence of small types (six types, 37.6%) varied across studies and within regions and was higher in Southern Asia (52.4%) than in Sub-Saharan Africa (34.9%).

CONCLUSIONS

Further investigation is needed to describe the mortality risks associated with newborn types and understand the implications of this framework for local targeting of interventions to prevent adverse pregnancy outcomes in LMICs.

Systemic medical complications following joint replacement: a review of the evidence

INTRODUCTION

Arthroplasty procedures are commonly performed in the UK. Informed consent is required for each procedure. To obtain informed consent the patient and their surgeon should discuss the risks and benefits of the proposed operation. This discussion should include both regional and systemic complication rates. Regional complications of arthroplasty are generally well documented in the literature. Systemic medical complications are less well described. This lack of accurate data could make it difficult for the treating surgeon to obtain valid consent. The aim of this paper was to review and compare the literature regarding the rate of systemic medical complications after common arthroplasty procedures.

METHODS

A literature search was conducted using the PubMed, Cochrane Library and MEDLINE databases. Studies regarding the systemic medical complications and mortality rate of joint replacement were included.

FINDINGS

We found that systemic complications were more frequent than regional complications following arthroplasty. The systemic complication rates were: hip, 5.1%; knee, 6.9%; ankle, 3.0%; shoulder, 11.2%; elbow, 8.5%; and wrist, 0%. Mortality rates for arthroplasty procedures were: hip, 0.3%; knee, 0.2%; ankle, 0.3%; shoulder, 0.3%; elbow, 0.2%; and wrist, 0%.

CONCLUSIONS

The most common systemic medical complication following arthroplasty was venous thromboembolism. Preoperative comorbidity was the most important risk factor for both postoperative mortality and systemic medical complications following arthroplasty procedures. We recommend that to obtain informed consent the given rates of systemic medical complications of joint replacement should be discussed and documented.

Elbow arthroplasty in trauma-current concepts review

Introduction

Despite advancements in modern locking plate technology, distal humerus fractures in the elderly remain difficult to treat. A subset of fractures in this osteoporotic bone includes multiple, shallow articular fragments that renders fixation unreliable, precluding early motion and acceptable functional outcomes. Arthroplasty, in the form of either Total Elbow Arthroplasty (TEA) or Distal Humeral Hemiarthroplasty (DHH) are alternative treatment options in this cohort and are being increasingly used.

Methods

This article reviews the use of TEA or DHH for acute distal humerus fracture, including patient selection, pre-operative planning, surgical approach, implant positioning, rehabilitation, outcomes and complications.

Results

Arthroplasties are being increasingly used for acute distal humerus fractures, however they introduce potential complications not seen with fixation. Due care must be employed to correct implant positioning which is a function of implant rotation, implant length and implant sizing. We describe a robust technique for epicondyle repair in DHH and unlinked TEA to avoid instability. Outcomes of DHH and TEA for acute distal humerus fracture are encouraging, however further long-term outcome and comparative data regarding arthroplasty is required.

Conclusions

Short to medium term outcomes demonstrate that both DHH and TEA are valuable options for selected patients, although attention to technique is required to minimise potential complications.

Knowledge and attitudes towards TB among healthcare workers in Yogyakarta, Indonesia

SETTING:

Healthcare workers (HCWs) are at an increased risk of TB worldwide. Individual knowledge and attitudes may influence HCW behaviour, and subsequently, TB risk. Indonesia has the second highest case-load globally.

OBJECTIVE:

To measure TB knowledge and attitudes among a subsection of HCWs in Yogyakarta, Indonesia, and to explore factors associated with knowledge.

DESIGN:

A cross-sectional study using an online survey targeting all HCW staff was conducted among HCWs from four pre-selected healthcare facilities in Yogyakarta. Descriptive analysis and a multivariable linear regression were undertaken.

RESULTS:

Of 792 HCWs, 290 (37%) completed the survey; 64% (n = 185) were medical staff, 33% (n = 95) reported previously being tested for active TB and 8% (n = 24) for latent TB. The mean knowledge score was 7.2/11 (SD 1.5): this was higher among medical staff and those with university education (average score increase: 0.53, 95% CI 0.15 to 0.90; and 0.38, 95% CI 0.01 to 0.74, respectively). Participants agreed that free access to TB screening (93%) and treatment (93%) should be available, and 57% of medical and 77% of non-medical staff would take preventive therapy if eligible.

CONCLUSION:

Participants had practical understanding of TB; however, gaps were identified in knowledge about TB disease progression and prevention. Prevention programmes were viewed positively. We suggest further TB education and engagement programmes for HCWs.

Impact of oral abrocitinib on signs, symptoms and quality of life among adolescents with moderate-to-severe atopic dermatitis: an analysis of patient-reported outcomes

Background

A significant improvement in clinical signs was demonstrated with abrocitinib relative to placebo in adolescents with moderate‐to‐severe atopic dermatitis (AD) in three phase 3, randomized, double‐blinded, placebo‐controlled studies (JADE TEEN [ClinicalTrials.gov, NCT03796676], JADE MONO‐1 [NCT03349060] and JADE MONO‐2 [NCT03575871]).

Objectives

To evaluate the impact of abrocitinib on patient‐reported signs/symptoms, including sleep loss and quality of life among adolescents with moderate‐to‐severe AD.

Methods

JADE TEEN, JADE MONO‐1 and JADE MONO‐2 were conducted in the Asia‐Pacific region, Europe and North America and included patients aged 12–17 years with moderate‐to‐severe AD and inadequate response to ≥ 4 consecutive weeks of topical medication or treatment with systemic therapy for AD. Patients were randomly assigned (1 : 1 : 1, JADE TEEN; 2 : 2 : 1, JADE MONO‐1/‐2) to receive once‐daily oral abrocitinib (200 or 100 mg) or placebo for 12 weeks in combination with topical therapy (JADE TEEN) or as monotherapy (JADE MONO‐1/‐2). Data from adolescent patients in JADE MONO‐1/‐2 were pooled for these analyses.

Results

At week 12, more adolescents treated with abrocitinib (200 or 100 mg) vs. placebo achieved a ≥ 4‐point improvement from baseline in the Patient‐Oriented Eczema Measure in JADE TEEN (83.9% and 77.0% vs. 60.2%) and JADE MONO‐1/‐2 (83.0% and 69.4% vs. 43.5%) and a ≥ 6‐point improvement from baseline in the Children’s Dermatology Life Quality Index in JADE TEEN (73.8% and 67.5% vs. 56.5%) and JADE MONO‐1/‐2 (70.0% and 57.1% vs. 19.0%). Significant improvements in SCORing Atopic Dermatitis Visual Analog Scale for sleep loss scores were demonstrated with abrocitinib vs. placebo at weeks 2‐12 in JADE TEEN and JADE MONO‐1/‐2.

Conclusions

Patient‐reported signs/symptoms, including reduction of sleep loss and quality of life, were substantially improved with abrocitinib monotherapy or combination therapy relative to placebo in adolescents with moderate‐to‐severe AD.

470 Financial and Efficacy Analysis of a Centralised Neck of Femur Fracture Service

Aim

Osteoporotic fractures are rising in incidence, costing the National Health Service up to £1.1 billion for hospital care. The implementation of the Best Practice Tariff (BPT) of fragility fractures in 2010 created a financial incentive to achieve standards of best practice. In June 2015, a dedicated hip fracture unit (HFU) was set up at Princess Royal Hospital (PRH). The aim of this study is (A) to assess changes in performance to the BPT after the introduction of a dedicated HFU, and (B) whether the performance of a HFU is affected by direct/indirect presentation to the HFU.

Method

The performance of Brighton and Sussex University Hospitals (BSUH) to BPT pre and post HFU was assessed by a retrospective review of BPT performance data between 2015 and 2016. 870 patients who were treated for NOFF at BSUH were reviewed to assess whether the performance of the HFU was impacted by patients presenting either directly (PRH) to the HFU or indirectly (presentation to Royal Sussex County Hospital). Appropriate statistical tests were used to analyse the significant differences between these outcome measures.

Results

The comparison between pre and post HFU showed there was a significant increase in the time between A&E admission to ward, theatre or orthogeriatric (OG) assessment (P &lt; 0.001) in patients presenting indirectly to HFU compared to direct presentations.

Conclusions

Having a HFU is cost neutral, and advantages of HFU include focusing NOFF care which improves in patient care. BPT achievements could be improved by increasing the direct admission of NOFF to the HFU.

Adapting active case-finding for TB during the COVID-19 pandemic in Yogyakarta, Indonesia

The COVID-19 pandemic and response measures, including lockdowns and the reorientation of health services, have disrupted essential health services for other diseases, including TB, HIV and malaria. For TB, reductions in case detection due to the COVID-19 pandemic are projected to result in increased TB transmission, morbidity and mortality. Active case-finding (ACF) for TB using community-based approaches is a potential strategy to offset reductions in TB detection by obviating the need for patients to seek care at a health facility. A number of approaches can be used to conduct TB ACF safely and screen designated target populations while managing the risks of SARS-CoV-2 transmission for staff, individuals and the community. We present a framework of options for and experience of adapting TB ACF services in response to the challenges of COVID-19 in our programme in Yogyakarta, Indonesia. Key changes have included revised prioritisation of target populations focusing on household contacts, reducing case-finding throughput, implementation of additional infection control measures and precautions, and integration of COVID-19 screening among those being screened for TB. Our approach could inform other programmes seeking to adapt TB ACF services to mitigate the negative impact of COVID-19 on TB case detection.

Management of peri-prosthetic joint infection and severe bone loss after total hip arthroplasty using a long-stemmed cemented custom-made articulating spacer (CUMARS)

Background

There is little evidence on techniques for management of peri-prosthetic infection (PJI) in the context of severe proximal femoral bone loss. Custom-made articulating spacers (CUMARS) utilising cemented femoral stems as spacers was described providing better bone support and longer survival compared to conventional articulating spacers. We retrospectively report our experience managing PJI by adaptation of this technique using long cemented femoral stems where bone loss precludes use of standard stems.

Methods

Patients undergoing 1st stage revision for infected primary and revision THA using a cemented long stem (> 205 mm) and standard all-polyethylene acetabulum between 2011 and 2018 were identified. After excluding other causes of revision (fractures or aseptic loosening), Twenty-one patients remained out of total 721 revisions. Medical records were assessed for demographics, initial microbiological and operative treatment, complications, eradication of infection and subsequent operations. 2nd stage revision was undertaken in the presence of pain or subsidence.

Results

Twenty-one patients underwent 1st stage revision with a cemented long femoral stem. Mean follow up was 3.9 years (range 1.7–7.2). Infection was eradicated in 15 (71.4%) patients. Two patients (9.5%) required repeat 1st stage and subsequently cleared their infection. Three patients (14.3%) had chronic infection and are on long term suppressive antibiotics. One patient (4.8%) was lost to follow up before 2 years. Complications occurred in seven patients (33%) during or after 1st stage revision. Where infection was cleared, 2nd stage revision was undertaken in 12 patients (76.5%) at average of 9 months post 1st stage. Five (23.8%) CUMARS constructs remained in-situ at an average of 3.8 years post-op (range 2.6–5.1).

Conclusions

Our technique can be used in the most taxing of reconstructive scenarios allowing mobility, local antibiotic delivery, maintenance of leg length and preserves bone and soft tissue, factors not afforded by alternative spacer options.

The effect of the COVID-19 lockdown on the epidemiology of hip fractures in the elderly: a multicentre cohort study

INTRODUCTION

The COVID-19 pandemic presented extraordinary challenges to the UK healthcare system. This study aimed to assess the impact of the COVID-19 lockdown on the epidemiology, treatment pathways and 30-day mortality rates of hip fractures. Outcomes of COVID-19 positive patients were compared against those who tested negative.

METHODS

An observational, retrospective, multicentre study was conducted across six hospitals in the South East of England. Data were retrieved from the National Hip Fracture Database and electronic medical records. Data was collected for the strictest UK lockdown period (period B=23 March 2020-11 May 2020), and the corresponding period in 2019 (period A).

RESULTS

A total of 386 patients were admitted during period A, whereas 381 were admitted during period B. Despite the suspension of the 'Best Practice Tariff' during period B, time to surgery, time to orthogeriatric assessment, and 30-day mortality were similar between period A and B. The length of inpatient stay was significantly shorter during period B (11.5 days vs 17.0 days, p<0.001). Comparison of COVID-19 positive and negative patients during period B demonstrated that a positive test was associated with a significantly higher rate of 30-day mortality (53.6% vs 6.7%), surgical delay >36h (46.4% vs 30.8%, p=0.049), and increased length of inpatient stay (15.8 vs 11.7 days, p=0.015).

CONCLUSIONS

The COVID-19 lockdown did not alter the epidemiology of hip fractures. A substantially higher mortality rate was observed among patients with a COVID-19 positive test. These findings should be taken into consideration by the healthcare policymakers while formulating contingency plans for a potential 'second wave'.

Thirty-day mortality following surgical management of hip fractures during the COVID-19 pandemic: findings from a prospective multi-centre UK study

PURPOSE

Thirty-day mortality of patients with hip fracture is well researched and predictive; validated scoring tools have been developed (Nottingham Hip Fracture Score, NHFS). COVID-19 has significantly greater mortality in the elderly and comorbid patients which includes hip fracture patients. Non-operative treatment is not appropriate due to significantly higher mortality, and therefore, these patients are often exposed to COVID-19 in the peri-operative period. What is unclear is the effect of concomitant COVID-19 infection in these patients.

METHODS

A multicentre prospective study across ten sites in the United Kingdom (responsible for 7% of hip fracture patients per annum in the UK). Demographic and background information were collected by independent chart review. Data on surgical factors included American Society of Anesthesiologists (ASA) score, time to theatre, Nottingham Hip fracture score (NHFS) and classification of fracture were also collected between 1st March 2020 and 30th April 2020 with a matched cohort from the same period in 2019.

RESULTS

Actual and expected 30-day mortality was found to be significantly higher than expected for 2020 COVID-19 positive patients (RR 3.00 95% CI 1.57-5.75, p < 0.001), with 30 observed deaths compared against the 10 expected from NHFS risk stratification.

CONCLUSION

COVID-19 infection appears to be an independent risk factor for increased mortality in hip fracture patients. Whilst non-operative management of these fractures is not suggested due to the documented increased risks and mortality, this study provides evidence to the emerging literature of the severity of COVID-19 infection in surgical patients and the potential impact of COVID-19 on elective surgical patients in the peri-operative period.

Factors affecting stability and infectivity of SARS-CoV-2

BACKGROUND

In late 2019, a novel human coronavirus - severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) - emerged in Wuhan, China. This virus has caused a global pandemic involving more than 200 countries. SARS-CoV-2 is highly adapted to humans and readily transmits from person-to-person.

AIM

To investigate the infectivity of SARS-CoV-2 under various environmental and pH conditions. The efficacies of various laboratory virus inactivation methods and home disinfectants against SARS-CoV-2 were investigated.

METHODS

The residual virus in dried form or in solution was titrated on to Vero E6 cells on days 0, 1, 3, 5 and 7 after incubation at different temperatures. Viral viability was determined after treatment with various disinfectants and pH solutions at room temperature (20-25^oC).

FINDINGS

SARS-CoV-2 was able to retain viability for 3-5 days in dried form or 7 days in solution at room temperature. SARS-CoV-2 could be detected under a wide range of pH conditions from pH 4 to pH 11 for several days, and for 1-2 days in stool at room temperature but lost 5 logs of infectivity. A variety of commonly used disinfectants and laboratory inactivation procedures were found to reduce viral viability effectively.

CONCLUSION

This study demonstrated the stability of SARS-CoV-2 on environmental surfaces, and raises the possibility of faecal-oral transmission. Commonly used fixatives, nucleic acid extraction methods and heat inactivation were found to reduce viral infectivity significantly, which could ensure hospital and laboratory safety during the SARS-CoV-2 pandemic.

Infection after operative fixation of tibia plateau fractures. A risk factor analysis

INTRODUCTION

Surgical fixation of tibial plateau fractures has been shown to improve long-term functional outcomes, but a major complication is that of postoperative infection which can be deleterious to long-term outcomes. This study aims to assess the impact of common comorbidities on the risk of postoperative infection.

METHOD

A retrospective study of 210 consecutive operatively treated patients, treated at two Level 1 Trauma Centres over a 27-month period was performed. Records were analysed to assess the presence of the study factors; smoking, alcohol intake >13 units/week, diabetes, and BMI > 30. The impact of these factors on infection was assessed with univariate and multivariate analyses.

RESULTS

175 patients were included in the study, 56.6% male with a mean age of 46.9 years (± 18.2 years). Excessive alcohol consumption of >13 units/week was the only significant risk factor for postoperative infection (p = 0.05) on multivariate analysis.

CONCLUSION

This study has identified excessive alcohol consumption as the only independent risk factor for postoperative infection in patients with all types of tibial plateau fracture treated with operative fixation. No relationship between smoking, diabetes nor obesity was found for postoperative infection.

Implementation of screening and management of household contacts of tuberculosis cases in Daru, Papua New Guinea

SETTING

Daru Island, Western Province, Papua New Guinea (PNG).

OBJECTIVE

To describe the implementation of a screening programme for household contacts of tuberculosis (TB) cases residing on Daru Island.

DESIGN

This was a retrospective descriptive study evaluating two periods of implementation: introduction and expansion of a screening programme for household contacts of drug-resistant TB (DR-TB) cases (March 2016 to September 2017), and inclusion of drug-susceptible TB (DS-TB) cases with provision of preventive therapy for eligible contacts between October 2017 and March 2018.

RESULTS

In the first period, the contact screening programme was established and strengthened by increasing coverage over time. There was a large number of contacts (median 8) in each household, and a high uptake of screening. In the second period of evaluation, respectively 412 and 223 contacts of 42 DS-TB and 25 DR-TB index cases were screened. Overall, 156 (24.6%) contacts reported TB-related symptoms and 9 (1.4%) were diagnosed with active TB. All 9 commenced TB treatment: 5 had DS-TB and 4 had DR-TB. Of 82 child contacts of DS-TB cases eligible for preventive therapy, 57 (69.5%) commenced treatment and 45 completed treatment.

CONCLUSION

Community-based household contact screening and management was successfully implemented under programme conditions in this high burden TB and DR-TB setting in PNG.

Successful implementation of bedaquiline for multidrug-resistant TB treatment in remote Papua New Guinea

SETTING

Bedaquiline (BDQ) was introduced in the multi-drug-resistant tuberculosis (MDR-TB) programme in Daru in remote Papua New Guinea in 2015, along with a core package of active drug-safety monitoring (aDSM).

OBJECTIVE

To assess interim results and safety of BDQ for the treatment of MDR-TB from 1 July 2015 to 31 December 2017.

DESIGN

A retrospective cohort analysis of routine programme data.

RESULTS

Of 277 MDR-TB patients, 77 (39%) received BDQ with a total of 8 serious adverse events including 5 (6.5%) deaths, of which 1 (1.3% QTcF prolongation, grade 3) was attributable to BDQ. Of 200 (61%) patients who did not receive BDQ, there were 17 (9%) deaths. Completeness of monitoring for the BDQ group was 90% for >5 electrocardiograms and 79% for ⩾2 cultures. In the interim result indicator analysis at month 6 in the BDQ and non-BDQ groups, there were respectively 0% and 1% lost to follow-up; 6.5% and 8.5% who died; 94% and 91% in care; and 92% and 96% with negative culture among those monitored.

CONCLUSION

Early experience in Daru shows BDQ is safe and feasible to implement with aDSM with good interim effectiveness supporting the rapid adoption and scale-up of the 2019 WHO MDR-TB treatment guidelines in the programme and in similar remote settings.

TB treatment delay associated with drug resistance and admission at Daru General Hospital in Papua New Guinea

SETTING

Daru General Hospital, Daru Island, Papua New Guinea, where high rates of tuberculosis (TB) have been reported. Prompt diagnosis and effective treatment are needed for improving TB outcomes and to prevent nosocomial transmission.

OBJECTIVE

To assess the time to treatment initiation and the risk factors associated with delayed treatment for patients started on TB treatment at Daru General Hospital from January to September 2017.

DESIGN

This was a retrospective cohort study that entailed reviewing the records from treatment, admission, discharge and presumptive TB registers.

RESULTS

The study included 360 patients on TB treatment. The median time from presentation to treatment initiation was 7 days [IQR 3-11]. Treatment was started <7 days for 215 patients (60%); however, only 16.2% commenced treatment <2 days. Risk factors for delayed treatment were diagnosis of TB as an inpatient (OR 2.67, 95% CI 1.35-5.28, P = 0.005) and having drug-resistant TB (OR 2.65, 95% CI 1.5-4.68. P = 0.001).

CONCLUSION

A high proportion of TB patients commenced treatment <7 days. Inpatient status, DR-TB and lack of microbiological confirmation were associated with delays in treatment initiation. We recommend that programmes monitor the time from presentation to treatment initiation, and propose that a period of >3 days from presentation to treatment initiation be considered as delayed treatment initiation.

The emergency response to multidrug-resistant tuberculosis in Daru, Western Province, Papua New Guinea, 2014-2017

SETTING

A response to an outbreak of multidrug-resistant tuberculosis (MDR-TB) on Daru Island, South Fly District (SFD), Western Province, Papua New Guinea (PNG) was implemented by a national emergency response taskforce.

OBJECTIVE

To describe programmatic interventions for TB in SFD and evaluate characteristics of TB case notifications, drug resistance and treatment outcomes.

DESIGN

This was a retrospective cohort study based on routine programmatic data for all patients enrolled on TB treatment at Daru General Hospital from 2014 to 2017.

RESULTS

The response involved high-level political commitment, joint planning, resource mobilisation, community engagement and strengthening TB case detection and treatment. Of 1548 people enrolled on TB treatment, 1208 (78%) had drug-susceptible TB (DS-TB) and 333 (21.5%) had MDR-TB. There was an increase in MDR-TB as a proportion of all TB. Treatment success rates increased over the study period from 55% to 86% for DS-TB, and from 70% to 81% for MDR-TB from 2014 to 2015. The 2014 case notification rate for TB in SFD was 1031/100 000, decreasing to 736/100 000 in 2017.

CONCLUSION

The outbreak was stabilised through the response from the national and provincial governments and international partners. Additional interventions are needed to decrease the TB burden in Daru.

A case of Capnocytophaga canimorsus meningitis and bacteraemia

Capnocytophaga canimorsus is a commonly detectable commensal in the oral flora of dogs and cats, found in 25.5% and 15%, respectively, by culture and 70% and 55%, respectively, by molecular methods [1]. Formerly known as dysgonic fermenter 2 (DF-2), it was first reported in 1976 as a Gram-negative bacillus causing septicaemia and meningitis following dog bites [2]. It causes a spectrum of clinical syndromes from wound infections to bacteraemia and meningitis, especially in those with hyposplenism and alcoholism. We report a case of C. canimorsus meningitis and bacteraemia, and give a review of the relevant literature.

An endophenotype approach to the genetics of alcohol dependence: a genome wide association study of fast beta EEG in families of African ancestry

Fast beta (20-28 Hz) electroencephalogram (EEG) oscillatory activity may be a useful endophenotype for studying the genetics of disorders characterized by neural hyperexcitability, including substance use disorders (SUDs). However, the genetic underpinnings of fast beta EEG have not previously been studied in a population of African-American ancestry (AA). In a sample of 2382 AA individuals from 482 families drawn from the Collaborative Study on the Genetics of Alcoholism (COGA), we performed a genome-wide association study (GWAS) on resting-state fast beta EEG power. To further characterize our genetic findings, we examined the functional and clinical/behavioral significance of GWAS variants. Ten correlated single-nucleotide polymorphisms (SNPs) (r²>0.9) located in an intergenic region on chromosome 3q26 were associated with fast beta EEG power at P<5 × 10^-8. The most significantly associated SNP, rs11720469 (β: -0.124; P<4.5 × 10^-9), is also an expression quantitative trait locus for BCHE (butyrylcholinesterase), expressed in thalamus tissue. Four of the genome-wide SNPs were also associated with Diagnostic and Statistical Manual of Mental Disorders Alcohol Dependence in COGA AA families, and two (rs13093097, rs7428372) were replicated in an independent AA sample (Gelernter et al.). Analyses in the AA adolescent/young adult (offspring from COGA families) subsample indicated association of rs11720469 with heavy episodic drinking (frequency of consuming 5+ drinks within 24 h). Converging findings presented in this study provide support for the role of genetic variants within 3q26 in neural and behavioral disinhibition. These novel genetic findings highlight the importance of including AA populations in genetics research on SUDs and the utility of the endophenotype approach in enhancing our understanding of mechanisms underlying addiction susceptibility.

SHP2 is required for BCR-ABL1-induced hematologic neoplasia

BCR-ABL1-targeting tyrosine kinase inhibitors (TKIs) have revolutionized treatment of Philadelphia chromosome-positive (Ph⁺) hematologic neoplasms. Nevertheless, acquired TKI resistance remains a major problem in chronic myeloid leukemia (CML), and TKIs are less effective against Ph⁺ B-cell acute lymphoblastic leukemia (B-ALL). GAB2, a scaffolding adaptor that binds and activates SHP2, is essential for leukemogenesis by BCR-ABL1, and a GAB2 mutant lacking SHP2 binding cannot mediate leukemogenesis. Using a genetic loss-of-function approach and bone marrow transplantation (BMT) models for CML and BCR-ABL1⁺ B-ALL, we show that SHP2 is required for BCR-ABL1-evoked myeloid and lymphoid neoplasia. Ptpn11 deletion impairs initiation and maintenance of CML-like myeloproliferative neoplasm, and compromises induction of BCR-ABL1⁺ B-ALL. SHP2, and specifically, its SH2 domains, PTP activity and C-terminal tyrosines, is essential for BCR-ABL1⁺, but not WT, pre-B cell proliferation. The MEK/ERK pathway is regulated by SHP2 in WT and BCR-ABL1⁺ pre-B cells, but is only required for the proliferation of BCR-ABL1⁺ cells. SHP2 is required for SRC family kinase (SFK) activation only in BCR-ABL1⁺ pre-B cells. RNAseq reveals distinct SHP2-dependent transcriptional programs in BCR-ABL1⁺ and WT pre-B cells. Our results suggest that SHP2, via SFKs and ERK, represses MXD3/4 to facilitate a MYC-dependent proliferation program in BCR-ABL1-transformed pre-B cells.

Multi-Domains Lifestyle Interventions Reduces Depressive Symptoms among Frail and Pre-Frail Older Persons: Randomized Controlled Trial

BACKGROUND

We investigated the effect of multi-domain lifestyle (physical, nutritional, cognitive) interventions among frail and pre-frail community-living older persons on reducing depressive symptoms.

METHOD

Participants aged 65 and above were randomly allocated to 24 weeks duration interventions with nutritional supplementation (N=49), physical training (N=48), cognitive training (N=50), combination intervention (N=49) and usual care control (N=50). Depressive symptoms were assessed by the Geriatric Depression Scale (GDS-15) at baseline (0M), 3 month (3M), 6 month (6M) and 12 month (12M).

RESULTS

Mean GDS scores in the control group increased from 0.52 (0M) and 0.54 (3M) to 0.74 (6M), and 0.83 (12M). Compared to the control group, interventions showed significant differences (∆=change) at 6M for cognitive versus control (∆=-0.39, p=0.021, group*time interaction p=0.14); physical versus control (∆ =-0.37, p=0.026, group*time interaction p=0.13), and at 12M for nutrition versus control (∆ =-0.46, p=0.016, group*time interaction p=0.15). The effect for combination versus control was significant at 6M (∆ =-0.43, p=0.020) and 12M (∆ =-0.51, p=0.005, group*time interaction p=0.026). Estimated 12-month cumulative incidence of depressive symptoms (GDS≥2) relative to control were OR=0.38, p=0.037 (nutrition); OR=0.71, p=0.40 (cognitive); OR=0.39, p=0.042 (physical training) and OR=0.38, p=0.037 (combination). Changes in gait speed and energy level were significantly associated with changes in GDS scores over time.

CONCLUSION

Multi-domain interventions that reverse frailty among community-living older persons also reduce depressive symptomatology. Public health education and programmatic measures combining nutritional, physical and cognitive interventions for at-risk frail older people may likely benefit psychological wellbeing.