SMT-738: a novel small-molecule inhibitor of bacterial lipoprotein transport targeting Enterobacteriaceae

Carbapenem-resistant Enterobacteriaceae (CREs) are described by the Centers for Disease Control as an urgent threat, and there is a critical need for new therapeutic agents able to treat infections caused by these pathogens. Herein, we describe the microbiological profile, the mechanism f action, and the in vitro safety as well as the pharmacokinetic (PK)/PD profile of SMT-738, a small molecule belonging to a new chemical class. SMT-738 is active against Enterobacterales [including multi-drug-resistant Escherichia coli with 90% of isolates having a minimum inhibitory concentration (MIC90) of 1 µg/mL and Klebsiella pneumoniae 2 µg/mL] and inactive against a broad panel of Gram-negative and Gram-positive pathogens. SMT-738 displays rapid bactericidal activity (2-4 h) and has a low propensity for resistance development (less than ~10-9). Characterization of resistant mutants following exposure to SMT-738 identified mutations within the lipoprotein transport complex (LolCDE), a clinically unexploited and essential bacterial molecular target in Gram-negative bacteria. SMT-738 has a promising in vitro toxicology profile. Furthermore, PK studies demonstrated that when dosed intravenously, SMT-738 maintained exposure levels across infection sites (bloodstream/urinary tract/lung). Proof-of-concept studies across multiple murine in vivo infection models (bloodstream/pneumonia/urinary tract) demonstrated that SMT-738 significantly reduced the bacterial burden compared to baseline and vehicle control. SMT-738 represents a promising novel drug candidate being developed to address clinically challenging serious life-threatening infections caused by highly resistant Enterobacteriaceae including CRE.

Molecular insight into CREBBP and TANGO2 variants causing intellectual disability

BACKGROUND

Intellectual disability (ID) can be associated with different syndromes such as Rubinstein-Taybi syndrome (RSTS) and can also be related to conditions such as metabolic encephalomyopathic crises, recurrent,with rhabdomyolysis, cardiac arrhythmias and neurodegeneration. Rare congenital RSTS1 (OMIM 180849) is characterized by mental and growth retardation, significant and duplicated distal phalanges of thumbs and halluces, facial dysmorphisms, and an elevated risk of malignancies. Microdeletions and point mutations in the CREB-binding protein (CREBBP) gene, located at 16p13.3, have been reported to cause RSTS. By contrast, TANGO2-related metabolic encephalopathy and arrhythmia (TRMEA) is a rare metabolic condition that causes repeated metabolic crises, hypoglycemia, lactic acidosis, rhabdomyolysis, arrhythmias and encephalopathy with cognitive decline. Clinicians need more clinical and genetic evidence to detect and comprehend the phenotypic spectrum of this disorder.

METHODS

Exome sequencing was used to identify the disease-causing variants in two affected families A and B from District Kohat and District Karak, Khyber Pakhtunkhwa. Affected individuals from both families presented symptoms of ID, developmental delay and behavioral abnormalities. The validation and co-segregation analysis of the filtered variant was carried out using Sanger sequencing.

RESULTS

In the present study, two families (A and B) exhibiting various forms of IDs were enrolled. In Family A, exome sequencing revealed a novel missense variant (NM 004380.3: c.4571A>G; NP_004371.2: p.Lys1524Arg) in the CREBBP gene, whereas, in Family B, a splice site variant (NM 152906.7: c.605 + 1G>A) in the TANGO2 gene was identified. Sanger sequencing of both variants confirmed their segregation with ID in both families. The in silico tools verified the aberrant changes in the CREBBP protein structure. Wild-type and mutant CREBBP protein structures were superimposed and conformational changes were observed likely altering the protein function.

CONCLUSIONS

RSTS and TRMEA are exceedingly rare disorders for which specific clinical characteristics have been clearly established, but more investigations are underway and required. Multicenter studies are needed to increase our understanding of the clinical phenotypes, mainly showing the genotype-phenotype associations.

Structural and functional implications of SLC13A3 and SLC9A6 mutations: an in silico approach to understanding intellectual disability

BACKGROUND

Intellectual disability (ID) is a condition that varies widely in both its clinical presentation and its genetic underpinnings. It significantly impacts patients' learning capacities and lowers their IQ below 70. The solute carrier (SLC) family is the most abundant class of transmembrane transporters and is responsible for the translocation of various substances across cell membranes, including nutrients, ions, metabolites, and medicines. The SLC13A3 gene encodes a plasma membrane-localized Na+/dicarboxylate cotransporter 3 (NaDC3) primarily expressed in the kidney, astrocytes, and the choroid plexus. In addition to three Na + ions, it brings four to six carbon dicarboxylates into the cytosol. Recently, it was discovered that patients with acute reversible leukoencephalopathy and a-ketoglutarate accumulation (ARLIAK) carry pathogenic mutations in the SLC13A3 gene, and the X-linked neurodevelopmental condition Christianson Syndrome is caused by mutations in the SLC9A6 gene, which encodes the recycling endosomal alkali cation/proton exchanger NHE6, also called sodium-hydrogen exchanger-6. As a result, there are severe impairments in the patient's mental capacity, physical skills, and adaptive behavior.

METHODS AND RESULTS

Two Pakistani families (A and B) with autosomal recessive and X-linked intellectual disorders were clinically evaluated, and two novel disease-causing variants in the SLC13A3 gene (NM 022829.5) and the SLC9A6 gene (NM 001042537.2) were identified using whole exome sequencing. Family-A segregated a novel homozygous missense variant (c.1478 C > T; p. Pro493Leu) in the exon-11 of the SLC13A3 gene. At the same time, family-B segregated a novel missense variant (c.1342G > A; p.Gly448Arg) in the exon-10 of the SLC9A6 gene. By integrating computational approaches, our findings provided insights into the molecular mechanisms underlying the development of ID in individuals with SLC13A3 and SLC9A6 mutations.

CONCLUSION

We have utilized in-silico tools in the current study to examine the deleterious effects of the identified variants, which carry the potential to understand the genotype-phenotype relationships in neurodevelopmental disorders.

Autosomal recessive variants c.953A>C and c.97-1G>C in NSUN2 causing intellectual disability: a molecular dynamics simulation study of loss-of-function mechanisms

Introduction

Intellectual disability (ID) is a clinically and genetically heterogeneous disorder. It drastically affects the learning capabilities of patients and eventually reduces their IQ level below 70.

Methods

The current genetic study ascertained two consanguineous Pakistani families suffering from autosomal recessive intellectual developmental disorder-5 (MRT5). We have used exome sequencing followed by Sanger sequencing to identify the disease-causing variants.

Results and discussion

Genetic analysis using whole exome sequencing in these families identified two novel mutations in the NSUN2 (NM_017755.5). Family-A segregated a novel missense variant c.953A>C; p.Tyr318Ser in exon-9 of the NSUN2. The variant substituted an amino acid Tyr318, highly conserved among different animal species and located in the functional domain of NSUN2 known as "SAM-dependent methyltransferase RsmB/NOP2-type". Whereas in family B, we identified a novel splice site variant c.97-1G>C that affects the splice acceptor site of NSUN2. The identified splice variant (c.97-1G>C) was predicted to result in the skipping of exon-2, which would lead to a frameshift followed by a premature stop codon (p. His86Profs^*16). Furthermore, it could result in the termination of translation and synthesis of dysfunctional protein, most likely leading to nonsense-mediated decay. The dynamic consequences of NSUN2 missense variant was further explored together with wildtype through molecular dynamic simulations, which uncovered the disruption of NSUN2 function due to a gain in structural flexibility. The present molecular genetic study further extends the mutational spectrum of NSUN2 to be involved in ID and its genetic heterogeneity in the Pakistani population.

Biallelic Variants in Seven Different Genes Associated with Clinically Suspected Bardet-Biedl Syndrome

Bardet-Biedl syndrome (BBS) is a rare clinically and genetically heterogeneous autosomal recessive multi-systemic disorder with 22 known genes. The primary clinical and diagnostic features include six different hallmarks, such as rod-cone dystrophy, learning difficulties, renal abnormalities, male hypogonadism, post-axial polydactyly, and obesity. Here, we report nine consanguineous families and a non-consanguineous family with several affected individuals presenting typical clinical features of BBS. In the present study, 10 BBS Pakistani families were subjected to whole exome sequencing (WES), which revealed novel/recurrent gene variants, including a homozygous nonsense mutation (c.94C>T; p.Gln32Ter) in the IFT27 (NM_006860.5) gene in family A, a homozygous nonsense mutation (c.160A>T; p.Lys54Ter) in the BBIP1 (NM_001195306.1) gene in family B, a homozygous nonsense variant (c.720C>A; p.Cys240Ter) in the WDPCP (NM_015910.7) in family C, a homozygous nonsense variant (c.505A>T; p.Lys169Ter) in the LZTFL1 (NM_020347.4) in family D, pathogenic homozygous 1 bp deletion (c.775delA; p.Thr259Leufs*21) in the MKKS/BBS5 (NM_170784.3) gene in family E, a pathogenic homozygous missense variant (c.1339G>A; p.Ala447Thr) in BBS1 (NM_024649.4) in families F and G, a pathogenic homozygous donor splice site variant (c.951+1G>A; p?) in BBS1 (NM_024649.4) in family H, a pathogenic bi-allelic nonsense variant in MKKS (NM_170784.3) (c.119C>G; p.Ser40*) in family I, and homozygous pathogenic frameshift variants (c.196delA; p.Arg66Glufs*12) in BBS5 (NM_152384.3) in family J. Our findings extend the mutation and phenotypic spectrum of four different types of ciliopathies causing BBS and also support the importance of these genes in the development of multi-systemic human genetic disorders.

Biallelic mutations in FLG, TGM1, and STS genes segregated with different types of ichthyoses in eight families of Pakistani origin

BACKGROUND

Congenital ichthyosis is a diverse group of keratinization disorders associated with generalized scaling of skin of varying severity. The non-syndromic forms of congenital ichthyosis are further grouped into common ichthyosis (ichthyosis vulgaris and X-linked ichthyosis), autosomal recessive congenital ichthyosis, and keratopathic ichthyosis.

OBJECTIVE

To identify sequence variants involved in different forms of hereditary ichthyoses.

METHODS

We studied eight families with different types of ichthyosis including four families with autosomal recessive congenital ichthyosis and four families with common ichthyosis. Whole exome sequencing and PCR based genotyping was carried out to find out the molecular basis of disease.

RESULTS

In one family, a novel duplication sequence variant NM_002016.2:c.2767dupT; NP_002007.1:p.Ser923PhefsTer2 was identified in FLG gene; in four families a previously reported nonsense sequence variant NM_000359.3:c.232C>T; NP_002007.1:p.Arg78Ter was identified in TGM1 gene, while, in three families of X-linked recessive ichthyosis, the whole STS gene (NM_001320752.2; NP_001307681.2) regions were deleted.

STUDY LIMITATION

Gene expression studies have not been performed that would have strengthened the findings of computational analysis.

CONCLUSION

This study highlights the significance of the c.232C>T variant in the TGM1 gene as a possible founder mutation, complete STS gene deletion as reported previously in Pakistani population, while novel sequence variant in the FLG gene expands the spectrum of variations in this gene. These findings may be used for genetic counseling of the studied families.

Consumer attitude toward Halal food in the case of the United Kingdom: the role of product attributes and marketing stimuli

The Halal market in the United Kingdom is worth $4.5 billion and is anticipated to grow at a rate of 5% each year. In the United Kingdom, there is a growing demand for Halal food, which has resulted in the formation of various unregulated Halal Certification Bodies. In the halal food market, the problem of halal authenticity has recently become a serious concern. The purpose of the paper was to determine the effect of product attributes and marketing stimuli on customer attitudes toward halal food among Muslim customers in the U.K. A cross-sectional study was adopted for this study. The sample of the study included the Muslim customers who have consumed halal food in the U.K. The authors used a survey method to collect the quantitative data. A total of 384 responses were received and data were analysed using SPSS. The findings of the study revealed that product attributes such as country of origin have a significantly greater influence on the customer attitude towards halal food compared to other product attributes. The findings further showed that marketing stimuli such as sales’ location impact on customer attitude however advertisement did not have any impact on customer attitude towards halal food. The finding held perspectives from Muslim customers in the U.K and contributes to the stimulus-organism-response theory by incorporating product attributes and marketing as stimulus factors that affect the internal psychological state i.e., customer’s attitude in the case of the U.K. The implication of this study was to recommend Halal enterprises import halal food from Islamic countries for U.K customers, research the strategic location and select the hypermarkets, that handle halal food with care.

National audit of non-melanoma skin cancer excisions performed by plastic surgery in the UK

A national, multi-centre audit of non-melanoma skin cancer excisions by plastic surgery.

Adult outcomes of complex pulmonary atresia, ventricular septal defect and major aortopulmonary collaterals following repair during childhood, a single centre experience

Background

Complex pulmonary atresia with a ventricular septal defect and major aortopulmonary collateral arteries (PA VSD MAPCA) is a rare and complex form of congenital heart disease. Staged surgical palliation is carried out in childhood, and in expert centres, is associated with good medium term survival. Adult outcomes following transition to adult care are not known.

Purpose

To establish adult outcomes of PA VSD MAPCA following repair during childhood in our institution

Methods

Review of clinical records for outcome data including life status, NYHA class, employment status, re-intervention in adult life, arrhythmia, pregnancy, exercise capacity and mode of death, where known. We predefined our population into two groups based on their status at transition to adult care, A) complete repair with RV-PA conduit and VSD closed and B) repaired but VSD left open.

Results

188 patients from our series have transitioned to adult services. As many were tertiary referrals (nationally and internationally) the local follow up population was 53 adults (54.7% male), mean age of those alive under follow up is 27.2±6.5 years, with a mean follow up of 25.3±6.1 years. There were 43 in group A and 10 in group B. Mortality in the total population was 18.9% (10/53), group A (16.3%), group B (30.0%), mean age at death 37.5±10.3 years and 29.9±8.4 years, 6/10 deaths were sudden. 22.6% of the whole group had DiGeorge/22q11 microdeletion, with a learning deficit in 32.7% of the cohort, where this could be assessed. Reinterventions included RV-PA conduit change, coil occlusion, pacemaker implantation, ICD implantation and ablation procedures, overall 39.6% underwent reintervention in adult life. Pregnancy occurred in 33.3% of 24 female patients. 50% of individuals were found to have undertaken some form of paid work and of these 11.5% had DiGeorge.

Conclusions

Complex PA VSD MAPCA is associated with good late survival with late attrition including sudden death and heart failure. 22q11 is associated with learning deficit and consequent lack of employment. Non 22q11 have good educational outcomes and there is less observed deficit regarding employment. Successful pregnancy is possible within this population.

Funding Acknowledgement

Type of funding sources: None.

The Impact of Living with INOCA

Background

There is limited literature available on the impact of myocardial ischemia but no obstructive coronary arteries (INOCA) on patients' lives.

Purpose

We sought to determine how INOCA impacts the physical, social, and mental health of persons with this diagnosis.

Methods

A survey was made available to all members of the patient support group from INOCA International over a 3-month time period. Fitness was estimated using the Duke Activity Status Index (DASI), assessing levels of activities performed prior to the onset of INOCA symptoms, and after the diagnosis of INOCA. The formula to estimate fitness in metabolic equivalents (METs) = 0.43 × DASI + 9.6 / 3.5

Results

A total of 297 patients with INOCA responded to the survey; 91.2% were women. The most common diagnosis was coronary microvascular dysfunction (64.3%) and coronary artery spasm (50.5%) (Table 1). 34.4% reported living with symptoms for ≥3 years before their diagnosis of INOCA was made. 77.8% who had been told their symptoms were not cardiac. The symptoms the respondents experienced were numerous, but 92.9% reported symptoms of chest pain, pressure, or discomfort. Fitness levels prior to the onset of INOCA symptoms were significantly higher compared to after diagnosed with INOCA (8.6±1.8 METs vs 5.6±1.8 METs; P<0.0001). Most respondents reported an adverse impact on their home life (80.5%), social life (80.1%), mental health (70.4%), outlook on life (69.7%), sex life (55.9%), and their partner/spouse relationship (53.9%). Work life was also affected once living with INOCA: approximately three-quarters had reduced their work hours or stopping work completely, 47.5% retired early, and 38.4% applied for disability. While living with INOCA, for each 1-MET decrease in fitness, there was a loss of 3.0±0.6 days/months of physical health, 1.8±0.6 days/month of mental health, and 2.9±0.7 days/months of inability to perform recreational activities (p<0.0001) (Figure 1).

Conclusions

Living with INOCA has significant impact on physical, mental and social health. Significant physical fitness declines are seen in those living with INOCA and are lower in those experiencing any adverse impact of living with INOCA. Additionally, the impact of INOCA on the ability to work has important economic consequences to both the patient and society. Increased recognition of the impact of INOCA on these aspects of health need to be recognized and further work is needed to better diagnosis and treat the symptoms of INOCA to improve the quality of life, cardiovascular outcomes, and overall health of this frequently encountered cardiovascular disorder.

Funding Acknowledgement

Type of funding sources: None.

Comparative Study between Acacia Nilotica versus Povidone Iodine in Topical Treatment of Omphalocele Major

Well established and common practice in conservative management of omphalocele major is escharotics therapy with different topical agents. Among them mercurochrome, alcohol, silver salts, povidone iodine, acacia nilotca paste are commonly used. It is a comparative study between application of acacia nilotica paste and povidone iodine solution as a primary non surgical treatment of omphalocele major regarding efficacy and safety of these two topical agents. A double blind randomized controlled study was conducted at the department of Paediatric Surgery, Mymensingh Medical College Hospital, Mymensingh, Bangladesh from July 2016 to June 2019. In this study 20 cases of omphalocele major and randomly divided into two equal groups. Group A and Group B treated with acacia nilotica paste and povidone iodine solution respectively. Gastroschisis, ruptured-omphalocele major or omphalocele minor excluded in this study. The size of the fascial defect in cm, time required for full oral feeding tolerance and duration of hospital stay were evaluating parameters. Patients with Group A tolerated full oral feeding earlier, shorter total hospital stay duration and low mortality rate than those from Group B. Application of acacia nilotica is a safe and effective treatment of omphalocele major regarding rapid full oral feeding tolerance, shorter hospital stay and low mortality rate.

363 A Comparative Analysis of Night-Time General Surgical Training

Aim

The aim of surgical training is to ensure trainees acquire competencies to perform as a Day 1 Consultant. The last decade has seen the introduction of European Working Time Directive, NELA guidelines and the revised Junior Doctor Contract. All of these, as well as the COVID 19 pandemic, have caused concerns regarding training. Our aim was to examine any changes to night-time on call activity during this time.

Method

We retrospectively analysed prospectively collected data from 2011, 2018, and 2021, in a busy District General Hospital. The data collection period was 31 days, looking at night-time (8pm to 8am) operative experience, supervision, and non-operative activity. A regression analysis was conducted to compare outcomes. A qualitative survey was used to assess attitudes and confidence.

Results

On average, trainees spent 11% of their time operating independently, 2% operating supervised, 11% attending trauma-calls and 73% clerking/non-educational activities. There was a significant difference between the hours spent on operative versus non-operative activity (P 0.00046) with no differences over the years. Junior trainees did not feel confident operating at night and only 33% of all trainees found night-time training effective.

Conclusions

Nightshifts comprise a substantial proportion of potential training opportunities and managing the unselected emergency take is one of the Capabilities in Practice. Effective solutions must be implemented to help improve night-time surgical experience and confidence in order for this time to be effective for training of both operative and non-operative competency attainment.

Awareness, Social Media, Ethnicity and Religion: are they Responsible for Vaccination Hesitancy? A Systematic Review with Annotated Bibliography

Vaccination is not only a medical term rather it is framed under socio-cultural perspectives and debates as well. Human history is full of illnesses caused bacteria and viruses killing millions of people including children and adults. Technological development in the health sector enabled to combat pathogenic illnesses through different methods whereby vaccination is one of them. However, it is a dilemma that vaccination has faced many barriers including logistical but most importantly sociocultural and religious. In 2019, WHO revealed vaccine hesitancy as a leading threat to health throughout the globe even in the top 10. This study looks to analyze peer reviewed literature to explore barriers to vaccination. Methodologically, this is desk research and systematic review. Numerous databases were searched with key words and purposively studies were selected for this study. A total of 17 most relevant studies were sampled. Findings show that there are four major factors hindering vaccination. 1st cultural and ethnic background matters whereby religion and the belief system are predominant factors. 2nd awareness and educational variables are also there, for instance, it is noted that many people are not aware of vaccination process specifically in case of HPV vaccination. 3rd social media plays a pivotal role whereby misinformation internalizes negative attitudes and misperceptions about vaccines. 4th social media is a key dimension whereby disinformation and misinformation are communicated through platforms whereby some are intentionally circulated. It is suggested that culturally relativism perspective can be helpful in increasing vaccination percentages. It pertains to intervention through culturally approved methods, for example, sensitizing the ethnic backgrounds through their leadership. In addition, vaccination tracking, media campaigns, focus on school level education to include health related course can be helpful.

Spreading Terrorism, Militancy, and Radicalization in Malakand Division Khyber Pakhtunkhwa Pakistan: An Analysis of the Economic Factors

The current study is to analyze the causes of militancy, terrorism, and radicalization where multifarious factors are contributing towards spreading such behavior. However, the study is delimited to focus on the economic factors, including poverty, unemployment and other such factors that lead towards militancy, terrorism, and radical behavior in society. The field information was collected from 200 respondents using purposive sampling technique with stratified approach from 3 strata of the society including businessmen, teachers and clergy or religious class of age 20 and above. The data was collected through a structured interview schedule, and the analysis was made in the form of tables, discussion and the findings have been verified through chi-square test. The findings show that militancy, terrorism, and radicalization have their roots in deep rooted poverty, unemployment, and lack of other life facilities in the area. The study suggests proper planning for provision of jobs, equal distribution of resources among people and provision of life facilities to the masses.

POS0685 LONG-TERM SAFETY AND EFFICACY OF UPADACITINIB IN PATIENTS WITH RHEUMATOID ARTHRITIS: FINAL RESULTS FROM THE BALANCE-EXTEND OPEN-LABEL EXTENSION STUDY

Background

Upadacitinib (UPA) was previously evaluated in two Phase 2, randomized, controlled trials (RCTs) in patients (pts) with rheumatoid arthritis (RA) and inadequate response to tumor necrosis factor inhibitors (BALANCE-1) or methotrexate (BALANCE-2).

Objectives

To assess the final safety and efficacy of UPA in BALANCE-EXTEND, a 312-week open-label extension (OLE) enrolling pts who completed either BALANCE-1 or BALANCE-2.

Methods

All pts initially received UPA 6 mg twice daily (BID). Increase to 12 mg BID was required for pts with <20% improvement in swollen or tender joint counts (S/TJC) at Week 6 or 12, and permitted for those not achieving Clinical Disease Activity Index (CDAI) low disease activity (LDA). Pts with <20% improvement in SJC or TJC 6 weeks after escalation, or at any two consecutive visits, discontinued. Return to 6 mg BID was permitted for safety or tolerability reasons. After January 2017, the 6 and 12 mg BID doses were replaced by 15 and 30 mg once-daily (QD) extended-release equivalents. As-observed efficacy data are shown at Week 312 for three subgroups: pts who received 6 mg BID/15 mg QD throughout (“Never titrated”), those titrated up to 12 mg BID/30 mg QD for efficacy (“Titrated up”), and those titrated up to 12 BID/30 mg QD and then back to 6 mg BID/15 mg QD due to safety concerns (“Titrated up and down”). Exposure-adjusted adverse events (EAERs) per 100 patient-years (PY) of exposure were summarized from OLE Day 1 in all pts who received UPA (Any UPA).

Results

Overall, 493 pts entered the OLE, receiving UPA for ≤6.2 years (Never titrated, n=306; Titrated up, n=149; Titrated up and down, n=38), and 270 pts (54.8%) discontinued, mostly due to withdrawal of consent (16.8%; n=83) or AEs (14.6%; n=72). Mean (standard deviation) duration of UPA exposure was 3.8 (2.4) years (range <1–6.2 years); cumulative exposure was 1863 PY. The AE profile in pts receiving UPA 15 mg was generally similar to the Any UPA population, and to that observed in the Phase 3 UPA 15 mg clinical trial population (Table 1). Efficacy was maintained to Week 312, with 84.5% and 86.6% of pts in the Never titrated group achieving DAS28-CRP ≤3.2 and CDAI LDA, respectively (Figure 1).

Table 1.

Summary of AEs in pts who received UPA 6 mg BID/15 mg QD in the OLE and in the UPA 15 mg Phase 3 study program

BALANCE-EXTEND (UPA 6 mg BID/15 mg QD)UPA 15 mg – Phase 3 programbEvents/100 PY (95 CI)aEvents/100 PY (95% CI)aN=493, PY=1277N=3209, PY=9079Any AE138.4 (132.0, 145.0)205.5 (202.5, 208.5)Any SAE7.9 (6.4, 9.6)12.4 (11.7, 13.2)AE leading to discontinuation4.2 (3.2, 5.5)4.9 (4.4, 5.3)Death0.4 (0.1, 0.9)0.5 (0.4, 0.7)cInfection49.2 (45.5, 53.2)63.9 (62.3, 65.6) Serious infection1.4 (0.8, 2.2)2.8 (2.4, 3.1) Opportunistic infection0.2 (0.0, 0.6)0.3 (0.2, 0.4) Herpes zoster2.0 (1.3, 3.0)3.0 (2.6, 3.3)Anemia1.1 (0.6, 1.8)3.0 (2.7, 3.4)Neutropenia1.3 (0.8, 2.1)2.1 (1.8, 2.5)Lymphopenia1.7 (1.1, 2.6)1.7 (1.4, 1.9)Gastrointestinal perforation0<0.1 (0.0, 0.1)Any malignancy1.2 (0.7, 1.9)1.1 (0.9, 1.4)Non-melanoma skin cancer (NMSC)0.4 (0.1, 0.9)0.4 (0.3, 0.5) Excluding NMSC0.8 (0.4, 1.4)0.7 (0.6, 0.9)Creatinine phosphokinase elevation3.4 (2.5, 4.6)4.4 (4.0, 4.9)Hepatic disorder4.1 (3.0, 5.3)10.2 (9.5, 10.8)Venous thromboembolism0.5 (0.2, 1.0)0.4 (0.3, 0.6)Major adverse cardiovascular event0.5 (0.2, 1.0)0.4 (0.3, 0.5)

aMultiple events occurring in the same pts are counted in the calculation of events/100 PY. bCut-off, June 30, 2021. cBased on 9080 PY.

Conclusion

In this OLE, UPA treatment over ~312 weeks showed sustained long-term efficacy in pts with RA who had completed Phase 2 RCTs. Overall safety results showed that UPA was well tolerated over time; the types and frequencies of AEs were consistent with those in pts with similar populations of moderately to severely active RA receiving Janus kinase inhibitors.

Acknowledgements

AbbVie funded this study; contributed to its design; participated in data collection, analysis, and interpretation of the data; and participated in the writing, review, and approval of the abstract. AbbVie and the authors thank all study investigators for their contributions and the patients who participated in this study. No honoraria or payments were made for authorship. Medical writing support was provided by Dan Booth, PhD, of 2 the Nth (Cheshire, UK), and was funded by AbbVie.

Disclosure of Interests

Alan Kivitz Shareholder of: Amgen, Gilead, GlaxoSmithKline, Novartis, Pfizer, and Sanofi (stocks or options), Consultant of: AbbVie, Amgen, Boehringer Ingelheim, Eli Lilly, Flexion, Genzyme, Gilead, Horizon, Janssen, Merck, Novartis, Pfizer, Regeneron, Sanofi, Sanofi Aventis, SUN Pharma Advanced Research, and UCB, Grant/research support from: AbbVie (his institution received fees for his role as a Principal Investigator in the study), Alvin F. Wells Consultant of: AbbVie, Juan Ignacio Vargas Consultant of: AbbVie, Grant/research support from: AbbVie (as a Principal Investigator in the study), Herbert S.B. Baraf Consultant of: Gilead and Janssen, Grant/research support from: AbbVie, Eli Lilly, Genentech, Gilead, and Janssen, Maureen Rischmueller Consultant of: AbbVie, Bristol-Myers Squibb, CSL Behring, Eli Lilly, Gilead Sciences, Janssen Global Services, Pfizer, Sanofi US Services, and UCB Biosciences, Grant/research support from: AbbVie, Amgen, Bristol-Myers Squibb, Eli Lilly, Janssen Global Services, Novartis, Pfizer, Sanofi Pasteur Biologics, and UCB Biosciences, Justin Klaff Shareholder of: AbbVie (may own stocks or options), Employee of: AbbVie, Nasser Khan Shareholder of: AbbVie (may own stocks or options), Employee of: AbbVie, Yihan Li Shareholder of: AbbVie (may own stocks or options), Employee of: AbbVie, Kyle Carter Shareholder of: AbbVie (may own stocks or options), Employee of: AbbVie, Alan Friedman Shareholder of: AbbVie (may own stocks or options), Employee of: AbbVie, Patrick Durez Speakers bureau: Eli Lilly and Galapagos

AB0652 Prevalence of Interstitial lung disease and pulmonary arterial hypertension in systemic sclerosis patients cohort at a rheumatology referral centre in the United Arab Emirates

Background

Scleroderma, also known as Systemic Sclerosis (SSc), is a connective tissue disease that affects multiple organ systems, including the cardiovascular and respiratory systems, namely, pulmonary arterial hypertension (PAH) and interstitial lung disease (ILD) as the leading causes of death in this patient population.

Objectives

The purpose of this study is to determine the prevalence of PAH and ILD in a cohort of patients diagnosed with SSc.

Methods

We performed a retrospective chart review of clinical characteristics of all patients diagnosed with SSc Cleveland Clinic Abu Dhabi between April 2015 and April 2020. PAH was estimated by echocardiographic findings and diagnosed based on right heart catheterization (RHC) using 2019 World Symposium on Pulmonary Hypertension. The CT scan of the chest was read by a board-certified radiologist in chest radiology.

Results

Fifty individuals were diagnosed with SSc, with 46% having diffuse cutaneous systemic sclerosis and 54% having limited cutaneous systemic sclerosis. The majority of the patients (88%) were female, with a mean age of 41 ±13 years. The average period from presentation to diagnosis was 5 ±5.4 years. The majority of the cohort (86%) were from the United Arab Emirates. The average BMI was 26.0 kg/m2. Patients’ most prevalent symptoms are fatigue (80%), gastrointestinal symptoms (72%) followed by shortness of breath (58%) and cough (50%). Twenty-six out of fifty patients (52%) underwent a CT chest scan, with 19 (38%) having ILD. Eight patients had more than 30% fibrotic alterations, four patients had 10-30% fibrotic changes, and seven patients had less than 10% fibrotic abnormalities. Patients with more than 10% fibrotic changes were more likely to have usual interstitial pneumonia, whereas those with less than 10% fibrotic changes were more likely to have none specific fibrosis. The majority of patients (92%) had echocardiogram. All except one patient had a normal ejection fraction, and five had grade 1 left ventricular diastolic dysfunction. Five patients were described as having mild, 1 moderate and 2 severe PAH. Only 4 patients underwent RHC. One patient had group II PAH based on elevated wedge pressure. One had group 1 PAH with systemic sclerosis as the only cause for her PAH and two patients had group III PAH due to having more than 30 % pulmonary fibrosis and severe restrictive defect on spirometry. Therefore, the precapillary PAH prevalence was 6% (3/50).

Conclusion

While the prevalence of pulmonary fibrosis in our SSc patients reflects what has been reported in the literature, the prevalence of PAH is significantly lower than the reported 15-20%.1 This is likely due to underdiagnosis of PAH considering the number of years of systemic sclerosis diagnosis on presentation to our clinic. A systematic approach is needed to assess for the presence and severity of PAH using tools as in Detect algorithm which has been validated and commonly used in Europe and North America to screen for PAH.2 Validation of such algorithm is likely needed in middle eastern population before it is universally adopted.

References

[1]Screening for pulmonary arterial hypertension in an unselected prospective systemic sclerosis cohort. Vandecasteele E, Eur Respir J. 2017;49(5) Epub 2017 May 11.

[2]Evidence-based detection of pulmonary arterial hypertension in systemic sclerosis: the DETECT study, Coghlan et al. Ann Rheum Dis 2014;73:1340–1349. doi:10.1136/annrheumdis-2013-203301.

Disclosure of Interests

None declared

POS0540 CLINICAL OUTCOMES ASSOCIATED WITH GLUCOCORTICOID DISCONTINUATION AMONG PATIENTS WITH RHEUMATOID ARTHRITIS RECEIVING UPADACITINIB OR ADALIMUMAB

Background

Patients (pts) with rheumatoid arthritis (RA) are often administered glucocorticoids (GCs) as bridging therapy when initiating or adjusting disease-modifying antirheumatic drugs (DMARDs). Due to their systemic effects, short-term use of GCs at the lowest possible dose is recommended with rapid tapering.1

Objectives

We describe GC discontinuation patterns and the associated clinical outcomes in pts with RA receiving upadacitinib (UPA) or adalimumab (ADA).

Methods

SELECT-COMPARE is a randomized phase 3 trial of UPA vs placebo and ADA with a 48-week (wk) double-blind treatment period and a 10-year long-term extension in pts with RA receiving concomitant methotrexate (MTX) who had an inadequate response to MTX.2 Background GCs (≤10 mg/day prednisone or equivalent) were permitted and could be tapered or discontinued starting at wk 26 per physician discretion. This post hoc analysis included pts who received ≥1 dose of UPA 15 mg once daily or ADA 40 mg every other wk while on concomitant GCs at baseline. The proportion of pts with disease worsening (Clinical Disease Activity Index [CDAI] >2 and Disease Activity Score 28-joint count C-reactive protein [DAS28-CRP] >0.6) following GC discontinuation through follow-up is described. Maintenance of clinical response, including remission and low disease activity based on CDAI ≤2.8 and ≤10, respectively, as well as DAS28-CRP <2.6 and ≤3.2, were assessed among pts who discontinued GCs. Adverse events (AEs) were assessed before and after GC discontinuation through follow-up. Data were analyzed descriptively.

Results

Of 1,629 pts randomized, 978 (60%) used GCs at baseline; 128 (13%) discontinued use at/after wk 26 (UPA, n=97; ADA, n=31). Baseline demographics and clinical characteristics were broadly similar between pts who continued or discontinued GCs. Median follow-up time after GC discontinuation was 60 wks for UPA and 84 wks for ADA. At the time of GC discontinuation, a numerically higher proportion of pts treated with UPA vs ADA were in disease control (CDAI ≤2.8: 55% vs 32%; CDAI ≤10: 85% vs 68%; DAS28-CRP <2.6: 71% vs 48%; DAS28-CRP ≤3.2: 87% vs 62%) (Table 1). Few pts receiving UPA experienced disease worsening following GC discontinuation (1% CDAI increase >2; 7% DAS28-CRP increase >0.6) and none on ADA (Table 1). At 6 months follow-up after GC discontinuation, most pts treated with UPA and ADA maintained CDAI ≤2.8 (74% vs 88%) and ≤10 (92% vs 95%) and DAS28-CRP <2.6 (89% vs 85%) and ≤3.2 (91% vs 94%), respectively (Table 1). GCs were reintroduced (albeit usually temporarily) in 14% of pts on UPA and 19% on ADA (Figure 1). AEs were generally similar across treatment groups. Rates of serious infection before and after GC discontinuation were 0.8 (95% CI 0.0–4.2) and 1.5 (0.2–5.4) events per 100 patient-years (E/100 PY) for UPA and 7.7 (1.6–22.4) and 0 E/100 PY for ADA, respectively. Interpretation of results is limited by small pt numbers and different exposure times.

Table 1.

Clinical outcomes of pts who discontinued GCs at/after wk 26

n/N (%)Pts who discontinued GCs N=128UPAn=97ADAn=31CDAI≤10 at discontinuation79/93 (85%)21/31 (68%) Maintained at 6 months post discontinuationa61/66 (92%)18/19 (95%)≤2.8 at withdrawal51/93 (55%)10/31 (32%) Maintained at 6 months post discontinuationa32/43 (74%)7/8 (88%)Increase >2 any visit after withdrawal1/93 (1%)0DAS28-CRP≤3.2 at withdrawal78/90 (87%)18/29 (62%) Maintained at 6 months post discontinuationa58/64 (91%)15/16 (94%)<2.6 at withdrawal64/90 (71%)14/29 (48%) Maintained at 6 months post discontinuationa47/53 (89%)11/13 (85%)Increase >0.6 any visit after withdrawal6/92 (7%)0

aAs a proportion of pts achieving outcome at GC discontinuation and with observed data 6 months post GC discontinuation.

Conclusion

In pts who achieved disease control and discontinued GCs, disease control was maintained in almost all without worsening disease activity over time following GC discontinuation.

Conclusion

In pts who achieved disease control and discontinued GCs, disease control was maintained in almost all without worsening disease activity over time following GC discontinuation.

References

[1]Smolen JS, et al. Ann Rheum Dis. 2020;79:685–99.

[2]Fleischmann R, et al. Ann Rheum Dis. 2019;78:1454–62.

Acknowledgements

AbbVie funded this study and participated in the study design, research, analysis, data collection, interpretation of data, review, and approval of the publication. All authors had access to relevant data and participated in the drafting, review, and approval of this publication. No honoraria or payments were made for authorship. Medical writing assistance was provided by Julia Zolotarjova, MSc, MWC of AbbVie Inc.

Disclosure of Interests

Roy M. Fleischmann Consultant of: AbbVie, Amgen, BMS, Galvani, Gilead, GSK, Janssen, Eli Lilly, Novartis, Pfizer, and UCB, Grant/research support from: AbbVie, Amgen, Astra-Zeneca, BMS, Flexion, Galvani, Gilead, GSK, Janssen, Eli Lilly, Novartis, Noven, Pfizer, Samumed, Selecta, Teva, UCB, Viela, and Vorso., Bernard Combe Speakers bureau: AbbVie, BMS, Celltrion, Eli Lilly, Gilead-Galapagos, Janssen, Merck Sharp & Dohme, Novartis, Pfizer, and Roche-Chugai, Consultant of: AbbVie, BMS, Celltrion, Eli Lilly, Gilead-Galapagos, Janssen, Merck Sharp & Dohme, Novartis, Pfizer, and Roche-Chugai, Grant/research support from: Pfizer and Roche-Chugai, Andrew Ostor Consultant of: AbbVie, BMS, Eli Lilly, Gilead, Janssen, Novartis, Paradigm, Pfizer, Roche, and UCB., Cesar Francisco Pacheco Tena Consultant of: AbbVie, Astra-Zeneca, Eli Lilly, Gilead, Janssen, Pfizer, Roche, R-Pharm, Sanofi Regeneron, and UCB., Grant/research support from: AbbVie, Astra-Zeneca, Eli Lilly, Gilead, Janssen, Pfizer, Roche, R-Pharm, Sanofi Regeneron, and UCB., Nasser Khan Shareholder of: May own AbbVie stock or stock options, Employee of: AbbVie, Jessica Suboticki Shareholder of: May own AbbVie stock or stock options, Employee of: AbbVie, Anna Shmagel Shareholder of: May own AbbVie stock or stock options, Employee of: AbbVie, Yanna Song Shareholder of: May own AbbVie stock or stock options, Employee of: AbbVie, Ivan Lagunes-Galindo Shareholder of: May own AbbVie stock or stock options, Employee of: AbbVie, Gerd Rüdiger Burmester Speakers bureau: AbbVie, Eli Lilly, Galapagos, Gilead, Janssen, MSD, Pfizer, Roche, Sanofi, and UCB., Consultant of: AbbVie, Eli Lilly, Galapagos, Gilead, Janssen, MSD, Pfizer, Roche, Sanofi, and UCB.

Cambridge hybrid closed-loop algorithm in children and adolescents with type 1 diabetes: a multicentre 6-month randomised controlled trial

BACKGROUND

Closed-loop insulin delivery systems have the potential to address suboptimal glucose control in children and adolescents with type 1 diabetes. We compared safety and efficacy of the Cambridge hybrid closed-loop algorithm with usual care over 6 months in this population.

METHODS

In a multicentre, multinational, parallel randomised controlled trial, participants aged 6-18 years using insulin pump therapy were recruited at seven UK and five US paediatric diabetes centres. Key inclusion criteria were diagnosis of type 1 diabetes for at least 12 months, insulin pump therapy for at least 3 months, and screening HbA1c levels between 53 and 86 mmol/mol (7·0-10·0%). Using block randomisation and central randomisation software, we randomly assigned participants to either closed-loop insulin delivery (closed-loop group) or to usual care with insulin pump therapy (control group) for 6 months. Randomisation was stratified at each centre by local baseline HbA1c. The Cambridge closed-loop algorithm running on a smartphone was used with either (1) a modified Medtronic 640G pump, Medtronic Guardian 3 sensor, and Medtronic prototype phone enclosure (FlorenceM configuration), or (2) a Sooil Dana RS pump and Dexcom G6 sensor (CamAPS FX configuration). The primary endpoint was change in HbA1c at 6 months combining data from both configurations. The primary analysis was done in all randomised patients (intention to treat). Trial registration ClinicalTrials.gov, NCT02925299.

FINDINGS

Of 147 people initially screened, 133 participants (mean age 13·0 years [SD 2·8]; 57% female, 43% male) were randomly assigned to either the closed-loop group (n=65) or the control group (n=68). Mean baseline HbA1c was 8·2% (SD 0·7) in the closed-loop group and 8·3% (0·7) in the control group. At 6 months, HbA1c was lower in the closed-loop group than in the control group (between-group difference -3·5 mmol/mol (95% CI -6·5 to -0·5 [-0·32 percentage points, -0·59 to -0·04]; p=0·023). Closed-loop usage was low with FlorenceM due to failing phone enclosures (median 40% [IQR 26-53]), but consistently high with CamAPS FX (93% [88-96]), impacting efficacy. A total of 155 adverse events occurred after randomisation (67 in the closed-loop group, 88 in the control group), including seven severe hypoglycaemia events (four in the closed-loop group, three in the control group), two diabetic ketoacidosis events (both in the closed-loop group), and two non-treatment-related serious adverse events. There were 23 reportable hyperglycaemia events (11 in the closed-loop group, 12 in the control group), which did not meet criteria for diabetic ketoacidosis.

INTERPRETATION

The Cambridge hybrid closed-loop algorithm had an acceptable safety profile, and improved glycaemic control in children and adolescents with type 1 diabetes. To ensure optimal efficacy of the closed-loop system, usage needs to be consistently high, as demonstrated with CamAPS FX.

FUNDING

National Institute of Diabetes and Digestive and Kidney Diseases.

Linking COVID-19 with Suicide: Suggestions for Future Research

COVID-19 has impacted the world socio-economically. Unemployment, poverty, social stigma, social isolation, domestic violence and mental illnesses are the notable social issues related to COVID-19 pandemic. Framed under a review based approach, the current study searches for the link between COVID-19 pandemic and an increased vulnerability to suicide across the globe. Linking the current situation with researched determinants of suicide shows that COVID-19 pandemic is exacerbating various socio-economic and psychological causes of suicide. In near future or even during the pandemic, suicide will be a key challenge for the public health sector across the globe. Besides, future research suggestions are given in light of the discussion in order to provide an impetus to researching the impact of the COVID-19 pandemic on suicide.

Phytochemical screening and evaluation of antioxidant, total phenolic and flavonoid contents in various weed plants associated with wheat crops

This study explores the antioxidant activity, phytochemical screening, total phenolic and flavonoids contents in the extracts of four locally available weeds plants namely Convolvulus arvensis, Chenopodium murale, Avena fatua and Phalaris minor with different solvents. The antioxidant activities of these extracts were determined via various in-vitro methods such as total antioxidant activity (TAA), reducing power (RP), DPPH (2,2-Diphenyl-1-Picrylhydrazyl) free radical scavenging and hydrogen peroxide scavenging assays. Phytochemical screening was performed both qualitatively as well as quantitatively. Total phenolic content (TPC) and total flavonoid content (TFC) were determined through Folin- Ciocalteu reagent and aluminium chloride methods respectively. Methanol-chloroform solvent showed the presence of a high amount of TPC in milligram of gallic acid equivalent per gram of dry weight (mg of GAE/g of DW) in the extracts of all weeds. Their descending sequence was Avena fatua (74.09) ˃ Phalaris minor (65.66) ˃ Chenopodium murale (64.04) ˃ Convolvulus arvensis (61.905), while, chloroform solvent found to be best solvent for the extraction of TFC. Methanol-chloroform solvent was also found to be best solvent for TAA (Total antioxidant activity assay) which showed values in milligram of ascorbic acid equivalent per gram of dry weight (mg of AAE /g of DW), for DPPH scavenging activity, reducing power (antioxidant activity) and hydrogen peroxide scavenging activity. Phytochemical screening indicated the presence of polyphenols, flavonoids, tannins, saponins, alkaloids and glycosides in these weeds.