Association of Race and Risk of Future Scleroderma Renal Crisis at Systemic Sclerosis Diagnosis.

OBJECTIVE: Scleroderma renal crisis (SRC) is a rare and severe manifestation of systemic sclerosis (SSc). Although it is well documented that Black patients with SSc have worse morbidity and mortality than non-Black patients, racial predilection for SRC is underreported. We examine the association of race and future development of SRC in an SSc cohort. METHODS: Using the electronic health record of the US Military Health System, we conducted a comprehensive chart review of each patient with SSc from 2005 to 2016. The final study cohort was comprised of 31 SRC cases and 322 SSc without SRC controls. We conducted logistic regression of SRC as the outcome variable and race (Black versus non-Black) as the primary predictor variable, adjusted for age, estimated glomerular filtration rate, hypertension, and proteinuria at SSc diagnosis. RESULTS: Of 353 patients, 294 had identifiable race (79 Black, 215 non-Black). Thirteen of 79 Black patients (16.5%) versus 16 of 215 (7.4%) non-Black patients developed SRC (P = 0.02). On adjusted analysis, Black patients had a significantly higher risk of developing SRC than non-Black patients (odds ratio 6.4 [95% confidence interval 1.3-31.2], P = 0.02). Anti-Ro antibody was present in a higher proportion of Black SRC patients versus Black patients without SRC (45% versus 14%, P = 0.01). Conversely, older age, thrombocytopenia, and anti-RNA polymerase III antibody at SSc diagnosis were significantly associated with future SRC in the non-Black cohort. CONCLUSION: Black race was independently associated with a higher risk of future SRC. Further studies are needed to elucidate the mechanisms that underlie this important association.

Abdominal and perineal hernia rates following vertical rectus abdominis myocutaneous (VRAM) flap reconstruction - a supraregional experience.

BACKGROUND: Vertical rectus abdominis myocutaneous (VRAM) flap has proven to be a robust reconstruction method following radical pelvic surgery. Radical pelvic surgery is associated with high morbidity due to pelvic complications and non-healing perineal wounds, as a result of non-collapsible pelvic dead space and pre-operative adjuvant radiotherapy insult. VRAM flap reconstruction addresses both issues by obliterating the dead space and introducing healthy non-radiated tissue. However, flap reconstruction complications can include donor site hernias (abdominal wall), perineal hernias, and flap-specific complications. This study aimed to evaluate the abdominal and perineal hernia rates as well as radiological evidence of flap vascularity post-operatively. METHODS: We conducted a retrospective analysis of patients who underwent a VRAM flap reconstruction following radical pelvic surgery at Christchurch hospital over a 10-year period. We identified the presence of donor site hernias (abdominal wall hernias), perineal hernias, and flap vascularity on post-operative radiological imaging performed within 48 months. RESULTS: Seventy-seven patients underwent a VRAM flap reconstruction of which 60 patients met the inclusion requirements for the study (mean age was 60.3 years [range 26-89]; 31 were male and 29 were female). Eighteen patients underwent an APR and 42 underwent a partial or a complete pelvic exenteration and the majority of them (75.0%) were for rectal cancers. Available imaging was on average 21.6 months post-operatively (IQR 11.8-31.3 months). The donor site hernia rate was 16.7%, and the perineal hernia rate was 3.3%. VRAM flap appeared to have DIEA flow in 98.3% of the patients. CONCLUSION: VRAM flap reconstruction of complex pelvic defects remains a robust method of choice in complex pelvic reconstruction with little morbidity.

Autoantibodies are present before the clinical diagnosis of systemic sclerosis.

Systemic sclerosis (SSc) is a heterogeneous autoimmune disorder associated with vascular dysfunction and fibrotic changes in the skin, vasculature and internal organs. Although serologic abnormalities are an important diagnostic tool for SSc, little is known about whether autoantibodies precede clinical diagnosis. Here we investigated the presence of autoantibodies before SSc diagnosis and assessed whether certain autoantibodies might associate with the future onset of scleroderma renal crisis (SRC), a potentially fatal complication of the disease. Using the Department of Defense Serum Repository, autoantibodies were analyzed from archived, prospectively collected, longitudinal serum samples from sixteen individuals with SRC (SSc/SRC) and thirty cases of SSc without SRC (SSc/no SRC), matched for age, sex, and race. Seventy five percent (12/16) of the SSc/SRC and 40% (12/30) of the SSc/no SRC were seropositive for at least one autoantibody prior to clinical diagnosis (up to 27.1 years earlier, mean = -7.4 years). Although both disease groups demonstrated a heterogeneous immunoreactivity profile against the autoantigen panel, the SSc/SRC subjects showed two enriched clusters with one featuring elevated levels of autoantibodies against Ro52 and/or Ro60 and another with high levels of immunoreactivity against the RNA polymerase complex. Consistent with larger spectrum of immunoreactivity and the elevated levels of autoantibodies in SSc/SRC, the total response against the autoantigen panel from the last time point of the seropositive subjects revealed that the SSc/SRC cohort harbored higher antibody levels (p = 0.02) compared to SSc/no SRC. Overall, our findings demonstrate that relevant seropositive autoantibodies often precede the clinical diagnosis of SSc/no SRC and SSc/SRC.

Risk Factors for Future Scleroderma Renal Crisis at Systemic Sclerosis Diagnosis.

OBJECTIVE: Systemic sclerosis (SSc) is a disease of autoimmunity, fibrosis, and vasculopathy. Scleroderma renal crisis (SRC) is one of the most severe complications. Corticosteroid exposure, presence of anti-RNA polymerase III antibodies (ARA), skin thickness, and significant tendon friction rubs are among the known risk factors at SSc diagnosis for developing future SRC. Identification of additional clinical characteristics and laboratory findings could expand and improve the risk profile for future SRC at SSc diagnosis. METHODS: In this retrospective cohort study of the entire military electronic medical record between 2005 and 2016, we compared the demographics, clinical characteristics, and laboratory results at SSc diagnosis for 31 cases who developed SRC after SSc diagnosis to 322 SSc without SRC disease controls. RESULTS: After adjustment for potential confounding variables, at SSc diagnosis these conditions were all associated with future SRC: proteinuria (p < 0.001; OR 183, 95% CI 19.1-1750), anemia (p = 0.001; OR 9.9, 95% CI 2.7-36.2), hypertension (p < 0.001; OR 13.1, 95% CI 4.7-36.6), chronic kidney disease (p = 0.008; OR 20.7, 95% CI 2.2-190.7), elevated erythrocyte sedimentation rate (p < 0.001; OR 14.3, 95% CI 4.8-43.0), thrombocytopenia (p = 0.03; OR 7.0, 95% CI 1.2-42.7), hypothyroidism (p = 0.01; OR 2.8, 95% CI 1.2-6.7), Anti-Ro antibody seropositivity (p = 0.003; OR 3.9, 95% CI 1.6-9.8), and ARA (p = 0.02; OR 4.1, 95% CI 1.2-13.8). Three or more of these risk factors present at SSc diagnosis was sensitive (77%) and highly specific (97%) for future SRC. No SSc without SRC disease controls had ≥ 4 risk factors. CONCLUSION: In this SSc cohort, we present a panel of risk factors for future SRC. These patients may benefit from close observation of blood pressure, proteinuria, and estimated glomerular filtration rate, for earlier SRC identification and intervention. Future prospective therapeutic studies could focus specifically on this high-risk population.

Western corn rootworm larval movement in SmartStax seed blend scenarios.

Insect resistance management (IRM) can extend the lifetime of management options, but depends on extensive knowledge of the biology of the pest species involved for an optimal plan. Recently, the Environmental Protection Agency (EPA) registered seed blends refuge for two of the transgenic Bacillus thuringiensis (Bt) corn products targeting the western corn rootworm, Diabrotica virgifera virgifera LeConte. Larval movement between Bt and isoline plants can be detrimental to resistance management for high dose Bt products because the larger larvae can be more tolerant of the Bt toxins. We assessed movement of western corn rootworm larvae among four spatial arrangements of SmartStax corn (expressing both the Cry34/35Ab1 and Cry3Bb1 proteins) and isoline plants by infesting specific plants with wild type western corn rootworm eggs. Significantly fewer western corn rootworm larvae, on average, were recovered from infested SmartStax plants than infested isoline plants, and the SmartStax plants were significantly less damaged than corresponding isoline plants. However, when two infested isoline plants surrounded a SmartStax plant, a significant number of larvae moved onto the SmartStax plant late in the season. These larvae caused significant damage both years and produced significantly more beetles than any other plant configuration in the study (including isoline plants) in the first year of the study. This plant configuration would occur rarely in a 5% seed blend refuge and may produce beetles of a susceptible genotype because much of their initial larval development was on isoline plants. Results are discussed in terms of their potential effects on resistance management.

Spatial distribution of Aphis glycines (Hemiptera: Aphididae): a summary of the suction trap network.

The soybean aphid, Aphis glycines Matsumura (Hemiptera: Aphididae), is an economically important pest of soybean, Glycine max (L.) Merrill, in the United States. Phenological information of A. glycines is limited; specifically, little is known about factors guiding migrating aphids and potential impacts of long distance flights on local population dynamics. Increasing our understanding of A. glycines population dynamics may improve predictions of A. glycines outbreaks and improve management efforts. In 2005 a suction trap network was established in seven Midwest states to monitor the occurrence of alates. By 2006, this network expanded to 10 states and consisted of 42 traps. The goal of the STN was to monitor movement of A. glycines from their overwintering host Rhamnus spp. to soybean in spring, movement among soybean fields during summer, and emigration from soybean to Rhamnus in fall. The objective of this study was to infer movement patterns of A. glycines on a regional scale based on trap captures, and determine the suitability of certain statistical methods for future analyses. Overall, alates were not commonly collected in suction traps until June. The most alates were collected during a 3-wk period in the summer (late July to mid-August), followed by the fall, with a peak capture period during the last 2 wk of September. Alate captures were positively correlated with latitude, a pattern consistent with the distribution of Rhamnus in the United States, suggesting that more southern regions are infested by immigrants from the north.

Autoimmune pancreatitis and primary sclerosing cholangitis in a 16-year-old boy with inflammatory bowel disease.

Autoimmune pancreatitis (AIP) is a rare systemic fibroinflammatory disorder. The disease usually occurs in elderly men and offers an excellent response to steroid treatment. AIP in childhood is exceedingly rare. We report the first case of AIP in a boy with primary sclerosing cholangitis (PSC) and inflammatory bowel disease (IBD). He presented with a six-year history of intermittent bloody diarrhoea. Colonoscopy revealed severe pancolitis and ileitis in keeping with IBD. Abnormal liver function tests and magnetic resonance cholangiopancreatography (MRCP) findings confirmed PSC and subsequent occurrence of renal lesions and pancreatic abnormalities on computed tomography imaging were suspicious for AIP. Immunoglobulin G4 (IgG4) serum levels were elevated and treatment with steroids led to complete resolution of renal lesions, pancreatic changes and normalization of IgG4 and liver function tests. Follow-up MRCP 6 months later revealed unchanged biliary abnormalities in keeping with PSC. The differentiation between PSC and extrapancreatic AIP affecting the biliary tree and liver is critical given the dramatic response of AIP to steroids. Recent recommendations therefore include IgG4 measurement in every adult with possible PSC. Our case documents for the first time that AIP has to be considered as a differential diagnosis in childhood PSC. IgG4 measurement should be recommended universally in possible PSC.

Population growth of soybean aphid, Aphis glycines, under varying levels of predator exclusion.

Although soybean aphid, Aphis glycines Matsumura (Hemiptera: Aphididae), has caused economic damage in several Midwestern states, growers in Missouri have experienced relatively minor damage. To evaluate whether existing predatory insect populations are capable of suppressing or preventing soybean aphid population growth or establishment in Missouri, a predator exclusion study was conducted to gauge the efficacy of predator populations. Three levels of predator exclusion were used; one that excluded all insects (small mesh), one that excluded insects larger than thrips (medium mesh), and one that excluded insects larger than Orius insidiosus (Say) (Hemiptera: Anthocoridae), a principal predator (large mesh). Along with manipulating predator exposure, timing of aphid arrival (infestation) was manipulated. Three infestation times were studied; vegetative (V5), beginning bloom (R1), and beginning pod set (R3). Timing of aphid and predator arrival in a soybean field may affect the soybean aphid's ability to establish and begin reproducing. Cages infested at V5 and with complete predator exclusion reached economic threshold within two weeks, while cages with predators reached economic threshold in four and a half weeks. Cages infested at R1 with complete predator exclusion reached economic threshold within five weeks; cages with predators reached economic threshold within six weeks. Cages infested at R3 never reached threshold (with or without predators). The predator population in Missouri seems robust, capable of depressing the growth of soybean aphid populations once established, and even preventing establishment when the aphid arrived late in the field.

Distribution of the long-horned beetle, Dectes texanus, in soybeans of Missouri, Western Tennessee, Mississippi, and Arkansas.

The long-horned beetle, Dectes texanus LeConte (Coleoptera: Cerambycidae), is a stem-boring pest of soybeans, Glycine max (L.) Merrill (Fabales: Fabaceae). Soybean stems and stubble were collected from 131 counties in Arkansas, Mississippi, Missouri, and Tennessee and dissected to determine D. texanus infestation rates. All states sampled had D. texanus present in soybeans. Data from Tennessee and Arkansas showed sample infestations of D. texanus averaging nearly 40%. Samples from Missouri revealed higher infestation in the twelve southeastern counties compared to the rest of the state. Data from Mississippi suggested that D. texanus is not as problematic there as in Arkansas, Missouri, and Tennessee. Infestation rates from individual fields varied greatly (0-100%) within states. In Tennessee, second crop soybeans (i.e. soybeans planted following winter wheat) had lower infestations than full season soybeans. A map of pest distribution is presented that documents the extent of the problem, provides a baseline from which changes can be measured, contributes data for emergency registration of pesticides for specific geographic regions, and provides useful information for extension personnel, crop scouts, and growers.