A phase I trial of pevonedistat in combination with ruxolitinib for the treatment of myelofibrosis

Janus kinase 2 (JAK2) inhibitors such as ruxolitinib have become standard-of-care therapy for patients with myeloproliferative neoplasms (MPNs); however, activation of alternate oncogenic pathways including nuclear factor kappa-light-chain-enhancer of activated B cells (NFκB) has limited durable response as single-agent therapy. With the rationale of targeting both pathways, we conducted a phase I dose escalation trial of pevonedistat in combination with ruxolitinib for the treatment of patients with myelofibrosis (NCT03386214). The primary objective was to assess the safety and tolerability of combination therapy with additional objectives of treatment efficacy and alterations of biomarkers. There were no dose-limiting toxicities observed with most adverse events being limited to grades 1/2. In secondary measures, anemia response was observed in two patients. Pro-inflammatory cytokines and iron parameters were longitudinally assessed, which revealed suppression of interleukin-6 and interferon-gamma in a dose-dependent manner across a subset of patients. These results suggest that combination therapy targeting both JAK2 and NFκB may hold clinical merit for MPN patients.

Chromoblastomycosis treated with posaconazole and adjunctive imiquimod: lending innate immunity a helping hand

Chromoblastomycosis (CBM) is a difficult-to-treat, chronic fungal infection of the skin and subcutaneous tissue. The evidence base for treatment is scarce, with no standardised therapeutic approach. Chronicity of CBM infection is postulated to be due in part to a failure of host cell-mediated immunity to generate a proinflammatory response sufficient for fungal clearance. We present a case of a chronic chromoblastomycosis lesion of the hand present for nearly four decades, previously refractory to itraconazole monotherapy, that was successfully treated with a combination of posaconazole and adjunctive immunotherapy with topical Imiquimod, a toll-like receptor 7 agonist. Serial biopsies and images demonstrate the clinical and histopathological improvement of the lesion. Randomised trials of antifungal therapy with adjunctive imiquimod are warranted to determine whether a combination of antifungal and host-directed therapy improves outcomes for this neglected tropical mycosis.

AB1473 EFFICACY RESPONSES ACROSS DISEASE SEVERITY AND TREATMENT HISTORY SUBGROUPS OF PATIENTS WITH MODERATE TO SEVERE PLAQUE PSORIASIS TREATED WITH GUSELKUMAB: POOLED RESULTS FROM VOYAGE-1 AND VOYAGE-2 THROUGH 5 YEARS

Background

The VOYAGE-1 and VOYAGE-2 phase 3 studies evaluated efficacy and safety of guselkumab (GUS) in patients with moderate-to-severe plaque psoriasis.

Objectives

To assess the five-year efficacy of GUS by baseline disease characteristics and treatment history.

Methods

This study evaluated 1829 patients randomized to GUS, placebo (PBO)→GUS, and adalimumab (ADA) →GUS from the VOYAGE-1 and VOYAGE-2 trials. All patients received open-label GUS 100 mg every 8 weeks (Q8W) during Week (W) 52 to W252 in VOYAGE-1 and during W76 to W252 in VOYAGE-2. The proportions of combined GUS patients (including PBO→GUS and ADA→GUS) achieving Investigator’s Global Assessment of cleared or minimal (IGA-0/1) and Psoriasis Area and Severity Index (PASI) 90 response were evaluated from W100 to W252 by baseline PASI (<20/≥20) and IGA (<4/=4) scores, body surface area (BSA; <20%/≥20%), and prior psoriasis treatments. Analysis was performed using observed data after applying treatment failure rules.

Results

At W252, proportions of combined GUS patients achieving IGA 0/1 or PASI 90, respectively, were comparable or numerically greater for patients with baseline PASI < 20 (85.4%; 81.1%) vs PASI ≥ 20 (81.4%; 83.8%); IGA < 4 (85.1%; 82.7%) vs IGA = 4 (78.9%; 81.1%); BSA < 20% (85.1%; 82.7%) vs BSA ≥ 20% (82.6%; 82.0%); no prior phototherapy (83.3%; 84.0%) vs prior phototherapy (83.8%; 81.1%); no prior non-biologic systemic therapy (84.5%; 83.0%) vs prior non-biologic systemic therapy (83.2%; 82.0%); and no prior biologics (85.3%; 83.8%) vs prior biologics (76.7%; 76.3%). This trend was consistent at each timepoint evaluated from W100 to W252.

Conclusion

This analysis demonstrated that the high degree of efficacy of GUS treatment is durable through 5 years among broad subpopulations of patients with varying disease severity characteristics and previous psoriasis treatments.

References

None

Disclosure of Interests

Kenneth Gordon Grant/research support from: AbbVie, Almirall, Amgen, BMS, Celgene, Dermira, Dermavant, Eli Lilly, Janssen, LEO Pharma, Novartis, Ortho Dermatologics, Pfizer, Sun Pharma, and UCB Pharma, Joseph F. Merola Consultant of: AbbVie, Arena, Avotres, Biogen, Bristol-Myers Squibb, Celgene, Dermavant, Eli Lilly, EMD Sorono, Janssen, Leo Pharma, Merck, Novartis, Pfizer, Regeneron, Sanofi, Sun Pharma, and UCB pharma, Peter Foley Speakers bureau: AbbVie, Celgene, Eli Lilly, Galderma, GSK, Janssen, Leo Pharma, Merck, Novartis, Pfizer, Roche, and Valeant, Consultant of: AbbVie, Amgen, Arcutis, Aslan, AstraZeneca, BMS, Boehringer Ingelheim, Celgene, Celtaxsys, CSL, Cutanea, Dermira, Eli Lilly, Galderma, Genentech, GSK, Hexima, Janssen, Leo Pharma, Merck, Novartis, Pfizer, Regeneron Pharmaceuticals Inc, Reistone, Roche, Sanofi, Sun Pharma, UCB Pharma, and Valeant, Grant/research support from: grant/research support from AbbVie, Amgen, Celgene, Eli Lilly, Janssen, Leo Pharma, Merck, Novartis, Pfizer, Sanofi, and Sun Pharma; and travel grants from AbbVie, Eli Lilly, Galderma, Janssen, Leo Pharma, Merck, Novartis, Pfizer, Roche, Sanofi, and Sun Pharma, Olivia Choi Shareholder of: may own stock or stock options in Johnson & Johnson, Employee of: Janssen Scientific Affairs, LLC, Daphne Chan Shareholder of: may own stock or stock options in Johnson & Johnson, Employee of: Janssen Scientific Affairs, LLC, Megan Miller Shareholder of: may own stock or stock options in Johnson & Johnson, Employee of: Janssen Research & Development, LLC, Yin You Shareholder of: may own stock or stock options in Johnson & Johnson, Employee of: Janssen Research & Development, LLC, Yaung-Kaung Shen Shareholder of: may own stock or stock options in Johnson & Johnson, Employee of: Janssen Research & Development, LLC, Ya-Wen Yang Shareholder of: may own stock or stock options in Johnson & Johnson, Employee of: Immunology Global Medical Affairs, Janssen Pharmaceutical Companies of Johnson & Johnson, Andrew Blauvelt Speakers bureau: AbbVie, Almirall, Arena, Athenex, Boehringer Ingelheim, Bristol-Myers Squibb, Dermavant, Eli Lilly, Evommune, Forte, Galderma, Incyte, Janssen, Leo Pharma, Novartis, Pfizer, Rapt, Regeneron, Sandoz, Sanofi Genzyme, Sun Pharma, and UCB Pharma, Consultant of: AbbVie, Almirall, Arena, Athenex, Boehringer Ingelheim, Bristol-Myers Squibb, Dermavant, Eli Lilly, Evommune, Forte, Galderma, Incyte, Janssen, Leo Pharma, Novartis, Pfizer, Rapt, Regeneron, Sandoz, Sanofi Genzyme, Sun Pharma, and UCB Pharma

Efficacy and Safety of Bimekizumab in Patients with Moderate to Severe Plaque Psoriasis: Results from BE VIVID, a 52-Week Phase 3, Randomized, Double-Blinded, Ustekinumab- and Placebo-Controlled Study

Abstract not available.

Efficacy and Safety of Bimekizumab in Patients with Moderate to Severe Plaque Psoriasis: Results from BE READY, a 56-Week Phase 3, Randomized, Double-Blinded, Placebo-Controlled Study with Randomized Withdrawal

Abstract not available.

Community resilience in a rural food system: documenting pathways to nutrition solutions

OBJECTIVE

To describe and determine the barriers and facilitators to food-related health behaviors of residents in a rural Mississippi Delta community.

STUDY DESIGN

Descriptive study of qualitative interviews.

METHODS

A non-random sample of 34 low-income, food-insecure adults residing in a rural Mississippi Delta community were interviewed using fuzzy cognitive mapping, a mixed methods approach.

RESULTS

Participants strongly emphasized the time restraints they faced in both procuring and preparing foods, due to substantial travel time required to procure groceries. Participants also identified key facilitators to healthy eating behaviors, including seasonal produce stands, foraging, fishing, home provisioning, and access to the local food pantry. These barriers and facilitators are highly interconnected with other influential factors including poverty, lack of health care, unemployment, and faith-based support systems.

CONCLUSIONS

While the connection between low food access and poor eating habits is well researched, this novel mixed-method approach details two important elements missing from the literature: (1) other factors often overlooked that mitigate or exacerbate this relationship and (2) the dynamic nature of the relationships between these factors, poor eating habits, and health. Additionally, this research examines these relationships in an underrepresented rural minority population where resources needed to mitigate poor health are often much more limited. Findings from this study are critical to health and food policy in Mississippi and more generally, rural communities.

Efficacy of risankizumab in patients with moderate-to-severe plaque psoriasis by baseline demographics, disease characteristics and prior biologic therapy: an integrated analysis of the phase III UltIMMa-1 and UltIMMa-2 studies

BACKGROUND

Risankizumab is a humanized IgG monoclonal antibody that selectively inhibits interleukin-23 through binding the p19 subunit. In Phase 3 trials, risankizumab demonstrated superior efficacy compared with adalimumab and ustekinumab in patients with moderate-to-severe plaque psoriasis. Here, we evaluated the impact of baseline characteristics on efficacy of risankizumab compared with ustekinumab in patients with moderate-to-severe plaque psoriasis.

METHODS

This analysis included all patients initially randomized to risankizumab or ustekinumab from the replicate, double-blinded, randomized, placebo-controlled phase 3 trials, UltIMMa-1 (NCT02684370) and UltIMMa-2 (NCT02684357). Patients received either risankizumab (150 mg) or ustekinumab (weight-based; 45 or 90 mg per label) at weeks 0, 4, 16, 28 and 40. Efficacy was assessed as the proportion of patients achieving ≥90% improvement in Psoriasis Area and Severity Index (PASI 90) at weeks 16 and 52 by baseline patient demographics, disease characteristics and prior biologic exposure. Mean per cent improvement in PASI was calculated by body weight and body mass index at week 52. Missing efficacy data were imputed as non-responders for categorical variables and last observation carried forward for continuous variables. Logistic regression analyses assessed for interactions between treatment and five independent variables (age, sex, weight, baseline PASI score and presence of psoriatic arthritis) at both weeks 16 and 52.

RESULTS

Baseline patient demographics, disease characteristics and prior biologic exposure were similar between patients randomized to risankizumab (n = 598) and ustekinumab (n = 199). At weeks 16 and 52, risankizumab demonstrated superior efficacy compared with ustekinumab across these patient characteristics (P < 0.01). Logistic regression analyses demonstrated that risankizumab was superior to ustekinumab at weeks 16 and 52 in all models tested (P < 0.0001 for all).

CONCLUSIONS

Risankizumab demonstrated consistent and superior efficacy compared with ustekinumab regardless of patient demographics, disease characteristics or prior biologic exposure.

Laparoscopic versus open colorectal surgery in the acute setting (LaCeS trial): a multicentre randomized feasibility trial

BACKGROUND

Approximately 30 000 people undergo major emergency abdominal gastrointestinal surgery annually, and 36 per cent of these procedures (around 10 800) are carried out for emergency colorectal pathology. Some 14 per cent of all patients requiring emergency surgery have a laparoscopic procedure. The aims of the LaCeS (laparoscopic versus open colorectal surgery in the acute setting) feasibility trial were to assess the feasibility, safety and acceptability of performing a large-scale definitive phase III RCT, with a comparison of emergency laparoscopic versus open surgery for acute colorectal pathology.

METHODS

LaCeS was designed as a prospective, multicentre, single-blind, parallel-group, pragmatic feasibility RCT with an integrated qualitative study. Randomization was undertaken centrally, with patients randomized on a 1 : 1 basis between laparoscopic or open surgery.

RESULTS

A total of 64 patients were recruited across five centres. The overall mean steady-state recruitment rate was 1·2 patients per month per site. Baseline compliance for clinical and health-related quality-of-life data was 99·8 and 93·8 per cent respectively. The conversion rate from laparoscopic to open surgery was 39 (95 per cent c.i. 23 to 58) per cent. The 30-day postoperative complication rate was 27 (13 to 46) per cent in the laparoscopic arm and 42 (25 to 61) per cent in the open arm.

CONCLUSION

Laparoscopic emergency colorectal surgery may have an acceptable safety profile. Registration number: ISRCTN15681041 ( http://www.controlled-trials.com).

Lipoedema – myths and facts, Part 5

The four previous articles in this series addressed the myths and facts surrounding lipoedema. We have shown that there is no scientific evidence at all for the key statements made about lipoedema – which are published time and time again. The main result of this “misunderstanding” of lipoedema is a therapeutic concept that misses the mark. The patient’s real problems are overlooked.

The national and especially the international response to the series, which can be read in both German and English, has been immense and has exceeded all our expectations. The numerous reactions to our articles make it clear that in other countries, too, the fallacies regarding lipoedema have led to an increasing discrepancy between the experience of healthcare workers and the perspective of patients and self-help groups, based on misinformation mostly generated by the medical profession.

Parts 1 to 4 in this series of articles on the myths surrounding lipoedema have made it clear that we have to radically change the view of lipoedema that has been held for decades. Changing our perspective means getting away from the idea of “oedema in lipoedema” – and hence away from the dogma that decongestion is absolutely necessary – and towards the actual problems faced by our patients with lipoedema. Such a paradigm shift in a disease that has been described in the same way for decades cannot be left to individuals but must be put on a much broader footing. For this reason, the lead author of this series of articles invited renowned lipoedema experts from various European countries to discussions on the subject. Experts from seven different countries took part in the two European Lipoedema Forums, with the goal of establishing a consensus. The consensus reflects the experts’ shared view on the disease, having scrutinized the available literature, and having taken into account the many years of clinical practice with this particular patient group. Appropriate to the clinical complexity of lipoedema, participants from different specialties provided an interdisciplinary approach. Nearly all of the participants in the European Lipoedema Forum had already published work on lipoedema, had been involved in drawing up their national lipoedema guidelines, or were on the executive board of their respective specialty society.

In this fifth and final part of our series on lipoedema, we will summarise the relevant findings of this consensus, emphasising the treatment of lipoedema as we now recommend it. As the next step, the actual consensus paper “European Best Practice of Lipoedema” will be issued as an international publication.

Instead of looking at the treatment of oedema, the consensus paper will focus on treatment of the soft tissue pain, as well as the psychological vulnerability of patients with lipoedema. The relationship between pain perception and the patient’s mental health is recognised and dealt with specifically. The consensus also addresses the problem of self-acceptance, and this plays a prominent role in the new therapeutic concept. The treatment of obesity provides a further pillar of treatment. Obesity is recognised as being the most common comorbid condition by far and an important trigger of lipoedema. Bariatric surgery should therefore also be considered for patients with lipoedema who are morbidly obese. The expert group upgraded the importance of compression therapy and appropriate physical activity, as the demonstrated anti-inflammatory effects directly improve the patients’ symptoms. Patients will be provided with tools for personalised self-management in order to sustain sucessful treatment. Should conservative therapy fail to improve the symptoms, liposuction may be considered in strictly defined circumstances.

The change in the view of lipoedema that we describe here brings the patients’ actual symptoms to the forefront. This approach allows us to focus on more comprehensive treatment that is not only more effective but also more sustainable than focusing on the removal of non-existent oedema.

Certolizumab Pegol for Treatment of Plaque Psoriasis: Pooled Three-Year Efficacy Outcomes from Two Phase 3 Trials (CIMPASI-1 and CIMPASI-2)

Abstract not available.

Systematic review of the real-world evidence of adalimumab safety in psoriasis registries

Long-term safety of adalimumab in psoriasis clinical studies has been established. The objective of this research was to review real-world evidence of adalimumab safety from registries of adult patients with psoriasis treated in clinical practice. Databases (BIOSIS Previews, Current Contents Search, Derwent Drug File, EMBASE, EMBASE Alert, EMCare, MEDLINE, SciSearch) were searched for psoriasis registries with adalimumab safety data. Eligible papers were English language manuscripts (conference abstracts excluded) from psoriasis registries presenting safety data for adult patients with psoriasis receiving adalimumab. The incidence and rate (events/100 patient-years [PY]) of adverse events (AEs), serious AEs (SAEs) and AEs of special interest are reported. Abstracts of 425 publications were screened, and 401 publications excluded (208 conference abstracts; 193 papers). Remaining manuscripts were fully screened; 14 were excluded (no adalimumab data, n = 10; no safety data, n = 2; no on-treatment data, n = 1; not English, n = 1), and 10 selected. Overall rates of AEs (4273 [22.2/100PY]) and SAEs (827 [4.3/100PY]) were reported in the ESPRIT registry (N = 6059). Rates of infections (7.7-14.7/100PY) and serious infections (<0.6-2.0/100PY) were reported in four studies. Cardiovascular-related events were reported in three studies: ≤0.1/100PY per major cardiac event in ESPRIT, <0.5/100PY major cardiac events in PsoBest and serious cardiovascular events in two patients (<1%) in DERMBIO. Malignancies were reported in three studies (any malignancy, 0.9/100PY; malignancies excluding non-melanoma skin cancer [NMSC], <0.6/100PY; NMSC, 0.6-<0.5/100PY). These findings suggest that real-world safety of adalimumab is consistent across different psoriasis registries, which supports the existing long-term safety profile of adalimumab from clinical studies.

Improvement in itch and other psoriasis symptoms with brodalumab in phase 3 randomized controlled trials

BACKGROUND

Patients with psoriasis have lesional symptoms, including itch, which can reduce quality of life. The efficacy and safety of brodalumab, an interleukin-17 receptor A antagonist, in treating moderate-to-severe psoriasis have been reported in three randomized, controlled, phase 3 trials (AMAGINE-1/-2/-3).

OBJECTIVE

The effect of brodalumab on lesional symptoms was assessed using the psoriasis symptom inventory (PSI), a validated patient-reported instrument.

METHODS

Patients were randomized to receive brodalumab (140 or 210 mg every 2 weeks [Q2W]), placebo (AMAGINE-1/-2/-3), or ustekinumab (AMAGINE-2/-3) during a 12-week induction phase, followed by a maintenance phase through week 52. Patients electronically rated the severity of PSI items (itch, burning, stinging, pain, redness, scaling, cracking and flaking) during the previous 24 h on a scale of 0 (not at all severe) to 4 (very severe). At each visit, the PSI total score responder status was assessed, with responders defined as having an average weekly total inventory score ≤8 with no item score >1 at week 12.

RESULTS

Across AMAGINE-1/-2/-3, brodalumab was associated with improvements in PSI total scores and itch scores vs. placebo from week 2 through week 12 (P < 0.001 in both domains). In AMAGINE-2/-3, brodalumab 210 mg Q2W demonstrated faster onset of PSI total score and itch responses (week 2, 22.1% and 36.4%, respectively) vs. ustekinumab (week 2, 6.9% and 17.1%, respectively) and was associated with improved itch responses vs. ustekinumab after 52 weeks of constant treatment.

CONCLUSION

Brodalumab demonstrated rapid, robust improvements in symptoms assessed by the PSI, including itch, vs. placebo and ustekinumab.

Day-case holmium laser enucleation of the prostate: feasibility, safety and predictive factors

Introduction Transurethral resection of the prostate has remained the most common operation for bladder outlet obstruction in the UK, but it is associated with potential morbidity and median two-day length of hospital stay. Holmium laser enucleation of the prostate (HoLEP) provides an alternative procedure. Provision of day-case HoLEP would improve patient care through increased efficiency. We assessed the feasibility and safety of day-case HoLEP and examined predictive factors for increased length of hospital stay. Materials and methods Patients presenting for HoLEP by a single surgeon from September 2013 to September 2016 were considered for day-case surgery. Patients were discharged following assessment by the operating surgeon and met predetermined discharge criteria. Factors contributing to day-case success were identified. Results In total, 210 patients (mean age 70.3 ± 8.5 years) underwent HoLEP, with 74 (35.3%) discharged as true day-cases and a further 84 (40.0%) discharged within 23 hours. Readmission rate was 5.5%, with all complications Clavien-Dindo grade I or II. Factors associated with successful day-case operation included low-volume prostates (≤ 40 g) (odds ratio, OR, 3.097, 95% confidence interval, CI, 1.619-5.924, P = 0.0001) and morning surgical lists (OR 6.124, 95% CI 2.526-14.845, p<0.001). Discussion and conclusion Day-case HoLEP is both feasible and safe, with low readmission rates. Two factors were significantly associated with successful day-case surgery: small volume prostate and morning theatre lists. Addressing these factors through preoperative planning can improve day-case surgery rates and improve bed throughput.

Abstract P5-03-03: A blood-based proteomic Videssa® breast assay performs comparably in women with dense and non-dense breasts

Breast density is associated with reduced imaging sensitivity and specificity for breast cancer (BC). Women with dense breasts are at a four- to six-fold increased risk of developing BC. A biochemical approach that is not affected by density would provide an additional tool to health-care professionals who are managing women with dense breasts and suspicious imaging findings. Videssa® Breast, a combinatorial proteomic biomarker assay, comprised of Serum Protein Biomarkers (SPBs) and Tumor –Associated Autoantibodies (TAAbs) integrated with clinical characteristic data to produce one diagnostic score that reliably detects BC was recently developed as an adjunctive tool to imaging. The goal of this study was to determine whether the diagnostic performance of Videssa® Breast was impacted by breast density.

Provista-001 enrolled 351 participants under the age of 50 years with no prior history of breast biopsy, and Provista-002 cohort one enrolled 210 participants under the age of 50 years with no history of breast biopsy within six months; all participants were assessed as BI-RADS 3 or 4. Breast density status was retrospectively obtained for participants; the four American College of Radiology breast density categories (a, b, c, and d) used for clinical reporting were applied. Serum was collected and tested with Videssa® Breast. Women were categorized into Dense, which included categories c and d, and Non-dense, which included categories a and b, groups.

To understand the performance of Videssa® Breast in women with dense breasts, the clinical sensitivity, specificity, NPV and PPV were evaluated in the dense and non-dense groups from the comprehensive Provista-001 and Provista-002 set (n=545). Of these 545, breast density information was available for 454; 62.6% (n=284) were categorized as having dense breasts and 37.4% (n=170) were categorized as having non-dense breasts. The sensitivity of Videssa® Breast in the non-dense and dense groups was 92.3% and 88.9%, respectively, and the specificity in the non-dense and dense groups was 86.6% and 81.2%, respectively. No significant differences were observed in the sensitivity (p=1.0) or specificity (p=0.1783) of Videssa® Breast in detecting BC in participants with non-dense breasts compared to those with dense breasts. The NPV in both groups exceeded 99%; the PPV was similar across groups.

In summary, this study demonstrates that Videssa® Breast has comparable performance in women with dense and non-dense breasts. Videssa® Breast demonstrates high sensitivity and specificity for detecting BC (Grades I through III), irrespective of density status. Videssa® breast provides an additional tool for health-care providers when women with dense breasts present with challenging imaging findings. In addition, Videssa® breast provides assurance to a woman with dense breasts that she does not have BC, potentially reducing further anxiety in this higher risk patient population.

Citation Format: Silver M, Tran Q, Gordon K, Benson KL, Henderson MC, Letsios E, Mulpuri R, Reese DE. A blood-based proteomic Videssa® breast assay performs comparably in women with dense and non-dense breasts [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P5-03-03.

Population structure and gene flow in the global pest, Helicoverpa armigera

Helicoverpa armigera is a major agricultural pest that is distributed across Europe, Asia, Africa and Australasia. This species is hypothesized to have spread to the Americas 1.5 million years ago, founding a population that is at present, a distinct species, Helicoverpa zea. In 2013, H. armigera was confirmed to have re-entered South America via Brazil and subsequently spread. The source of the recent incursion is unknown and population structure in H. armigera is poorly resolved, but a basic understanding would highlight potential biosecurity failures and determine the recent evolutionary history of region-specific lineages. Here, we integrate several end points derived from high-throughput sequencing to assess gene flow in H. armigera and H. zea from populations across six continents. We first assemble mitochondrial genomes to demonstrate the phylogenetic relationship of H. armigera with other Heliothine species and the lack of distinction between populations. We subsequently use de novo genotyping-by-sequencing and whole-genome sequences aligned to bacterial artificial chromosomes, to assess levels of admixture. Primarily, we find that Brazilian H. armigera are derived from diverse source populations, with strong signals of gene flow from European populations, as well as prevalent signals of Asian and African ancestry. We also demonstrate a potential field-caught hybrid between H. armigera and H. zea, and are able to provide genomic support for the presence of the H. armigera conferta subspecies in Australasia. While structure among the bulk of populations remains unresolved, we present distinctions that are pertinent to future investigations as well as to the biosecurity threat posed by H. armigera.

Assessment of liposome bupivacaine infiltration versus continuous femoral nerve block for postsurgical analgesia following total knee arthroplasty: a retrospective cohort study

OBJECTIVE

Perioperative pain management is an important aspect of recovery from total knee arthroplasty (TKA) because severe pain can delay ambulation and hospital discharge. The objective of this retrospective sequential cohort study was to determine the impact of local infiltration analgesia using liposome bupivacaine (Exparel ¹ ) when compared with a continuous femoral nerve block (FNB) following TKA.

METHODS

This retrospective cohort study included consecutive patients who underwent TKA between April 2011 and April 2014, and received one of three interventions. Study Group A received adductor canal infiltration with bupivacaine HCl and knee infiltration with liposome bupivacaine. Study Group B received adductor canal infiltration with liposome bupivacaine and knee infiltration with liposome bupivacaine. The control group received a continuous FNB with ropivacaine HCl delivered via an elastomeric pump. Numeric pain rating scores (NPRS), distance walked, length of stay (LOS), and dose of narcotic medication were the key efficacy variables of interest.

RESULTS

A total of 237 patients were included in this study: 98 in Group A, 34 in Group B, and 105 controls. On postoperative day (POD) 0, mean (standard deviation [SD]) NPRSs were similar between Group A (1.8 [1.7]), Group B (2.7 [1.8]), and the control group (2.3 [2.4]). Significantly (p < 0.05) more patients in Group A (58%) and Group B (44%) walked on POD0 than in the control group (0%); almost all patients walked on POD1. The mean (SD) distance walked was also significantly greater (p < 0.05) on POD1 in Group A (193 [203] feet) and Group B (211 [144] feet) than in the control group (46 [73] feet). Mean (SD) LOS was significantly (p < 0.05) shorter in Group B (2.2 [1.2] days), than in the control group (3.2 [0.7] days) and Group A (3.0 [1.7] days).

CONCLUSIONS

Local infiltration analgesia using liposome bupivacaine was associated with improved ambulation and shorter LOS following TKA when compared with continuous FNB in this retrospective cohort study.

Soybean Stem Fly, Melanagromyza sojae (Diptera: Agromyzidae), in the New World: detection of high genetic diversity from soybean fields in Brazil

Soybean Stem Fly (SSF), Melanagromyza sojae (Zehntner), belongs to the family Agromyzidae and is highly polyphagous, attacking many plant species of the family Fabaceae, including soybean and other beans. SSF is regarded as one of the most important pests in soybean fields of Asia (e.g., China, India), North East Africa (e.g., Egypt), parts of Russia, and South East Asia. Despite reports of Agromyzidae flies infesting soybean fields in Rio Grande do Sul State (Brazil) in 1983 and 2009 and periodic interceptions of SSF since the 1940s by the USA quarantine authorities, SSF has not been officially reported to have successfully established in the North and South Americas. In South America, M. sojae was recently confirmed using morphology and its complete mitochondrial DNA (mtDNA) was characterized. In the present study, we surveyed the genetic diversity of M. sojae, collected directly from soybean host plants, using partial mtDNA cytochrome oxidase I (COI) gene, and provide evidence of multiple (>10) maternal lineages in SSF populations in South America, potentially representing multiple incursion events. However, a single incursion involving multiple-female founders could not be ruled out. We identified a haplotype that was common in the fields of two Brazilian states and the individuals collected from Australia in 2013. The implications of SSF incursions in southern Brazil are discussed in relation to the current soybean agricultural practices, highlighting an urgent need for better understanding of SSF population movements in the New World, which is necessary for developing effective management options for this significant soybean pest.

Effect of hoof angle on joint contact area in the equine metacarpophalangeal joint following simulated impact loading ex vivo

REASONS FOR PERFORMING STUDY

To add to the existing data on impact loading of the metacarpophalangeal (MCP) joint as a precursor to assessing the potential role of impact in joint disease.

OBJECTIVES

To examine the effect of impact loading on contact areas of the first phalanx (P1) and proximal sesamoids (PS) with the third metacarpal (McIII) under 3 hoof-strike conditions (toe-first, flat, heel-first).

STUDY DESIGN

Randomised, repeated controlled experiment using cadaver material.

METHODS

Eight cadaver limbs were subjected to randomised, repeated controlled trials where the hoof was struck by a pendulum impact machine (impact velocity 3.55 m/s) under 3 strike conditions. Data from pressure sensitive film placed over medial and lateral McIII condyles and lateromedially across the dorsal aspect of McIII were quantified: total areas of P1 and PS contact (cm(2) ) at maximum recorded pressure; centroid locations of contact areas relative to the sagittal ridge (cm) and transverse ridge (cm) and dispersion of pixels (cm(4) ) for each McIII condyle (medial/lateral). The effect of the strike conditions on each variable were statistically tested using repeated-measures ANOVA (α = 0.05).

RESULTS

Contact area between P1 and McIII condyles fell in well-defined areas bounded by the sagittal and transverse ridge, contact areas from PS were smaller and widely dispersed across McIII palmar border. Ratio of contact area of P1 to PS was 2.83 (P<0001). Hoof strike had no significant effect on contact area (P>0.54) CONCLUSIONS: Contact at impact (primarily from P1 and distally situated on McIII), contrasts with contact areas at midstance from both P1 and PS, symmetrically placed. Under impact, the greatest contact area was on the dorsal aspect of the medial condyle and coincides with the area subjected to the greatest increase in subchondral bone stiffening in joint disease.

Weighing up the weighted case mix tool (WCMT): a psychometric investigation using confirmatory factor analysis

OBJECTIVE

To assess the use of the WCMT in two Scottish health boards and to consider the impact of simplifying the tool to improve efficient use.

DESIGN

A retrospective analysis of routine WCMT data (47,276 cases).

CLINICAL SETTING

Public Dental Service (PDS) within NHS Lothian and Highland.

METHOD

The WCMT consists of six criteria. Each criterion is measured independently on a four-point scale to assess patient complexity and the dental care for the disabled/impaired patient. Psychometric analyses on the data-set were conducted. Conventional internal consistency coefficients were calculated. Latent variable modelling was performed to assess the 'fit' of the raw data to a pre-specified measurement model. A Confirmatory Factor Analysis (CFA) was used to test three potential changes to the existing WCMT that included, the removal of the oral risk factor question, the removal of original weightings for scoring the Tool, and collapsing the 4-point rating scale to three categories.

RESULTS

The removal of the oral risk factor question had little impact on the reliability of the proposed simplified CMT to discriminate between levels of patient complexity. The removal of weighting and collapsing each item's rating scale to three categories had limited impact on reliability of the revised tool. The CFA analysis provided strong evidence that a new, proposed simplified Case Mix Tool (sCMT) would operate closely to the pre-specified measurement model (the WMCT).

CONCLUSIONS

A modified sCMT can demonstrate, without reducing reliability, a useful measure of the complexity of patient care. The proposed sCMT may be implemented within primary care dentistry to record patient complexity as part of an oral health assessment.

Long-term safety of ustekinumab in patients with moderate-to-severe psoriasis: final results from 5 years of follow-up

BACKGROUND

Long-term safety evaluations of biologics are needed to inform patient management decisions.

OBJECTIVES

To evaluate the safety of ustekinumab in patients with moderate-to-severe psoriasis treated for up to 5 years.

METHODS

Safety data were pooled from four studies of ustekinumab for psoriasis. Rates of adverse events (AEs), serious AEs (SAEs) and AEs of interest [infections, nonmelanoma skin cancers (NMSCs), other malignancies and major adverse cardiovascular events (MACE)] per 100 patient-years (PY) of follow-up were analysed by ustekinumab dose (45 or 90 mg) and by year of follow-up (years 1-5) to evaluate the dose response and impact of cumulative exposure. Observed rates of overall mortality and other malignancies were compared with those expected in the general U.S. population.

RESULTS

Analyses included 3117 patients (8998 PY) who received one or more doses of ustekinumab, with 1482 patients treated for ≥4 years (including 838 patients ≥5 years). At year 5, event rates (45 mg, 90 mg, respectively) for overall AEs (242·6, 225·3), SAEs (7·0, 7·2), serious infections (0·98, 1·19), NMSCs (0·64, 0·44), other malignancies (0·59, 0·61) and MACE (0·56, 0·36) were comparable between dose groups. Year-to-year variability was observed, but no increasing trend was evident. Rates of overall mortality and other malignancies were comparable with those expected in the general U.S. population.

CONCLUSIONS

No dose-related or cumulative toxicity was observed with increasing duration of ustekinumab exposure for up to 5 years. Rates of AEs reported in ustekinumab psoriasis trials are generally comparable with those reported for other biologics approved for the treatment of moderate-to-severe psoriasis.