IF1 Promotes Cellular Proliferation and Inhibits Oxidative Phosphorylation in Mouse Embryonic Fibroblasts under Normoxia and Hypoxia

ATP synthase inhibitory factor subunit 1 (IF1) is an inhibitory subunit of mitochondrial ATP synthase, playing a crucial role in regulating mitochondrial respiration and energetics. It is well-established that IF1 interacts with the F1 sector of ATP synthase to inhibit the reversal rotation and, thus, ATP hydrolysis. Recent evidence supports that IF1 also inhibits forward rotation or the ATP synthesis activity. Adding to the complexity, IF1 may also facilitate mitophagy and cristae formation. The implications of these complex actions of IF1 for cellular function remain obscure. In the present study, we found that IF1 expression was markedly upregulated in hypoxic MEFs relative to normoxic MEFs. We investigate how IF1 affects cellular growth and function in cultured mouse embryonic fibroblasts derived from mouse lines with systemic IF1 overexpression and knockout under normoxia and hypoxia. Cell survival and proliferation analyses revealed that IF1 overexpression exerted limited effects on cellular viability but substantially increased proliferation under normoxia, whereas it facilitated both cellular viability and proliferation under hypoxia. The absence of IF1 may have a pro-survival effect but not a proliferative one in both normoxia and hypoxia. Cellular bioenergetic analyses revealed that IF1 suppressed cellular respiration when subjected to normoxia and was even more pronounced when subjected to hypoxia with increased mitochondrial ATP production. In contrast, IF1 knockout MEFs showed markedly increased cellular respiration under both normoxia and hypoxia with little change in mitochondrial ATP. Glycolytic stress assay revealed that IF1 overexpression modestly increased glycolysis in normoxia and hypoxia. Interestingly, the absence of IF1 in MEFs led to substantial increases in glycolysis. Therefore, we conclude that IF1 mainly inhibits cellular respiration and enhances cellular glycolysis to preserve mitochondrial ATP. On the other hand, IF1 deletion can significantly facilitate cellular respiration and glycolysis without leading to mitochondrial ATP deficit.

Effects of 25-hydroxycholecalciferol on performance, gut health, and bone quality of broilers fed with reduced calcium and phosphorus diet during Eimeria challenge

This study evaluated the effects of 25-hydroxycholecalciferol (25-OHD) on performance, gut health, and bone quality of broilers fed with reduced calcium (Ca) and phosphorus (P) diet during Eimeria spp. challenge. A total of 576 fourteen-day-old Cobb 500 male chicks were randomly distributed in a 2 × 2 × 2 factorial arrangement, with 6 replicates of 12 birds each. The main factors were 25-OHD level (0 or 3,000 IU/kg of feed), mineral level (0.84% of Ca/0.42% of P, the levels recommended for the grower phase (NOR) or 0.64% of Ca/0.22% of P (RED), and mid-high mixed Eimeria challenge or nonchallenge. 25-OHD improved phosphorus retention (P = 0.019), bone ash weight (P = 0.04), cortical bone trabecular connectivity (P = 0.043) during coccidiosis. For birds fed with reduced mineral levels, 25-OHD supplementation increased bone ash weight (P = 0.04). However, 25-OHD did not improve bone ash weight when birds were challenged and fed with reduced mineral levels. The dietary 3,000 IU of 25-OHD supplementation did not improve performance or gut morphology but support bone health during coccidiosis. Future investigations are needed for better understand 25-OHD role on bone microarchitecture and oxidative metabolism during coccidiosis.

Factors affecting quality of life in rectal cancer survivors who have undergone laparoscopic surgery: patient-reported outcomes over 10 years at a single institution

INTRODUCTION

Colorectal cancer survivors have many problems affecting their quality of life (QOL). Traditional follow-up focuses on the detection of recurrence rather than QOL. Efforts are being made to assess patient-reported outcomes (PROMS) more formally. Such changes may enable patients to consider QOL factors when deciding on treatment.

METHODS

Patients who underwent laparoscopic surgery for rectal cancer between 2005 and 2015 at a single institution were identified and sent European Organisation for Research and Treatment of Cancer (EORTC) QLQ-C30 and QLQ-CR29 QOL questionnaires. QOL and the impact of radiotherapy, chemotherapy and formation of end colostomy were assessed.

RESULTS

Some 141 patients were identified: 12 died and 118 (83.7%) responded, of whom 101 completed the questionnaires and 17 declined to participate; 11 were lost to follow-up. Mean age was 67 years, median follow-up was 58 months. Median QOL score was 6 (maximum 7) and 4.5% of patients reported a poor QOL score (<4). Significant rectal/perianal pain, sexual dysfunction and urinary symptoms were reported in 3.6%, 10.9% and 2.7% of respondents, respectively. Significant differences between treatment groups were uncommon. All cohorts reported similar QOL, functional and symptom scores.

CONCLUSIONS

These results compare favourably with the published data. Future studies may benefit from baseline assessment to better assess treatment impact, prescient in an increasingly elderly and comorbid population. This paper establishes that good PROMs are achievable with laparoscopic surgery for rectal cancer. It identifies limited differences in QOL between treatment modalities. Restoration of intestinal continuity and end colostomy result in similar QOL. This may address common concerns regarding stomata, sexual function and low anterior resection syndrome in this cohort.

Real world data on outcomes of anti-CD38 antibody treated, including triple class refractory, patients with multiple myeloma: a multi-institutional report from the Canadian Myeloma Research Group (CMRG) Database

Multiple myeloma (MM) remains incurable despite the availability of novel agents. This multi-center retrospective cohort study used the Canadian Myeloma Research Group Database to describe real-world outcomes of patients withanti-CD38 monoclonal antibody (mAb) refractory MM subsequently treated with standard of care (SoC) regimens. Patients with triple class refractory (TCR) disease (refractory to a proteasome inhibitor, immunomodulatory drug, and anti-CD38 mAb) were examined as a distinct cohort. Overall, 663 patients had disease progression on anti-CD38 mAb therapy, 466 received further treatment (346 with SoC regimens were included, 120 with investigational agents on clinical trial and were excluded). The median age at initiation of subsequent SoC therapy of 67.9 (range 39.6-89.6) years with a median of 3 prior lines (range 1-9). The median PFS and OS from the start of subsequent therapy was 4.6 (95% CI 4.1-5.6) months and 13.3 (95% CI 10.6-16.6) months, respectively. The median PFS and OS of patients with TCR disease (n = 199) was 4.4 (95% CI 3.6-5.3) months and 10.5 (95% CI 8.5-13.8) months. Our results reinforce that real-world patients with relapsed MM, particularly those with TCR disease, have dismal outcomes. There remains an urgent unmet need for the development of and access to effective therapeutics for these patients.

Defining Myocardial Infarction in trials of people receiving hemodialysis: consensus report from the SONG-HD MI Expert Working group

Cardiovascular disease is the leading cause of death in patients receiving hemodialysis. Currently there is no standardized definition of myocardial infarction (MI) for patients receiving hemodialysis. Through an international consensus process MI was established as the core CVD measure for this population in clinical trials. The Standardised Outcomes in Nephrology Group - Hemodialysis (SONG-HD) initiative convened a multidisciplinary, international working group to address the definition of MI in this population.Based on current evidence, the working group recommends using the 4th Universal Definition of MI with specific caveats with regard to the interpretation of "ischemic symptoms" and performing a baseline 12-lead electrocardiogram to facilitate interpretation of acute changes on subsequent tracings. The working group does not recommend obtaining baseline cardiac troponin values, though does recommend obtaining serial cardiac biomarkers in settings where ischemia is suspected. Application of an evidence-based uniform definition should increase the reliability and accuracy of trial results.

Magnetic hydrogel particles improve nanopore sequencing of SARS-CoV-2 and other respiratory viruses

Presented here is a magnetic hydrogel particle enabled workflow for capturing and concentrating SARS-CoV-2 from diagnostic remnant swab samples that significantly improves sequencing results using the Oxford Nanopore Technologies MinION sequencing platform. Our approach utilizes a novel affinity-based magnetic hydrogel particle, circumventing low input sample volumes and allowing for both rapid manual and automated high throughput workflows that are compatible with Nanopore sequencing. This approach enhances standard RNA extraction protocols, providing up to 40 × improvements in viral mapped reads, and improves sequencing coverage by 20-80% from lower titer diagnostic remnant samples. Furthermore, we demonstrate that this approach works for contrived influenza virus and respiratory syncytial virus samples, suggesting that it can be used to identify and improve sequencing results of multiple viruses in VTM samples. These methods can be performed manually or on a KingFisher automation platform.

Multi-Phenotypic Breast Cancer Post-Radiotherapy for Hodgkin Lymphoma: A Case of Secondary Malignancy

Morbidity and mortality associated with radiation-induced secondary malignancies (RISMs) have shifted treatment paradigms to minimize or eliminate radiation from treatment regimens. In this case, a 48-year-old woman was diagnosed with Hodgkin lymphoma (HL) and treated with radiotherapy in 2000. In 2018, she was diagnosed with ductal carcinoma in situ (DCIS) of the right breast and treated with a mastectomy. Soon after, she developed triple-negative invasive ductal carcinoma (IDC) in her reconstructed breast. The patient underwent a left lumpectomy, and pathology showed ER-/PR-/HER2+ IDC. This patient's multi-phenotypic DCIS and IDC presentation are suspected to be RISM due to her previous HL treatment regimen.

Genetically Encoded ATP Biosensors for Direct Monitoring of Cellular ATP Dynamics

Adenosine 5'-triphosphate, or ATP, is the primary molecule for storing and transferring energy in cells. ATP is mainly produced via oxidative phosphorylation in mitochondria, and to a lesser extent, via glycolysis in the cytosol. In general, cytosolic glycolysis is the primary ATP producer in proliferative cells or cells subjected to hypoxia. On the other hand, mitochondria produce over 90% of cellular ATP in differentiated cells under normoxic conditions. Under pathological conditions, ATP demand rises to meet the needs of biosynthesis for cellular repair, signaling transduction for stress responses, and biochemical processes. These changes affect how mitochondria and cytosolic glycolysis function and communicate. Mitochondria undergo remodeling to adapt to the imbalanced demand and supply of ATP. Otherwise, a severe ATP deficit will impair cellular function and eventually cause cell death. It is suggested that ATP from different cellular compartments can dynamically communicate and coordinate to adapt to the needs in each cellular compartment. Thus, a better understanding of ATP dynamics is crucial to revealing the differences in cellular metabolic processes across various cell types and conditions. This requires innovative methodologies to record real-time spatiotemporal ATP changes in subcellular regions of living cells. Over the recent decades, numerous methods have been developed and utilized to accomplish this task. However, this is not an easy feat. This review evaluates innovative genetically encoded biosensors available for visualizing ATP in living cells, their potential use in the setting of human disease, and identifies where we could improve and expand our abilities.

POS1024 EFFICACY AND SAFETY OF RISANKIZUMAB (RZB) FOR ACTIVE PSORIATIC ARTHRITIS (PsA): 52-WEEK RESULTS FROM KEEPsAKE 1

Background

RZB, a humanized immunoglobulin G1 monoclonal antibody that specifically inhibits the p19 subunit of the human cytokine IL-23, is being investigated as a treatment for PsA.

Objectives

To compare efficacy and safety of RZB vs. placebo (PBO) in patients with PsA who had an inadequate response or intolerance to conventional synthetic disease modifying antirheumatic drug (csDMARD-IR).

Methods

KEEPsAKE 1 (NCT03675308) is an ongoing, phase 3 study that includes a screening period; a 24-week double-blinded, placebo-controlled, parallel-group period (period 1); and an open-label extension period (period 2). Eligible patients aged ≥18 years with active PsA (symptom onset ≥6 months prior to screening, meeting the Classification Criteria for PsA [CASPAR], and ≥5 swollen and ≥5 tender joints) and who had an inadequate response or intolerance to ≥1 csDMARD-IR, were randomized 1:1 to receive RZB 150 mg or placebo (PBO) at weeks 0, 4, and 16. The primary endpoint was the proportion of patients achieving ≥20% improvement in American College of Rheumatology (ACR20) response at week 24. Period 2 started at week 24, and patients were switched to receive open-label RZB 150 mg every 12 weeks through week 208. Mixed-effect model repeated measures and nonresponder imputation methods were used to assess continuous and binary variables, respectively. Efficacy and safety were analyzed in all patients who received ≥1 dose of study drug through week 52. Treatment-emergent adverse events (TEAE) were summarized using exposure-adjusted event rates (EAERs, events/100 patient-years [PY]).

Results

At week 24, a greater proportion of RZB-treated (N=483) vs PBO-treated (N=481) patients achieved ACR20 (55.3% and 32.8%, respectively). At week 52, 70% of patients who were randomized to receive RZB and 63% of patients who were randomized to receive PBO and switch to RZB at week 24 achieved ACR20. In patients with ≥3% of body surface area affected at baseline, 52.7% of RZB-treated patients (N=273) and 9.9% of PBO-treated patients (N=272) achieved ≥90% improvement in Psoriasis Area and Severity Index (PASI 90) at week 24; 67.8% who were randomized to receive RZB and 59.9% who were randomized to receive PBO and switch to RZB at week 24 achieved PASI 90 at week 52. Similar results were observed for other efficacy measures. RZB was well tolerated through 52 weeks of treatment. EAERs of adverse events were stable between weeks 24 and 52. At the week 52 data cut-off (19 April 2021), the total EAER of any TEAE in patients receiving RZB was 143.1/100 PY.

Conclusion

Continuous RZB treatment provided durable efficacy and a consistent safety profile through 52 weeks of treatment in patients with active PsA who were csDMARD-IR.

Acknowledgements

AbbVie, Inc. participated in the study design; study research; collection, analysis, and interpretation of data. AbbVie funded the research for this study. Medical writing assistance, funded by AbbVie, was provided by Jay Parekh, PharmD, of JB Ashtin.

Disclosure of Interests

Lars Erik Kristensen Speakers bureau: AbbVie, Amgen, Biogen, Bristol Myers Squibb, Gilead, Janssen, Lilly, Merck, Novartis, Pfizer, and UCB, Consultant of: AbbVie, Amgen, Biogen, Bristol Myers Squibb, Gilead, Janssen, Lilly, Merck, Novartis, Pfizer, and UCB, Grant/research support from: AbbVie, Biogen, Gilead, Janssen, Lilly, Novartis, Pfizer, and UCB, MAURO KEISERMAN Speakers bureau: AbbVie, Amgen, Bristol Myers Squibb, Celgene, GlaxoSmithKline, Janssen, Novartis, Pfizer, Roche, and UCB, Consultant of: AbbVie, Amgen, Bristol Myers Squibb, Celgene, GlaxoSmithKline, Janssen, Novartis, Pfizer, Roche, and UCB, Grant/research support from: AbbVie, Amgen, Bristol Myers Squibb, Celgene, GlaxoSmithKline, Janssen, Novartis, Pfizer, Roche, and UCB, Kim Papp Speakers bureau: AbbVie, Amgen, Arcutis, Astellas, Bausch Health, Boehringer Ingelheim, Bristol Myers Squibb, Celgene, Dermavant, Dermira, Incyte, Janssen, LEO Pharma, Lilly, Novartis, Pfizer, Sandoz, Sanofi Genzyme, and UCB, Consultant of: AbbVie, Amgen, Arcutis, Astellas, Bausch Health, Baxalta, Baxter, Boehringer Ingelheim, Bristol Myers Squibb, Celgene, Coherus, Dermavant, Dermira, EMD Serono, Forward Pharma, Galderma, Genentech, Gilead, Incyte, Janssen, LEO Pharma, Lilly, Meiji Seika Pharma, Merck, Mitsubishi Tanabe Pharma, Novartis, Pfizer, Regeneron, Sandoz, Sanofi Genzyme, Stiefel, Sun Pharma, Takeda, and UCB, Grant/research support from: AbbVie, Amgen, Arcutis, Astellas, Bausch Health, Baxalta, Baxter, Boehringer Ingelheim, Bristol Myers Squibb, Celgene, Coherus, Dermavant, Dermira, EMD Serono, Forward Pharma, Galderma, Genentech, Gilead, Incyte, Janssen, LEO Pharma, Lilly, Merck, Novartis, Ortho Dermatologics, Pfizer, Regeneron, Sanofi Genzyme, Sun Pharma, and UCB, Leslie McCasland Consultant of: Lilly, Douglas White Speakers bureau: AbbVie and Novartis, Consultant of: AbbVie and Novartis, Wenjing Lu Shareholder of: AbbVie Inc., Employee of: AbbVie Inc., Ahmed M. Soliman Shareholder of: AbbVie Inc., Employee of: AbbVie Inc., Ann Eldred Shareholder of: AbbVie Inc., Employee of: AbbVie Inc., Lisa Barcomb Shareholder of: AbbVie Inc., Employee of: AbbVie Inc., Frank Behrens Speakers bureau: AbbVie, Amgen, Boehringer Ingelheim, Celgene, Chugai, Galapagos, Genzyme, Gilead, Janssen, Lilly, Merck, Novartis, Pfizer, Roche, and Sanofi, Consultant of: AbbVie, Amgen, Boehringer Ingelheim, Celgene, Chugai, Galapagos, Genzyme, Gilead, Janssen, Lilly, Merck, Novartis, Pfizer, Roche, and Sanofi, Grant/research support from: AbbVie, Amgen, Boehringer Ingelheim, Celgene, Chugai, Galapagos, Genzyme, Gilead, Janssen, Lilly, Merck, Novartis, Pfizer, Roche, and Sanofi

POS1042 IMPACT OF RISANKIZUMAB ON IMPROVING HEALTH-RELATED QUALITY OF LIFE, WORK PRODUCTIVITY, AND REDUCING FATIGUE AMONG PATIENTS WITH ACTIVE PSORIATIC ARTHRITIS: A POOLED ANALYSIS OF TWO PHASE 3 CLINICAL TRIALS

Background

Risankizumab (RZB) has been approved in the UK and Europe for the treatment of adults with active PsA. Patient-reported outcomes (PROs) are important tools for understanding a therapy’s efficacy from the patient’s perspective.

Objectives

This study evaluated the impact of RZB versus placebo on health-related quality of life (HRQoL), fatigue, and work productivity in patients with psoriatic arthritis (PsA) and inadequate response to 1 or 2 biologics and/or ≥1 conventional synthetic DMARDs in two Phase 3 trials (KEEPsAKE 1&2).

Methods

Eligible patients with active PsA (n=1402) were randomized (1:1) to receive risankizumab 150 mg (n=706) or placebo (n=696). Patient-reported outcomes assessed were 36-Item Short-Form Health Survey (SF-36), Functional Assessment of Chronic Illness Therapy–Fatigue (FACIT-Fatigue), EQ-5D-5L, and Work Productivity and Activity Impairment–PsA questionnaire. Least squares (LS) mean changes from baseline at Week 24 were compared between risankizumab versus placebo by mixed-effects repeated regression modeling.

Results

At Week 24, risankizumab- versus placebo-treated patients reported greater improvements in LS mean changes with between-group differences (all nominal P<0.001) in SF-36 physical component score (mean difference=3.5, 95% confidence interval [CI] 2.7, 4.2) and mental component score (mean difference=1.8, 95% CI 0.9, 2.6), FACIT-Fatigue (mean difference=2.5, 95% CI 1.5, 3.4), EQ-5D-5L index score (mean=0.07, 95% CI 0.05, 0.09), and EQ-5D-5L visual analogue scale score (mean difference=5.8, 95% CI 3.6, 8.0). In addition, risankizumab- versus placebo-treated patients reported greater reductions with between-group differences (all nominal P<0.001) in overall work impairment (mean difference= −8.9%, 95% CI −13.1, −4.7), activity impairment (mean difference= −7.7%, 95% CI −10.3, −5.2), and presenteeism (mean difference= −9.8%, 95% CI −13.3, −6.3).

Conclusion

Compared to placebo, risankizumab resulted in greater improvements in HRQoL, fatigue, and work productivity among patients with PsA.

Acknowledgements

This work/study was funded by AbbVie Inc. AbbVie participated in the study design, research, data collection, analysis and interpretation of data. No honoraria or payments were made for authorship. Medical writing services provided by Natalie Mitchell of Fishawack Facilitate Ltd, part of Fishawack Health, and funded by AbbVie.

Disclosure of Interests

Lars Erik Kristensen Speakers bureau: AbbVie, Amgen, Biogen, Bristol Myers Squibb, Eli Lilly, Gilead, Janssen, MSD, Novartis, Pfizer, and UCB; and received research grants from AbbVie, Biogen, Eli Lilly, Janssen Pharmaceutical, Novartis, Pfizer, and UCB., Consultant of: AbbVie, Amgen, Biogen, Bristol Myers Squibb, Eli Lilly, Gilead, Janssen, MSD, Novartis, Pfizer, and UCB; and received research grants from AbbVie, Biogen, Eli Lilly, Janssen Pharmaceutical, Novartis, Pfizer, and UCB., Ahmed M. Soliman Shareholder of: AbbVie Inc., Employee of: AbbVie Inc., Kim Papp Speakers bureau: AbbVie, Amgen, Astellas, Baxalta, Baxter, Boehringer Ingelheim, Bristol Myers Squibb, Celgene, Coherus, Dermira, Eli Lilly, Forward Pharma, Galderma, Genentech, GlaxoSmithKline, Janssen, Kyowa-Hakko Kirin, LEO Pharma, MedImmune, Merck-Serono, Merck Sharp & Dohme, Novartis, Pfizer, Regeneron, Roche, Sanofi-Genzyme, Stiefel, Sun Pharma, Takeda, UCB, and Valeant., Consultant of: AbbVie, Amgen, Astellas, Baxalta, Baxter, Boehringer Ingelheim, Bristol Myers Squibb, Celgene, Coherus, Dermira, Eli Lilly, Forward Pharma, Galderma, Genentech, GlaxoSmithKline, Janssen, Kyowa-Hakko Kirin, LEO Pharma, MedImmune, Merck-Serono, Merck Sharp & Dohme, Novartis, Pfizer, Regeneron, Roche, Sanofi-Genzyme, Stiefel, Sun Pharma, Takeda, UCB, and Valeant., Grant/research support from: AbbVie, Amgen, Astellas, Baxalta, Baxter, Boehringer Ingelheim, Bristol Myers Squibb, Celgene, Coherus, Dermira, Eli Lilly, Forward Pharma, Galderma, Genentech, GlaxoSmithKline, Janssen, Kyowa-Hakko Kirin, LEO Pharma, MedImmune, Merck-Serono, Merck Sharp & Dohme, Novartis, Pfizer, Regeneron, Roche, Sanofi-Genzyme, Stiefel, Sun Pharma, Takeda, UCB, and Valeant., Lisa Barcomb Shareholder of: AbbVie Inc., Employee of: AbbVie Inc., Ann Eldred Shareholder of: AbbVie Inc., Employee of: AbbVie Inc., Zailong Wang Shareholder of: AbbVie Inc., Employee of: AbbVie Inc., Douglas White Speakers bureau: AbbVie, Novartis, and Roche., Consultant of: AbbVie, Novartis, and Roche., Frank Behrens Speakers bureau: AbbVie, Amgen, BMS, Boehringer, Celgene, Chugai, Genzyme, Janssen, Lilly, MSD, Novartis, Pfizer, Roche, Sandoz, and UCB, Consultant of: AbbVie, Amgen, BMS, Boehringer, Celgene, Chugai, Genzyme, Janssen, Lilly, MSD, Novartis, Pfizer, Roche, Sandoz, and UCB, Grant/research support from: AbbVie, Chugai, Janssen, Pfizer, and Roche

AB0897 Impact of risankizumab on improving symptoms and health-related quality of life and reducing fatigue and pain among psoriatic arthritis patients with moderate-to-severe skin involvement: Evidence from two Phase III trials

Background

Psoriatic arthritis (PsA) greatly affects patient-reported health-related quality of life (HRQoL).

Objectives

To assess the impact of risankizumab (RZB) on patient-reported outcomes (PROs) in patients with high skin burden using integrated efficacy data from two Phase III clinical trials (KEEPsAKE-1 and KEEPsAKE-2).

Methods

Adult patients with PsA with inadequate response or intolerance to disease-modifying antirheumatic drugs were randomized 1:1 to receive RZB (150 mg) or placebo (PBO). Improvement from baseline in PROs (Patient’s Global Assessment of Disease Activity [PtGA] by visual analog scale [VAS], Short-Form 36 Health Questionnaire physical and mental component summary scores [SF-36 PCS and MCS], Health Assessment Questionnaire – Disability Index [HAQ-DI], EQ-5D 5-Level questionnaire [EQ-5D-5L] index and by VAS, Functional Assessment of Chronic Illness Therapy – Fatigue [FACIT-Fatigue], and pain by VAS) were assessed at Week 24 in patients with high skin burden (body surface area involvement ≥3% and Psoriasis Area Severity Index >10). Least squares mean (LSM) difference (95% confidence interval [CI]) between RZB and PBO groups based on mixed-model repeated measures regression is reported.

Results

RZB- vs PBO-treated patients demonstrated greater improvements in PROs with notable LSM differences (95% CI) between groups (P<0.01) in PtGA (-18.7 [-25.1, -12.2]), SF-36 PCS (6.3 [4.2, 8.4]) and MCS (4.4 [2.3, 6.6]), HAQ-DI (-0.4 [-0.5, -0.3]), EQ-5D-5L index (0.1 [0.1, 0.2]) and VAS (8.2 [2.5,13.9]), FACIT-Fatigue (4.9 [2.7, 7.2]), and pain (-18.9 [-25.1, -12.7]).

Conclusion

In patients with PsA with high skin burden, 24 weeks of RZB treatment, as compared with PBO, improved patients’ HRQoL, including fatigue and pain.

Acknowledgements

AbbVie funded the study and participated in interpretation of data, review, and approval of the abstract. No honoraria or payments were made for authorship. Medical writing services were provided by Samantha Francis Stuart (Fishawack Facilitate Ltd) and funded by AbbVie.

Disclosure of Interests

Kim Papp Speakers bureau: AbbVie, Akros, Amgen, Anacor Pharmaceuticals, Arcutis Biotherapeutics, Astellas, Avillion, Bausch Health, Baxalta, Boehringer Ingelheim, Bristol Myers Squibb, Can-Fite Biopharma, Celgene, Coherus BioSciences, Dermavant, Dermira, Dice Pharmaceuticals, Dow Pharma, Eli Lilly, Evelo Biosciences, Galapagos NV, Galderma, Gilead, GlaxoSmithKline, Incyte, Janssen, Kyowa-Hakko Kirin, LEO Pharma, MedImmune, Meiji Seika Pharma, Merck-Serono, Merck Sharp & Dohme, Mitsubishi Pharma, Novartis, Pfizer, PRCL Research, Regeneron, Roche, Sanofi-Genzyme, Sun Pharma, Takeda, UCB, and Xencor., Consultant of: AbbVie, Akros, Amgen, Anacor Pharmaceuticals, Arcutis Biotherapeutics, Astellas, Avillion, Bausch Health, Baxalta, Boehringer Ingelheim, Bristol Myers Squibb, Can-Fite Biopharma, Celgene, Coherus BioSciences, Dermavant, Dermira, Dice Pharmaceuticals, Dow Pharma, Eli Lilly, Evelo Biosciences, Galapagos NV, Galderma, Gilead, GlaxoSmithKline, Incyte, Janssen, Kyowa-Hakko Kirin, LEO Pharma, MedImmune, Meiji Seika Pharma, Merck-Serono, Merck Sharp & Dohme, Mitsubishi Pharma, Novartis, Pfizer, PRCL Research, Regeneron, Roche, Sanofi-Genzyme, Sun Pharma, Takeda, UCB, and Xencor., Grant/research support from: AbbVie, Akros, Amgen, Anacor Pharmaceuticals, Arcutis Biotherapeutics, Astellas, Avillion, Bausch Health, Baxalta, Boehringer Ingelheim, Bristol Myers Squibb, Can-Fite Biopharma, Celgene, Coherus BioSciences, Dermavant, Dermira, Dice Pharmaceuticals, Dow Pharma, Eli Lilly, Evelo Biosciences, Galapagos NV, Galderma, Gilead, GlaxoSmithKline, Incyte, Janssen, Kyowa-Hakko Kirin, LEO Pharma, MedImmune, Meiji Seika Pharma, Merck-Serono, Merck Sharp & Dohme, Mitsubishi Pharma, Novartis, Pfizer, PRCL Research, Regeneron, Roche, Sanofi-Genzyme, Sun Pharma, Takeda, UCB, and Xencor., Ahmed M. Soliman Shareholder of: AbbVie Inc., Employee of: AbbVie Inc., Christian Kaufmann Shareholder of: AbbVie Inc., Employee of: AbbVie Inc., Lisa Barcomb Shareholder of: AbbVie Inc., Employee of: AbbVie Inc., Zailong Wang Shareholder of: AbbVie Inc., Employee of: AbbVie Inc., Douglas White Speakers bureau: AbbVie and Novartis., Consultant of: AbbVie and Novartis., Andrew Ostor Speakers bureau: BMS, Janssen, Roche, UCB, AbbVie, Pfizer, Merck, Celgene, Sanofi, Eli Lilly, and Novartis., Consultant of: BMS, Janssen, Roche, UCB, AbbVie, Pfizer, Merck, Celgene, Sanofi, Eli Lilly, and Novartis., Grant/research support from: BMS, Janssen, Roche, UCB, AbbVie, Pfizer, Merck, Celgene, Sanofi, Eli Lilly, and Novartis., Lars Erik Kristensen Speakers bureau: Pfizer, AbbVie, Amgen, Forward Pharma, UCB, Gilead, Biogen, BMS, MSD, Novartis, Eli Lilly, and Janssen, Consultant of: Pfizer, AbbVie, Amgen, Forward Pharma, UCB, Gilead, Biogen, BMS, MSD, Novartis, Eli Lilly, and Janssen, Grant/research support from: UCB, Novartis, Pfizer, Eli Lilly, Biogen, AbbVie, and Janssen Pharmaceuticals and UCB.

Enhancing clinician participation in quality improvement training: implementation and impact of an evidence-based initiative to maximise antenatal clinician participation in training regarding women’s alcohol consumption during pregnancy

Background

There are significant challenges in ensuring sufficient clinician participation in quality improvement training. Clinician capability has been identified as a barrier to the delivery of evidence-based care. Clinician training is an effective strategy to address this barrier, however, there are significant challenges in ensuring adequate clinician participation in training. This study aimed to assess the extent of participation by antenatal clinicians in evidence-based training to address alcohol consumption during pregnancy, and to assess differences in participation by profession.

Methods

A 7-month training initiative based on six evidence-based principles was implemented in a maternity service in New South Wales, Australia. Descriptive statistics described participation in training (% attending: any training; six evidence-based principles of training; all principles). Regression analyses examined differences by profession.

Results

Almost all antenatal clinicians participated in some training (182/186; 98%); 69% participated in ≥1 h of training (μ = 88.2mins, SD:56.56). The proportion of clinicians participating in training that satisfied each of the six principles ranged from 35% (training from peers and experts) to 82% (training was educational and instructional). Only 7% participated in training that satisfied all principles. A significantly higher proportion of midwifery compared to medical clinicians participated in training satisfying five of the six training principles.

Conclusions

A training initiative based on evidence-based principles resulted in almost all clinicians receiving some training and 69% participating in at least 1 h of training. Variability between professions suggests training needs to be tailored to such groups. Further research is required to determine possible associations with care delivery outcomes.

Trial registration

Australian and New Zealand Clinical Trials Registry, No. ACTRN12617000882325 (date registered: 16/06/2017).

A highly virulent variant of HIV-1 circulating in the Netherlands

We discovered a highly virulent variant of subtype-B HIV-1 in the Netherlands. One hundred nine individuals with this variant had a 0.54 to 0.74 log₁₀ increase (i.e., a ~3.5-fold to 5.5-fold increase) in viral load compared with, and exhibited CD4 cell decline twice as fast as, 6604 individuals with other subtype-B strains. Without treatment, advanced HIV-CD4 cell counts below 350 cells per cubic millimeter, with long-term clinical consequences-is expected to be reached, on average, 9 months after diagnosis for individuals in their thirties with this variant. Age, sex, suspected mode of transmission, and place of birth for the aforementioned 109 individuals were typical for HIV-positive people in the Netherlands, which suggests that the increased virulence is attributable to the viral strain. Genetic sequence analysis suggests that this variant arose in the 1990s from de novo mutation, not recombination, with increased transmissibility and an unfamiliar molecular mechanism of virulence.

Current status of Phytophthora in Australia

Among the most economically relevant and environmentally devastating diseases globally are those caused by Phytophthora species. In Australia, production losses in agriculture and forestry result from several well-known cosmopolitan Phytophthora species and infestation of natural ecosystems by Phytophthora cinnamomi have caused irretrievable loss to biodiversity especially in proteaceous dominated heathlands. For this review, all available records of Phytophthora in Australia were collated and curated, resulting in a database of 7 869 records, of which 2 957 have associated molecular data. Australian databases hold records for 99 species, of which 20 are undescribed. Eight species have no records linked to molecular data, and their presence in Australia is considered doubtful. The 99 species reside in 10 of the 12 clades recognised within the complete phylogeny of Phytophthora. The review includes discussion on each of these species' status and additional information provided for another 29 species of concern. The first species reported in Australia in 1900 was Phytophthora infestans. By 2000, 27 species were known, predominantly from agriculture. The significant increase in species reported in the subsequent 20 years has coincided with extensive surveys in natural ecosystems coupled with molecular taxonomy and the recognition of numerous new phylogenetically distinct but morphologically similar species. Routine and targeted surveys within Australian natural ecosystems have resulted in the description of 27 species since 2009. Due to the new species descriptions over the last 20 years, many older records have been reclassified based on molecular identification. The distribution of records is skewed toward regions with considerable activity in high productivity agriculture, horticulture and forestry, and native vegetation at risk from P. cinnamomi. Native and exotic hosts of different Phytophthora species are found throughout the phylogeny; however, species from clades 1, 7 and 8 are more likely to be associated with exotic hosts. One of the most difficult challenges to overcome when establishing a pest status is a lack of reliable data on the current state of a species in any given country or location. The database compiled here for Australia and the information provided for each species overcomes this challenge. This review will aid federal and state governments in risk assessments and trade negotiations by providing a comprehensive resource on the current status of Phytophthora species in Australia. Citation: Burgess TI, Edwards J, Drenth A, et al. 2021. Current status of Phytophthora in Australia. Persoonia 47: 151-177. https://doi.org/10.3767/persoonia.2021.47.05.

Current status of Phytophthora in Australia

Among the most economically relevant and environmentally devastating diseases globally are those caused by Phytophthora species. In Australia, production losses in agriculture and forestry result from several well-known cosmopolitan Phytophthora species and infestation of natural ecosystems by Phytophthora cinnamomi have caused irretrievable loss to biodiversity especially in proteaceous dominated heathlands. For this review, all available records of Phytophthora in Australia were collated and curated, resulting in a database of 7 869 records, of which 2 957 have associated molecular data. Australian databases hold records for 99 species, of which 20 are undescribed. Eight species have no records linked to molecular data, and their presence in Australia is considered doubtful. The 99 species reside in 10 of the 12 clades recognised within the complete phylogeny of Phytophthora. The review includes discussion on each of these species' status and additional information provided for another 29 species of concern. The first species reported in Australia in 1900 was Phytophthora infestans. By 2000, 27 species were known, predominantly from agriculture. The significant increase in species reported in the subsequent 20 years has coincided with extensive surveys in natural ecosystems coupled with molecular taxonomy and the recognition of numerous new phylogenetically distinct but morphologically similar species. Routine and targeted surveys within Australian natural ecosystems have resulted in the description of 27 species since 2009. Due to the new species descriptions over the last 20 years, many older records have been reclassified based on molecular identification. The distribution of records is skewed toward regions with considerable activity in high productivity agriculture, horticulture and forestry, and native vegetation at risk from P. cinnamomi. Native and exotic hosts of different Phytophthora species are found throughout the phylogeny; however, species from clades 1, 7 and 8 are more likely to be associated with exotic hosts. One of the most difficult challenges to overcome when establishing a pest status is a lack of reliable data on the current state of a species in any given country or location. The database compiled here for Australia and the information provided for each species overcomes this challenge. This review will aid federal and state governments in risk assessments and trade negotiations by providing a comprehensive resource on the current status of Phytophthora species in Australia. Citation: Burgess TI, Edwards J, Drenth A, et al. 2021. Current status of Phytophthora in Australia. Persoonia 47: 151-177. https://doi.org/10.3767/persoonia.2021.47.05.

AB0559 EFFICACY AND SAFETY OF RISANKIZUMAB IN PATIENTS WITH ACTIVE PSORIATIC ARTHRITIS AFTER INADEQUATE RESPONSE OR INTOLERANCE TO DMARDs: 24-WEEK RESULTS FROM THE PHASE 3, RANDOMIZED, DOUBLE-BLIND KEEPsAKE 1 TRIAL

Background:

Risankizumab (RZB) is a humanized immunoglobulin G1 monoclonal antibody that specifically inhibits interleukin 23 by binding to its p19 subunit. RZB is being investigated as a treatment for adults with psoriatic arthritis (PsA).

Objectives:

To compare the efficacy and safety of RZB vs placebo (PBO) for the treatment of active PsA in patients who have had inadequate response or intolerance to ≥ 1 conventional synthetic disease modifying antirheumatic drug (csDMARD-IR).

Methods:

In KEEPsAKE 1 (NCT03675308), eligible adults (csDMARD-IR with ≥ 5 swollen joints [SJC] and ≥ 5 tender joints [TJC]) were randomized (1:1) to receive blinded subcutaneous RZB 150 mg or PBO at weeks 0, 4, and 16. The primary endpoint was the proportion of patients achieving 20% improvement in American College of Rheumatology score (ACR20) at week 24. Ranked secondary and other secondary endpoints are shown in the Table 1. Safety was assessed throughout the study. Results reported here are from the 24-week double-blind period; the open-label period with all patients receiving RZB is ongoing.

Results:

964 patients (RZB, N = 483; PBO, N = 481) were evaluated at week 24. Demographics and baseline characteristics were generally balanced between treatment groups (mean duration of PsA: 7.12 years; mean SJC: 12.2; mean TJC: 20.6; mean body surface area involved with psoriasis [BSA] in patients with BSA ≥ 3%: 16.7%). A significantly greater proportion of RZB- vs PBO-treated patients (57.3% and 33.5%, respectively) achieved the primary endpoint of ACR20 at week 24 (P < .001; Table 1). Significant differences were also observed for RZB vs PBO for the first 8 ranked secondary endpoints (P < .001 for all; Table 1). Serious adverse events were reported for 2.5% and 3.7% of RZB- and PBO-treated patients, respectively; serious infections were reported for 1.0% and 1.2%. There was 1 death in the RZB group.

Conclusion:

RZB resulted in significantly greater improvements in signs and symptoms of PsA compared with PBO and was well tolerated in patients who were csDMARD-IR.

Disclosure of Interests:

Lars Erik Kristensen Speakers bureau: LK has received honoraria or fees for serving as a speaker or consultant from AbbVie, Amgen, Biogen, Bristol-Myers Squibb, Gilead, Janssen, Lilly, Merck, Novartis, Pfizer, and UCB., Consultant of: LK has received honoraria or fees for serving as a speaker or consultant from AbbVie, Amgen, Biogen, Bristol-Myers Squibb, Gilead, Janssen, Lilly, Merck, Novartis, Pfizer, and UCB., MAURO KEISERMAN Speakers bureau: MK has received honoraria or fees for serving on advisory boards, as a speaker or as a consultant, and grants as a principal investigator from AbbVie, Amgen, Bristol-Myers Squibb, Celgene, GlaxoSmithKline, Janssen, Novartis, Pfizer, Roche, and UCB., Consultant of: MK has received honoraria or fees for serving on advisory boards, as a speaker or as a consultant, and grants as a principal investigator from AbbVie, Amgen, Bristol-Myers Squibb, Celgene, GlaxoSmithKline, Janssen, Novartis, Pfizer, Roche, and UCB., Grant/research support from: MK has received honoraria or fees for serving on advisory boards, as a speaker or as a consultant, and grants as a principal investigator from AbbVie, Amgen, Bristol-Myers Squibb, Celgene, GlaxoSmithKline, Janssen, Novartis, Pfizer, Roche, and UCB., Kim Papp Speakers bureau: KP has received honoraria or fees for serving on advisory boards, as a speaker, and as a consultant, as well as grants as principal investigator from AbbVie, Amgen, Astellas, Bausch Health (Valeant), Baxalta, Baxter, Boehringer Ingelheim, Bristol-Myers Squibb, Celgene, Coherus, Dermira, EMD Serono, Forward Pharma, Galderma, Genentech, GlaxoSmithKline, Janssen, Kyowa Kirin, LEO Pharma, Lilly, MedImmune, Merck, Novartis, Pfizer, Regeneron, Roche, Sanofi Genzyme, Stiefel, Sun Pharma, Takeda, and UCB., Consultant of: KP has received honoraria or fees for serving on advisory boards, as a speaker, and as a consultant, as well as grants as principal investigator from AbbVie, Amgen, Astellas, Bausch Health (Valeant), Baxalta, Baxter, Boehringer Ingelheim, Bristol-Myers Squibb, Celgene, Coherus, Dermira, EMD Serono, Forward Pharma, Galderma, Genentech, GlaxoSmithKline, Janssen, Kyowa Kirin, LEO Pharma, Lilly, MedImmune, Merck, Novartis, Pfizer, Regeneron, Roche, Sanofi Genzyme, Stiefel, Sun Pharma, Takeda, and UCB., Grant/research support from: KP has received honoraria or fees for serving on advisory boards, as a speaker, and as a consultant, as well as grants as principal investigator from AbbVie, Amgen, Astellas, Bausch Health (Valeant), Baxalta, Baxter, Boehringer Ingelheim, Bristol-Myers Squibb, Celgene, Coherus, Dermira, EMD Serono, Forward Pharma, Galderma, Genentech, GlaxoSmithKline, Janssen, Kyowa Kirin, LEO Pharma, Lilly, MedImmune, Merck, Novartis, Pfizer, Regeneron, Roche, Sanofi Genzyme, Stiefel, Sun Pharma, Takeda, and UCB., Leslie McCasland Speakers bureau: LM has received fees for serving on an advisory board from Lilly., Douglas White Speakers bureau: DW has received honoraria or fees for serving on advisory boards, as a speaker, and as a consultant from AbbVie, Merck, Novartis, and Roche., Consultant of: DW has received honoraria or fees for serving on advisory boards, as a speaker, and as a consultant from AbbVie, Merck, Novartis, and Roche., Lisa Barcomb Shareholder of: LB is a full-time employee of AbbVie, and may hold AbbVie stock or stock options., Employee of: LB is a full-time employee of AbbVie, and may hold AbbVie stock or stock options., Wenjing Lu Shareholder of: WL is a full-time employee of AbbVie, and may hold AbbVie stock or stock options., Employee of: WL is a full-time employee of AbbVie, and may hold AbbVie stock or stock options., Zailong Wang Shareholder of: ZE is a full-time employee of AbbVie, and may hold AbbVie stock or stock options., Employee of: ZE is a full-time employee of AbbVie, and may hold AbbVie stock or stock options., Ahmed M. Soliman Shareholder of: AMS is a full-time employee of AbbVie, and may hold AbbVie stock or stock options., Employee of: AMS is a full-time employee of AbbVie, and may hold AbbVie stock or stock options., Ann Eldred Shareholder of: AE is a full-time employee of AbbVie, and may hold AbbVie stock or stock options., Employee of: AE is a full-time employee of AbbVie, and may hold AbbVie stock or stock options., Frank Behrens Speakers bureau: FB has received research grants, honoraria, or fees for serving as a consultant or speaker from AbbVie, Amgen, Boehringer Ingelheim, Celgene, Chugai, Galapagos, Genzyme, Gilead, Janssen, Lilly, Merck, Novartis, Pfizer, Roche, and Sanofi., Consultant of: FB has received research grants, honoraria, or fees for serving as a consultant or speaker from AbbVie, Amgen, Boehringer Ingelheim, Celgene, Chugai, Galapagos, Genzyme, Gilead, Janssen, Lilly, Merck, Novartis, Pfizer, Roche, and Sanofi., Grant/research support from: FB has received research grants, honoraria, or fees for serving as a consultant or speaker from AbbVie, Amgen, Boehringer Ingelheim, Celgene, Chugai, Galapagos, Genzyme, Gilead, Janssen, Lilly, Merck, Novartis, Pfizer, Roche, and Sanofi.

342 Rib Fracture Scoring at The Royal Sussex County Hospital, A Major Trauma Centre

Introduction

In April 2017, The Royal Sussex County Hospital introduced rib fracture scoring to help guide the management of rib fractures.

Rib fracture score = (number of fractures x number of sides) + age score1

In this study, we audit our adherence to the scoring system and compare our management of chest trauma before and after its implementation.

Method

All admissions with rib fractures between 1/10/2016- 28/02/2017 (N = 35) and 1/10/2019- 31/01/2020 (N = 41) were recorded. Electronic and written notes were used to retrospectively record multidisciplinary care involvement, analgesics, chest infection and death.

Results

The pre-intervention cohort had an average age of 55.1 years and rib score of 8.8. The post intervention cohort had an average age of 67.2 years and score of 11.3. Following implementation, 45% of patients had a rib score recorded. Post-intervention, anaesthetic involvement increased by 34.5% and 15.4% more patients received a regional block. Inpatient nights fell from 11.2 to 10.1, mortality rate from 7% to 4% but the incidence of chest infection remained similar.

Conclusions

The implementation of a rib fracture scoring system has led to greater multidisciplinary care and higher levels of pain management. A larger study is required to assess patient outcome given the change in sample population over time.

The development and testing of a novel Cognitive Behavioural Therapy (CBT)-based intervention to support medicines-related consultations for healthcare professionals

Introduction

The cost to healthcare of wasted medicines has been estimated at around £300million per annum (1). In response to this figure and efforts to increase medicines management performance across pharmacy and patient outcomes, the practice of ‘medicines optimisation’ has developed into a key aspect of patient care. In particular, concerns exist around whether patients are deriving the optimum benefit from their medications and the extent to which adherence ‘drops off’ at varying intervals after prescription and collection.

In order to tackle medicines adherence and waste, a multi-disciplinary approach must be applied to ensure patients who are prescribed a new medicine take it as intended, experience no problems and receive as much information as they feel they need from healthcare professionals (HCP’s). Adapting Cognitive Behavioural Therapy (CBT)-based techniques to medicines-related consultations has proven effective in supporting medicines adherence in previous studies (2). Collectively, findings demonstrate scope for improving the way HCP’s communicate with patients around starting a new medication and monitoring ongoing use.

Aim

The study aim was to adapt an existing, Royal College of General Practitioners accredited ’10-minute CBT’ training package to be suitable for wider use by a range of healthcare professionals (HCP’s) (i.e. Practice Nurses, Community Pharmacists, Hospital Pharmacists and General Practitioners).

Methods

The research design adopted a repeated-measures, pre/ post questionnaire study that gathered data on HCP knowledge around the use of CBT-based techniques in consultations at the start and end of the training intervention. Two training days were attended by HCP’s that took place three weeks apart. The degree of satisfaction with the training intervention was assessed, along with a formulation exercise that was completed on a hypothetical patient case study pre- and post-training.

Results

Training of healthcare professionals took place at the Oxford Science Park and 105 NHS staff members participated. Feedback questionnaires were received by 96 HCP’s and 46 HCP’s provided additional follow-up questionnaires at 6-months, demonstrating favourable results regarding intervention content and delivery that were consistent with a prior feasibility study. Paired samples t-tests were performed on each formulation exercise rating scale domain and for total scores. There was a highly statistically significant increase in scores for all domains including total pre- and post-training scores as measured by the Formulation Rating Scale. Intra-class Correlation Coefficient for mean FRS ratings was 0.99 (p=.000) and there was no statistically significant change in any score when attendees repeated the skills assessment at 6 months, indicating once learning had been incorporated into practice, there was no recognisable training degradation over the 6-month period. See Table 1.

Conclusion

The training intervention was rated favourably by attendees and was reported by participants as providing a safe environment from which to increase knowledge of CBT-based techniques, practice implementation of formulation skills and access additional peer support to help integrate learning into medicines-related consultations. The study also demonstrates this group of HCP’s were able to integrate CBT-based techniques into hypothetical medicines-related scenarios and that learning was retained over a six-month period following training intervention.

References

1. York Health Economics Consortium and the School of Pharmacy, University of London. Evaluation of the Scale, Causes and Costs of Waste Medicines. 2010. http://php.york.ac.uk/inst/yhec/web/news/documents/Evaluation_of_NHS_Medicines_Waste_Nov_2010.pdf

2. Easthall C, Song F, Bhattacharya D. A meta-analysis of cognitive-based behaviour change techniques as interventions to improve medication Adherence. BMJ Open 2013;3:e002749.

Canadian perspective on managing multiple myeloma during the COVID-19 pandemic: lessons learned and future considerations

The coronavirus disease 2019 (covid-19) pandemic caused by the novel severe acute respiratory syndrome coronavirus 2 has necessitated changes to the way patients with chronic diseases are managed. Given that patients with multiple myeloma are at increased risk of covid-19 infection and related complications, national bodies and experts around the globe have made recommendations for risk mitigation strategies for those vulnerable patients. Understandably, because of the novelty of the virus, many of the proposed risk mitigation strategies have thus far been reactionary and cannot be supported by strong evidence. In this editorial, we highlight some of the risk mitigation strategies implemented at our institutions across Canada during the first wave of covid-19, and we discuss the considerations that should be made when managing patients during the second wave and beyond.

Phytophthora acaciivora sp. nov. associated with dying Acacia mangium in Vietnam

Acacia mangium plantations account for more than 50 % of the exotic plantations in Vietnam. A new black butt symptom was discovered in 2012, followed by the wilting sign in Acacia seedlings in Tuyen Quang Province. Isolations recovered two Phytophthora species, the well-known Acacia pathogen P. cinnamomi, and an unknown species. The new species is described here as Phytophthora acaciivora sp. nov. Phylogenetically this species resides in clade 2d and is most closely related to P. frigida. Phytophthora acaciivora is a heterothallic species, oospores are aplerotic and antheridia are amphigynous. It produces predominantly elongated ovoid, semi papillate, persistent sporangia, no hyphal swellings and no chlamydospores. Optimum temperature for the growth is 25-30 °C and the maximum temperature is over 37.5 °C. Studies are underway to determine the impact of this new species on Acacia plantations in Vietnam.

Heparin resistance in COVID-19 patients in the intensive care unit

Patients with COVID-19 have a coagulopathy and high thrombotic risk. In a cohort of 69 intensive care unit (ICU) patients we investigated for evidence of heparin resistance in those that have received therapeutic anticoagulation. 15 of the patients have received therapeutic anticoagulation with either unfractionated heparin (UFH) or low molecular weight heparin (LMWH), of which full information was available on 14 patients. Heparin resistance to UFH was documented in 8/10 (80%) patients and sub-optimal peak anti-Xa following therapeutic LMWH in 5/5 (100%) patients where this was measured (some patients received both anticoagulants sequentially). Spiking plasma from 12 COVID-19 ICU patient samples demonstrated decreased in-vitro recovery of anti-Xa compared to normal pooled plasma. In conclusion, we have found evidence of heparin resistance in critically unwell COVID-19 patients. Further studies investigating this are required to determine the optimal thromboprophylaxis in COVID-19 and management of thrombotic episodes.

FRI0514 USE OF OPIATE FOR HIP AND KNEE OSTEOARTHRITIS BEFORE AND AFTER JOINT REPLACEMENT SURGERY

Background:

Osteoarthritis of the hip and knee is one of the most common causes of reduced mobility. It also causes stiffness and pain. Opioids can offer pain relief but is usually used for severe acute pain caused by major trauma or surgery. The use of opioids for relief of chronic pain caused by arthritis has increased over the last few decades.[1]

Objectives:

This study aims to investigate the use of strong opiates for patients with hip and knee osteoarthritis before and after joint replacement surgery, over a 13 years period in New Zealand.

Methods:

This study included patients with osteoarthritis who underwent publicly funded primary hip and knee replacement surgeries in 2005-2017 in New Zealand. These records were identified from the National Minimum Dataset (NMD). They were cross referenced with the NZJR data to exclude the admissions not for primary hip or knee replacement surgeries. Patients without a diagnosis of osteoarthritis were excluded.

The PHARMS dataset was linked to the NMD to identify the use of strong opiates before and after surgeries. The strong opiates available for community dispensing in New Zealand and included in this study are: dihydrocodeine, fentanyl, methadone, morphine, oxycodone and pethidine. Use of opiate within three months prior to surgery and within 12 months post-surgery were examined by gender, age group, ethnicity, Charlson Comorbidity Index score and year of surgery. Differences by subgroup was examined with Chi- square test. Logistic regression model was used to calculate the adjusted odds ratios of strong opiate use before and after surgery compared with no opiate use.

Results:

We identified 53,439 primary hip replacements and 50,072 primary knee replacements with a diagnosis of osteoarthritis. Of patients with hip osteoarthritis, 6,251 (11.7%) had strong opiate before hip replacement surgeries and 11,939 (22.3%) had opiate after surgeries. Of patients with knee osteoarthritis, 2,922 (5.8%) had strong opiate before knee replacement surgeries and 15,252 (30.5%) had opiate after surgeries.

The probability of patients with hip and knee osteoarthritis having opiate decreased with age, increased with Charlson comorbidity index score, and increased over time both before and after surgeries. Male patients with hip and knee osteoarthritis were less likely to have opiate than female patients both before and after surgeries. New Zealand Europeans with hip and knee osteoarthritis were more likely to receive opiate than other ethnic groups prior to surgeries, but were less likely to have opiate than Asians post-surgeries.

Patients who had opiate before surgeries were more likely to have opiate after surgeries than those who did not have opiate before surgeries. The odds ratio was 8.34 (95% confidence interval (CI): 7.87-8.84) for hip osteoarthritis and 11.94 (95% CI: 10.84-13.16) for knee osteoarthritis after adjustment for age, gender, ethnicity, year of surgery and Charlson comorbidity index score. Having opiate prior to surgeries also increased the probability of having opiate for 6 weeks or more after surgeries substantially. The adjusted odds ratio was 21.46 (95% CI: 19.74-23.31) for hip osteoarthritis and 27.22 (95% CI: 24.95-29.68) for knee osteoarthritis.

Conclusion:

Preoperative opiate holidays should be encouraged. Multiple strategies need to be used to develop analgesic plans that allow adequate rehabilitation, without precipitating a chronic opiate dependence. Clinicians would also benefit from clear guidelines for prescribing strong opiates.

References:

[1] Nguyen, L.C., D.C. Sing, and K.J. Bozic,Preoperative Reduction of Opioid Use Before Total Joint Arthroplasty.J Arthroplasty, 2016.31(9 Suppl): p. 282-7.

Disclosure of Interests:

None declared

The two-week rule colorectal cancer pathway: an update on recent practice, the unsustainable burden on diagnostics and the role of faecal immunochemical testing

INTRODUCTION

Survival for colorectal cancer is improved by earlier detection. Rapid assessment and diagnostic demand have created a surge in two-week rule referrals and have subsequently placed a greater burden on endoscopy services. Between 2009 and 2014, a mean of 709 patients annually were referred to Royal Surrey County Hospital with a detection rate of 53 cancers per year giving a positive predictive value for these patients of 7.5%. We aimed to assess what impact the 2015 changes in National Institute for Health and Care Excellence referral criteria had on local cancer detection rate and endoscopy services.

METHODS

A prospectively maintained database of patients referred under the two-week rule pathway for April 2017-2018 was sub-analysed and the data cross-referenced with all diagnostic reports.

FINDINGS

There were 1,414 referrals, which is double the number of previous years; 80.6% underwent endoscopy as primary investigation and 62 cancers were identified, 51 being of colorectal and anal origin (positive predictive value 3.6%). A total of 88 patients were diagnosed, with other significant colorectal disease defined as high-risk adenomas, colitis and benign ulcers. Overall, a total of 10.6% of our two-week rule patients had a significant finding.Since the 2015 referral criteria, despite a dramatic rise in two-week rule referrals, there has been no increase in cancer detection. It has placed significant pressure on diagnostic services. This highlights the need for a less invasive, cheaper yet sensitive test to rule out cancer such as faecal immunochemical testing that can enable clinicians to triage and reduce referral to endoscopy in symptomatic patients.

Effects of additional dosage of vitamin D3, vitamin D2, and 25-hydroxyvitamin D3 on calcium and phosphorus utilization, egg quality and bone mineralization in laying hens

Vitamin D is essential for the metabolism of calcium (Ca) and phosphorus (P) in birds. The objective of the study was to evaluate the effect of different isoforms of dietary vitamin D on Ca and P utilization, egg quality, and bone mineralization of laying hens. A total of 42 Lohmann white laying hens at 57 wk of age were randomly assigned to 7 dietary treatments for 6 wk. Dietary treatments were: 3,000 IU/kg Vit D₃ as control, and control with additional 3,000 IU/kg 25-hydroxyvitamin D₃ (T1), 9,000 IU/kg 25-hydroxyvitamin D₃ (T2), 3,000 IU/kg vitamin D3 (T3), 9,000 IU/kg vitamin D₃ (T4), 3,000 IU/kg of vitamin D₂ (T5), or 9,000 IU/kg of vitamin D₂ (T6). Egg production and egg quality were measured weekly. Fecal samples were collected at weeks 2 and 6 to measure Ca and P utilization. After 6 wk, the left tibia and femurs were collected to measure bone mineral density (BMD) and bone mineral content (BMC). A 1-way ANOVA with Tukey HSD means separation test was used for statistical analysis. There were no significant differences in egg production, egg quality, BMD, or BMC of tibia and femurs among the treatments (P > 0.05). T6 significantly reduced feed intake (P < 0.05). The apparent total tract digestibility (ATTD) of Ca was higher (P < 0.012) in treatments supplemented with additional vitamin D, irrespective of forms. The ATTD of P was higher (P < 0.0001) in T5 compared to the other treatments at both time points. The utilization of Ca and P by laying hens can be improved through the addition of different isoforms of vitamin D in diets. However, additional vitamin D supplementation to laying hens, regardless of forms, had no effect on either bone mineralization or measures of egg quality.

Post-exercise hypotension and skeletal muscle oxygenation is regulated by nitrate-reducing activity of oral bacteria

Post-exercise hypotension (PEH) is a common physiological phenomenon leading to lower blood pressure after acute exercise, but it is not fully understood how this intriguing response occurs. This study investigated whether the nitrate-reducing activity of oral bacteria is a key mechanism to trigger PEH. Following a randomized, double blind and crossover design, twenty-three healthy individuals (15 males/8 females) completed two treadmill trials at moderate intensity. After exercise, participants rinsed their mouth with antibacterial mouthwash to inhibit the activity of oral bacteria or a placebo mouthwash. Blood pressure was measured before, 1h and 2 h after exercise. The microvascular response to a reactive hyperaemia test, as well as blood and salivary samples were taken before and 2 h after exercise to analyse nitrate and nitrite concentrations and the oral microbiome. As expected, systolic blood pressure (SBP) was lower (1 h: -5.2 ± 1.0 mmHg; P < 0.001); 2 h: -3.8 ± 1.1 mmHg, P = 0.005) after exercise compared to baseline in the placebo condition. This was accompanied by an increase of circulatory nitrite 2 h after exercise (2h: 100 ± 13 nM) compared to baseline (59 ± 9 nM; P = 0.013). Additionally, an increase in the peak of the tissue oxygenation index (TOI) during the reactive hyperaemia response was observed after exercise (86.1 ± 0.6%) compared to baseline levels (84.8 ± 0.5%; P = 0.010) in the placebo condition. On the other hand, the SBP-lowering effect of exercise was attenuated by 61% at 1 h in the recovery period, and it was fully attenuated 2 h after exercise with antibacterial mouthwash. This was associated with a lack of changes in circulatory nitrite (P > 0.05), and impaired microvascular response (peak TOI baseline: 85.1 ± 3.1%; peak TOI post-exercise: 84.6 ± 3.2%; P > 0.05). Diversity of oral bacteria did not change after exercise in any treatment. These findings show that nitrite synthesis by oral commensal bacteria is a key mechanism to induce the vascular response to exercise over the first period of recovery thereby promoting lower blood pressure and greater muscle oxygenation.

The rate of bone loss slows after 1-2 years of initial antiretroviral therapy: final results of the Strategic Timing of Antiretroviral Therapy (START) bone mineral density substudy

OBJECTIVES

Initial antiretroviral therapy (ART) causes loss of bone mineral density (BMD) over the first 1-2 years. Whether this loss continues with longer therapy is unclear. We determined changes in bone and spine BMD over 5 years in adults receiving immediate or deferred initial ART.

METHODS

In the Strategic Timing of Antiretroviral Therapy (START) BMD substudy, ART-naïve adults with CD4 counts > 500 cells/μL were randomized to immediate or deferred ART. Deferred group participants not yet on ART were offered ART after May 2015. Mean per cent changes in total hip and lumbar spine BMD (measured annually by dual-energy X-ray absorptiometry) were compared between groups using longitudinal mixed models. Fracture rates were also compared between groups for all START participants.

RESULTS

Substudy participants (immediate group, n = 201; deferred group, n = 210; median age 32 years; 80% non-white; 24% female) were followed for a mean 4.5 years until December 2016. In the immediate group, > 96% used ART throughout. In the deferred group, 16%, 58% and 94% used ART at years 1, 3 and 5, respectively. BMD decreased more in the immediate group initially; groups had converged by year 3 at the spine and year 4 at the hip by intent-to-treat (ITT). BMD changes after year 1 were similar in the immediate group and in those off ART in the deferred group [mean difference: spine, 0.03% per year; 95% confidence interval (CI) -0.4, 0.4; P = 0.88; hip, -0.2% per year; 95% CI -0.7, 0.3; P = 0.37]. Fracture incidence did not differ significantly between groups (immediate group, 0.86/100 person-years versus deferred group, 0.85/100 person-years; hazard ratio 1.01; 95% CI 0.76, 1.35; P = 0.98).

CONCLUSIONS

Significant ART-induced bone loss slowed after the first year of ART and became similar to that in untreated HIV infection.

Updates from the 2019 American Society of Clinical Oncology and European Hematology Association annual meetings: a Canadian perspective on high-risk cytogenetics in multiple myeloma

The 2019 annual meetings of the American Society of Clinical Oncology and the European Hematology Association took place, respectively, in Chicago, Illinois, 31 May-4 June, and in Amsterdam, Netherlands, 13-16 June. At the meetings, results from key studies on the treatment of patients with relapsed or refractory multiple myeloma with high-risk cytogenetics were presented. Our meeting report describes those studies and includes interviews with investigators and commentaries by Canadian hematologists about the potential impact on Canadian practice.

Exercise prehabilitation may lead to augmented tumor regression following neoadjuvant chemoradiotherapy in locally advanced rectal cancer

  Purpose: We evaluate the effect of an exercised prehabilitation programme on tumour response in rectal cancer patients following neoadjuvant chemoradiotherapy (NACRT). Patients and Methods: Rectal cancer patients with (MRI-defined) threatened resection margins who completed standardized NACRT were prospectively studied in a post hoc, explorative analysis of two previously reported clinical trials. MRI was performed at Weeks 9 and 14 post-NACRT, with surgery at Week 15. Patients undertook a 6-week preoperative exercise-training programme. Oxygen uptake (VO2) at anaerobic threshold (AT) wasmeasured at baseline (pre-NACRT), after completion of NACRT and at week 6 (post-NACRT). Tumour related outcome variables: MRI tumour regression grading (ymrTRG) at Week 9 and 14; histopathological T-stage (ypT); and tumour regression grading (ypTRG)) were compared. Results: 35 patients (26 males) were recruited. 26 patients undertook tailored exercise-training with 9 unmatched controls. NACRT resulted in a fall in VO2 at AT -2.0 ml/kg^-1/min^-1(-1.3,-2.6), p < 0.001. Exercise was shown to reverse this effect. VO2 at AT increased between groups, (post-NACRT vs. week 6) by +1.9 ml/kg^-1/min^-1(0.6, 3.2), p = 0.007. A significantly greater ypTRG in the exercise group at the time of surgery was found (p = 0.02). Conclusion: Following completion of NACRT, exercise resulted in significant improvements in fitness and augmented pathological tumour regression.

New species from Phytophthora Clade 6a: evidence for recent radiation

During routine vegetation health surveys in the southwest of Western Australia (SWWA), several Phytophthora isolates with affinity to Clade 6a have been recovered. In this study, all known taxa from Clade 6a, P. inundata, P. humicola, P. gemini, P. 'walnut' and P. 'personii', and the new isolates were compared based on morphology and DNA sequence data from three nuclear genes and two mitochondrial genes resulting in the description of five new species, P. balyanboodja, P. condilina, P. cooljarloo, P. kwongonina and P. pseudorosacearum. With the exception of P. gemini and P. humicola, all species from Clade 6a have been recovered from natural ecosystems in SWWA. These species are morphologically similar, with predominantly ovoid sporangia and nested and extended internal proliferation. If oospores are present, they tend to be aplerotic with paragynous antheridia mostly attached adjacent to the oogonial stalk. They can all grow at 35 °C and have a fast growth rate on most agar media. These species have all been recovered from the rhizosphere soil and dead and dying plants within dry kwongon heathlands, often from water gaining sites and frequently from very isolated areas. The radiation, origin and potential ecological role of these species are discussed.

Validity of code based algorithms to identify primary open angle glaucoma (POAG) in Veterans Affairs (VA) administrative databases

PURPOSE

The validity of the International Classification of Diseases, 9th revision, Clinical Modification (ICD-9) code for primary open angle glaucoma (POAG) in the Department of Veterans Affairs (VA) electronic medical record has not been examined. We determined the accuracy of the ICD-9 code for POAG and developed diagnostic algorithms for the detection of POAG.

METHODS

We conducted a retrospective study of abstracted data from the Michael E. DeBakey VA Medical Center's medical records of 334 unique patients with at least one visit to the Eye Clinic between 1999 and 2013. Algorithms were developed to validly identify POAG using ICD-9 codes and pharmacy data. The positive predictive value (PPV), negative predictive value (NPV), sensitivity, specificity and percent agreement of the various algorithms were calculated.

RESULTS

For the ICD-9 code 365.1x, the PPV was 65.9%, NPV was 95.2%, sensitivity was 100%, specificity was 82.6%, and percent agreement was 87.8%. The algorithm with the highest PPV was 76.3%, using pharmacy data in conjunction with two or more ICD-9 codes for POAG, but this algorithm also had the lowest NPV at 88.2%.

CONCLUSIONS

Various algorithms for identifying POAG in the VA administrative databases have variable validity. Depending on the type of research being done, the ICD-9 code 365.1x can be used for epidemiologic or health services database research.

The safety and efficacy of benzbromarone in gout in Aotearoa New Zealand

BACKGROUND

Benzbromarone is a potent uricosuric but is not widely available due to concerns about hepatotoxicity. In Aotearoa New Zealand, benzbromarone has been available since April 2013, subject to funding restrictions, for patients with inadequate urate-lowering response or intolerance to allopurinol and probenecid.

AIM

To assess the safety and efficacy of benzbromarone in a real-life setting.

METHODS

All patients who received funding for benzbromarone from 1 April 2013 to 30 September 2014 were identified. Prescribers were sent a questionnaire for each individual. Information on demographics, efficacy of previous urate-lowering drugs and reasons for discontinuation were collected. Specific information about the dose, effect on serum urate, adverse effects and liver function tests after commencing benzbromarone was recorded.

RESULTS

Completed questionnaires were returned for 123 of 164 (75%) patients. Mean (SD) serum urate prior to benzbromarone was 0.57 (0.12) mmol/L, and estimated glomerular filtration rate was 50.3 (22.8) mL/min/1.73 m(2) . The median dose of benzbromarone was 100 mg/day (25-200 mg/day). Six months after commencing benzbromarone, mean (SD) serum urate was 0.35 (0.12) mmol/L. Benzbromarone-related adverse events included rash (n = 4), diarrhoea (n = 9), nausea (n = 6) and urate stones (n = 3). Liver function test abnormalities were uncommon and tended to be mild. There were 14 patient deaths; none was considered related to benzbromarone. Allopurinol had been prescribed prior to benzbromarone in 117 of 123 patients; median maximum allopurinol dose was 200 mg/day (range 25-600 mg/day), and 19% patients received allopurinol >300 mg/day.

CONCLUSION

Benzbromarone provides useful urate-lowering efficacy and does not appear unsafe in patients with gout. Urate-lowering therapy prescribing requires further optimisation.

Characteristics of children undergoing dental extractions under general anaesthesia in Wolverhampton: 2007-2012

INTRODUCTION

Studying characteristics of children requiring extractions under dental general anaesthesia (DGA) can help identify trends, which can be used to facilitate future planning of healthcare services.

OBJECTIVE

To report on the profile of children who underwent extractions under DGA between 2007 and 2012 at the New Cross Hospital in Wolverhampton, England.Methods Retrospective analyses of hospital records.

RESULTS

Of the 2692 patients seen between 2007 and 2012, 49.6% were boys and 50.4% were girls. The mean age was 7.1 and 7 to 12 years was the largest age group (43%). The majority of the sample was White British (67%). Of the 8,286 teeth extracted, 85% were primary teeth and 15% permanent. More teeth were extracted in boys than girls (P = 0.002) and 'Other' ethnicities had a higher mean number of extractions compared to White British (P <0.001) and South Asians (P = 0.046). The mean age of the patients has decreased over the years (P = 0.001) and the mean number of primary teeth extracted has increased (P = 0.001).

CONCLUSIONS

A clear dental public health issue has been reinforced through the relatively high level of DGA activity reported. Though rigorous caries prevention remains the ultimate goal, a better assessment and discharge process may help reduce the need for first time DGAs as well as repeats.

Hydrochemical profiles in urban groundwater systems: New insights into contaminant sources and pathways in the subsurface from legacy and emerging contaminants

It has long been known that groundwaters beneath urban areas carry a fingerprint from urban activities but finding a consistent tracer for anthropogenic influence has proved elusive. The varied sources of urban contaminants means that a single consistent and inexpensive means of tracing the fate of urban contaminants is not generally possible and multiple tracers are often required to understand the contaminant sources and pathways in these complex systems. This study has utilized a combination of micro-organic (MO) contaminants and inorganic hydrochemistry to trace recharge pathways and quantify the variability of groundwater quality in multi-level piezometers in the city of Doncaster, UK. A total of 23 MOs were detected during this study, with more compounds consistently detected during higher groundwater table conditions highlighting the importance of sampling under different hydrological conditions. Four of the compounds detected are EU Water Framework Directive priority substances: atrazine, simazine, naphthalene and DEHP, with a maximum concentration of 0.18, 0.03, 0.2, 16μg/l respectively. Our study shows that the burden of the banned pesticide atrazine persists in the Sherwood Sandstone and is detected at two of the three study sites. Emerging contaminants are seen throughout the borehole profiles and provide insights into transient pathways for contaminant migration in the sub-surface. Long term changes in inorganic hydrochemistry show possible changes in contaminant input or the dissolution of minerals. Nitrate was detected above 50mg/l but on the whole nitrate concentrations have declined in the intervening years either due to a reduction of nitrate application at the surface or a migration of peak nitrate concentrations laterally or to greater depth. This study shows that multiple tracers together with multi-level piezometers can give a better resolution of contaminant pathways and variable flow regimes within the relatively uncomplicated aquifer of the Sherwood Sandstone compared with single long screened wells.