Gender Difference in sidE eFfects of ImmuNotherapy: a possible clue to optimize cancEr tReatment (G-DEFINER): study protocol of an observational prospective multicenter study.

BACKGROUND: Immune checkpoint inhibitors (ICIs) have significantly improved outcomes in various cancers. ICI treatment is associated with the incidence of immune-related adverse events (irAEs) which can affect any organ. Data on irAEs occurrence in relation to sex- differentiation and their association with gender-specific factors are limited. AIMS: The primary objective of the G-DEFINER study is to compare the irAEs incidence in female and male patients who undergo ICI treatment. Secondary objectives are: to compare the irAEs incidence in pre- and postmenopausal female patients; to compare the irAEs incidence in female and male patients according to different clinical and gender-related factors (lifestyle, psychosocial, and behavioral factors). Exploratory objectives of the study are to compare and contrast hormonal, gene-expression, SNPs, cytokines, and gut microbiota profiles in relation to irAEs incidence in female and male patients. METHODS AND RESULTS: The patients are recruited from Fondazione IRCCS Istituto Nazionale dei Tumori, Italy, St Vincent's University Hospital, Ireland, Oslo University Hospital, Norway, and Karolinska Insitutet/Karolinska University Hospital, Sweden. The inclusion of patients was delayed due to the Covid pandemic, leading to a total of 250 patients recruited versus a planned number of 400 patients. Clinical and translational data will be analyzed. INTERPRETATION: The expected outcomes are to improve the management of cancer patients treated with ICIs, leading to more personalized clinical approaches that consider potential toxicity profiles. The real world nature of the trial makes it highly applicable for timely irAEs diagnosis.

Loss in life expectancy in patients with stage II-III cutaneous melanoma in Sweden: A population-based cohort study.

BACKGROUND: Survival in cutaneous melanoma (CM) is heterogeneous. Loss in life expectancy (LLE) measures impact of CM on remaining lifespan compared to general population. OBJECTIVES: Investigating LLE in operated stage II-III CM patients. METHODS: Data from 8061 patients (aged 40-80 years) with stage II-III CM in Sweden, diagnosed between 2005 and 2018, were analyzed (Swedish Melanoma Registry). A flexible parametric survival model estimated life expectancy and LLE. RESULTS: Based on 2018 diagnoses, stage II and III CM patients lost 2209 and 1902 life years, respectively. LLE was higher in stage III: 5.2 versus 10.9 years (stage II vs III 60-year-old females). Younger patients had higher LLE: 10.7 versus 3.9 years (stage II CM in 40 vs 70-year-old males). In stage II, females had lower LLE than males; 50-year-old females and males stage II CM had LLE equal to 7.3 and 8.3 years, respectively. LLE increased with higher substages, stage IIB resembling IIIB and IIC resembling IIIC-D. LIMITATIONS: Extrapolation was used to estimate LLE. Varying stage group sizes require caution. CONCLUSIONS: Our results are both clinically relevant and easy-to-interpret measures of the impact of CM on survival, but the results also summarize the prognosis over the lifetime of a CM patient.

Increasing melanoma incidence and survival trend shifts with improved melanoma-specific survival between 1990 and 2020 in Sweden.

BACKGROUND: Melanoma-specific survival (MSS) is heterogenous between stages and is highly dependent on the T stage for primary localized disease. New systemic therapies for metastatic cutaneous melanoma (CM) have been introduced since 2012 in Sweden. OBJECTIVES: To analyse the incidence and MSS time trends between 1990 and 2020 in Sweden. METHODS: Nationwide, population-based and prospectively collected clinico-pathological data on invasive CM from the Swedish Melanoma Registry (SweMR) were analysed for survival trends between 1990 and 2020 using Kaplan-Meier curves and Cox proportional hazard ratios (HRs). RESULTS: In total, 77 036 primary invasive CMs were diagnosed in 70 511 patients in Sweden between 1990 and 2020. The 5-year MSS [95% confidence interval (CI)] was 88.9% (88.3-89.4) for 1990-2000, 89.2% (88.7-89.6) for 2001-2010 and 93.0% (92.7-93.9) for 2011-2020. The odds ratios for being diagnosed with nodular melanoma (vs. superficial spreading melanoma) was significantly reduced by 20% (2001-2010) and by 46% (2011-2020) vs. the reference period 1990-2000. Overall, the MSS improved over both diagnostic periods (2001-2010 and 2011-2020) vs. the reference period 1990-2000 among men and women, respectively [HRmen: 2001-2010: 0.89 (95% CI 0.82-0.96) and 2011-2020: 0.62 (95% CI 0.56-0.67); HRwomen: 2001-2010: 0.82 (95% CI 0.74-0.91) and 2011-2020: 0.62 (95% CI 0.56-0.70)]. The risk of death from CM was significantly lower in all age groups for both men and women in the most recent diagnostic period (2011-2020 vs.1990-2000). CONCLUSIONS: The results emphasize the improved MSS among men and women in Sweden. The MSS improvements, specifically for the period 2011-2020, may be correlated to the introduction of new systemic therapies and are here shown for the first time in detail for Sweden.

Association of metformin use and survival in patients with cutaneous melanoma and diabetes.

BACKGROUND: Metformin use has been associated with improved survival in patients with different types of cancer, but research regarding the effect of metformin on cutaneous melanoma (CM) survival is sparse and inconclusive. OBJECTIVES: To investigate the association between metformin use and survival among patients with CM and diabetes. METHODS: All adult patients with a primary invasive CM between 2007 and 2014 were identified in the Swedish Melanoma Registry and followed until death, or end of follow-up on 31 December 2017 in this population-based cohort study. Patients with both CM and type 2 diabetes mellitus were assessed further. Overall survival (OS) and melanoma-specific survival (MSS) were the primary endpoints. Cox proportional hazard models estimating crude and adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) were used comparing peridiagnostic use vs. nonuse of metformin. Dose response was evaluated based on defined daily doses. RESULTS: Among a total of 23 507 patients, 1162 patients with CM and type 2 diabetes mellitus were included in the final cohort, with a median follow-up time of 4.1 years (interquartile range 2.4-6.1). Peridiagnostic metformin use was associated with a significantly decreased risk of death by any cause (HR 0.68, 95% CI 0.57-0.81). Cumulative pre- and postdiagnostic metformin use was also associated with improved OS: the HR for prediagnostic use was 0.90 (95% CI 0.86-0.95) for every 6 months of use and the HR for postdiagnostic use ranged from 0.98 (95% CI 0.97-0.98) for 0-6 months to 0.59 (0.49-0.70) for 24-30 months of use. No association was found for metformin use and MSS. CONCLUSIONS: Metformin use was associated with improved OS in patients with CM and diabetes regardless of timing (pre-, post- or peridiagnostic use) and followed a dose-response pattern. However, further research regarding the underlying mechanisms is warranted.

Risk of poststroke epilepsy after reperfusion therapies: A national cohort study.

BACKGROUND AND PURPOSE: The risk of poststroke epilepsy (PSE) after endovascular treatment (EVT) is not well characterized. In this nationwide study, we assessed the risk of PSE after EVT and identified associated predictors. METHODS: We included all individuals (n = 3319) treated with EVT (±intravenous thrombolysis [IVT]) between 2015 and 2019 in the Swedish National Quality Register for EVT. Two control groups were identified from the Swedish Stroke Register: the first treated with IVT alone (n = 3132) and the second with no treatment (n = 3184), both matched for age, sex, stroke severity, and time of stroke. RESULTS: PSE developed in 7.9% (n = 410). The survival-adjusted 2-year risk was 6.5% (95% confidence interval [CI] = 5.28-7.70) after EVT, 10.0% (95% CI = 8.25-11.75) after IVT, and 12.3% after no revascularization (95% CI = 10.33-14.25). The hazard ratio (HR) of PSE after EVT was almost half compared to no treatment (HR = 0.51, 95% CI = 0.41-0.64). The risk of PSE after EVT was lower compared to no treatment in a multivariable Cox model that adjusted for age, sex, hemicraniectomy, and stroke severity (HR = 0.76, 95% CI = 0.60-0.96). Multivariable predictors of PSE after EVT were large infarction on computed tomography Day 1, high posttreatment National Institutes of Health Stroke Scale score, and need of assistance 3 months after stroke. IVT before EVT was associated with a lower risk of PSE (HR = 0.66, 95% CI = 0.46-0.94). CONCLUSIONS: This nationwide study identified a reduced risk of PSE after EVT. Markers of severe infarction after EVT were associated with PSE, whereas IVT given before EVT was protective.

Proposed methods for estimating loss of saleable milk in a cow-calf contact system with automatic milking.

Cow-calf contact (CCC) systems, although beneficial in many respects, introduce additional challenges to collect reliable data on milk production, which is important to assess individual cow efficiency and dairy farm profitability. Apart from weighing calves before and after each feeding, the amount of saleable milk lost due to calf suckling is practically impossible to measure. Here, we assess 2 indirect methods for estimating loss of saleable milk when housing cows and calves together in a robotic milking unit. In our study, treatment (CCC) cows and calves were kept together full time until the calves were 127 ± 6.6 d old (mean ± SD). Control cows were separated from their calves within 12 h of birth and then kept in the same unit as the treatment cows but with no access to either their own or treatment calves. Milk yield recording of both groups was performed from calving until pasture release at 233 ± 20 d in milk. The first estimation method relied on observed postseparation milk yield data, which were fed into a modified Wilmink regression model to determine the best-fitting lactation curve for the preseparation period. The second method was based on the cows' daily energy intake postseparation, calculated by measuring the daily feed intake and analyzing the energy content of the ration. The calculated energy intake was used to determine the average ratio between energy intake and the observed milk yield the following day for each individual cow, assuming constant rates of mobilization and deposition of body fat. The obtained ratio was then used to calculate the expected daily milk yield based on daily energy intake data during the preseparation period. In this paper, we analyzed data from 17 CCC cows kept together with their calves and 16 control cows; both groups calved from September to October 2020 and were followed up until release to pasture in May 2021. Saleable milk yield was lower in CCC cows than in control cows, both before and after separation. The 2 methods were used on data for control cows and showed milk yield loss using the lactation curve method (average of -3.4 ± 2.8 kg/d) and almost no loss using energy intake data (average of -1.4 ± 2.7 kg/d). Milk yield loss for CCC cows was estimated at average 11.3 ± 4.8 and 7.3 ± 6.6 kg milk/d, respectively. The proposed lactation curve estimation method tends to overestimate milk yield loss, whereas the method based on energy intake is more accurate. However, collecting detailed energy intake data per individual cow requires additional effort and equipment, which is not always feasible on commercial farms. Further research is needed to improve milk loss estimation and to better understand trade-offs in CCC systems.

Novel loss-of-function variant in DENND5A impedes melanosomal cargo transport and predisposes to familial cutaneous melanoma.

PURPOSE: More than half of the familial cutaneous melanomas have unknown genetic predisposition. This study aims at characterizing a novel melanoma susceptibility gene. METHODS: We performed exome and targeted sequencing in melanoma-prone families without any known melanoma susceptibility genes. We analyzed the expression of candidate gene DENND5A in melanoma samples in relation to pigmentation and UV signature. Functional studies were carried out using microscopic approaches and zebrafish model. RESULTS: We identified a novel DENND5A truncating variant that segregated with melanoma in a Swedish family and 2 additional rare DENND5A variants, 1 of which segregated with the disease in an American family. We found that DENND5A is significantly enriched in pigmented melanoma tissue. Our functional studies show that loss of DENND5A function leads to decrease in melanin content in vitro and pigmentation defects in vivo. Mechanistically, harboring the truncating variant or being suppressed leads to DENND5A losing its interaction with SNX1 and its ability to transport the SNX1-associated vesicles from melanosomes. Consequently, untethered SNX1-premelanosome protein and redundant tyrosinase are redirected to lysosomal degradation by default, causing decrease in melanin content. CONCLUSION: Our findings provide evidence of a physiological role of DENND5A in the skin context and link its variants to melanoma susceptibility.

The effects of social environment on standing behavior and the development of claw horn lesions.

The primary aim of this prospective experimental study was to evaluate how the social environment after calving influenced standing behavior in primiparous cows. At calving, primiparous cows were mixed with familiar peers in a low-stocked pen (≤33% stocking density; n = 22) or mixed with unknown older cows at 100% stocking density (n = 20). All study cows were mixed with older cows 3 wk after calving. Time spent standing and perching (standing with only the front feet in the stall) were measured d 1 to 3 after calving using 5-min scan sampling. To evaluate if the low-stocked treatment constituted a low-stress social environment, agonistic interactions at the feed barrier were measured for 90 min following feed delivery for a subsample of cows in both treatments (12 cows/treatment). The daily behavioral time budget, including the 90 min following milking, was examined for this subset of cows. A secondary aim was to assess if the social environment after calving was related to the risk of developing claw horn lesions later in lactation. Sole and white line lesions were recorded at wk 6 and 12 after calving, and cows were categorized as either having or not having at least 1 hemorrhage of severity ≥3 (scale 1 to 5) for each lesion type and assessment. Prolonged standing after regrouping was not observed, and we found no differences in standing time and time spent perching between treatments. Agonistic behaviors directed toward the focal cows occurred less frequently in the low-stocked pen compared with the control. The number and severity of sole and white line lesions increased after calving. At wk 6 postpartum there was a numeric (but not statistically significant) difference between treatments in the proportion of primiparous cows that had white line hemorrhages of severity score ≥3 (low-stress social environment: 20% vs. control: 50%). In conclusion, under the conditions of this study the social environment did not influence standing behavior, but did affect agonistic interactions and may have influenced the risk of claw horn lesions in the weeks following calving. Further studies should evaluate the relationship between the social environment and claw health.

Standing behavior and sole horn lesions: A prospective observational longitudinal study.

Studies performed on individual research farms have reported that dairy cattle developing sole hemorrhages or sole ulcers in peak to mid lactation spent more time standing during the weeks around calving. The aim of this prospective observational longitudinal study was to evaluate whether this relationship is evident in commercial dairy herds. A convenience sample of 8 herds were visited every other week, and animals without previous severe horn lesions and deemed sound at 4 to 8 wk before calving were enrolled. Standing behavior was measured with data loggers attached to a rear leg, and standing time and duration of the longest standing bout were determined for each cow. Standing behavior was summarized into 3 periods: before (d -14 to -2), around (d -1 to 1), and after (d 2 to 14) calving. Average daily standing time and average daily longest standing bout were determined for each cow and period. Average daily standing time was normally distributed, with a mean ± standard deviation of 12.1 ± 1.6, 14.4 ± 2.2, and 13.8 ± 1.7 h/d for the 3 periods, respectively. Average daily longest standing bout was right skewed with a median of 3.6 h/d [interquartile range (IQR): 3.0 to 4.3; range: 1.7 to 12.1], 3.9 h/d (IQR: 3.1 to 4.8; range: 1.3 to 11.5), and 3.7 (IQR: 3.2 to 4.4; range: 1.5 to 11.7) h/d before, around, and after calving, respectively. Hoof trimming was performed 8 to 12 wk postpartum; hoof lesion data were summarized per cow, and the most serious injury of each type of lesion was noted. Sole hemorrhages or sole ulcers were found in 25 of 256 cows. Mixed-effect logistic regression models with herd as random effect were used to analyze the risk of developing sole hemorrhages and sole ulcers, using animals without hoof lesions as reference category. Separate models were fitted for the 2 standing behaviors, and for the periods before, around, and after calving. Change in standing behavior from before to after calving was also analyzed. Body condition score at calving, body condition score loss in early lactation, milk yield, parity, and days in milk at trimming were included as covariates. In this study, no evidence for an association was found between sole hemorrhages and sole ulcers and standing behavior before or around calving. Longer standing time and longer standing bouts after calving were associated with increased odds of developing sole hemorrhages and sole ulcers, as was an increase in standing bout duration from before to after calving. Animals with sole horn or white line lesions had higher unconditional sample odds of becoming lame (odds ratio = 2.5) and severely lame (odds ratio = 11.7) after calving, compared with animals with no registered lesions at trimming. Multiparous animals had higher lameness incidence, both before and after calving. Avoiding practices that exacerbate increases in standing time and standing bout duration in early lactation may reduce the incidence of sole hemorrhages and sole ulcers.

Treating co-morbid insomnia and social anxiety disorder with sequential CBT protocols: a single-case experimental study.

BACKGROUND: Although insomnia disorder and social anxiety disorder are among the most prevalent psychiatric disorders, no studies have yet evaluated the use of sequential evidence-based treatment protocols in the population with co-morbid social anxiety disorder and insomnia disorder. AIMS: This study aimed to investigate the effects of sequential treatments on co-morbid insomnia disorder and social anxiety disorder. As depression is a common co-morbid syndrome for both insomnia and social anxiety, a secondary aim was to examine depressive symptoms. METHOD: A single-case repeated crossover AB design was used. Ten participants between 18 and 59 years of age with co-morbid DSM-5 diagnoses of insomnia disorder and social anxiety disorder received sequential treatments with cognitive behavioural therapy (CBT). Seven participants completed the treatment course. The primary outcomes were symptoms of insomnia and social anxiety, and the secondary outcome was symptoms of depression. RESULTS: The effects of CBT on people with co-morbid social anxiety disorder and insomnia disorder were mixed. The majority of participants improved their sleep quality and lessened symptoms of social anxiety and depression. However, participants differed in their degree of improvement concerning all three disorders. CONCLUSIONS: Sequential CBT treatments are potentially effective at decreasing symptoms of social anxiety and insomnia for people with co-morbid social anxiety disorder and insomnia disorder. The variation in outcome across participants makes firm conclusions about the treatment efficacy difficult to draw.

2-cm versus 4-cm surgical excision margins for primary cutaneous melanoma thicker than 2 mm: long-term follow-up of a multicentre, randomised trial.

BACKGROUND: The optimal surgical excision margins are uncertain for patients with thick (>2 mm) localised cutaneous melanomas. In our previous report of this multicentre, randomised controlled trial, with a median follow-up of 6·7 years, we showed that a narrow excision margin (2 cm vs 4 cm) did not affect melanoma-specific nor overall survival. Here, we present extended follow-up of this cohort. METHODS: In this open-label, multicentre randomised controlled trial, we recruited patients from 53 hospitals in Sweden, Denmark, Estonia, and Norway. We enrolled clinically staged patients aged 75 years or younger diagnosed with localised cutaneous melanoma thicker than 2 mm, and with primary site on the trunk or upper or lower extremities. Patients were randomly allocated (1:1) to treatment either with a 2-cm or a 4-cm excision margin. A physician enrolled the patients after histological confirmation of a cutaneous melanoma thicker than 2 mm. Some patients were enrolled by a physician acting as responsible for clinical care and as a trial investigator (follow-up, data collection, and manuscript writing). In other cases physicians not involved in running the trial enrolled patients. Randomisation was done by telephone call to a randomisation office, by sealed envelope, or by computer generated lists using permuted blocks. Patients were stratified according to geographical region. No part of the trial was masked. The primary outcome in this extended follow-up study was overall survival and the co-primary outcome was melanoma-specific survival. All analyses were done on an intention-to-treat basis. The study is registered with ClinicalTrials.gov, number NCT03638492. FINDINGS: Between Jan 22, 1992, and May 19, 2004, 936 clinically staged patients were recruited and randomly assigned to a 4-cm excision margin (n=465) or a 2-cm excision margin (n=471). At a median overall follow-up of 19·6 years (235 months, IQR 200-260), 621 deaths were reported-304 (49%) in the 2-cm group and 317 (51%) in the 4-cm group (unadjusted HR 0·98, 95% CI 0·83-1·14; p=0·75). 397 deaths were attributed to cutaneous melanoma-192 (48%) in the 2-cm excision margin group and 205 (52%) in the 4-cm excision margin group (unadjusted HR 0·95, 95% CI 0·78-1·16, p=0·61). INTERPRETATION: A 2-cm excision margin was safe for patients with thick (>2 mm) localised cutaneous melanoma at a follow-up of median 19·6 years. These findings support the use of 2-cm excision margins in current clinical practice. FUNDING: The Swedish Cancer Society, Stockholm Cancer Society, the Swedish Society for Medical Research, Radiumhemmet Research funds, Stockholm County Council, Wallström funds.

Acute symptomatic seizures and epilepsy after mechanical thrombectomy.

PURPOSE: The purpose of this study was to assess the incidence of acute symptomatic seizures and poststroke epilepsy (PSE) in a well-characterized cohort of patients treated with mechanical thrombectomy. In addition, we aimed to describe the dynamics of blood markers of brain injury in patients that developed PSE. METHODS: Participants of the prospective AnStroke Trial of anesthesia method during mechanical thrombectomy were included and acute symptomatic seizures and PSE ascertained by medical records review. Blood markers neurofilament light (NFL), tau, glial fibrillary acidic protein (GFAP), S100 calcium-binding protein B (S100B), and neuron-specific enolase (NSE) were assessed. RESULTS: A total of 90 patients with acute anterior ischemic stroke were included. Median National Institutes of Health Stroke Scale (NIHSS) at admission to hospital was 18 (IQR 15-22). Recanalization was achieved in 90%. No patients had epilepsy prior to the ischemic stroke. Four patients (4.4%) had acute symptomatic seizures and four patients (4.4%) developed PSE during the follow-up time (to death or last medical records review) of 0-4.5 years (median follow-up 1070 days IQR 777-1306), resulting in a two-year estimated PSE risk of 5.3% (95%CI: 0.2-10.4%). Blood markers of brain injury (NFL, tau, GFAP, S100B, and NSE) were generally above the cohort median in patients that developed PSE. CONCLUSIONS: The incidence of PSE after mechanical thrombectomy was low in our cohort. All blood biomarkers displayed interesting sensitivity and specificity. However, the number of PSE cases was small and more studies are needed on risk factors for PSE after mechanical thrombectomy. The potential of blood markers of brain injury markers to contribute to assessment of PSE risk should be explored further. This article is part of the Special Issue "Seizures & Stroke".

Effects of case definition and assessment frequency on lameness incidence estimates.

The reliability of locomotion scoring is often low, making it unclear how a single gait score should be interpreted. In addition, differences in assessment frequency between longitudinal studies makes it hard to compare results. Our aims were to evaluate how lameness definition and assessment frequency affect measures of lameness incidence. Six dairy farms in British Columbia, Canada, were enrolled, and 262 cows that were sound at dry-off had their locomotion score (LS) assessed weekly from dry-off to calving, using a 1 to 5 scale. Cows were categorized as remaining sound or becoming lame using 3 different case definitions (LAME1: ≥LS3 at least once; LAME2: ≥2 consecutive scores of LS3, or ≥LS4 at least once; and LAME3: ≥3 consecutive scores of LS3, or ≥LS4 at least once). We analyzed the correspondence between the 3 definitions with percent agreement and weighted κ (linear and quadratic weighting). Comparing LAME1 to LAME3 resulted in lower percent agreement (53%) and κ values (linear κw = 0.50; quadratic κw = 0.64) than comparing LAME2 and LAME3 (85%; linear κw = 0.83; quadratic κw = 0.89), indicating that cows scored LS3 twice were likely to be scored LS3 a third time. We also compared the 3 case definitions against trim records from trimmings occurring 90 d or less before calving (n = 117), and used logistic regression models to determine sensitivity, specificity, and positive and negative predictive value. Using the LAME1 criterion resulted in high sensitivity (horn lesions = 0.90; infectious lesions = 0.92) and low specificity (horn = 0.21; infectious = 0.24). We observed higher specificity for LAME2 (horn = 0.62; infectious = 0.66) and LAME3 (horn = 0.71; infectious = 0.77), but LAME2 had higher sensitivity than LAME3 (horn = 0.89 vs. 0.64; infectious = 0.69 vs. 0.64). When evaluating the effects of assessment frequency, we obtained 3 data sets by keeping every, every other, and every third locomotion assessment, and using LAME2 as a case definition. More cows were categorized as lame when assessment frequency increased. Of the cows that were classified as lame when assessed weekly, 72% of the mildly lame, and 33% of the severely lame were classified as sound when assessed every third week. Our results suggest that a single LS3 score should not be used as a criterion for lameness in longitudinal studies. To correctly identify new cases of lameness, dairy cows should be assessed at least every 2 wk.

The relationship between transition period diseases and lameness, feeding time, and body condition during the dry period.

In this longitudinal study, we tested the hypothesis that cows that are lame around dry-off are at increased risk of transition diseases (TD), including metritis, subclinical ketosis (SCK), retained fetal membranes, hypocalcemia, or displaced abomasum. We also hypothesized that the relationship between lameness and TD would be mediated through reduced feeding time. We enrolled 461 cows at 9 wk before their expected calving date on 6 commercial freestall farms in the lower Fraser Valley, British Columbia, Canada. Cows were gait-scored weekly using a scale of 1 to 5. Lameness status was classified based on consecutive gait scores as lame (2 consecutive gait scores = 3 or 1 score ≥4) or sound (2 consecutive gait scores ≤2). Lameness status was summarized as (1) lameness at dry-off (sound or lame); (2) lameness group (always sound = sound on all visits, chronically lame = lame on all visits, and other = changed from sound to lame or vice versa); and (3) proportion of weeks lame during the dry period. Body condition scores were recorded at dry-off and at calving and collectively used to calculate change in body condition for each cow. A subsample of cows (n = 159) was evaluated for feeding time once a week during the dry period. All cows were evaluated for SCK (positive = ß-hydroxybutyrate ≥1.2 mmol/L) and metritis (positive = foul smell, red/brown watery vaginal discharge) every 3 to 4 d between d 3 and 17 after calving. We retrieved data on treatment of retained fetal membranes, hypocalcemia, and displaced abomasum during the first 17 d after calving, cow parity, and milk production in the previous lactation from farm records. We created a binary variable, TD (any of SCK, metritis, retained fetal membranes, hypocalcemia, or displaced abomasum), to differentiate between healthy cows and cows that developed TD. Lameness at dry-off was associated with the occurrence of metritis and TD, but not with SCK. Cows that were chronically lame and cows that had an increased proportion of weeks lame during the dry period had higher occurrence of metritis and TD. Lameness was also associated with reduced feeding time, which in turn was associated with increased likelihood of SCK and TD, but not with metritis. Lameness was not associated with change in body condition; however, cows that lost body condition score during the dry period had increased odds of developing SCK, metritis, and TD. Change in body condition was highly associated with body condition score at dry-off. These results suggest that association between lameness and TD is partially mediated through reduced feeding time.

Identification of the optimal combination dosing schedule of neoadjuvant ipilimumab plus nivolumab in macroscopic stage III melanoma (OpACIN-neo): a multicentre, phase 2, randomised, controlled trial.

BACKGROUND: The outcome of patients with macroscopic stage III melanoma is poor. Neoadjuvant treatment with ipilimumab plus nivolumab at the standard dosing schedule induced pathological responses in a high proportion of patients in two small independent early-phase trials, and no patients with a pathological response have relapsed after a median follow up of 32 months. However, toxicity of the standard ipilimumab plus nivolumab dosing schedule was high, preventing its broader clinical use. The aim of the OpACIN-neo trial was to identify a dosing schedule of ipilimumab plus nivolumab that is less toxic but equally effective. METHODS: OpACIN-neo is a multicentre, open-label, phase 2, randomised, controlled trial. Eligible patients were aged at least 18 years, had a WHO performance status of 0-1, had resectable stage III melanoma involving lymph nodes only, and measurable disease according to the Response Evaluation Criteria in Solid Tumors version 1.1. Patients were enrolled from three medical centres in Australia, Sweden, and the Netherlands, and were randomly assigned (1:1:1), stratified by site, to one of three neoadjuvant dosing schedules: group A, two cycles of ipilimumab 3 mg/kg plus nivolumab 1 mg/kg once every 3 weeks intravenously; group B, two cycles of ipilimumab 1 mg/kg plus nivolumab 3 mg/kg once every 3 weeks intravenously; or group C, two cycles of ipilimumab 3 mg/kg once every 3 weeks directly followed by two cycles of nivolumab 3 mg/kg once every 2 weeks intravenously. The investigators, site staff, and patients were aware of the treatment assignment during the study participation. Pathologists were masked to treatment allocation and all other data. The primary endpoints were the proportion of patients with grade 3-4 immune-related toxicity within the first 12 weeks and the proportion of patients achieving a radiological objective response and pathological response at 6 weeks. Analyses were done in all patients who received at least one dose of study drug. This trial is registered with ClinicalTrials.gov, number NCT02977052, and is ongoing with an additional extension cohort and to complete survival analysis. FINDINGS: Between Nov 24, 2016 and June 28, 2018, 105 patients were screened for eligibility, of whom 89 (85%) eligible patients were enrolled and randomly assigned to one of the three groups. Three patients were excluded after randomisation because they were found to be ineligible, and 86 received at least one dose of study drug; 30 patients in group A, 30 in group B, and 26 in group C (accrual to this group was closed early upon advice of the Data Safety Monitoring Board on June 4, 2018 because of severe adverse events). Within the first 12 weeks, grade 3-4 immune-related adverse events were observed in 12 (40%) of 30 patients in group A, six (20%) of 30 in group B, and 13 (50%) of 26 in group C. The difference in grade 3-4 toxicity between group B and A was -20% (95% CI -46 to 6; p=0·158) and between group C and group A was 10% (-20 to 40; p=0·591). The most common grade 3-4 adverse events were elevated liver enzymes in group A (six [20%)]) and colitis in group C (five [19%]); in group B, none of the grade 3-4 adverse events were seen in more than one patient. One patient (in group A) died 9·5 months after the start of treatment due to the consequences of late-onset immune-related encephalitis, which was possibly treatment-related. 19 (63% [95% CI 44-80]) of 30 patients in group A, 17 (57% [37-75]) of 30 in group B, and nine (35% [17-56]) of 26 in group C achieved a radiological objective response, while pathological responses occurred in 24 (80% [61-92]) patients in group A, 23 (77% [58-90]) in group B, and 17 (65% [44-83]) in group C. INTERPRETATION: OpACIN-neo identified a tolerable neoadjuvant dosing schedule (group B: two cycles of ipilimumab 1 mg/kg plus nivolumab 3 mg/kg) that induces a pathological response in a high proportion of patients and might be suitable for broader clinical use. When more mature data confirm these early observations, this schedule should be tested in randomised phase 3 studies versus adjuvant therapies, which are the current standard-of-care systemic therapy for patients with stage III melanoma. FUNDING: Bristol-Myers Squibb.

Lameness during the dry period: Epidemiology and associated factors.

Lameness has been extensively studied in lactating cows, whereas few studies have reported on lameness during the dry period. We conducted a prospective longitudinal study to describe the epidemiology of lameness during the dry period and to identify risk factors associated with onset, cure, and chronic cases of lameness. A total of 455 cows from 6 freestall commercial dairy farms were enrolled at 9 wk before calving and gait scored weekly until calving using a 5-point scale. A subset of cows was also followed fortnightly after calving to measure the association between lameness during the dry period and lameness during early lactation. Body condition score (BCS) was assessed in a 5-point scale using increments of 0.5. Hoof-trimming records, parity, and previous lactation milk production were retrieved from farm's database. Cows were considered sound when 2 consecutive scores were ≤2 and lame when 2 consecutive scores = 3, or any assessment with score >3; when in a sequence of scores only one score = 3 (or ≤2), the cow was considered sound (or alternatively lame). Following this lameness definition, we derived weekly lameness status for each cow and calculated the number of new cases of lameness, the number of cure cases and the number of chronic cases. The incidence rate of lameness cases during the dry period was 8.2 lameness cases/100 cow per wk, whereas cure rate was 7.1 cure cases/100 cow per wk; at the end of the dry period 50% of cows had developed lameness and 36% were cured. Multilevel logistic regression models using farm as random effect were fitted to assess (1) the association between being lame in wk 2 or 8 postcalving with being lame in the last week precalving, (2) risk factors for lameness onset, (3) risk factors for lameness cure, and (4) risk factors for chronic lameness. Cows that were lame in the week immediately before calving were more likely to be lame in wk 2 and 8 after calving. We found that the interaction between parity and hoof-trimming before dry-off was associated with lameness onset; primiparous cows that were trimmed before dry-off had lower odds of developing lameness, whereas the opposite was found for multiparous cows. The same interaction was also associated with the odds of chronic lameness. Cows that were diagnosed with noninfectious hoof lesions compared with cows that were not diagnosed with hoof lesions before dry-off, and cows that had BCS <3 compared with cows with BCS 3.0 to 3.5 at dry-off had higher odds of chronic lameness. Conversely, primiparous cows and cows with BCS 3.0 to 3.5 had higher odds of curing lameness during the dry period. Our results suggest that the dry period may be a period of high risk for lameness development and that hoof-trimming before dry-off may not be effective for all cows.

Reduced disease-specific survival following a diagnosis of multiple primary cutaneous malignant melanomas-a nationwide, population-based study.

Outcome data comparing patients with multiple primary invasive cutaneous malignant melanomas (MPMs) to single primary invasive cutaneous malignant melanomas (SPMs) show conflicting results. We have analyzed differences in disease-specific survival between these patients in a nationwide population-based setting. From the Swedish Melanoma Register, 27,235 patients were identified with a first invasive cutaneous malignant melanoma (CMM) between 1990 and 2007, followed-up through 2013. Of these, 700 patients developed MPMs. Cox proportional hazard regression was used for adjusted cause-specific hazard ratios (HRs). An interval of ≤5 years between CMM diagnoses was significantly correlated to a decreased CMM-specific survival in Stage I-II MPM- vs. SPM-patients (HR 1.32; 95% CI 1.04-1.67; p = 0.02). MPM-patients with longer time interval between diagnoses experienced similar risk of CMM-death as SPM-patients. The risk of CMM-death increased by almost 50% above the expected outcome according to stage of the index CMM by the diagnosis of a second CMM (HR 1.48; 95% CI 1.19-1.85; p < 0.001). MPM vs. SPM-patients had a worse outcome (HR 1.38; 95% CI 1.05-1.83; p = 0.001). This emphasizes the importance of prevention efforts in SPM-patients to decrease the risk of subsequent CMMs and has implications for more vigilant follow-up in MPM-patients.

The role of germline alterations in the DNA damage response genes BRIP1 and BRCA2 in melanoma susceptibility.

We applied a targeted sequencing approach to identify germline mutations conferring a moderately to highly increased risk of cutaneous and uveal melanoma. Ninety-two high-risk melanoma patients were screened for inherited variation in 120 melanoma candidate genes. Observed gene variants were filtered based on frequency in reference populations, cosegregation with melanoma in families and predicted functional effect. Several novel or rare genetic variants in genes involved in DNA damage response, cell-cycle regulation and transcriptional control were identified in melanoma patients. Among identified genetic alterations was an extremely rare variant (minor allele frequency of 0.00008) in the BRIP1 gene that was found to cosegregate with the melanoma phenotype. We also found a rare nonsense variant in the BRCA2 gene (rs11571833), previously associated with cancer susceptibility but not with melanoma, which showed weak association with melanoma susceptibility in the Swedish population. Our results add to the growing knowledge about genetic factors associated with melanoma susceptibility and also emphasize the role of DNA damage response as an important factor in melanoma etiology. © 2016 Wiley Periodicals, Inc.

The proportion cured of patients diagnosed with Stage III-IV cutaneous malignant melanoma in Sweden 1990-2007: A population-based study.

The survival in cutaneous malignant melanoma (CMM) is highly dependent on the stage of the disease. Stage III-IV CMM patients are at high risk of relapse with a heterogeneous outcome, but not all experience excess mortality due to their disease. This group is referred to as the cure proportion representing the proportion of patients who experience the same mortality rate as the general population. The aim of this study was to estimate the cure proportion of patients diagnosed with Stage III-IV CMM in Sweden. From the population-based Swedish Melanoma Register, we included 856 patients diagnosed with primary Stage III-IV CMM, 1990-2007, followed-up through 2013. We used flexible parametric cure models to estimate cure proportions and median survival times (MSTs) of uncured by sex, age, tumor site, ulceration status (in Stage III patients) and disease stage. The standardized (over sex, age and site) cure proportion was lower in Stage IV CMMs (0.15, 95% CI 0.09-0.22) than non-ulcerated Stage III CMMs (0.48, 95% CI 0.41-0.55) with a statistically significant difference of 0.33 (95% CI = 0.24-0.41). Ulcerated Stage III CMMs had a cure proportion of 0.27 (95% CI 0.21-0.32) with a statistically significant difference compared to non-ulcerated Stage III CMMs (difference 0.21; 95% CI = 0.13-0.30). The standardized MST of uncured was approximately 9-10 months longer for non-ulcerated versus ulcerated Stage III CMMs. We could demonstrate a significantly better outcome in patients diagnosed with non-ulcerated Stage III CMMs compared to ulcerated Stage III CMMs and Stage IV disease after adjusting for age, sex and tumor site.