CURE on yeast genes of unknown function increases students' bioinformatics proficiency and research confidence

Course-based undergraduate research experiences (CUREs) can reduce barriers to research opportunities while increasing student knowledge and confidence. However, the number of widely adopted, easily transferable CUREs is relatively small. Here, we describe a CURE aimed at determining the function of poorly characterized Saccharomyces cerevisiae genes. More than 20 years after sequencing of the yeast genome, nearly 10% of open reading frames (ORFs) still have at least one uncharacterized Gene Ontology (GO) term. We refer to these genes as "ORFans" and formed a consortium aimed at assigning functions to them. Specifically, over 70 faculty members attended summer workshops to learn the bioinformatics workflow and basic laboratory techniques described herein. Ultimately, this CURE was adapted for implementation at 34 institutions, resulting in over 1,300 students conducting course-based research on ORFans. Pre-/post-tests confirmed that students gained both (i) an understanding of gene ontology and (ii) knowledge regarding the use of bioinformatics to assign gene function. After using these data to craft their own hypotheses, then testing their predictions by constructing and phenotyping deletion strains, students self-reported significant gains in several areas, including computer modeling and exposure to a project where no one knows the outcome. Interestingly, most net gains self-reported by ORFan Gene Project participants were greater than published findings for CUREs assessed with the same survey instrument. The surprisingly strong impact of this CURE may be due to the incoming lack of experience of ORFan Project participants and/or the independent thought required to develop testable hypotheses from complex data sets.

Dryland rock detention structures increase herbaceous vegetation cover and stabilize shrub cover over 10 years but do not directly affect soil fertility

Rock detention structures (RDS) such as check dams, gabions, and one rock dams are commonly used to mitigate erosion impacts in dryland ephemeral stream channels. RDS increase local water infiltration and floodplain connectivity, reduce sediment transport, and enhance vegetation growth and establishment. In addition to increasing overall vegetation cover, RDS may also buffer against a cycle of vegetation growth and collapse during years of extremely variable precipitation, helping to maintain stable cover. Although widely employed by land managers, success as reported in scientific literature varies, especially with regard to RDS effects on vegetation and soil fertility. We present the results of a 10-year field experiment in southeastern Arizona, USA, designed in collaboration with local land practitioners to measure local in-channel effects of RDS. Over 10 years, cover of herbaceous vegetation (forbs and grasses) doubled from 11 % to 22 % in channels treated with RDS, but did not significantly increase in untreated control channels. Shrub cover in treated channels was significantly less variable than in control channels over time. We analyzed the complex relationships between RDS, vegetation cover, and soil fertility using structural equation modeling (SEM), which represented conditions of the tenth year alone. SEM revealed that RDS did not directly affect soil fertility, as measured by total soil nitrogen, total soil carbon, soil organic matter, microbial richness, and potential nutrient cycling capacity. Notably, SEM did not yield the same trends as temporal monitoring, possibly because our structural equation models could not capture change over time. This discrepancy highlights the need for long-term, frequent monitoring of aboveground and belowground conditions to evaluate treatment success on a management scale. Overall, installing rock detention structures in ephemeral channels in arid and semiarid regions is a low-cost, feasible way to increase channel sediment aggradation, forb, and grass cover; stabilize shrub cover; and combat dryland degradation.

Primary data on symptom burden and quality of life among elderly patients at risk of dying during unplanned admissions to an NHS hospital: a cohort study using EuroQoL and the integrated palliative care outcome scale

BACKGROUND

Older people account heavily for palliative care needs at the population level and are growing in number as the population ages. There is relatively little high-quality data on symptom burden and quality of life, since these data are not routinely collected, and this group are under-recruited in primary research. It is unclear which measurement tools are best suited to capture burdens and experience.

METHODS

We recruited a cohort of 221 patients aged 75 + years with poor prognosis who had an unplanned admission via the emergency department in a large urban hospital in England between 2019 and 2020. Risk of dying was assessed using the CriSTAL tool. We collected primary data and combined these with routine health records. Baseline clinical data and patient reported quality of life outcomes were collected on admission and reassessed within the first 72 h of presentation using two established tools: EQ-5D-5 L, EQ-VAS and the Integrated Palliative Outcomes Scale (IPOS).

RESULTS

Completion rate was 68% (n = 151) and 33.1% were known to have died during admission or within 6 months post-discharge. The vast majority (84.8%) reported severe difficulties with at least one dimension of EQ-5D-5 L at baseline and improvements in EQ-VAS observed at reassessment in 51.7%. The baseline IPOS revealed 78.2% of patients rating seven or more items as moderate, severe or overwhelming, but a significant reduction (-3.6, p < 0.001) in overall physical symptom severity and prevalence was also apparent. No significant differences were noted in emotional symptoms or changes in communication/practical issues. IPOS total score at follow up was positively associated with age, having comorbidities (Charlson index score > = 1) and negatively associated with baseline IPOS and CriSTAL scores.

CONCLUSION

Older people with poor prognosis admitted to hospital have very high symptom burden compared to population norms, though some improvement following assessment was observed on all measures. These data provide valuable descriptive information on quality of life among a priority population in practice and policy and can be used in future research to identify suitable interventions and model their effects.

Achievement of Target Gain Larger than Unity in an Inertial Fusion Experiment

On December 5, 2022, an indirect drive fusion implosion on the National Ignition Facility (NIF) achieved a target gain G_{target} of 1.5. This is the first laboratory demonstration of exceeding "scientific breakeven" (or G_{target}>1) where 2.05 MJ of 351 nm laser light produced 3.1 MJ of total fusion yield, a result which significantly exceeds the Lawson criterion for fusion ignition as reported in a previous NIF implosion [H. Abu-Shawareb et al. (Indirect Drive ICF Collaboration), Phys. Rev. Lett. 129, 075001 (2022)PRLTAO0031-900710.1103/PhysRevLett.129.075001]. This achievement is the culmination of more than five decades of research and gives proof that laboratory fusion, based on fundamental physics principles, is possible. This Letter reports on the target, laser, design, and experimental advancements that led to this result.

Ecology of End-of-life Medical Care for Advanced Cancer Patients in China

AIMS

Cancer is a leading cause of death worldwide. Approximately 30% of global cancer-related deaths occur in mainland China. However, there is a paucity of information regarding the end-of-life care-seeking behavior of patients with advanced cancer in China. Our study was to investigate end-of-life care-seeking behavior and to quantify the association between sociodemographic characteristics and the location and pattern of end-of-life care.

METHODS

We conducted a mortality follow-back survey using caregivers' interviews to estimate the number of individuals pre 1000 who died between 2013 and 2021 in the last 3 months of life. We collected data on hospitalization, outpatient visits, cardiopulmonary resuscitation, palliative care and hospice utilization, and place of death, stratified by age, gender, marital status, household income, residential zone, insurance type, and the primary end-of-life decision-maker of the decedents.

RESULTS

We analyzed data from 857 deceased cancer patients, representing an average of 1000 individuals. Among these patients, 861 experienced at least moderate or more severe pain, 774 were hospitalized at least once, 468 received intensive treatment, 389 had at least one outpatient visit, 270 died in the hospital, 236 received cardiopulmonary resuscitation and 99 received specialist hospice care.

CONCLUSIONS

Our study provides insights into the end-of-life care-seeking behavior of advanced cancer patients in China and our findings serve as a useful benchmark for estimating the use of end-of-life medical care. It highlights the need for the establishment of an accessible and patient-centered palliative care and hospice system.

Risk Factors Associated with Development of Peritumoral Edema Following Stereotactic Radiosurgery and Radiotherapy for Intracranial Meningioma

PURPOSE/OBJECTIVE(S)

Peritumoral edema (PTE) is a potential adverse effect following radiotherapy for intracranial meningioma. The purpose of this study is to identify which baseline factors may increase risk for PTE.

MATERIALS/METHODS

A retrospective chart review was conducted of 431 patients who underwent primary radiotherapy to 480 radiographically-defined intracranial meningiomas between January 2008 and December 2021 within an integrated health care system. Patients with prior surgical management were excluded. Patients were treated with frameless LINAC-based image-guided single fraction stereotactic radiosurgery (SRS) (32.9%), 5 fraction SRS (FSRS) (30.8%), or fractionated stereotactic radiotherapy (FSRT) (36.3%). Pre- and post-radiotherapy MRI studies were reviewed to evaluate for PTE following treatment. An event was defined as new or worsening PTE compared to pre-radiotherapy imaging or development of new symptoms post-radiotherapy. Univariate and stepwise logistics regression analyses were performed to compare the risk of PTE between groups.

RESULTS

Median follow-up was 85.8 months (IQR: 49.4-125.4). Median patient age was 66 years (IQR: 56-73). Patients treated with SRS (median age: 61 years) were younger than those treated with FSRS/FSRT (median age: 68 years) (p<0.001). Lesions treated with SRS (median volume: 1.33cc) were smaller than those treated with FSRS/FSRT (median volume: 6.36cc) (p<0.001). For all-comers, 68 (14.2%) lesions developed any PTE, and 27 (5.6%) developed symptomatic PTE (SPTE). Of these, 4 patients developed symptoms post-treatment without radiographic evidence of new or worsening PTE. Incidence of PTE/SPTE by site was as follows: base of skull (BOS): 10.3%/6.1%, convexity: 22.7%/7.6%, falcine: 17.6%/4.1%, parasagittal: 27.8%/8.3%, posterior fossa/tentorium 7.0%/0.0%. Incidence of PTE/SPTE by technique was as follows: SRS: 6.3%/3.8%, FSRS: 20.9%/7.4%, FSRT: 15.5%/5.7%. On univariate analysis, age >65 (OR = 2.17 (95% CI: 1.26-3.77) p = 0.006), tumor volume (OR = 1.05 (1.02-1.08), p = 0.003), pre-treatment PTE (OR = 6.82 (95% CI: 3.59-12.94) p<0.001), and convexity/falcine/parasagittal (CFPS) location (OR = 2.52 (95% CI: 1.49-4.23) p<0.001) were associated with increased incidence of PTE. On multivariate analysis, age >65 (OR = 1.91 (95% CI: 1.05-3.45) p<0.03), tumor volume (OR = 1.04 (95% CI: 1.00-1.08) p = 0.03), pre-treatment PTE (OR = 4.64 (95% CI: 2.33-9.24) p<0.001), and CFPS location (OR = 2.53 (95% CI: 1.41-4.52) p = 0.002) were associated with increased incidence of PTE. Two patients with PTE underwent resection for local failure which revealed atypical meningioma.

CONCLUSION

Age >65, larger tumor volume, presence of pre-treatment PTE, and CFPS location were associated with increased incidence of PTE following radiotherapy. Patients with these risk factors should be counseled regarding post-treatment effects. Infrequently, PTE following treatment may be an indicator of higher-grade meningioma.

Impact of Concurrent Targeted Therapy and Immunotherapy on the Incidence of Radiation Necrosis Following Stereotactic Radiosurgery for Brain Metastases

PURPOSE/OBJECTIVE(S)

The management of metastatic disease has evolved with the advent of immunotherapy (IT) and targeted therapies (TT). Yet, there is limited understanding of the toxicity associated with combining these agents with stereotactic radiosurgery (SRS). We retrospectively evaluated the impact of concurrent systemic therapy (ST) on the risk of radiation necrosis (RN) following LINAC-based SRS for brain metastases (BM).

MATERIALS/METHODS

A retrospective study was conducted within an integrated health care system from March 2017 to December 2021 of 313 patients who underwent SRS or fractionated SRS in 3 or 5 treatments to a total of 1,644 intact BM. Post-operative cavity SRS and re-irradiated lesions were excluded. RN was diagnosed using perfusion MRI, contrast clearance MRI, or serial standard MRI and graded using CTCAE (v.5). Concurrent ST was defined as administration within 1 month preceding or following SRS. Overall survival (OS) and risk of RN were estimated by the Kaplan-Meier method. Logistics regression analyses were performed to compare risk of RN in patients who received concurrent systemic therapy to those who did not, adjusted for PTV volume and receipt of whole brain radiotherapy (WBRT).

RESULTS

Median follow-up was 12.2 months. Median age was 64 years (range: 24-92). Primary sites per patient included lung (48.9%), breast (18.2%), melanoma (11.5%), kidney (6.1%), and other (15.3%). Median total lesions treated was 3 (range: 1-44); 65.9% of patients underwent 1 course of SRS, 23.4% underwent 2 courses, 6.2% underwent 3 courses, 4.5% underwent >4 courses. Seventy-six (24.2%) patients received WBRT. Overall, 70.6% of lesions received concurrent ST including chemotherapy (CT) (32.5%), IT (26.8%), and TT (27.6%); 16.4% received a combination of ST. Median OS was 12.9 months (95% CI: 10.4-15.5). RN was observed in 50 (3.0%) lesions in 42 (13.4%) patients. The 1-year risk of RN was 4.0% per lesion and 15.4% per patient. Symptomatic RN (SRN) was observed in 31 (1.9%) lesions in 24 (7.7%) patients. The 1-year risk of SRN was 2.7% per lesion and 10.1% per patient. When compared to lesions treated without concurrent systemic therapy, there was no increased risk of RN observed in lesions treated with concurrent CT (adjusted OR = 0.86 (95% CI: 0.43-1.73) p = 0.68), concurrent IT (adjusted OR = 0.84 (95% CI: 0.41-1.71) p = 0.84), or concurrent TT (adjusted OR = 0.57 (95% CI: 0.25-1.30) p = 0.18). Treatments of SRN included dexamethasone (96.8%), bevacizumab (22.6%), and laser interstitial thermal therapy (6.5%).

CONCLUSION

Concurrent IT and TT appears well-tolerated in patients who undergo SRS for treatment of BM. No increased risk of RN was observed in lesions treated with concurrent IT or TT compared to lesions treated in the absence of concurrent ST. Further prospective and agent-specific evaluation is necessary to confirm these findings.

Childhood-Onset Lupus Nephritis in the Childhood Arthritis and Rheumatology Research Alliance Registry: Short-Term Kidney Status and Variation in Care

OBJECTIVE

The goal was to characterize short-term kidney status and describe variation in early care utilization in a multicenter cohort of patients with childhood-onset systemic lupus erythematosus (cSLE) and nephritis.

METHODS

We analyzed previously collected prospective data from North American patients with cSLE with kidney biopsy-proven nephritis enrolled in the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry from March 2017 through December 2019. We determined the proportion of patients with abnormal kidney status at the most recent registry visit and applied generalized linear mixed models to identify associated factors. We also calculated frequency of medication use, both during induction and ever recorded.

RESULTS

We identified 222 patients with kidney biopsy-proven nephritis, with 64% class III/IV nephritis on initial biopsy. At the most recent registry visit at median (interquartile range) of 17 (8-29) months from initial kidney biopsy, 58 of 106 patients (55%) with available data had abnormal kidney status. This finding was associated with male sex (odds ratio [OR] 3.88, 95% confidence interval [95% CI] 1.21-12.46) and age at cSLE diagnosis (OR 1.23, 95% CI 1.01-1.49). Patients with class IV nephritis were more likely than class III to receive cyclophosphamide and rituximab during induction. There was substantial variation in mycophenolate, cyclophosphamide, and rituximab ever use patterns across rheumatology centers.

CONCLUSION

In this cohort with predominately class III/IV nephritis, male sex and older age at cSLE diagnosis were associated with abnormal short-term kidney status. We also observed substantial variation in contemporary medication use for pediatric lupus nephritis between pediatric rheumatology centers. Additional studies are needed to better understand the impact of this variation on long-term kidney outcomes.

Consumption of sugar-sweetened beverages and T2D diabetes in the Eastern Caribbean

OBJECTIVE

Sugar-sweetened beverages (SSB) are implicated in the increasing risk of diabetes in the Caribbean. Few studies have examined associations between SSB consumption and diabetes in the Caribbean.

DESIGN

SSB was measured as teaspoon/d using questions from the National Cancer Institute Dietary Screener Questionnaire about intake of soda, juice and coffee/tea during the past month. Diabetes was measured using self-report, HbA1C and use of medication. Logistic regression was used to examine associations.

SETTING

Baseline data from the Eastern Caribbean Health Outcomes Research Network Cohort Study (ECS), collected in Barbados, Puerto Rico, Trinidad and Tobago and US Virgin Islands, were used for analysis.

PARTICIPANTS

Participants (n 1701) enrolled in the ECS.

RESULTS

Thirty-six percentage of participants were unaware of their diabetes, 33% aware and 31% normoglycaemic. Total mean intake of added sugar from SSB was higher among persons 40-49 (9·4 tsp/d), men (9·2 tsp/d) and persons with low education (7·0 tsp/d). Participants who were unaware (7·4 tsp/d) or did not have diabetes (7·6 tsp/d) had higher mean SSB intake compared to those with known diabetes (5·6 tsp/d). In multivariate analysis, total added sugar from beverages was not significantly associated with diabetes status. Results by beverage type showed consumption of added sugar from soda was associated with greater odds of known (OR = 1·37, 95 % CI (1·03, 1·82)) and unknown diabetes (OR = 1·54, 95 % CI (1·12, 2·13)).

CONCLUSIONS

Findings indicate the need for continued implementation and evaluation of policies and interventions to reduce SSB consumption in the Caribbean.

Doom or Deliciousness: Challenges and Opportunities for Visualization in the Age of Generative Models

Generative text-to-image models (as exemplified by DALL-E, MidJourney, and Stable Diffusion) have recently made enormous technological leaps, demonstrating impressive results in many graphical domains-from logo design to digital painting to photographic composition. However, the quality of these results has led to existential crises in some fields of art, leading to questions about the role of human agency in the production of meaning in a graphical context. Such issues are central to visualization, and while these generative models have yet to be widely applied in visualization, it seems only a matter of time until their integration is manifest. Seeking to circumvent similar ponderous dilemmas, we attempt to understand the roles that generative models might play across visualization. We do so by constructing a framework that characterizes what these technologies offer at various stages of the visualization workflow, augmented and analyzed through semi-structured interviews with 21 experts from related domains. Through this work, we map the space of opportunities and risks that might arise in this intersection, identifying doomsday prophecies and delicious low-hanging fruits that are ripe for research.

The impact of thromboelastography on patients with penetrating abdominal trauma requiring intensive care

BACKGROUND

Trauma-induced coagulopathy (TIC) is a complex multifaceted process which contributes to higher mortality rates in severely injured trauma patients. Thromboelastography (TEG) is effective in detecting TIC which assists in instituting goal-directed therapy as part of damage control resuscitation.

METHODS

This retrospective study included all adult patients over a 36-month period with penetrating abdominal trauma who required a laparotomy, blood products and admission for critical care. Analysis included demographics, admission data, 24-hour interventions, TEG parameters and 30-day outcomes.

RESULTS

Eighty-four patients with a median age of 28 years were included. The majority (93%; 78/84) suffered from a gunshot injury, with 75% (63/84) receiving a damage control laparotomy. Forty-eight patients (57%) had a TEG. Injury severity score and total fluid and blood product administered in the first 24 hours were all significantly higher in patients who had a TEG (p < 0.05). TEG profiles were: 42% (20/48) normal, 42% (20/48) hypocoagulable, 12% (6/48) hypercoagulable and 4% (2/48) mixed parameters. Fibrinolysis profiles were: 48% (23/48) normal, 44% (21/48) fibrinolysis shutdown and 8% (4/48) hyperfibrinolysis. Mortality rate was 5% (4/84) at 24 hours and 26% (22/84) at 30 days, with no difference between the two groups. High-grade complication rates, days on a ventilator and intensive care unit length of stay were all significantly higher in patients who did not have a TEG.

CONCLUSION

TIC is common in severely injured penetrating trauma patients. The usage of a thromboelastogram did not impact on 24-hour or 30-day mortality but did result in a decreased intensive care stay and a decreased high-grade complication rate.

Classification of blood pressure during sleep impacts designation of nocturnal nondipping

The identification of nocturnal nondipping blood pressure (< 10% drop in mean systolic blood pressure from awake to sleep periods), as captured by ambulatory blood pressure monitoring, is a valuable element of risk prediction for cardiovascular disease, independent of daytime or clinic blood pressure measurements. However, capturing measurements, including determination of wake/sleep periods, is challenging. Accordingly, we sought to evaluate the impact of different definitions and algorithms for defining sleep onset on the classification of nocturnal nondipping. Using approaches based upon participant self-reports, applied definition of a common sleep period (12 am -6 am), manual actigraphy, and automated actigraphy we identified changes to the classification of nocturnal nondipping, and conducted a secondary analysis on the potential impact of an ambulatory blood pressure monitor on sleep. Among 61 participants in the Eastern Caribbean Health Outcomes Research Network hypertension study with complete ambulatory blood pressure monitor and sleep data, the concordance for nocturnal nondipping across methods was 0.54 by Fleiss' Kappa (depending on the method, 36 to 51 participants classified as having nocturnal nondipping). Sleep quality for participants with dipping versus nondipping was significantly different for total sleep length when wearing the ambulatory blood pressure monitor (shorter sleep duration) versus not (longer sleep duration), although there were no differences in sleep efficiency or disturbances. These findings indicate that consideration of sleep time measurements is critical for interpreting ambulatory blood pressure. As technology advances to detect blood pressure and sleep patterns, further investigation is needed to determine which method should be used for diagnosis, treatment, and future cardiovascular risk.

Shear bond strength of adhesive precoated brackets: A comparative in vitro study

OBJECTIVE

This study compared the shear bond strength of orthodontic precoated brackets from different manufacturers.

METHODS

Sixty extracted human premolar teeth were divided into six groups (n=10). The groups were bonded with one of the following brackets: 3M™ Unitek Victory™ Series™ with APC, 3M™ Unitek Clarity™ Advanced Ceramic™ with APC, TP Nu-Edge® NX Cobalt-Chromium and TP In-Vu® ceramic Readi-Base® both with eXact® orthodontic adhesive, 3M™ Unitek Clarity Advanced Ceramic™ and 3M™ Unitek Victory™ Series™ both with Transbond™ XT Adhesive. Each group was tested for shear bond strength using a universal testing machine. Each sample was observed under a dissecting microscope and received an adhesive remnant index (ARI) score. Statistical analysis was performed using Tukey's Standardized Range (HSD) Test to make comparisons among all groups and a Wilcoxon rank-sum test to evaluate for pairwise comparisons between the groups. The P-values<0.05 were considered significant.

RESULTS

The ceramic control was not statistically different from the metal control, 3M™ Victory™ APC™, TP In-Vu® ceramic eXact® or TP Nu-EDGE® eXact® in terms of shear bond strength (7.69±1.41MPa, 7.72±1.25MPa, 8.70±1.93MPa, 4.90±1.76MPa, 5.33±0.78MPa, respectively). However, it was statistically different from 3M™ Ceramic APC™ (10.29±2.78MPa). In terms of modulus, there were no statistical differences. TP's Nu-edge® had the lowest average ARI score, but was not statistically different when compared to the other groups.

CONCLUSION

3M™ Unitek's Ceramic APC had a statistically higher SBS than the non-precoated brackets and TP Orthodontics' precoated brackets. However, all SBS were 4.9 MPA or above, which is deemed clinically acceptable in terms of laboratory forces. There was no statistical difference between manufacturing companies or precoated vs. non-precoated modulus and ARI scores.

Transforming medical education in Liberia through an international community of inquiry

A critical component of building capacity in Liberia's physician workforce involves strengthening the country's only medical school, A.M. Dogliotti School of Medicine. Beginning in 2015, senior health sector stakeholders in Liberia invited faculty and staff from U.S. academic institutions and non-governmental organizations to partner with them on improving undergraduate medical education in Liberia. Over the subsequent six years, the members of this partnership came together through an iterative, mutual-learning process and created what William Torbert et al describe as a "community of inquiry," in which practitioners and researchers pair action and inquiry toward evidence-informed practice and organizational transformation. Incorporating faculty, practitioners, and students from Liberia and the U.S., the community of inquiry consistently focused on following the vision, goals, and priorities of leadership in Liberia, irrespective of funding source or institutional affiliation. The work of the community of inquiry has incorporated multiple mixed methods assessments, stakeholder discussions, strategic planning, and collaborative self-reflection, resulting in transformation of medical education in Liberia. We suggest that the community of inquiry approach reported here can serve as a model for others seeking to form sustainable global health partnerships focused on organizational transformation.

Intraarticular steroids as DMARD-sparing agents for juvenile idiopathic arthritis flares: Analysis of the Childhood Arthritis and Rheumatology Research Alliance Registry

BACKGROUND

Children with juvenile idiopathic arthritis (JIA) who achieve a drug free remission often experience a flare of their disease requiring either intraarticular steroids (IAS) or systemic treatment with disease modifying anti-rheumatic drugs (DMARDs). IAS offer an opportunity to recapture disease control and avoid exposure to side effects from systemic immunosuppression. We examined a cohort of patients treated with IAS after drug free remission and report the probability of restarting systemic treatment within 12 months.

METHODS

We analyzed a cohort of patients from the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry who received IAS for a flare after a period of drug free remission. Historical factors and clinical characteristics and of the patients including data obtained at the time of treatment were analyzed.

RESULTS

We identified 46 patients who met the inclusion criteria. Of those with follow up data available 49% had restarted systemic treatment 6 months after IAS injection and 70% had restarted systemic treatment at 12 months. The proportion of patients with prior use of a biologic DMARD was the only factor that differed between patients who restarted systemic treatment those who did not, both at 6 months (79% vs 35%, p < 0.01) and 12 months (81% vs 33%, p < 0.05).

CONCLUSION

While IAS are an option for all patients who flare after drug free remission, it may not prevent the need to restart systemic treatment. Prior use of a biologic DMARD may predict lack of success for IAS. Those who previously received methotrexate only, on the other hand, are excellent candidates for IAS.

Icosapent Ethyl diminishes CVD risk in smokers: REDUCE-IT smoking

Background/Introduction

Cigarette smoking is associated with increased risk of cardiovascular (CV) events with effective treatment currently limited to smoking cessation. REDUCE-IT, a multinational, double-blind trial, randomised 8179 statin-treated patients with controlled low density lipoprotein cholesterol, elevated triglycerides, and CV risk, to icosapent ethyl (IPE) 4 grams/day or placebo, with a median of 4.9 years of follow-up. IPE reduced the primary composite (CV death, nonfatal myocardial infarction [MI], nonfatal stroke, coronary revascularisation, or hospitalisation for unstable angina) and key secondary composite (CV death, nonfatal MI, or nonfatal stroke) endpoints 25% and 26%, respectively (each P&lt;0.0001), and individual components including stroke (28%), MI (31%), cardiac arrest (48%), and sudden cardiac death (31%) (all P≤0.01).

Purpose

To evaluate the effects of IPE on the risk of CV events and safety measures in patients by history of smoking.

Methods

The effect of IPE on first and total primary and key secondary endpoints was evaluated in the REDUCE-IT study using post hoc analyses based upon smoking history. Groups were classified as never smokers (n=3264), former smokers (n=3672), and current smokers (n=1241).

Results

Compared with placebo, IPE use in combined current and former smokers (n=4913) was associated with significant reductions in time to the primary composite endpoint (hazard ratio, 0.77 [95% CI, 0.68–0.87]; P&lt;0.0001) and in total events (rate ratio, 0.71 [95% CI, 0.61–0.82]; P&lt;0.0001) (Figure 1). These benefits remained significant when subdivided into current and former smokers and were associated with reductions in the key secondary composite endpoint (P=0.04, P=0.005), and the individual components of CV death or nonfatal MI (P=0.04, P=0.01) and fatal or nonfatal MI (P=0.009, P=0.01, respectively). Never smokers also had a significant benefit from IPE for both the primary and key secondary endpoints. Overall, there were similar estimated rates of first occurrences of CV death, MI, stroke, coronary revascularisation, or hospitalisation for unstable angina in current smokers (23.8%) and former smokers (23.0%) assigned to IPE compared with never smokers on placebo (25.7%) (Figure 2).

Conclusions

In the REDUCE-IT study, IPE treatment significantly reduced the risk of CV events in current and former smokers to levels observed in never smokers. While smoking cessation should always be recommended, these data raise the possibility that IPE treatment may markedly attenuate the CV hazards attributable to smoking.

Funding Acknowledgement

Type of funding sources: None.

Orodispersible and transmucosal alternative medications for symptom control in adults

BACKGROUND

Paediatric palliative care makes frequent use of orodispersible and transmucosal drug delivery routes. The limited published experience of this practice suggests that it enables the delivery of needle-free symptom relief, with the potential to train family carers to administer anticipatory medications without reliance on trained health professionals.

AIMS

To identify orodispersible and potential transmucosal alternatives that may be used in adults in the event of a patient having no oral or intravenous route and no access to subcutaneous injections.

METHODS

The author panel identified medications through review of multiple drug formularies, review of the published evidence and their experience. Where possible, licensed alternatives were identified and any 'off label' or unlicensed medications clearly highlighted.

RESULTS

A list of 27 medications is provided, which could be used either via the orodispersible or transmucosal alternative route for healthcare professionals delivering end of life care to consider when the licensed alternative routes are unavailable. All users of this guide are encouraged to use their professional judgement whenever selecting a medication for a patient, recognising that this review is neither a guideline nor a systematic review, and taking account of licensing considerations, adverse effects, potential unpredictability of time to effect and contraindications.

CONCLUSION

Should it be necessary to use these orodispersible or transmucosal alternatives then any experience gained should be reported in the literature. Combined with further research, this experience offers the possibility of reducing injection frequency and inherent delays in medication administration, particularly in the community setting during the COVID-19 pandemic.

How good is end of life care for patients dying with cystic fibrosis?

Background

Cystic Fibrosis (CF) is a life-limiting illness. Audit of the care of patients dying of CF has not been published to date.

Methods

Newcastle and Oxford teams adapted the National Audit of Care at the End of Life and agreed additional questions that were particularly pertinent for patients dying as a consequence of their CF. Data were extracted and analysed for 15 patients.

Results

On recognition that the patient was dying, the CF teams were less good at reviewing the need for physiological observations (50% vs national 70%) but better at reviewing the need for capillary blood glucose monitoring, oxygen support and intravenous antibiotics compared with the national average for all patients.

On recognition that the patient was dying, the CF teams were better at assessing pain (87% vs national 80%) and breathlessness (93% vs national 73%), but less good at assessing nausea and vomiting (47% vs national 74%).

There was documented evidence that 100% of families and 64% of patients were aware that the patient was at risk of dying.

Conclusion

Comparing care of this sample of patients dying with CF against the national data is a useful first step in understanding that many aspects of care are of high quality. This audit identifies the need to offer earlier conversations to patients as their voices may be missing from the conversation. Undertaking a national audit would provide a more reliable and a fuller picture.

Population genomic monitoring provides insight into conservation status but no correlation with demographic estimates of extinction risk in a threatened trout

The current extinction crisis requires effective assessment and monitoring tools. Genetic approaches are appealing given the relative ease of field sampling required to estimate genetic diversity characteristics assumed related to population size, evolutionary potential, and extinction risk, and to evaluate hybridization with non‐native species simultaneously. However, linkages between population genetic metrics of diversity from survey‐style field collections and demographic estimates of population size and extinction risk are still in need of empirical examples, especially for remotely distributed species of conservation concern where the approach might be most beneficial. We capitalized on an exceptional opportunity to evaluate congruence between genetic diversity metrics and demographic‐based estimates of abundance and extinction risk from a comprehensive Multiple Population Viability Analysis (MPVA) in a threatened fish, the Lahontan cutthroat trout (LCT). We sequenced non‐native trout reference samples and recently collected and archived tissue samples of most remaining populations of LCT (N = 60) and estimated common genetic assessment metrics, predicting minimal hybridization with non‐native trout, low diversity, and declining diversity over time. We further hypothesized genetic metrics would correlate positively with MPVA‐estimated abundance and negatively with extinction probability. We uncovered several instances of hybridization that pointed to immediate management needs. After removing hybridized individuals, cautious interpretation of low effective population sizes (2–63) suggested reduced evolutionary potential for many LCT populations. Other genetic metrics did not decline over time nor correlate with MPVA‐based estimates of harmonic mean abundance or 30‐year extinction probability. Our results demonstrate benefits of genetic monitoring for efficiently detecting hybridization and, though genetic results were disconnected from demographic assessment of conservation status, they suggest reduced evolutionary potential and likely a higher conservation risk than currently recognized for this threatened fish. We emphasize that genetic information provides essential complementary insight, in addition to demographic information, for evaluating species status.

Lawson Criterion for Ignition Exceeded in an Inertial Fusion Experiment

For more than half a century, researchers around the world have been engaged in attempts to achieve fusion ignition as a proof of principle of various fusion concepts. Following the Lawson criterion, an ignited plasma is one where the fusion heating power is high enough to overcome all the physical processes that cool the fusion plasma, creating a positive thermodynamic feedback loop with rapidly increasing temperature. In inertially confined fusion, ignition is a state where the fusion plasma can begin "burn propagation" into surrounding cold fuel, enabling the possibility of high energy gain. While "scientific breakeven" (i.e., unity target gain) has not yet been achieved (here target gain is 0.72, 1.37 MJ of fusion for 1.92 MJ of laser energy), this Letter reports the first controlled fusion experiment, using laser indirect drive, on the National Ignition Facility to produce capsule gain (here 5.8) and reach ignition by nine different formulations of the Lawson criterion.

Super-Response to Guselkumab Treatment in Patients With Moderate-to-Severe Psoriasis: Age, Body Weight, Baseline Psoriasis Area and Severity Index, and Baseline Investigator's Global Assessment Scores Predict Complete Skin Clearance

BACKGROUND

Psoriasis is a chronic immune-mediated inflammatory skin disease that often leads to a diminished quality of life. Goals of treating patients with psoriasis have shifted with more focus on achieving near or complete clearance of the skin. Guselkumab, a fully human monoclonal antibody targeting interleukin-23, is effective in treating moderate-to-severe psoriasis.

OBJECTIVE

To describe the baseline characteristics of patients with moderate-to-severe psoriasis achieving super-response (Psoriasis Area and Severity Index [PASI] 100 response at Weeks 20 and 28) after commencing guselkumab treatment.

METHODS

Pooled data from VOYAGE-1 and VOYAGE-2 studies identified super-response; baseline demographic, disease, and pharmacokinetic characteristics were compared with non-super-response. A stepwise logistic regression analysis identified which factors were potentially predictive of super-response status, with significance level of 0.1.

RESULTS

A subset of patients randomized to guselkumab comprised this post hoc analysis (n=664); 271 patients achieved super-response vs 393 with non-super-response. Patient age at study entry and baseline body weight (≤90 kg vs >90 kg), PASI, and Investigator's Global Assessment (IGA) score were significant predictors of super-response status, with odds ratios (95% confidence intervals) of 0.98 (0.967-0.993; p=0.003), 1.42 (1.026-1.977; p=0.034), 0.97 (0.955-0.993; p=0.007), and 0.66 (0.433-0.997; p=0.048), respectively. More patients with super-response achieved an early response: Week 2 PASI 75 (5.5% vs 1.8%) and Week 8 PASI 100 (22.5% vs 3.3%) vs non-super-response. Median serum guselkumab concentrations through Week 28 were slightly greater in patients with super-response vs non-super-response.

CONCLUSION

Guselkumab was more likely to achieve early clinical responses (complete skin clearance) in younger patients, less obese patients, and patients with less severe psoriasis.

Rock structures improve seedling establishment, litter catchment, fungal richness, and soil moisture in the first year after installation

Grasslands are essential natural and agricultural ecosystems that encompass over one-third of global lands. However, land conversion and poor management have caused losses of these systems which contributed to a 10% reduction of net primary production, a 4% increase in carbon emissions, and a potential loss of US $42 billion a year. It is, therefore, important to restore, enhance and conserve these grasslands to sustain natural plant communities and the livelihoods of those that rely on them. We installed low cost rock structures (media lunas) to assess their ability to restore grasslands by slowing water flow, reducing erosion and improving plant establishment. Our treatments included sites with small and large rock structures that were seeded with a native seed mix as well as sites with no seed or rock and sites with only seed addition. We collected summer percent cover for plants, litter, and rock and spring seedling count data. We also collected soil for nutrient, moisture, and microbial analysis. Within the first year, we found no change in plant cover between rock structures of two rock sizes. We did find, however, an increase in soil moisture, litter, fungal richness, and spring seedling germination within the rock structures, despite a historic drought. This work demonstrates that rock structures can positively impact plants and soils of grasslands even within the first year. Our results suggest that managers should seriously consider employing these low-cost structures to increase short-term plant establishment and possibly, soil health, in grasslands.

AB0892 Targeted Safety Analyses of Guselkumab: Long-Term Results from Randomized Clinical Trials in Patients with Active Psoriatic Arthritis and Moderate to Severe Psoriasis

Background

Guselkumab (GUS) demonstrated efficacy and a favorable safety profile in active PsA in the Phase (Ph) 21 and Ph3 DISCOVER-1&2 trials2,3 and in moderate-to-severe plaque psoriasis (PsO) in the Ph3 VOYAGE-1&2 trials.4,5

Objectives

To assess long-term safety of GUS across PsA/PsO trials.

Methods

Using pooled safety data through 2 years (yrs) from PsA trials (N=1229; GUS 100 mg every 4/8 weeks [Q4W/Q8W])1-3 and through 5 yrs from PsO trials (N=1721; GUS 100 mg Q8W),4,5 incidences of serious adverse events (SAEs); gastrointestinal (GI)-related SAEs and other targeted AEs; including candidiasis, uveitis, and opportunistic infections (OIs) were evaluated. Incidence rates (IRs) were calculated as the number of events per 100 pt-yrs (PY) of follow-up with 95% CI. Patients (pts) with an IBD history were not excluded in PsA/PsO trials. Max exposure duration was W100 for PsA trials and W252 for PsO trials.

Results

The PsA and PsO populations had comparable mean age and BMI. IRs of SAEs and GI-related SAEs were generally similar between GUS- and PBO-treated pts during PBO-controlled periods, and between PsA pts receiving GUS Q4W/Q8W for up to 2 yrs and PsO pts receiving GUS Q8W for up to 5 yrs (Table 1). IRs of other targeted AEs of interest were low. OIs did not occur in PsO pts and were infrequent in PsA pts (Table 1). Candidal infections were infrequent and non-serious. Iridocyclitis was reported in 1 PBO- and 1 GUS Q8W-treated PsA pt. No exacerbations or new onset of IBD or active tuberculosis was reported in GUS-treated PsA/PsO pts.

Table 1.

Targeted AEs of Interest

Pooled PsA*Pooled PsOThrough 2 YrsThrough 5 YrsGUS 100 mg Q4W (N=373)GUS 100 mg Q8W (N=475)PBO→GUS 100 mg Q4W (N=352)aPBO→GUS 100 mg Q8W (N=29)aGUS Combined (N=1229)GUS 100 mg Q8W (N=1221)bADA→GUS 100 mg Q8W (N=500)cGUS Combined (N=1721)Total PY645748461171871525419127166Mean PY1.71.61.30.61.54.33.84.2Events/100 PY (95% CI)Overall SAEs4.65(3.14, 6.64)6.42(4.73, 8.51)5.86(3.86, 8.52)0.00(0.00, 17.24)5.61(4.59, 6.79)5.18(4.58, 5.83)4.55(3.64, 5.61)5.01(4.50, 5.56)GI-related SAEs0.46(0.10, 1.36)0.27(0.03, 0.97)0.00 (0.00, 0.65)0.00(0.00, 17.24)0.27(0.09, 0.62)0.44(0.28, 0.66)0.42(0.18, 0.82)0.43(0.29, 0.61)OIsd0.00(0.00, 0.46)0.27(0.03, 0.97)0.22(0.01, 1.21)0.00(0.00, 17.24)0.16(0.03, 0.47)0.00(0.00, 0.06)0.00(0.00, 0.16)0.00(0.00, 0.04)Candida infections0.31(0.04, 1.12)0.00(0.00, 0.40)0.00(0.00, 0.65)0.00(0.00, 17.24)0.11(0.01, 0.39)0.49(0.32, 0.73)0.52(0.25, 0.96)0.50(0.35, 0.70)Non-pathogen specific fungal infections, suspicious for candida0.00(0.00, 0.46)0.27(0.03, 0.97)0.00(0.00, 0.65)0.00(0.00, 17.24)0.11(0.01, 0.39)0.11(0.04, 0.25)0.16(0.03, 0.46)0.13(0.06, 0.24)Uveitis/ Iridocyclitis0.00(0.00, 0.46)0.13(0.00, 0.75)0.00(0.00, 0.65)0.00(0.00, 17.24)0.05(0.00, 0.30)0.00(0.00, 0.06)0.00(0.00, 0.16)0.00(0.00, 0.04)

*In PsA Ph2, data after early escape at W16 were excluded. AEs are coded using MedDRA Version 23.1

aFor PBO→GUS, data on/after 1st GUS administration were included

bPBO crossover pts were included in GUS column after crossover to GUS

cEvents prior to GUS (ADA events) were excluded. Only includes pts randomized to ADA at W0 and crossed over to GUS at/after W52 for VOYAGE-1 & W28 for VOYAGE-2

dHerpes zoster disseminated, fungal oesophagitis, and meningitis listeria (1 each)

ADA=Adalimumab

Conclusion

IRs of SAEs; GI-related SAEs; and AEs of interest including candidiasis, uveitis, and OIs were low, or no cases were reported. No new safety concerns were identified with GUS treatment through 2 yrs and 5 yrs of follow-up in the pooled PsA and PsO trials, respectively, supporting a durable and favorable GUS safety profile consistent between pts with active PsA and moderate-to-severe PsO.

References

[1]Deodhar A, et al. Lancet. 2018;391:2213-2224.

[2]Deodhar A, et al. Lancet. 2020;395:1115-1125.

[3]Mease PJ, et al. Lancet. 2020;395:1126-1136.

[4]Blauvelt A, et al. J Am Acad Dermatol. 2017;76:405-417.

[5]Reich K, et al. J Am Acad Dermatol. 2017;76:418-431.

Disclosure of Interests

Philip J Mease Speakers bureau: AbbVie, Aclaris, Amgen, Bristol-Myers Squibb, Celgene, Eli Lilly, Galapagos, Gilead, GlaxoSmithKline, Celgene, Crescendo Bioscience, Genentech, Inmagene, Janssen, Lilly, Merck, Novartis, Pfizer, SUN Pharma, and UCB, Consultant of: AbbVie, Aclaris, Amgen, Bristol-Myers Squibb, Celgene, Eli Lilly, Galapagos, Gilead, GlaxoSmithKline, Celgene, Crescendo Bioscience, Genentech, Inmagene, Janssen, Lilly, Merck, Novartis, Pfizer, SUN Pharma, and UCB, Grant/research support from: AbbVie, Aclaris, Amgen, Bristol-Myers Squibb, Celgene, Eli Lilly, Galapagos, Gilead, GlaxoSmithKline, Celgene, Crescendo Bioscience, Genentech, Inmagene, Janssen, Lilly, Merck, Novartis, Pfizer, SUN Pharma, and UCB, Peter Foley Speakers bureau: AbbVie, Celgene, Janssen, Eli Lilly, Merck, Novartis, Pfizer, Valeant, Galderma, GlaxoSmithKline, Leo Pharma, and Roche, Paid instructor for: (Advisory boards) AbbVie, Amgen, Aslan, Bristol-Myers Squibb, Boehringer Ingelheim, Celgene, Janssen, Eli Lilly, Merck, Novartis, Pfizer, Sun Pharma, UCB Pharma, Valeant, Galderma, GlaxoSmithKline, Leo Pharma, and Sanofi, Consultant of: Janssen, Eli Lilly, Novartis, Pfizer, UCB Pharma, Bristol-Myers Squibb, Galderma, Leo Pharma, and Roche; investigator for AbbVie, Amgen, AstraZeneca, Arcutis, Aslan, Boehringer Ingelheim, Celgene, Hexima, Janssen, Eli Lilly, Merck, Novartis, Pfizer, Sun Pharma, UCB Pharma, Valeant, Bristol-Myers Squibb, Celtaxsys, CSL, Cutanea, Dermira, Galderma, Genentech, GlaxoSmithKline, Leo Pharma, Regeneron Pharmaceuticals Inc, Reistone, Roche, and Sanofi, Grant/research support from: AbbVie, Amgen, Celgene, Janssen, Leo Pharma, Eli Lilly, Merck, Novartis, Pfizer, Sanofi, and Sun Pharma; travel grants from AbbVie, Janssen, Eli Lilly, Merck, Novartis, Pfizer, Galderma, Leo Pharma, Roche, Sun Pharma, and Sanofi; served as speaker for or received honoraria from AbbVie, Celgene, Janssen, Eli Lilly, Merck, Novartis, Pfizer, Valeant, Galderma, GlaxoSmithKline, Leo Pharma, and Roche, Kristian Reich Speakers bureau: Abbvie, Affibody, Amgen, Biogen, Boehringer Ingelheim Pharma, Bristol Myers Squibb, Celgene, Centocor, Covagen, Eli Lilly, Forward Pharma, Galderma, GlaxoSmithKline, Janssen-Cilag, Leo, Medac, Merck Sharp & Dohme Corp., Novartis, Ocean Pharma, Pfizer, Regeneron, Sanofi, Takeda, UCB Pharma, and Xenoport, Paid instructor for: Abbvie, Affibody, Amgen, Biogen, Boehringer Ingelheim Pharma, Bristol Myers Squibb, Celgene, Centocor, Covagen, Eli Lilly, Forward Pharma, Galderma, GlaxoSmithKline, Janssen-Cilag, Leo, Medac, Merck Sharp & Dohme Corp., Novartis, Ocean Pharma, Pfizer, Regeneron, Sanofi, Takeda, UCB Pharma, and Xenoport, Consultant of: Participated in clinical trials sponsored by Abbvie, Affibody, Amgen, Biogen, Boehringer Ingelheim Pharma, Bristol Myers Squibb, Celgene, Centocor, Covagen, Eli Lilly, Forward Pharma, Galderma, GlaxoSmithKline, Janssen-Cilag, Leo, Medac, Merck Sharp & Dohme Corp., Novartis, Ocean Pharma, Pfizer, Regeneron, Sanofi, Takeda, UCB Pharma, and Xenoport, Soumya D Chakravarty Employee of: Janssen Scientific Affairs, LLC and may own stock or stock options in Johnson & Johnson, May Shawi Employee of: Janssen Global Services, LLC and may own stock or stock options in Johnson & Johnson, Ya-Wen Yang Employee of: Janssen Global Services, LLC and may own stock or stock options in Johnson & Johnson, Megan Miller Employee of: Janssen Research & Development, LLC and may own stock or stock options in Johnson & Johnson, Alexa Kollmeier Employee of: Janssen Research & Development, LLC and may own stock or stock options in Johnson & Johnson, Xie L Xu Employee of: Janssen Research & Development, LLC and may own stock or stock options in Johnson & Johnson, Jenny Yu Employee of: Janssen Research & Development, LLC and may own stock or stock options in Johnson & Johnson, Yanli Wang Employee of: Janssen Research & Development, LLC and may own stock or stock options in Johnson & Johnson, Shihong Sheng Employee of: Janssen Research & Development, LLC and may own stock or stock options in Johnson & Johnson, Yin You Employee of: Janssen Research & Development, LLC and may own stock or stock options in Johnson & Johnson, Iain McInnes Consultant of: AbbVie, Bristol-Myers Squibb, Boehringer-Ingelheim, Celgene, Eli Lilly, Gilead, Janssen, Novartis and UCB., Grant/research support from: Astra Zeneca, Bristol-Myers Squibb, Celgene, Janssen, Lilly, Novartis, and UCB

AB0893 An Analysis of Fatigue in Patients With Psoriatic Disease Utilizing SF-36 Vitality Scores: Results Through Week 24 in Phase 3 Trials of Guselkumab in Patients With Psoriasis and Psoriatic Arthritis

Background

Patients with chronic inflammatory diseases can experience significant fatigue, negatively impacting health-related quality-of-life.1,2

Objectives

This post-hoc analysis evaluated baseline fatigue severity among patients with psoriasis and/or psoriatic arthritis (PsA) and the effect of guselkumab treatment on patient-reported fatigue.

Methods

VOYAGE-2 evaluated guselkumab every 8 weeks (Q8W) versus placebo (W16→guselkumab) and adalimumab in treating moderate-to-severe psoriasis.3 DISCOVER-14 and DISCOVER-25 evaluated guselkumab Q4W and Q8W versus placebo in treating active PsA. Fatigue was assessed using 36-item Short Form (SF-36) vitality scale score (includes 4 questions on fatigue/energy level); the US population norm=50±10; 5-10-point decrements are typically observed in conditions known to cause fatigue2; scores ≤35 indicate clinically important fatigue1; increases ≥5 indicate clinically meaningful improvement.2

Results

Across randomized groups at baseline, mean SF-36 vitality scores were 47.7-48.5 in psoriasis and 42.2-44.0 in PsA patients; 11%-15% of psoriasis and 20%-28% of PsA patients had scores <35. In psoriasis patients, mean increases in SF-36 vitality score at W16 were: placebo, 1.1; adalimumab, 3.9 (p<0.001 versus placebo); guselkumab, 5.6 (p<0.001 versus placebo); at W24: placebo→guselkumab, 4.6; adalimumab, 3.9; guselkumab, 5.8 (p=0.0148 versus adalimumab). In PsA patients, mean increases at W24 were: placebo, 2.3-4.0; guselkumab, 5.5-7.5 (p≤0.001 versus placebo). Through the placebo-controlled periods, significantly greater proportions of guselkumab-treated patients achieved clinically meaningful improvement in fatigue versus placebo (W16 psoriasis: guselkumab, 48%; placebo, 32%; p<0.001; W24 PsA: guselkumab, 53%-55%; placebo, 34%-44%; p<0.05).

Conclusion

At baseline, patients with psoriatic disease experienced clinically important fatigue, more so with PsA (20%-28%) than psoriasis (11%-15%). In guselkumab-treated psoriasis and PsA patients, clinically meaningful improvements in fatigue were achieved at W16 and W24, respectively.

References

[1]Skoie IM et al. Br J Dermatol. 2017;177:505-12

[2]Bjorner JB et al. Curr Med Res Opin. 2007;23:731-9

[3]Reich K et al. J Am Acad Dermatol. 2017;76:418-31

[4]Deodhar A et al. Lancet. 2020;395:1115-25

[5]Mease PJ et al. Lancet. 2020;395:1126-36

Disclosure of Interests

Joseph F. Merola Consultant of: AbbVie, Arena, Biogen, Bristol-Myers Squibb, Dermavant, Eli Lilly, Janssen, Novartis, Pfizer, Sun Pharma, and UCB Pharma, Yi-Hsuan Liu Employee of: Janssen Global Services, LLC and may own stock or stock options in Johnson & Johnson, Ya-Wen Yang Employee of: Immunology Global Medical Affairs, Janssen Pharmaceutical Companies of Johnson & Johnson, and may own stock or stock options in Johnson & Johnson, Megan Miller Employee of: Janssen Research & Development, LLC and may own stock or stock options in Johnson & Johnson, May Shawi Employee of: Immunology Global Medical Affairs, Janssen Pharmaceutical Companies of Johnson & Johnson, and may own stock or stock options in Johnson & Johnson, Daphne Chan Employee of: Janssen Scientific Affairs, LLC and may own stock or stock options in Johnson & Johnson, Saakshi Khattri Speakers bureau: Abbvie, Eli Lilly, UCB, Janssen, Paid instructor for: Abbvie, Eli Lilly, UCB, Janssen, Consultant of: Abbvie, Eli Lilly, UCB, Janssen, Grant/research support from: Pfizer, Abbvie, Leo, BMS, Eli Lilly, Laura Savage Speakers bureau: AbbVie, Almirall, Amgen, Celgene, Celltrion, Eli Lilly, Galderma, Janssen, LEO Pharma, MSD, Novartis, Sanofi and UCB Pharma, Consultant of: AbbVie, Almirall, Amgen, Celgene, Celltrion, Eli Lilly, Galderma, Janssen, LEO Pharma, MSD, Novartis, Sanofi and UCB Pharma, Grant/research support from: Janssen and Pfizer, Wolf-Henning Boehncke Speakers bureau: AbbVie, Almirall, Celgene, Eli Lilly, Janssen, LEO Pharma, Novartis, and UCB Pharma; and has received a research grant from Pfizer, Consultant of: AbbVie, Almirall, Celgene, Eli Lilly, Janssen, LEO Pharma, Novartis, and UCB Pharma; and has received a research grant from Pfizer, Chenglong Han Employee of: Janssen Global Services, LLC and may own stock or stock options in Johnson & Johnson

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

Social determinants of health influence disease activity and functional disability in Polyarticular Juvenile Idiopathic Arthritis

BACKGROUND

Social determinants of health (SDH) greatly influence outcomes during the first year of treatment in rheumatoid arthritis, a disease similar to polyarticular juvenile idiopathic arthritis (pJIA). We investigated the correlation of community poverty level and other SDH with the persistence of moderate to severe disease activity and functional disability over the first year of treatment in pJIA patients enrolled in the Childhood Arthritis and Rheumatology Research Alliance Registry.

METHODS

In this cohort study, unadjusted and adjusted generalized linear mixed effects models analyzed the effect of community poverty and other SDH on disease activity, using the clinical Juvenile Arthritis Disease Activity Score-10, and disability, using the Child Health Assessment Questionnaire, measured at baseline, 6, and 12 months.

RESULTS

One thousand six hundred eighty-four patients were identified. High community poverty (≥20% living below the federal poverty level) was associated with increased odds of functional disability (OR 1.82, 95% CI 1.28-2.60) but was not statistically significant after adjustment (aOR 1.23, 95% CI 0.81-1.86) and was not associated with increased disease activity. Non-white race/ethnicity was associated with higher disease activity (aOR 2.48, 95% CI: 1.41-4.36). Lower self-reported household income was associated with higher disease activity and persistent functional disability. Public insurance (aOR 1.56, 95% CI 1.06-2.29) and low family education (aOR 1.89, 95% CI 1.14-3.12) was associated with persistent functional disability.

CONCLUSION

High community poverty level was associated with persistent functional disability in unadjusted analysis but not with persistent moderate to high disease activity. Race/ethnicity and other SDH were associated with persistent disease activity and functional disability.

Anthropometry Based Growth and Body Composition in Infants with Complex Congenital Heart Disease

BACKGROUND

Infants with congenital heart disease (CHD) often have poor growth and altered body composition (fat and muscle accretion).

AIM

Describe growth patterns in infants with CHD using interval weight, length, head circumference (HC), triceps (TSF), subscapular skinfolds (SSSF), and mid-upper arm circumference (MUAC) measurements.

SUBJECTS AND METHODS

A total of 120 infants enrolled: 48% healthy and 58% with CHD (45% single ventricle [SV]; 55% two ventricle [2V] physiology). Weight, length, HC, TSF, SSSF, and MUAC measured at 3-, 6-, 9-, and 12-months of age.

RESULTS

CHD infants had lower weight, length, and HC z-scores at 3-, 6-, and 9-months. At 9-months, infants with SV physiology had larger TSF and SSSF z-scores over 2V and healthy infants. Overall MUAC z-scores were smaller at 3- and 6-months in infants with CHD.

CONCLUSISON

Infants with CHD have a complex pattern of growth. Longitudinal growth and body composition measurements provide information to better understand this pattern.

What can we Learn from Patients who Died from Covid-19 Following Escalation to a Respiratory High Dependency Unit for Trial of Non-Invasive Respiratory Support?

Background: Covid-19 infection is associated with significant risk of death, particularly in older, comorbid patients. Emerging evidence supports use of non-invasive respiratory support (CPAP and high-flow nasal oxygen [HFNO]) in this context, but little is known about its use in patients receiving end-of-life care. Methods: This was a retrospective study of 33 patients who died of Covid-19 on the Respiratory High Dependency Unit at the John Radcliffe Hospital, Oxford between 28/03/20 and 20/05/20. Data was sourced via retrospective review of electronic patient records and drug charts. Results: Patients dying from Covid-19 on the Respiratory HDU were comorbid with median Charlson Comorbidity Index 5 (IQR 4-6); median age 78 (IQR 72-85). Respiratory support was trialled in all but one case with CPAP being the most common form of first line respiratory support (84.8%) however, was only tolerated in 44.8% of patients. Median time to death was 10.7 days from symptom onset (IQR 7.5-14.6) and 4.9 days from hospital admission (IQR 3.1-8.3). 48.5% of patients remained on respiratory support at the time of death. Conclusions: End-of-life care for patients with Covid-19 remains a challenge. Patients tend to be frail and comorbid with a rapid disease trajectory. Non-Invasive Respiratory Support may play a key role in symptom management in select patients, however, further work is needed in order to identify patients who will most benefit from Respiratory Support and those for whom withdrawal may prevent unnecessary distress at the end of life or potential prolongation of suffering.

'It's changed how we have these conversations': emergency department clinicians' experiences implementing firearms and other lethal suicide methods counseling for caregivers of adolescents

Counseling parents to reduce access to firearms and other potentially lethal suicide methods is commonly known as lethal means counseling (LMC). The current study explores the experiences that emergency department-based behavioural health clinicians described having as they provided lethal means counseling to parents of adolescents at risk for suicide. Clinicians were purposively sampled from four hospital networks in Colorado after their hospitals adopted LMC protocols as part of an intervention that also included online training in LMC and provision of free medication and firearm lockboxes. Twenty-three clinicians were interviewed using semi-structured interviews. Data were analysed using a modified grounded theory-based approach. Clinicians felt more comfortable and effective in their abilities to provide LMC after the intervention. Clinicians also described how being able to offer free storage devices helped them engage in LMC. In advising parents to make guns and medications inaccessible to their at-risk child, most clinicians pointed to at least one of three research findings highlighted in the online training: (1) Suicide attempts with guns rarely afford second chances, (2) medication overdoses can kill, (3) suicidal behaviour is always unpredictable and often impulsive. All clinicians described a desire to continue LMC as currently protocolized at their hospital after the study ended.

Heart failure with preserved ejection fraction (HFpEF) pathophysiology study (IDENTIFY-HF): rise in arterial stiffness associates with HFpEF with increase in comorbidities

Background

There has been a shift in paradigm proposing that comorbidities play a significant role towards the pathophysiology of the heart failure with preserved ejection fraction (HFpEF) syndrome. Further, HFpEF patients have abnormal macrovascular function, potentially contributing significantly in altered ventricular-vascular coupling in these patients. However, our full understanding of the role of comorbidities, arterial stiffness and it relationship with HFpEF remains incomplete.

Purpose

The IDENTIFY-HF study aims to shed light on the HFpEF pathophysiology and investigates whether gradually increase in arterial stiffness (in addition to ageing) due to increasing common comorbidities, such as hypertension and diabetes, is associated with HFpEF.

Methods

Arterial compliance was assessed in five groups (Groups A to E) matched for age, (≥70 years), sex and renal function: Group A; normal healthy volunteers without major comorbidities (control). Group B; patients with hypertension only. Group C; patients with hypertension and diabetes mellitus only. Group D; patients with HFpEF. Group E; patients with heart failure and reduced ejection fraction (HFrEF); the parallel group. Arterial compliance was assessed using pulse wave velocity (PWV), as the primary outcome measure and was compared between Group A to D. A separate comparison was made between Groups D and E. To avoid confounding factors, participants were asked to omit their morning blood pressure medication and abstain from caffeine for 12 hours prior to the study.

Results

From the 95 volunteers recruited, PWV was obtained in 94 subjects. The mean PWV in group A, B, C, D and E was 10.2-, 12.2-, 13.0-, 13.7- and 10.0 m/s respectively. After adjusting for covariance (age, sex, BMI and renal function), the mean difference between Group A (healthy volunteers) and D (HFpEF) was 2.14 m/s (p=0.023). Whilst the mean difference between the HFpEF and HFrEF group D and E respectively was 2.68 m/s (p=0.003).

Conclusion

Rise in comorbidities increases arterial stiffness, as measured by pulse wave velocity, which in turn significantly associates with HFpEF (p=0.023). It is therefore possible that the HFpEF syndrome may not be due to a primary cardiac pathology but rather an end-result of non-cardiac comorbidities affecting vascular resistance with perhaps some secondary cardiac involvement.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): 1)West Midlands Clinical Research Network, National Institute of Health Research, UK2)Research, Development & Innovation department of the University Hospitals Coventry & Warwickshire NHS Trust (RDI, UHCW), UK.

Cardiovascular benefits outweigh risks in patients with atrial fibrillation in REDUCE-IT (Reduction of Cardiovascular Events with Icosapent Ethyl-Intervention Trial)

Background/Introduction

REDUCE-IT, a multinational, double-blind trial, randomized 8179 statin-treated patients with controlled low density lipoprotein cholesterol, elevated triglycerides, and cardiovascular (CV) risk, to icosapent ethyl (IPE) 4 grams/day or placebo. IPE reduced the primary (CV death, myocardial infarction [MI], stroke, coronary revascularization, hospitalization for unstable angina) and key secondary (CV death, MI, stroke) endpoints 25% and 26%, respectively (each p&lt;0.0001), and individual components including stroke (28%), MI (31%), cardiac arrest (48%), and sudden cardiac death (31%) (all p≤0.01). With IPE, bleeding was greater (11.8% vs 9.9%; p=0.006), serious bleeding trended higher (2.7% vs 2.1%; p=0.06), and atrial fibrillation/flutter (AF/F) hospitalization endpoints increased (3.1% vs 2.1%; p=0.004).

Purpose

To evaluate the effects of IPE on the risk of CV events and safety measures in patients by either history of AF/F or in-study occurrence of positively adjudicated AF/F hospitalization.

Methods

Conduct post hoc efficacy and safety subgroup analyses of patients with or without either baseline history of AF/F or in-study adjudicated AF/F hospitalization, including hospitalization for ≥24 hours; AF/F not meeting endpoint criteria were reported as adverse events.

Results

Patients with (n=751; 9.2%) AF/F history at baseline (vs without; n=7428; 90.8%) (Figure 1), or those with (n=211; 2.6%) positively adjudicated in-study AF/F hospitalization endpoints (vs without; n=7968; 97.4%) (Figure 2), had higher event rates of primary, key secondary, and fatal or nonfatal stroke endpoints, but relative risk reductions with IPE were not significantly different (all interaction p-values [pint]=ns). Similar reductions were observed with IPE across the prespecified endpoint testing hierarchy in patients with or without AF/F history or in-study hospitalization endpoints. Patients with baseline AF/F history had similar relative risk for in-study occurrence of AF/F hospitalization with IPE versus placebo (pint=0.21) but had greater absolute risk (12.5% vs 6.3%, IPE vs placebo) vs patients without baseline AF/F history (2.2% vs 1.6%, IPE vs placebo); i.e., recurrent AF/F in those with a prior history of AF/F was more prevalent than de novo AF/F. Serious bleeding trended higher regardless of AF/F history or in-study AF/F hospitalization endpoints (all pint=ns); absolute risk of serious bleeding was greater in patients with AF/F history at baseline (7.3% vs 6.0%) vs those without a baseline history of AF/F (2.3% vs 1.7%), and serious bleeding also trended higher in patients with in-study AF/F hospitalization (8.7% vs 6.0%) vs without (2.5% vs 2.0%) [all IPE vs placebo].

Conclusion

REDUCE-IT patients with AF/F history or in-study AF/F hospitalization endpoints had greater CV risk, but similar relative risk reduction in primary, key secondary, and fatal or nonfatal stroke endpoints with IPE.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Amarin Pharma, Inc.