Genome-wide association study of age at puberty and its (co)variances with fertility and stature in growing and lactating Holstein-Friesian dairy cattle.

Reproductive performance is a key determinant of cow longevity in a pasture-based, seasonal dairy system. Unfortunately, direct fertility phenotypes such as intercalving interval or pregnancy rate tend to have low heritabilities and occur relatively late in an animal's life. In contrast, age at puberty (AGEP) is a moderately heritable, early-in-life trait that may be estimated using an animal's age at first measured elevation in blood plasma progesterone (AGEP4) concentrations. Understanding the genetic architecture of AGEP4 in addition to genetic relationships between AGEP4 and fertility traits in lactating cows is important, as is its relationship with body size in the growing animal. Thus, the objectives of this research were 3-fold. First, to estimate the genetic and phenotypic (co)variances between AGEP4 and subsequent fertility during first and second lactations. Second, to quantify the associations between AGEP4 and height, length, and BW measured when animals were approximately 11 mo old (standard deviation = 0.5). Third, to identify genomic regions that are likely to be associated with variation in AGEP4. We measured AGEP4, height, length, and BW in approximately 5,000 Holstein-Friesian or Holstein-Friesian × Jersey crossbred yearling heifers across 54 pasture-based herds managed in seasonal calving farm systems. We also obtained calving rate (CR42, success or failure to calve within the first 42 d of the seasonal calving period), breeding rate (PB21, success or failure to be presented for breeding within the first 21 d of the seasonal breeding period) and pregnancy rate (PR42, success or failure to become pregnant within the first 42 d of the seasonal breeding period) phenotypes from their first and second lactations. The animals were genotyped using the Weatherby's Versa 50K SNP array (Illumina, San Diego, CA). The estimated heritabilities of AGEP4, height, length, and BW were 0.34 (90% credibility interval [CRI]: 0.30, 0.37), 0.28 (90% CRI: 0.25, 0.31), 0.21 (90% CRI: 0.18, 0.23), and 0.33 (90% CRI: 0.30, 0.36), respectively. In contrast, the heritabilities of CR42, PB21 and PR42 were all <0.05 in both first and second lactations. The genetic correlations between AGEP4 and these fertility traits were generally moderate, ranging from 0.11 to 0.60, whereas genetic correlations between AGEP4 and yearling body-conformation traits ranged from 0.02 to 0.28. Our GWAS highlighted a genomic window on chromosome 5 that was strongly associated with variation in AGEP4. We also identified 4 regions, located on chromosomes 14, 6, 1, and 11 (in order of decreasing importance), that exhibited suggestive associations with AGEP4. Our results show that AGEP4 is a reasonable predictor of estimated breeding values for fertility traits in lactating cows. Although the GWAS provided insights into genetic mechanisms underpinning AGEP4, further work is required to test genomic predictions of fertility that use this information.

Genome-wide association study of anogenital distance and its (co)variances with fertility in growing and lactating Holstein-Friesian dairy cattle.

Anogenital distance (AGD) is a moderately heritable trait that can be measured at a young age that may provide an opportunity to indirectly select for improved fertility in dairy cattle. In this study, we characterized AGD and its genetic and phenotypic relationships with a range of body stature and fertility traits. We measured AGD, shoulder height, body length, and body weight in a population of 5,010 Holstein-Friesian and Holstein-Friesian × Jersey crossbred heifers at approximately 11 mo of age (AGD1). These animals were born in 2018 across 54 seasonal calving, pasture-based dairy herds. A second measure of AGD was collected in a subset of herds (n = 17; 1,956 animals) when the animals averaged 29 mo of age (AGD2). Fertility measures included age at puberty (AGEP), then time of calving, breeding, and pregnancy during the first and second lactations. We constructed binary traits reflecting the animal's ability to calve during the first 42 d of their herd's seasonal calving period (CR42), be presented for breeding during the first 21 d of the seasonal breeding period (PB21) and become pregnant during the first 42 d of the seasonal breeding period (PR42). The posterior mean of sampled heritabilities for AGD1 was 0.23, with 90% of samples falling within a credibility interval (90% CRI) of 0.20 to 0.26, whereas the heritability of AGD2 was 0.29 (90% CRI 0.24 to 0.34). The relationship between AGD1 and AGD2 was highly positive, with a genetic correlation of 0.89 (90% CRI 0.82 to 0.94). Using a GWAS analysis of 2,460 genomic windows based on 50k genotype data, we detected a region on chromosome 20 that was highly associated with variation in AGD1, and a second region on chromosome 13 that was moderately associated with variation in AGD1. We did not detect any genomic regions associated with AGD2 which was measured in fewer animals. The genetic correlation between AGD1 and AGEP was 0.10 (90% CRI 0.00 to 0.19), whereas the genetic correlation between AGD2 and AGEP was 0.30 (90% CRI 0.15 to 0.44). The timing of calving, breeding, and pregnancy (CR42, PB21, and PR42) during first or second lactations exhibited moderate genetic relationships with AGD1 (0.19 to 0.52) and AGD2 (0.46 to 0.63). Genetic correlations between AGD and body stature traits were weak (≤0.16). We conclude that AGD is a moderately heritable trait, which may have value as an early-in-life genetic predictor for reproductive success during lactation.

Animal- and herd-level factors associated with onset of puberty in grazing dairy heifers.

AIMS: To explore animal- and herd-level risk factors influencing age at puberty in predominantly Holstein-Friesian dairy heifers managed in seasonal, pasture-based systems. METHODS: Heifers born in spring 2018 (n = 5,010) from 54 commercial dairy herds in New Zealand were visited on three occasions when the mean heifer age, within herd, was 10 (visit 1; V1), 11 (V2) and 12 (V3) months old. Blood samples were collected on each visit and liveweight, stature and anogenital distance (AGD) were measured at V2. Heifers were defined as having reached puberty at the first visit where blood progesterone was elevated (≥ 1 ng/mL). Animal-level response variables included pubertal status by V1, V2 and V3, and age at puberty (or age at V3 plus 31 days for those that had not attained puberty by V3). To explore herd-level management factors, farmers answered a questionnaire relating to animal location, land type, health, feeding, and management between weaning and mating. A partial least squares regression was undertaken to identify herd-level factors associated with the greatest influence on puberty rate within herd. RESULTS: The mean age at puberty was 352 (SD 34.9) days. Heavier animals at a greater proportion of expected mature liveweight based on their breeding value for liveweight, or animals with a higher breed proportion of Jersey and lower breed proportion of Holstein, were associated with earlier puberty. Herd puberty rates varied widely among enrolled herds, and averaged 20%, 39% and 56% by V1, V2 and V3, respectively. Liveweight, followed by breed and land type, had the greatest influence on the herd puberty rate. Heifer herds with a greater mean liveweight (absolute and proportion of expected mature weight) or greater Jersey proportion had more animals that reached puberty at any visit, whereas herds located on steep land or with greater Holstein breed proportions had lower puberty rates. Management-related factors such as vaccinations, provision of feed supplements, and weighing frequency were also herd-level risk factors of puberty but had less influence. CONCLUSIONS AND CLINICAL RELEVANCE: This study highlights the importance of having well-grown heifers for increasing the chances of earlier puberty onset and the effect of breed and youngstock management to achieve growth targets. These outcomes have important implications for the optimal management of heifers to achieve puberty before their maiden breeding and for the timing of measurements to potentially incorporate a puberty trait in genetic evaluations.

Practical challenges and potential approaches to predicting low-incidence diseases on farm using individual cow data: A clinical mastitis example.

Clinical mastitis (CM) incidence is considerable in terms of cows affected per year, but cases are much less common in terms of detections per cow per milking. From a modeling perspective, where predictions are made every time any cow is milked, low CM incidence per cow day makes training, evaluating, and applying CM prediction models a challenge. The objective of this study was to build models for predicting CM incidence using time-series sensor data and choose models that maximize net return based on a cost matrix. Data collected from 2 university dairy farms, the University of Florida and Virginia Polytechnic Institute and State University, were used to gather representative data, including 110,156 milkings and 333 CM cases. Variables used in the models were milk yield, protein, lactose, fat, electrical conductivity, days in milk, lactation number, and activity as the number of steps, lying time, lying bouts, and lying bout duration. Models that predicted either likelihood of CM caused by gram-negative (GN) or gram-positive (GP) bacteria on each day were derived using extreme gradient boosting with weighting favoring true-positive cases, logistic responses, and log-loss errors. Model accuracies were determined using data randomly held out from the training set on each run. All variables considered were in terms of change (slope) over previous days, including the day CM was visually detected. The GN models had a median sensitivity (Se) of 52.6% and specificity (Sp) of 99.8%, whereas the GP models had a median Se of 37.5% and Sp of 99.9% when tested on the held-out data. In our models optimized to reduce cost from predictions, the Se was much less than Sp, suggesting that CM models might benefit from greater model weighting placed on Sp. Results also highlight the importance of positive predictive value (true positive cases per predicted positive case) along with Sp and Se, as models built on sparse data tend to predict too many false-positive cases. The calculated partial net return of our GN and GP models were -$0.15 and -$0.10 per cow per lactation, respectively, whereas International Organization for Standardization (ISO) standard models with Se of 80% and Sp of 99% would return -$1.32 per cow per lactation. Models chosen that minimized the cost to the farmer differed markedly from models that met ISO guidelines, showing asymmetry in targets between Sp and Se when the disease incidence rate is low. Because of the unique challenges that low-incidence diseases like CM present, we recommend that future CM predictive models consider the economic and practical implications in addition to the traditional model evaluation metrics.

Long-term cancer surveillance: results from the Forteo Patient Registry Surveillance Study.

The Forteo Patient Registry estimated the incidence of osteosarcoma in US patients treated with teriparatide and enrolled in the study between 2009 and 2019. No incident cases of osteosarcoma were identified among patients registered, and the crude incidence rate was 0 (95% confidence interval [CI], 0-10.2) cases per million person-years. PURPOSE: The prospective, voluntary Forteo Patient Registry was established to estimate the incidence of osteosarcoma in patients who have received treatment with teriparatide (Forteo). METHODS: Information on US adults prescribed teriparatide and enrolled in the Forteo Patient Registry 2009-2019 was linked with data from participating state cancer registries annually (2010-2019) to identify incident osteosarcoma cases using a standardized linkage algorithm. Teriparatide exposure was ascertained from self-reported data that included teriparatide initiation and demographics necessary to complete linkage. Osteosarcoma cases diagnosed on or after January 1, 2009, were identified by participating state cancer registries. The crude incidence rate (IR) and standardized incidence ratio (SIR) of observed cases to the expected number of cases adjusted to the background rate (3 per million person-years) and corresponding 95% CIs for the occurrence of osteosarcoma were calculated whereby the cumulative amount of person-time observed was adjusted for mortality. RESULTS: Data for 75,247 enrolled patients (representing 361,763 cumulative person-years) were linked to each of 42 participating state cancer registries (covering 93% of the US population), which included information on 6180 cases of osteosarcoma. No matches with incident cases of osteosarcoma following registry enrollment were found. The crude IR was 0 (95% CI, 0-10.2) cases per million person-years and the SIR was 0 (95% CI, 0-3.0). CONCLUSIONS: The ability to draw conclusions about the incidence of osteosarcoma among patients participating in the registry was limited due to the smaller than expected amount of patient follow-up time and the fact that no cases were identified.

Identifying gram-negative and gram-positive clinical mastitis using daily milk component and behavioral sensor data.

Opportunities exist for automated animal health monitoring and early detection of diseases such as mastitis with greater on-farm adoption of precision technologies. Our objective was to evaluate time series changes in individual milk component or behavioral variables for all clinical mastitis (CM) cases (ACM), for CM caused by gram-negative (GN) or gram-positive (GP) pathogens, or CM cases in which no pathogen was isolated (NPI). We developed algorithms using a combination of milk and activity parameters for predicting each of these infection types. Milk and activity data were collated for the 14 d preceding a CM event (n = 170) and for controls (n = 166) matched for breed, parity, and days in milk. Explanatory variables in the univariate and multiple regression models were the slope change in milk (milk yield, conductivity, somatic cell count, lactose percentage, protein percentage, and fat percentage) and activity parameters (steps, lying time, lying bout duration, and number of lying bouts) over 7 d. Slopes were estimated using linear regression between d -7 and -5, d -7 and -4, d -7 and -3, d -7 and -2, and d -7 and -1 relative to CM detection for all parameters. Univariate analyses determined significant slope ranges for explanatory variables against the 4 responses: ACM, GN, GP, and NPI. Next, all slope ranges were offered into the multivariate models for the same 4 responses using 3 baselines: d -10, -7, and -3 relative to CM detection. In the univariate analysis, no explanatory variables were significant indicators of ACM, whereas at least 1 parameter was significant for each of GN, GP, and NPI models. Superior sensitivity (Se) and specificity (Sp) estimates were observed for the best GP (Se = 82%, Sp = 87%) and NPI (Se = 80%, Sp = 94%) multiple regression models compared with the best ACM (Se = 73%, Sp = 75%) and GN (Se = 71%, Sp = 74%) models. Sensitivity for the GN model was greater at the baseline closest to the day of CM detection (d -3), whereas the opposite was observed for the GP and NPI model as Se was maximized at the d -10 baseline. Based on this screening of relationships, milk and activity sensor data could be used in CM detection systems.

The effect of J5 bacterins on clinical, behavioral, and antibody response following an Escherichia coli intramammary challenge in dairy cows at peak lactation.

Vaccination against coliform mastitis has become part of mastitis control programs in the past 3 decades, as a means of reducing the severity of clinical mastitis. Our study objective was to evaluate the effect of 2 commercially available vaccines on clinical, behavioral, and antibody response following Escherichia coli intramammary challenge in cows near peak lactation. Cows (n = 12 per group) were vaccinated with vaccine 1 (V1) or vaccine 2 (V2) at dry-off, 21 d pre-calving, and 14 d post-calving. Twelve cows served as unvaccinated controls (CTL). Cows were challenged with E. coli in a rear quarter at approximately 100 d in milk. Milk samples were collected pre- and post-challenge to enumerate E. coli and determine somatic cell count. Serum was collected before each vaccination and at d 0, 1, 2, 3, 6, 30, and 60 relative to challenge, to study antibody response. Milk IgA and tumor necrosis factor-α concentrations were determined in whey. Vaginal temperature, cow activity, and milk yield and components were monitored post-challenge. Bacterial count, somatic cell score, milk yield and component decline, vaginal temperature, activity measures, and antibody and cytokine response were analyzed for treatment differences. The effects of parity, breed, and a repeated measure of time were also tested. Seven cows had to be removed from the study post-challenge for antibiotic treatment (CTL and V1, n = 3 each; V2, n = 1), 2 of which were euthanized (both CTL). Vaccinated cows exhibited fever (vaginal temperature ≥39.4°C) 3 h earlier than CTL cows, but we found no differences between treatments for bacterial count, somatic cell score, or milk yield reduction. Vaccinated cows spent more time lying per rest bout 2 d post-challenge, but total daily lying time was not different from CTL cows during the 7 d post-challenge. The vaccines differed in antibody response: V1 cows had greater serum IgG1 and IgG2 post-challenge. A parity effect was also evident: primiparous cows had lower bacterial counts, somatic cell score and a smaller milk yield decline than multiparous cows, but also had lower antibody production. Immunization with either J5 bacterin did not reduce clinical signs of mastitis in cows challenged at 100 d in milk, demonstrating that the effects of J5 vaccination had diminished at peak lactation.

A sustainable method to reduce postoperative oxycodone discharge prescribing in a metropolitan tertiary referral hospital.

The primary objective of this quality improvement project was to measure and reduce the number of oxycodone immediate-release tablets dispensed to overnight stay surgical patients at discharge. The secondary objective was to reduce the proportion of inappropriate oxycodone immediate-release prescriptions at discharge. Interrupted time series analysis was performed in four surgical wards of St Vincent's Public Hospital, Sydney. The baseline period was from January 2005 to August 2013. Interventions and follow-up occurred until July 2017. Baseline audit of oxycodone immediate-release tablet numbers showed prescribing increased significantly with a monthly linear trend of 1.8 (95%CI = 1.4-2.3; p = 0.001) tablets/100 surgical admissions from January 2005 to August 2013. Four sequential interventions produced no significant change in the primary objective. At the end of the first month of a fifth intervention, comprising audit-feedback plus individual academic detailing, the average number of oxycodone tablets decreased by 77 (95%CI 39-115) tablets/100 surgical cases, and the postintervention linear trend was a monthly reduction of 3.2 (coefficient -3.2 (95%CI -4.5 to -1.8); p = 0.001) tablets/100 surgical admissions. Baseline audit showed 27% of oxycodone prescriptions to be inappropriate. Following our intervention, this dropped to 17% (p = 0.048), and then to 10% (p = 0.002) after 3 years.

The Forteo Patient Registry linkage to multiple state cancer registries: study design and results from the first 8 years.

The Forteo Patient Registry (FPR) aims to estimate the incidence of osteosarcoma in US patients treated with teriparatide. Enrollment began in 2009 and will continue through 2019, with linkage planned through 2024. To date, no incident cases of osteosarcoma have been identified among patients registered in the FPR. INTRODUCTION: The Forteo Patient Registry (FPR) was established in 2009 to estimate the incidence of osteosarcoma in US patients treated with teriparatide. The objective of this paper is to describe study methods, challenges encountered, and progress to date. METHODS: The FPR is a prospective US registry designed to link data from participants annually with state cancer registries. Patient enrollment is planned for 10 years (2009-2019) and annual linkage with US state cancer registries for 15 years (2010-2024). All US state cancer registries and DC were invited to participate. Patients are recruited using pre-enrollment materials included in teriparatide device packaging, kits, and brochures distributed by health-care providers; a toll-free number; and a study website. A linkage algorithm is used to match data from enrolled participants with cancer registry data. RESULTS: For the eighth annual linkage in 2017, information necessary for linkage with 63,270 patients in the FPR was submitted to each of the 42 participating registries. These patients contributed approximately 242,782 person-years of follow-up. A total of 5268 adult osteosarcoma cases diagnosed since January 1, 2009, were available for linkage from participating state cancer registries. To date, no incident cases of osteosarcoma have been identified among patients registered in the FPR. CONCLUSIONS: Based on the estimated 242,782 person-years of observation as of the eighth annual linkage and projecting current enrollment rate to study end in 2024, it is anticipated that the completed study will be able to detect a fourfold increase in the risk of osteosarcoma if one exists.

Vistusertib (dual m-TORC1/2 inhibitor) in combination with paclitaxel in patients with high-grade serous ovarian and squamous non-small-cell lung cancer.

Background: We have previously shown that raised p-S6K levels correlate with resistance to chemotherapy in ovarian cancer. We hypothesised that inhibiting p-S6K signalling with the dual m-TORC1/2 inhibitor in patients receiving weekly paclitaxel could improve outcomes in such patients. Patients and methods: In dose escalation, weekly paclitaxel (80 mg/m2) was given 6/7 weeks in combination with two intermittent schedules of vistusertib (dosing starting on the day of paclitaxel): schedule A, vistusertib dosed bd for 3 consecutive days per week (3/7 days) and schedule B, vistusertib dosed bd for 2 consecutive days per week (2/7 days). After establishing a recommended phase II dose (RP2D), expansion cohorts in high-grade serous ovarian cancer (HGSOC) and squamous non-small-cell lung cancer (sqNSCLC) were explored in 25 and 40 patients, respectively. Results: The dose-escalation arms comprised 22 patients with advanced solid tumours. The dose-limiting toxicities were fatigue and mucositis in schedule A and rash in schedule B. On the basis of toxicity and pharmacokinetic (PK) and pharmacodynamic (PD) evaluations, the RP2D was established as 80 mg/m2 paclitaxel with 50 mg vistusertib bd 3/7 days for 6/7 weeks. In the HGSOC expansion, RECIST and GCIG CA125 response rates were 13/25 (52%) and 16/25 (64%), respectively, with median progression-free survival (mPFS) of 5.8 months (95% CI: 3.28-18.54). The RP2D was not well tolerated in the SqNSCLC expansion, but toxicities were manageable after the daily vistusertib dose was reduced to 25 mg bd for the following 23 patients. The RECIST response rate in this group was 8/23 (35%), and the mPFS was 5.8 months (95% CI: 2.76-21.25). Discussion: In this phase I trial, we report a highly active and well-tolerated combination of vistusertib, administered as an intermittent schedule with weekly paclitaxel, in patients with HGSOC and SqNSCLC. Clinical trial registration: ClinicialTrials.gov identifier: CNCT02193633.

Evaluating a commercial PCR assay against bacterial culture for diagnosing Streptococcus uberis and Staphylococcus aureus throughout lactation.

The performance of a commercial, real-time PCR assay was compared with traditional bacterial culture for the identification of Streptococcus uberis and Staphylococcus aureus in bovine milk collected at different stages of lactation. Initial validation tests using fresh and frozen quarter milk samples identified factors that affected the success of the PCR. Therefore, the standard protocol was adjusted for samples collected at the first milking postpartum (colostrum) and from clinical mastitis cases. The adjustment involved PCR testing both undiluted and diluted (1 in 10 with sterile water) DNA extracts. The performance comparison between culture and the PCR assay used milk samples collected aseptically from individual quarters of mixed-age spring-calving dairy cows, during early, mid, and late lactation. Bacterial culture results were used to select a subset of samples for PCR testing (n = 315) that represented quarters with a current or prior Strep. uberis or Staph. aureus infection. Compared with culture, PCR had a sensitivity of 86.8% and specificity of 87.7% for detecting Strep. uberis (kappa = 0.74) and 96.4% and 99.7%, respectively, for detecting Staph. aureus (kappa = 0.96). The dilution of DNA extracts for colostrum and clinical samples increased the relative sensitivity from 79.2% to 86.8% for Strep. uberis detection and from 92.9% to 96.4% for Staph. aureus, presumably through diluting unidentified PCR inhibitors. The sensitivity for detecting Strep. uberis using PCR, relative to culture, was similar throughout lactation (85-89%), whereas relative specificity was lowest immediately postcalving (64%) but improved in mid and late lactation (98%). Specificity estimates for samples collected in early lactation can be optimized by reducing the cutoff cycle threshold (Ct) value from the recommended value of 37 to 34. Although using this value improved specificity (77%), it reduced test sensitivity (77%). The PCR assay lacked agreement with culture in early lactation, specifically for diagnosing Strep. uberis. Thus, PCR should not be used as the only tool for diagnosing mastitis in early lactation.

Effect of prolonged duration therapy of subclinical mastitis in lactating dairy cows using penethamate hydriodide.

AIM: To evaluate the efficacy of nil, three or six treatments of penethamate hydriodide on successive days for treatment of subclinical mastitis on the bacteriological cure proportion and subsequent somatic cell count (SCC). METHODS: Milk samples were collected from all glands of 102 cows with SCC of >200,000 cells/mL, and at least one gland with a rapid mastitis test (RMT) score >0. Cows from which a bacterial pathogen was isolated were treated (Day 0) with either three (3 × PH; n=31 cows), six (6 × PH; n=30) or no (Control; n=31) daily I/M injections of 5 g of penethamate hydriodide. Milk samples were collected on Days 21 and 28 for bacteriology. Bacteriological cure was defined as having occurred when the pathogen isolated pre-treatment was isolated from neither of the post-treatment samples. Post-treatment, cow-level composite SCC data were collated. The identity of Staphylococcus aureus isolates was confirmed by PCR and antimicrobial resistance patterns for these isolates were determined by zone diffusion testing. RESULTS: Corynebacterium spp. (40%) and S. aureus (32%) were the most common isolates pre-treatment. The proportion of glands cured increased from 0.16 (SE 0.04) for the Control, to 0.32 (SE 0.06) for the 3 × PH, and 0.56 (SE 0.02) for the 6 × PH groups (p<0.001); decreased with increasing age (p=0.02); and was lower for S. aureus than for other isolates (p<0.001). Of the 60 isolates defined as S. aureus by phenotypic bacteriology, 55 were confirmed as S. aureus by PCR. Of these, 24 (45%) were resistant to penicillin. One of 24 (4%) glands with S. aureus resistant to penicillin was cured compared with 7/29 (24%) sensitive isolates (p=0.04). The geometric mean SCC at the subsequent herd test declined from 481 (95% CI=350-659) × 10(3) cells/mL in Control, to 352 (95% CI=255-486) × 10(3) cells/mL in 3 × PH, and 276 (95% CI=199-383) × 10(3) cells/mL in 6× PH cows (p=0.05). CONCLUSIONS: Increasing the duration of treatment of subclinical mastitis using penethamate hydriodide in dairy cows resulted in a higher bacteriological cure proportion, a lower proportion of glands infected post-treatment, and a reduced SCC. Cure proportion was reduced in older cows, and for glands infected with S. aureus, especially when resistant to penicillin. CLINICAL RELEVANCE: This study demonstrated that bacteriological cure of subclinical intramammary infections can be increased by increasing the duration of therapy, but a number of cow and pathogen factors also affected the probability of cure.

A case of familial paediatric atlantoaxial subluxation.

INTRODUCTION: Fixed atlantoaxial rotary subluxation (FAARS) is a rare cause of torticollis in children. Familial FAARS has not been described in the literature previously. We present case reports of two siblings who both developed spontaneous atlantoaxial rotary subluxation and discuss the possible causes. Both patients were treated conservatively and made a successful recovery. METHODS: The notes and images of two siblings were reviewed following permission from their parents. A literature search was also performed to look at what is currently known about atlantoaxial subluxation. RESULTS: Both siblings were successfully treated with halter traction and subsequent collar treatment. Os terminale was iden- tified on the CT images of both children. CONCLUSIONS: Atlantoaxial rotary subluxation should be considered as a cause of torticollis in children and can occasionally occur spontaneously. Both siblings had os terminale and it raises the possibility that this may predispose children to develop- ing FAARS. There may also be an underlying previously unidentified familial cause. Appropriate imaging followed by prompt treatment in halter traction is usually successful. If a diagnosis of FAARS is confirmed in a paediatric patient, the clinician should have a high index of suspicion when a sibling presents with torticollis or associated neck pain subsequently.

A phase 1 trial of recombinant human IL-21 in combination with cetuximab in patients with metastatic colorectal cancer.

BACKGROUND: Pre-clinical data indicate enhanced anti-tumour activity when combining recombinant human interleukin-21 (rIL-21), a class 1 cytokine, with cetuximab, a monoclonal antibody, targeting the epidermal growth factor receptor. This phase 1 trial assessed the safety and tolerability of escalating doses of rIL-21 in combination with cetuximab in chemo-naïve patients with stage IV colorectal cancer. PATIENTS AND METHODS: Sequential cohorts of PS 0-1, asymptomatic patients, were treated weekly with cetuximab 250 mg m(-2) intravenously (i.v.) plus escalating i.v. doses of rIL-21 following an initial loading dose of cetuximab 400 mg m(-2). Initial treatment period was 8 weeks, with extension permitted in patients without disease progression. RESULTS: In all, 15 patients were included in this study. Adverse events related to rIL-21 or rIL-21 plus cetuximab included lethargy, nausea/vomiting, stomatitis, lymphopenia and pyrexia and were mainly ≤ grade 2. One dose limiting toxicity occurred (grade 3 diarrhoea). Maximum tolerated dose was not determined because of the premature study closure. Maximum administered dose was 100 µg kg(-1) rIL-21 weekly. In all, 60% of the patients had stable disease. Immune activation was confirmed by various T- and NK-cell activation biomarkers, including dose-dependent increases in serum sCD25. CONCLUSION: rIL-21 weekly combined with cetuximab is well tolerated at doses up to 100 µg kg(-1) and results in activation of immune response biomarkers.

Candidate DNA methylation drivers of acquired cisplatin resistance in ovarian cancer identified by methylome and expression profiling.

Multiple DNA methylation changes in the cancer methylome are associated with the acquisition of drug resistance; however it remains uncertain how many represent critical DNA methylation drivers of chemoresistance. Using isogenic, cisplatin-sensitive/resistant ovarian cancer cell lines and inducing resensitizaton with demethylating agents, we aimed to identify consistent methylation and expression changes associated with chemoresistance. Using genome-wide DNA methylation profiling across 27 578 CpG sites, we identified loci at 4092 genes becoming hypermethylated in chemoresistant A2780/cp70 compared with the parental-sensitive A2780 cell line. Hypermethylation at gene promoter regions is often associated with transcriptional silencing; however, expression of only 245 of these hypermethylated genes becomes downregulated in A2780/cp70 as measured by microarray expression profiling. Treatment of A2780/cp70 with the demethylating agent 2-deoxy-5'-azacytidine induces resensitization to cisplatin and re-expression of 41 of the downregulated genes. A total of 13/41 genes were consistently hypermethylated in further independent cisplatin-resistant A2780 cell derivatives. CpG sites at 9 of the 13 genes (ARHGDIB, ARMCX2, COL1A, FLNA, FLNC, MEST, MLH1, NTS and PSMB9) acquired methylation in ovarian tumours at relapse following chemotherapy or chemoresistant cell lines derived at the time of patient relapse. Furthermore, 5/13 genes (ARMCX2, COL1A1, MDK, MEST and MLH1) acquired methylation in drug-resistant ovarian cancer-sustaining (side population) cells. MLH1 has a direct role in conferring cisplatin sensitivity when reintroduced into cells in vitro. This combined genomics approach has identified further potential key drivers of chemoresistance whose expression is silenced by DNA methylation that should be further evaluated as clinical biomarkers of drug resistance.

Pharmacokinetic and pharmacodynamic properties of an oral formulation of the histone deacetylase inhibitor Belinostat (PXD101).

PURPOSE: The primary objective of this sub-study, undertaken as an extension to the previously reported phase-I study, was to explore the feasibility, tolerability and pharmacokinetics (PK) of belinostat when administered by the oral route. Preliminary pharmacodynamic (PD) studies were also performed to enable comparison of the biological effects of the oral and intravenous formulations. PATIENTS AND METHODS: Oral belinostat was administered in a range of doses and schedules (once, twice or thrice daily), on either day 1 or days 1-5, of the second or a subsequent treatment cycle in 15 patients who were included in the phase-I trial of intravenous belinostat. Serial blood samples were collected for PK and PD (histone acetylation) analyses, and the results compared with corresponding analyses following intravenous administration. RESULTS: A total mean daily AUC of 2,767 ± 1,453 ng h/ml (8.7 ± 4.6 µM h) resulted from a dose of 1,000 mg/m(2) once daily (qd). There was no clear evidence of drug accumulation on twice daily dosing (bid); however, a trend towards accumulation was apparent when belinostat was given three times daily (tid). Mean half-life (T½) of a single dose of 1,000 mg/m(2) was 1.5 h (± 0.3 h) and peak levels were reached in an average of 1.9 h (± 0.3 h). The half-life was found to be independent of dose, but a trend towards increasing half-life following multiple dosing was observed. Histone H4 hyperacetylation in PBMCs estimated after oral dosing was comparable to that achieved after intravenous administration. CONCLUSIONS: High doses of oral belinostat, up to 1,000 mg/m(2) bid for 5 consecutive days, have been tolerated in this small study. An oral formulation could lead to enhanced drug exposure and, more importantly, prolonged effects on the intended drug target. Future trials are required to establish the optimal dose and schedule of oral administration of belinostat.

Combined inhibition of DNA methylation and histone acetylation enhances gene re-expression and drug sensitivity in vivo.

Histone deacetylation and DNA methylation have a central role in the control of gene expression in tumours, including transcriptional repression of tumour suppressor genes and genes involved in sensitivity to chemotherapy. Treatment of cisplatin-resistant cell lines with an inhibitor of DNA methyltransferases, 2-deoxy-5'azacytidine (decitabine), results in partial reversal of DNA methylation, re-expression of epigenetically silenced genes including hMLH1 and sensitisation to cisplatin both in vitro and in vivo. We have investigated whether the combination of decitabine and a clinically relevant inhibitor of histone deacetylase activity (belinostat, PXD101) can further increase the re-expression of genes epigenetically silenced by DNA methylation and enhance chemo-sensitisation in vivo at well-tolerated doses. The cisplatin-resistant human ovarian cell line A2780/cp70 has the hMLH1 gene methylated and is resistant to cisplatin both in vitro and when grown as a xenograft in mice. Treatment of A2780/cp70 with decitabine and belinostat results in a marked increase in expression of epigenetically silenced MLH1 and MAGE-A1 both in vitro and in vivo when compared with decitabine alone. The combination greatly enhanced the effects of decitabine alone on the cisplatin sensitivity of xenografts. As the dose of decitabine that can be given to patients and hence the maximum pharmacodynamic effect as a demethylating agent is limited by toxicity and eventual re-methylation of genes, we suggest that the combination of decitabine and belinostat could have a role in the efficacy of chemotherapy in tumours that have acquired drug resistance due to DNA methylation and gene silencing.

Effects of upper-limb immobilisation on driving safety.

Doctors are frequently asked by patients whether it is safe to drive with an upper limb immobilised in a cast. In the literature there are no objective measurements of the effects of upper-limb immobilisation upon driving performance. Eight healthy volunteers performed four 20-min driving circuits in a driving simulator (STISIM 400W), circuits 1 and 4 without immobilisation and circuits 2 and 3 with immobilisation. Immobilisation involved a lightweight below-elbow cast with the thumb left free. Volunteers were randomised to right or left immobilisation for circuit 2, and the contralateral wrist was immobilised for circuit 3. Circuits included urban and rural environments and specific hazards (pedestrians crossing, vehicles emerging from a concealed entrance, traffic lights changing suddenly, avoidance of an oncoming vehicle in the driver's carriageway). Limb immobilisation led to more cautious rural and urban driving, with less adjustment of speed and lateral road position than when unrestricted. However when responding to hazards immobilisation caused less safe driving, with higher speeds, a greater proximity to the hazard before action was taken and less steering adjustment. The effects of restriction upon performance were more prevalent and severe with right-arm immobilisation. Upper-limb immobilisation appears to have little effect on the ability to drive a car unchallenged, but to adversely affect responses to routine hazards. Advice on ability to drive safely should be cautious, as the impact of immobilisation appears to be more subtle and wide ranging than previously thought.

Fast-track assessment clinic: selection of patients for a one-stop hip assessment clinic.

INTRODUCTION: The fast-track assessment clinic (FTAC) is a process to select patients who are very likely to require primary total hip replacement. Selected patients can then be seen in a one-off clinic reducing the number of hospital visits, cost to primary care trusts and delay between referral and treatment. PATIENTS AND METHODS: Fifty patients on the waiting list for hip replacement were analysed to see if there were common parameters that led to their inclusion. From these data, fast-track selection criteria (FTSCs) were generated. These FTSCs were used to make a dual comparison of outcomes between 52 patients seen in a traditional clinic. Finally, a pilot study was conducted in which patients fulfilling FTSCs were seen in a designated clinic. RESULTS: An Oxford hip score (OHS) of 34 and above combined with severe loss of joint space, severe marginal osteophytes, or both was common to most patients on the waiting list (84%). FTSCs correctly predicted the outcome of the orthopaedic clinic in 38 patients out of a total of 52. During the pilot stage, positive FTSCs were shown to have a positive predictive value of 92% for joint replacement being carried out and a negative predictive value of 46%. CONCLUSIONS: An OHS of 34 or above combined with complete loss of joint space and/or severe marginal osteophyte formation can be used to select patients who are very likely to need total hip replacement. These patients can be seen in a clinic that combines assessment of surgical indication with medical fitness for surgery.