Well-posedness of stochastic modified Kawahara equation

In this paper we consider the Cauchy problem for the stochastic modified Kawahara equation, which is a fifth-order shallow water wave equation. We prove local well-posedness for data in $H^{s}(\mathbb{R})$Hs(R), $s\geq -1/4$s≥−1/4. Moreover, we get the global existence for $L^{2}( \mathbb{R})$L2(R) solutions. Due to the non-zero singularity of the phase function, a fixed point argument and the Fourier restriction method are proposed.

Diagnostic accuracy of Xpert MTB/RIF ultra for detection of Mycobacterium tuberculosis in children: a prospective cohort study

The Xpert MTB/RIF Ultra is a recent advancement in molecular diagnostics of tuberculosis (TB) with higher sensitivity compared to its predecessor, the Xpert MTB/RIF assay. Prospective studies evaluating the performance of Xpert MTB/RIF Ultra in children with suspected TB are lacking. In this study, we evaluated the Xpert MTB/RIF Ultra for detection of Mycobacterium tuberculosis in samples from 156 children, of which one was excluded from the analysis. Of the remaining 155 samples, 6·5% (10/155), 21·3% (33/155), 20% (31/155) and 21·9% (34/155) were positive by smear examination, MGIT culture, Xpert MTB/RIF and Xpert MTB/RIF Ultra, respectively. The Xpert MTB/RIF and Xpert MTB/RIF Ultra had a similar overall sensitivity of 81·8% (95% CI: 64·5-93) and 84·8% (95% CI: 68·1-94·9), respectively. In suspected pediatric TB patients, the Xpert MTB/RIF Ultra had higher sensitivity compared to the Xpert MTB/RIF (72·7 vs 63·6). The AUC (area under the curve) of 0·905 for the Xpert MTB/RIF and 0·893 for the Xpert MTB/RIF Ultra indicate similar and good overall performance. Both Xpert assays were found to be equally efficient, however Xpert MTB/RIF Ultra showed better detection rate in suspected TB cases.

Exploring how virtual primary care visits affect patient burden of treatment

BACKGROUND

There is growing emphasis on the role of digital solutions in supporting chronic disease management. This has the potential to increase the burden patients experience in managing their health by offloading care from the health system to patients. This paper explores the effects of virtual visits on patient burden using an explicit framework measuring both the work patients do to care for their health and the challenges they experience that exacerbate burden.

METHODS

This mixed methods study evaluates a large pilot implementation of virtual visits (video, audio, and asynchronous messaging with providers) in primary care in Ontario, Canada. Participants were recruited using convenience sampling from patients using a virtual visit platform to complete a semi-structured interview or a survey including a free-text response. We conducted 17 interviews and reviewed 427 free text responses related to explore patients' perceived value and burden of these visits. We used qualitative analyses to map patients' feedback on their experience to the framework on patient burden.

MAIN FINDINGS

Virtual visits appear to reduce the work patients must do to manage their care by 1) improving access, convenience, and time needed for medical appointments, and 2) making it easier to access information and support for chronic disease management. Virtual visits also alleviate patients' perceived burden by improving continuity of care, experience of care, and providing some cost savings.

CONCLUSIONS

Virtual visits reduced overall patient burden of treatment by decreasing the required patient effort of managing medical appointments and monitoring their health, and by minimizing challenges experienced when accessing care. For regions that want to improve patient experience of care, virtual visits are likely to be of benefit. There is need for further research on the generalizability of the findings herein, particularly for high-needs populations under-represented such as those of low socioeconomic status and those in rural and remote locations.

OP0054 EFFICACY OF GUSELKUMAB, A MONOCLONAL ANTIBODY THAT SPECIFICALLY BINDS TO THE P19-SUBUNIT OF IL-23, ON ENDPOINTS RELATED TO AXIAL INVOLVEMENT IN PATIENTS WITH ACTIVE PSA WITH IMAGING-CONFIRMED SACROILIITIS: WEEK-24 RESULTS FROM TWO PHASE 3, RANDOMIZED, DOUBLE-BLIND, PLACEBO-CONTROLLED STUDIES

Background:

Guselkumab (GUS), an interleukin-23 inhibitor, was efficacious in reducing signs and symptoms of active psoriatic arthritis (PsA) in patients (pts) in two phase 3 trials (DISCOVER-1 and DISCOVER-2).

Objectives:

To evaluate the efficacy of GUS in PsA pts with imaging-confirmed axial involvement consistent with sacroiliitis in DISCOVER-1&2.

Methods:

In DISCOVER-1, 381 pts with active PsA (≥ 3 swollen joints, ≥ 3 tender joints; C-reactive protein ≥ 0.3mg/dL despite standard therapies) and in DISCOVER-2, 739 pts with active PsA (≥ 5 swollen joints, ≥ 5 tender joints, CRP ≥ 0.6mg/dL despite standard therapies) were randomized 1:1:1 to GUS 100mg Q4W, GUS 100mg Q8W (Wk0, Wk4, then Q8W), or PBO. This analysis included pts with sacroiliitis at baseline who had either documented imaging confirmation of sacroiliitis in the past or pelvic X-ray confirmation of sacroiliitis at screening (pooled data from DISCOVER-1&2) based on investigators’ judgment of presence/absence of sacroiliitis. Efficacy was assessed by BASDAI score, BASDAI50, modified BASDAI (mBASDAI; excludes Q#3), spinal pain (BASDAI Q#2), ASDAS-CRP score, and ASDAS responses of inactive disease (<1.3), major improvement (decrease ≥2.0), and clinically important improvement (decrease ≥1.1). Pts with missing data at wk24 were classified as nonresponders.

Results:

312 pts presented with axial involvement (PBO, n= 118; GUS q8w, n = 91; GUS q4w, n = 103). The LS mean changes from baseline to wk24 in BASDAI, spinal pain, mBASDAI, and ASDAS-CRP were greater in the two GUS groups vs PBO (Table). Greater proportions of GUS-treated pts achieved BASDAI50 (Table) and ASDAS responses of inactive disease, major improvement, and clinically important improvement (Figure) at wk24 vs PBO.

Conclusion:

GUS improved axial symptoms over 24 weeks in active PsA patients with imaging-confirmed sacroiliitis.

Table.

Efficacy of GUS in PsA patients with axial involvement at week 24.a

PBO(n=118)GUS 100 mg every 8 weeks(n=91)GUS100 mg every 4 weeks(n=103)LS Mean change in BASDAI-1.35-2.67*-2.68*LS Mean change in spinal painb-1.30-2.73*-2.48*BASDAI50c, %21/110 (19.1%)34/84 (40.5%)**36/95 (37.9%)**LS Mean change in modified BASDAId-1.13-2.16*-2.18*LS Mean change in ASDAS-CRP-0.71-1.43*-1.46*

aPts with axial involvement consistent with sacroiliitis at baseline and either a history of imaging confirmation or pelvic X-ray at screening (pooled data from DISCOVER-1 & 2)

bQuestion 2 of the BASDAI.

cPts with BASDAI > 0 at baseline.

dExcludes question 3 of the BASDAI.

Unadjusted p-values as noted: *p < 0.001, ** p < 0.01

Acknowledgments:

None

Disclosure of Interests:

Philip Helliwell: None declared, Dafna D Gladman Grant/research support from: AbbVie, Amgen Inc., BMS, Celgene Corporation, Janssen, Novartis, Pfizer, UCB – grant/research support, Consultant of: AbbVie, Amgen Inc., BMS, Celgene Corporation, Janssen, Novartis, Pfizer, UCB – consultant, Denis Poddubnyy Grant/research support from: AbbVie, MSD, Novartis, and Pfizer, Consultant of: AbbVie, Bristol-Myers Squibb, Eli Lilly, MSD, Novartis, Pfizer, Roche, UCB, Speakers bureau: AbbVie, Bristol-Myers Squibb, Eli Lilly, MSD, Novartis, Pfizer, Roche, UCB, Philip J Mease Grant/research support from: AbbVie, Amgen, Bristol-Myers Squibb, Janssen, Eli Lilly, Novartis, Pfizer, Sun Pharma, UCB Pharma, Consultant of: AbbVie, Amgen, Bristol-Myers Squibb, Celgene, Janssen, Eli Lilly, Galapagos, Gilead, Novartis, Pfizer, Sun Pharma, UCB Pharma, Speakers bureau: AbbVie, Amgen, Bristol-Myers Squibb, Celgene, Genentech, Janssen, Novartis, Pfizer, UCB Pharma, Xenofon Baraliakos Grant/research support from: Grant/research support from: AbbVie, BMS, Celgene, Chugai, Merck, Novartis, Pfizer, UCB and Werfen, Consultant of: AbbVie, BMS, Celgene, Chugai, Merck, Novartis, Pfizer, UCB and Werfen, Speakers bureau: AbbVie, BMS, Celgene, Chugai, Merck, Novartis, Pfizer, UCB and Werfen, Alexa Kollmeier Shareholder of: Johnson & Johnson, Employee of: Janssen Research & Development, LLC, Elizabeth C Hsia Shareholder of: Johnson & Johnson, Employee of: Janssen Research & Development, LLC, Xie L Xu Shareholder of: Johnson & Johnson, Employee of: Janssen Research & Development, LLC, Shihong Sheng Shareholder of: Johnson & Johnson, Employee of: Janssen Research & Development, LLC, Prasheen Agarwal Shareholder of: Johnson & Johnson, Employee of: Janssen Research & Development, LLC, Bei Zhou Shareholder of: Johnson & Johnson, Employee of: Janssen Research & Development, LLC, Soumya D Chakravarty Shareholder of: Johnson & Johnson, Employee of: Janssen Scientific Affairs, LLC, May Shawi Shareholder of: Johnson & Johnson, Employee of: Janssen Research & Development, LLC, Chetan Karyekar Shareholder of: Johnson & Johnson, Consultant of: Janssen, Employee of: Janssen Global Services, LLC. Previously, Novartis, Bristol-Myers Squibb, and Abbott Labs., Atul Deodhar Grant/research support from: AbbVie, Eli Lilly, GSK, Novartis, Pfizer, UCB, Consultant of: AbbVie, Amgen, Boehringer Ingelheim, Bristol Myer Squibb (BMS), Eli Lilly, GSK, Janssen, Novartis, Pfizer, UCB, Speakers bureau: AbbVie, Amgen, Boehringer Ingelheim, Bristol Myer Squibb (BMS), Eli Lilly, GSK, Janssen, Novartis, Pfizer, UCB, Désirée van der Heijde Consultant of: AbbVie, Amgen, Astellas, AstraZeneca, BMS, Boehringer Ingelheim, Celgene, Cyxone, Daiichi, Eisai, Eli-Lilly, Galapagos, Gilead Sciences, Inc., Glaxo-Smith-Kline, Janssen, Merck, Novartis, Pfizer, Regeneron, Roche, Sanofi, Takeda, UCB Pharma; Director of Imaging Rheumatology BV

AB0756 GUSELKUMAB IMPROVED WORK PRODUCTIVITY AND DAILY ACTIVITY IN PATIENTS WITH PSORIATIC ARTHRITIS: RESULTS FROM A PHASE 3 TRIAL

Background:

DISCOVER 2 (DISC 2) is a Phase 3 trial of anti-IL-23-specific mAb guselkumab (GUS) in psoriatic arthritis (PsA) pts, who experience impaired physical function, resulting in disability, work productivity loss, and economic consequences.1

Objectives:

To evaluate the effect of GUS on impaired work productivity and daily activity in DISC 2 using the Work Productivity and Activity Impairment Questionnaire: Psoriatic Arthritis (WPAI-PsA).

Methods:

Bio-naïve adults with active PsA despite nonbiologic DMARDs &/or NSAIDs received subcutaneous GUS 100 mg every (q) 4 weeks (W); GUS 100 mg W0, W4, q8W; or placebo (PBO). WPAI-PsA assesses, due to PsA over the previous week, work time missed (absenteeism), impairment while working (presenteeism), and impaired overall work productivity (absenteeism + presenteeism) and daily activity. Percentage change from baseline was analyzed for WPAI-PsA domains using mixed-effect model repeated measure (MMRM). Indirect savings from improved overall work productivity were estimated with 2018 US mean yearly wage estimate (all occupations).2

Results:

At Week 24, impaired overall work productivity and daily activity were improved 20-22% in GUS-treated and 10-11% in PBO-treated pts (Table). Potential yearly indirect savings from improved overall work productivity was $10,242 with GUS q8W and $10,404 with GUS q4W vs $5,648 with PBO; $4,594 and $4,756 difference, respectively.

Conclusion:

Improvement in overall work productivity and daily activity was greater with GUS versus PBO among pts with moderate-to-severe PsA, resulting in potential annual incremental economic gains.

References:

[1]Tillett W et al. Rheumatol (Oxford). 2012;51:275–283.

[2]US Bureau of Labor Statistics. May 2018 National Occupational Employment and Wage Estimates United States.https://www.bls.gov/oes/current/oes_nat.htm#00-000

Table.

Model-based estimates of mean change from baseline in WPAI-PsA domains

% change from baselinePBOGUS 100 mg q8WGUS 100 mg q4WW16W24W16W24W16W24Work time missed (absenteeism), n155152141145145143LSMean-4.6 (-7.2,-1.9)-3.5 (-6.4,-0.6)-3.5 (-6.2,-0.7)-3.1 (-6.1,-0.1)-4.7 (-7.4,-2.0)-3.8 (-6.8,-0.8)LSMean diff1.1 (-2.6,-4.8)*0.4 (-3.7,4.5)*-0.2 (-3.9,3.5)*-0.3 (-4.4,3.8)*Impairment while working (presenteeism), n131130125129133130LSMean-10.3 (-13.9,-6.7)-10.2 (-13.7,-6.7)-16.1 (-19.7,-12.4)-19.4 (-22.9,-15.9)-15.1 (-18.7,-11.5)-19.5 (-23.0,-16.0)LSMean diff-5.8 (-10.8,-0.8)†-9.2 (-14.0,-4.4)‡-4.8 (-9.7,0.1)*-9.3 (-14.1,-4.5)‡Overall work productivity impairment (absenteeism + presenteeism), n131130125129133130LSMean-11.2 (-15.0,-7.5)-10.9 (-14.6,-7.1)-15.9 (-19.7,-12.2)-19.7 (-23.4,-16.0)-15.8 (-19.5,-12.1)-20.0 (-23.7,-16.3)LSMean diff-4.7 (-9.9,0.5)*-8.8 (-14.0,-3.7)‡-4.6 (-9.7,0.5)*-9.2 (-14.3,-4.0)‡Daily activity impairment, n244244247246243245LSMean-10.6 (-13.3,-7.9)-10.3 (-13.1,-7.6)-17.1 (-19.8,-14.4)-21.5 (-24.2,-18.7)-17.0 (-19.7,-14.3)-20.5 (-23.2,-17.7)LSMean diff-6.5 (-10.2,-2.8)‡-11.1 (-15.0,-7.4)‡-6.5 (-10.2,-2.7)‡-10.2 (-14.0,-6.4)‡

Data are % (95% CI)

*p>0.05, †p<0.05,‡p<0.001

LSmeans, p values based on MMRM

LSmean diffs, p values vs PBO

Acknowledgments:

None

Disclosure of Interests:

Jeffrey Curtis Grant/research support from: AbbVie, Amgen, Bristol-Myers Squibb, Corrona, Janssen, Lilly, Myriad, Pfizer, Regeneron, Roche, UCB, Consultant of: AbbVie, Amgen, Bristol-Myers Squibb, Corrona, Janssen, Lilly, Myriad, Pfizer, Regeneron, Roche, UCB, Iain McInnes Grant/research support from: Bristol-Myers Squibb, Celgene, Eli Lilly and Company, Janssen, and UCB, Consultant of: AbbVie, Bristol-Myers Squibb, Celgene, Eli Lilly and Company, Gilead, Janssen, Novartis, Pfizer, and UCB, Proton Rahman Grant/research support from: Janssen and Novartis, Consultant of: Abbott, AbbVie, Amgen, BMS, Celgene, Lilly, Janssen, Novartis, and Pfizer., Speakers bureau: Abbott, AbbVie, Amgen, BMS, Celgene, Lilly, Janssen, Novartis, Pfizer, William Tillett Grant/research support from: AbbVie, Celgene, Eli Lilly, Janssen, Novartis, Pfizer Inc, UCB, Consultant of: AbbVie, Amgen, Celgene, Lilly, Janssen, Novartis, MSD, Pfizer Inc, UCB, Speakers bureau: AbbVie, Amgen, Celgene, Lilly, Janssen, Novartis, Pfizer Inc, UCB, Philip J Mease Grant/research support from: Abbott, Amgen, Biogen Idec, BMS, Celgene Corporation, Eli Lilly, Novartis, Pfizer, Sun Pharmaceutical, UCB – grant/research support, Consultant of: Abbott, Amgen, Biogen Idec, BMS, Celgene Corporation, Eli Lilly, Novartis, Pfizer, Sun Pharmaceutical, UCB – consultant, Speakers bureau: Abbott, Amgen, Biogen Idec, BMS, Eli Lilly, Genentech, Janssen, Pfizer, UCB – speakers bureau, Alexa Kollmeier Shareholder of: Johnson & Johnson, Employee of: Janssen Research & Development, LLC, Elizabeth C Hsia Shareholder of: Johnson & Johnson, Employee of: Janssen Research & Development, LLC, Bei Zhou Shareholder of: Johnson & Johnson, Employee of: Janssen Research & Development, LLC, Prasheen Agarwal Shareholder of: Johnson & Johnson, Employee of: Janssen Research & Development, LLC, Steve Peterson Employee of: Janssen Research & Development, LLC, Chenglong Han Employee of: Janssen Research & Development, LLC

FRI0359 INTEGRATED SAFETY RESULTS OF TWO PHASE-3 TRIALS OF GUSELKUMAB IN PATIENTS WITH PSORIATIC ARTHRITIS THROUGH THE PLACEBO-CONTROLLED PERIODS

Background:

DISCOVER 1 & 2 are phase 3 psoriatic arthritis (PsA) trials investigating guselkumab (GUS), an IL-23 inhibitor that specifically binds the IL-23p19 subunit. In both studies, GUS showed significant improvement vs placebo (PBO) through week (W) 24 in the PBO-controlled period.1,2

Objectives:

To present integrated safety results of DISC 1 & 2 through the PBO-controlled periods.

Methods:

Adult patients (pts) with active PsA despite standard therapy were enrolled. All pts were biologic-naïve, except ~30% in DISC 1 with previous exposure to 1-2 TNF inhibitors. Pts were randomized to SC GUS 100 mg Q4W; GUS 100 mg at W0, W4, then Q8W; or PBO. Adverse events (AEs) and lab results were analyzed from pooled data.

Results:

The rates of pts experiencing ≥1 AE, serious AE, infection, serious infection, and discontinuation due to an AE were similar between GUS and PBO (Table 1). There were 2 deaths, 3 malignancies, 2 Major Adverse Cardiac Events (MACE), and no opportunistic infections (treatment group not shown to prevent unblinding). Among the AEs reported by ≥5% pts in any group (Table 1), nasopharyngitis and elevated serum hepatic aminotransferases were more common with GUS vs PBO. Laboratory ALT and AST elevations were mostly mild, transient, and not associated with significant bilirubin elevation. There was a trend to decreased neutrophil count (mostly Grade 1, transient, and not associated with infection) with GUS vs PBO (Table 2). Low rates of injection-site reactions were seen with GUS vs PBO. Anti-drug antibody development was also low (Table 1).

Table 1.

Patient Reported AEs, n (%)

GUS100 mgQ8WGUS100 mgQ4WPBON375373372≥1 AE182 (48.5)182 (48.8)176 (47.3)≥1 Serious AE7 (1.9)8 (2.1)12 (3.2)Discontinuation due to AE5 (1.3)8 (2.1)7 (1.9)≥1 Infection73 (19.5)80 (21.4)77 (20.7)≥1 Serious infection1 (0.3)3 (0.8)3 (0.8)≥1 Opportunistic Infection (including Candida)000Active Tuberculosis000≥1 Injection-site reaction5 (1.3)4 (1.1)1 (0.3)Anti-GUS antibody +, n/N (%)6/373 (1.6)9/371 (2.4)--AEs* reported by ≥5% of patients in any treatment groupNasopharyngitis26 (6.9)19 (5.1)17 (4.6)Upper respiratory tract infection13 (3.5)23 (6.2)17 (4.6)Increased ALT23 (6.1)28 (7.5)14 (3.8)Increased AST23 (6.1)14 (3.8)9 (2.4)

*Medical Dictionary for Regulatory Activities (MedDRA) preferred term

Table 2.

Lab Results*

GUS100 mgQ8WGUS100 mgQ4WPBON373371370ALT Increased (%)Grade 128.235.030.121.12.71.43-40.81.10.8Neutrophil Count Decreased (%)Grade 15.65.93.221.61.60.83-400.30.3

*NCI toxicity grade

ALT=Alanine aminotransferase

Conclusion:

GUS was safe and well tolerated through the PBO-controlled period in 2 randomized, phase 3 trials of patients with active PsA. There were no meaningful safety differences between the Q8W and Q4W groups, no significant safety issues identified when comparing GUS to PBO, and no safety signals with regards to infections, malignancy, and MACE. The safety profile of GUS Q4W and Q8W in PsA pts was generally consistent with that in the Phase 3 trials of GUS Q8W for psoriasis.3,4

References:

[1]Deodhar et al. ACR 2019 (#807). Arth Rheum 2019;71 S10:1386

[2]Mease et al. ACR 2019 (#L13). Arth Rheum 2019;71 S10:5247

[3]Blauvelt et al. J Am Acad Derm 2017;76:405

[4]Reich et al. J Am Acad Derm 2017;76:418

Acknowledgments:

None

Disclosure of Interests:

Proton Rahman Grant/research support from: Janssen and Novartis, Consultant of: Abbott, AbbVie, Amgen, BMS, Celgene, Lilly, Janssen, Novartis, and Pfizer., Speakers bureau: Abbott, AbbVie, Amgen, BMS, Celgene, Lilly, Janssen, Novartis, Pfizer, Christopher T. Ritchlin Grant/research support from: UCB Pharma, AbbVie, Amgen, Consultant of: UCB Pharma, Amgen, AbbVie, Lilly, Pfizer, Novartis, Gilead, Janssen, Philip Helliwell: None declared, Wolf-Henning Boehncke Grant/research support from: Janssen Research & Development, LLC, Consultant of: Janssen, Philip J Mease Grant/research support from: Abbott, Amgen, Biogen Idec, BMS, Celgene Corporation, Eli Lilly, Novartis, Pfizer, Sun Pharmaceutical, UCB – grant/research support, Consultant of: Abbott, Amgen, Biogen Idec, BMS, Celgene Corporation, Eli Lilly, Novartis, Pfizer, Sun Pharmaceutical, UCB – consultant, Speakers bureau: Abbott, Amgen, Biogen Idec, BMS, Eli Lilly, Genentech, Janssen, Pfizer, UCB – speakers bureau, Alice B Gottlieb Grant/research support from:: Research grants, consultation fees, or speaker honoraria for lectures from: Pfizer, AbbVie, BMS, Lilly, MSD, Novartis, Roche, Sanofi, Sandoz, Nordic, Celltrion and UCB., Consultant of:: Research grants, consultation fees, or speaker honoraria for lectures from: Pfizer, AbbVie, BMS, Lilly, MSD, Novartis, Roche, Sanofi, Sandoz, Nordic, Celltrion and UCB., Speakers bureau:: Research grants, consultation fees, or speaker honoraria for lectures from: Pfizer, AbbVie, BMS, Lilly, MSD, Novartis, Roche, Sanofi, Sandoz, Nordic, Celltrion and UCB., Shelly Kafka Employee of: Janssen Scientific Affairs, LLC, Alexa Kollmeier Shareholder of: Johnson & Johnson, Employee of: Janssen Research & Development, LLC, Elizabeth C Hsia Shareholder of: Johnson & Johnson, Employee of: Janssen Research & Development, LLC, Xie L Xu Shareholder of: Johnson & Johnson, Employee of: Janssen Research & Development, LLC, May Shawi Shareholder of: Johnson & Johnson, Employee of: Janssen Research & Development, LLC, Shihong Sheng Shareholder of: Johnson & Johnson, Employee of: Janssen Research & Development, LLC, Prasheen Agarwal Shareholder of: Johnson & Johnson, Employee of: Janssen Research & Development, LLC, Bei Zhou Shareholder of: Johnson & Johnson, Employee of: Janssen Research & Development, LLC, Paraneedharan Ramachandran Employee of: Janssen Research & Development, LLC, Iain McInnes Grant/research support from: Bristol-Myers Squibb, Celgene, Eli Lilly and Company, Janssen, and UCB, Consultant of: AbbVie, Bristol-Myers Squibb, Celgene, Eli Lilly and Company, Gilead, Janssen, Novartis, Pfizer, and UCB

AB0801 EFFECTS OF GUSELKUMAB, A MONOCLONAL ANTIBODY THAT SPECIFICALLY BINDS TO THE P19-SUBUNIT OF INTERLEUKIN-23, ON DACTYLITIS AND ENTHESITIS IN PATIENTS WITH ACTIVE PSORIATIC ARTHRITIS: POOLED RESULTS THROUGH WEEK 24 FROM TWO PHASE 3 STUDIES

Background:

Guselkumab (GUS), a novel monoclonal antibody that specifically binds to the p19-subunit of IL-23, demonstrated efficacy in the Ph 3 DISCOVER-1 (D1) & DISCOVER-2 (D2) trials of pts with active psoriatic arthritis (PsA).1,2Dactylitis & enthesitis, key PsA clinical manifestations, can be difficult to treat and may portend more significant disease burden.3,4

Objectives:

In pts with dactylitis or enthesitis at baseline, assess: 1) changes in symptoms over time and 2) relationships between improvements in dactylitis or enthesitis and other PsA domains.

Methods:

Adults with active PsA despite standard therapies were eligible for D1 & D2. Approx. 30% of D1 pts previously received 1-2 TNF inhibitors; D2 pts were biologic-naïve. Pts were randomized 1:1:1 to GUS 100mg Q4W; GUS 100mg at W0, W4, Q8W; or PBO. Independent assessors evaluated dactylitis (total score: 0-60) & enthesitis (Leeds Enthesitis Index [LEI]; total score 0-6). Dactylitis and enthesitis findings through W24 were prespecified to be pooled across D1 & D2. P-values are unadjusted. We assessed changes in dactylitis and LEI scores over time (ANCOVA); associations between dactylitis or enthesitis resolution and ACR/PASI responses at W24 (Chi-square); and correlations between dactylitis or LEI and HAQ-DI/SF-36 change scores at W24 (Spearman’s correlation). AEs through W24 were reported.1,2

Results:

At W0, 42% of pooled D1+D2 pts had dactylitis; 65% had enthesitis. GUS improved dactylitis and LEI scores vs PBO at W8, W16, W24. GUS vs PBO differences were significant for dactylitis changes at W16 & W24 and LEI changes at W8 (Q4W only), W16 & W24; no dose response was observed (Fig). Rates of dactylitis or enthesitis resolution by W24 were consistently significantly (p<0.001) associated with ACR20/50/70 and PASI75/90 response (Table). In GUS-treated pts at W24, significant correlations were observed between dactylitis change scores and PASI (p<0.001 Q4W; p=0.006 Q8W) and SF-36 MCS (p=0.038 Q4W; p=0.003 Q8W) changes, and between LEI and HAQ-DI change scores (p<0.001 Q4W; p=0.005 Q8W). No consistent correlations/associations were observed between dactylitis or LEI scores and other clinical outcomes.

Conclusion:

In PsA pts with dactylitis or enthesitis at W0, GUS improved dactylitis or LEI scores vs PBO by W8; treatment differences were significant at W16 & W24. Resolution of dactylitis or enthesitis was significantly associated with clinically meaningful improvements in PsA joint & skin symptoms. Improved dactylitis scores correlated with improved skin symptoms and mental health; improved LEI scores correlated with improved physical function.

References:

[1]Deodhar A (A#807),

[2]Mease P (A#L13), Arthritis Rheumatol 2019;71(suppl 10);

[3]DOI: 10.1186/s13075-017-1399-5;4DOI: 10.1016/j.semarthrit.2018.02.002

Table.

Pooled DISCOVER-1&2: associations between dactylitis/enthesitis resolution and joint/skin response

ACR20ACR50ACR70PASI75aPASI90aDactylitis resolutionbN%pts%pts%ptsN%pts%pts Q4W37355*34*16*12178*55* Q8W37553*31*16*11680*65* PBO37226*12*5*11519*10*Enthesitis resolutionc Q4W24334*31*11*18782*63* Q8W23040*7*12*16277*62* PBO25514*13*5*18219*9*

* p < 0.001 (Chi-square)

aIn pts with ≥3% BSA psoriasis & IGA ≥2 at W0

bIn pts with D at W0

cIn pts with E at W0

Acknowledgments:

None

Disclosure of Interests:

Dennis McGonagle Grant/research support from: Janssen Research & Development, LLC, Iain McInnes Grant/research support from: Bristol-Myers Squibb, Celgene, Eli Lilly and Company, Janssen, and UCB, Consultant of: AbbVie, Bristol-Myers Squibb, Celgene, Eli Lilly and Company, Gilead, Janssen, Novartis, Pfizer, and UCB, Atul Deodhar Grant/research support from: AbbVie, Eli Lilly, GSK, Novartis, Pfizer, UCB, Consultant of: AbbVie, Amgen, Boehringer Ingelheim, Bristol Myer Squibb (BMS), Eli Lilly, GSK, Janssen, Novartis, Pfizer, UCB, Speakers bureau: AbbVie, Amgen, Boehringer Ingelheim, Bristol Myer Squibb (BMS), Eli Lilly, GSK, Janssen, Novartis, Pfizer, UCB, Georg Schett Speakers bureau: AbbVie, BMS, Celgene, Janssen, Eli Lilly, Novartis, Roche and UCB, Philip J Mease Grant/research support from: Abbott, Amgen, Biogen Idec, BMS, Celgene Corporation, Eli Lilly, Novartis, Pfizer, Sun Pharmaceutical, UCB – grant/research support, Consultant of: Abbott, Amgen, Biogen Idec, BMS, Celgene Corporation, Eli Lilly, Novartis, Pfizer, Sun Pharmaceutical, UCB – consultant, Speakers bureau: Abbott, Amgen, Biogen Idec, BMS, Eli Lilly, Genentech, Janssen, Pfizer, UCB – speakers bureau, May Shawi Shareholder of: Johnson & Johnson, Employee of: Janssen Research & Development, LLC, Shelly Kafka Employee of: Janssen Scientific Affairs, LLC, Chetan Karyekar Shareholder of: Johnson & Johnson, Consultant of: Janssen, Employee of: Janssen Global Services, LLC. Previously, Novartis, Bristol-Myers Squibb, and Abbott Labs., Alexa Kollmeier Shareholder of: Johnson & Johnson, Employee of: Janssen Research & Development, LLC, Elizabeth C Hsia Shareholder of: Johnson & Johnson, Employee of: Janssen Research & Development, LLC, Xie L Xu Shareholder of: Johnson & Johnson, Employee of: Janssen Research & Development, LLC, Shihong Sheng Shareholder of: Johnson & Johnson, Employee of: Janssen Research & Development, LLC, Prasheen Agarwal Shareholder of: Johnson & Johnson, Employee of: Janssen Research & Development, LLC, Bei Zhou Shareholder of: Johnson & Johnson, Employee of: Janssen Research & Development, LLC, Christopher T. Ritchlin Grant/research support from: UCB Pharma, AbbVie, Amgen, Consultant of: UCB Pharma, Amgen, AbbVie, Lilly, Pfizer, Novartis, Gilead, Janssen, Proton Rahman Grant/research support from: Janssen and Novartis, Consultant of: Abbott, AbbVie, Amgen, BMS, Celgene, Lilly, Janssen, Novartis, and Pfizer., Speakers bureau: Abbott, AbbVie, Amgen, BMS, Celgene, Lilly, Janssen, Novartis, Pfizer

SAT0402 EFFICACY AND SAFETY OF GUSELKUMAB, A MONOCLONAL ANTIBODY SPECIFIC TO THE P19-SUBUNIT OF INTERLEUKIN-23, THROUGH WEEK 52 OF A PHASE 3, RANDOMIZED, DOUBLE-BLIND, PLACEBO-CONTROLLED STUDY CONDUCTED IN BIOLOGIC-NAÏVE PATIENTS WITH ACTIVE PSORIATIC ARTHRITIS

Background:

Guselkumab (GUS), a monoclonal antibody that specifically binds to the p19-subunit of IL-23, is approved to treat psoriasis. Through Week24 (W24) of the Ph3, double-blind, placebo (PBO)-controlled trial in biologic-naïve pts with active PsA (DISCOVER-2), GUS every 4 or 8 weeks (Q4W or Q8W) demonstrated efficacy for joint & skin symptoms and inhibition of structural damage progression (Q4W), and was well tolerated.

Objectives:

Assess GUS efficacy and safety through W52.

Methods:

Biologic-naïve adults with active PsA (≥5 swollen+≥5 tender joints; CRP ≥0.6mg/dL) were randomized (1:1:1) to GUS 100 mg Q4W; GUS 100 mg at W0, W4, Q8W; or PBO. At W24, PBO pts crossed over to GUS 100 mg Q4W (PBO X Q4W). ACR response rates at W52, based on nonresponder imputation (NRI) for missing data and as observed in pts who continued study agent at W24, are shown. Observed data for additional endpoints, including PsA-modified van der Heijde Sharp (vdH-S) scores derived from blinded radiographic images collected at W0, W24, W52 (or at d/c) and scored in a new Read Campaign, are shown.

Results:

712/739 (96.3%) randomized & treated pts continued study agent at W24; 689/739 (93.2%) completed Wk52. NRI ACR20 response rates continued to increase after W24, and at W52 were 70.6% for GUS Q4W and 74.6% for GUS Q8W (Fig 1A). Similar response patterns were observed for the more stringent ACR50/70 criteria (Fig 1C,E). Observed ACR (Fig, 1B,D,F), IGA, PASI & MDA/VLDA responses; dactylitis & enthesitis resolution; and mean improvements in HAQ-DI and SF-36 PCS/MCS scores were also sustained through W52 in pts receiving Q4W & Q8W; W52 data for PBO X Q4W pts were generally consistent with other GUS-treated pts (Fig 1, Table 1). Changes in vdH-S scores were similar for W24-52 (0.62) and W0-24 (0.46) for Q4W; less radiographic progression occurred from W24-52 v W0-24 for Q8W (0.23 v 0.73) & PBO X Q4W (0.25 v 1.00). In 731 GUS-treated pts, 4.2% had SAEs; 1.2% had serious infections; no pt died; and no pt had IBD, opportunistic infections or active TB, or anaphylactic or serum sickness-like reactions.

Table 1.

Observed Efficacy1

GUSQ4WGUSQ8WPBO X(W0-24)GUS Q4W(W24-52)Data are % unless otherwise statedW24W52W24W52W24W52Dactylitis at W0,n1161111071059593Resolution68.181.160.781.941.178.5Enthesitis at W0,n165160151148172168Resolution45.560.057.665.532.667.3≥3% BSA psoriasis, IGA ≥2 at W0,n176173172170176172IGA 0/1 + ≥2-grade decrease71.084.472.177.119.984.3PASI7581.891.980.888.823.388.4PASI9063.681.570.377.110.276.7PASI10046.661.346.554.72.855.2HAQ-DI,n234229238234237230Mean change-0.4-0.5-0.4-0.5-0.2-0.4SF-36 scores,n (mean change)234229238234237230Physical Component - PCS7.29.07.89.53.88.1Mental Component - MCS4.14.14.54.52.24.3MDA/VLDA, n234228238234238231MDA19.736.826.532.96.331.6VLDA5.112.224.6317.11.36.9

1Randomized pts still on study agent at W24;2N=229;3N=237

Conclusion:

In biologic-naïve pts with active PsA, GUS elicited sustained improvements in joint & skin symptoms; inhibition of radiographic progression & improvements in physical function, quality of life & composite indices through W52. GUS safety in PsA was similar at W241& W52 and consistent with GUS safety in psoriasis.

References:

[1]Mease P (A#L13), Arthritis Rheumatol 2019;71(suppl 10)

Acknowledgments:

None

Disclosure of Interests:

Iain McInnes Grant/research support from: Bristol-Myers Squibb, Celgene, Eli Lilly and Company, Janssen, and UCB, Consultant of: AbbVie, Bristol-Myers Squibb, Celgene, Eli Lilly and Company, Gilead, Janssen, Novartis, Pfizer, and UCB, Proton Rahman Grant/research support from: Janssen and Novartis, Consultant of: Abbott, AbbVie, Amgen, BMS, Celgene, Lilly, Janssen, Novartis, and Pfizer., Speakers bureau: Abbott, AbbVie, Amgen, BMS, Celgene, Lilly, Janssen, Novartis, Pfizer, Alice B Gottlieb Grant/research support from:: Research grants, consultation fees, or speaker honoraria for lectures from: Pfizer, AbbVie, BMS, Lilly, MSD, Novartis, Roche, Sanofi, Sandoz, Nordic, Celltrion and UCB., Consultant of:: Research grants, consultation fees, or speaker honoraria for lectures from: Pfizer, AbbVie, BMS, Lilly, MSD, Novartis, Roche, Sanofi, Sandoz, Nordic, Celltrion and UCB., Speakers bureau:: Research grants, consultation fees, or speaker honoraria for lectures from: Pfizer, AbbVie, BMS, Lilly, MSD, Novartis, Roche, Sanofi, Sandoz, Nordic, Celltrion and UCB., Elizabeth C Hsia Shareholder of: Johnson & Johnson, Employee of: Janssen Research & Development, LLC, Alexa Kollmeier Shareholder of: Johnson & Johnson, Employee of: Janssen Research & Development, LLC, Xie L Xu Shareholder of: Johnson & Johnson, Employee of: Janssen Research & Development, LLC, Ramanand A Subramanian Employee of: Janssen Research & Development, LLC, Prasheen Agarwal Shareholder of: Johnson & Johnson, Employee of: Janssen Research & Development, LLC, Shihong Sheng Shareholder of: Johnson & Johnson, Employee of: Janssen Research & Development, LLC, Yusang Jiang: None declared, Bei Zhou Shareholder of: Johnson & Johnson, Employee of: Janssen Research & Development, LLC, Désirée van der Heijde Consultant of: AbbVie, Amgen, Astellas, AstraZeneca, BMS, Boehringer Ingelheim, Celgene, Cyxone, Daiichi, Eisai, Eli-Lilly, Galapagos, Gilead Sciences, Inc., Glaxo-Smith-Kline, Janssen, Merck, Novartis, Pfizer, Regeneron, Roche, Sanofi, Takeda, UCB Pharma; Director of Imaging Rheumatology BV, Philip J Mease Grant/research support from: Abbott, Amgen, Biogen Idec, BMS, Celgene Corporation, Eli Lilly, Novartis, Pfizer, Sun Pharmaceutical, UCB – grant/research support, Consultant of: Abbott, Amgen, Biogen Idec, BMS, Celgene Corporation, Eli Lilly, Novartis, Pfizer, Sun Pharmaceutical, UCB – consultant, Speakers bureau: Abbott, Amgen, Biogen Idec, BMS, Eli Lilly, Genentech, Janssen, Pfizer, UCB – speakers bureau

Meckel Gruber syndrome – a case report

Background

Meckel Gruber Syndrome (MKS) is a rare autosomal recessive malformation syndrome characterized by multiple congenital anomalies ultimately leading to the death of fetus in utero or shortly after birth. It is characterized by classical triad of occipital encephalocele, infantile polycystic kidneys and postaxial polydactyly. Diagnosis of MKS is made on the basis of ultrasonography, gross morphology & histopathological findings. Here, we describe a case of MKS presenting with the classical triad.

Case presentation

A 25 year old lady presented with missed abortion at 17 weeks of gestation on her first conception. There was no history of previous fetal demise or any congenital anomaly. History of consanguineous marriage was not present. Ultra sonogram revealed death of the fetus in utero. Planned termination of pregnancy was performed & the products of conception were sent for study to the laboratory for autopsy, histopathological examination & genetic studies.

Conclusion

Rare genetic anomalies can present with missed abortion & an understanding of the same is important considering the clinical as well as psychological strain it can have on the pregnant mother. The case moreover should be reported for it being a genetic anomaly which results in death at a young age & also for its historical value.

Laying the Foundation of Medical Professionalism among Pre-clinical Students: Importance of Reflection

This article was migrated. The article was marked as recommended. Introduction: The escalating problem of unprofessionalism calls for teaching medical professionalism in a manner that should lead to deeper learning. Early clinical exposure (ECE) to an Intensive Care Unit (ICU) presents the issues pertaining to medical professionalism to the students in a more explicit and emotionally challenging manner. And reflection note writing evokes the critical process of thought and analysis required for learning. We conducted the present study to sensitize the pre-clinical students towards medical professionalism using these two tools, ECE and Reflection. Methods:Two hundred students of 1st MBBS were given an Objective Structured Clinical Examinations (OSCE). The students were then taken for ECE to an ICU. There, the students observed different ongoing activities and critical patients, a doctor discussed some cases with them, and they also interacted with the relatives of patients admitted in the ICU. Thereafter, students wrote a 'reflection' note describing what did you see? so what? and now what? Students were again given an OSCE, similar to the one given before the ECE, for assessing any change in their professional behaviour.Analysis of reflection notes was done thematically and of OSCE scores using paired t-test (p<0.05). Results: The analysis of reflection notes revealed the budding of different elements of professionalism among the students. Post-visit OSCE scores also showed significant improvement. Conclusion: Incorporation of reflection note writing along with ECE is helpful in laying the foundation of medical professionalism among pre-clinical students.

Thermal injury in pregnancy: predicting maternal and fetal outcome

This study was undertaken to assess the parameters that may predict maternal and foetal outcome in 49 thermally injured pregnant women in a Plastic surgery unit in tertiary referral center in the last five years. There were 33 maternal deaths and 34 fetal deaths. In general, pregnancy as such does not influence maternal outcome after thermal injury. In first and second trimester best chance for foetal survival is to ensure maternal survival and in the last trimester fetal survival depends upon fetal maturity. Maternal survival is less likely if the burn wound exceeds 50% total body surface area. Thermal injury does increase the risk of spontaneous abortion and premature labour. Early obstetric intervention is indicated in patients with fatal burn and complications.

Effects of phase space variables on oscillations of modified combinants

It has been shown recently that additional information can be ob- tained from charged particle multiplicity distribution by investigating their mod- ified combinantsC j, which exhibit periodic oscillatory behaviour. The modified combinants obtained from experimental data can be expressed in a recurrent form involving the probability of obtainingNcharged particlesP(N), scaled by the void probabilityP(0). The effects of various experimental observables such as |η|,pTand centre-of-mass collision energy √son the oscillations ofCjwill be discussed.

Sex-dependent effects of paternal deprivation and chronic variable stress on novel object recognition in adult California mice (Peromyscus californicus)

Early-life stress exposure can confer vulnerability for development of psychiatric illnesses and impaired cognition in adulthood. It is well-known that early-life stress can dysregulate the hypothalamic-pituitary-adrenal (HPA) axis in a sex-dependent manner. Specifically, uniparental rodent models of prolonged disrupted mother-offspring relationships (e.g., maternal separation) have demonstrated greater alterations in stress responsivity in adult males, compared to females. Also, chronic early-life stressors (e.g., limited bedding model) impair cognitive function in males more than females. However, the sex-dependent effects of early-life stress and later-life chronic HPA axis activation on cognition have not been well-characterized. Here, we utilized the biparental California mouse (Peromyscus californicus) to model the early-life adversity of paternal deprivation (PD). Fathers either remained in the nest (biparental care) or were permanently removed (PD) on postnatal day (PND) 1. Adult offspring were exposed to daily handling (control) or chronic variable stress (CVS; three stressors for seven days). Twenty-four hours after the final stressor, the novel object recognition (NOR) task commenced, followed by serum collection for corticosterone (CORT) analysis. Independent of sex or rearing, CVS increased CORT. Exploration during acquisition for the NOR task was increased as a result of CVS and PD. During NOR testing, non-stressed females exhibited greater difference scores (i.e., increased recognition memory), compared to non-stressed males. However, the addition of CVS diminished difference scores in females - an effect not observed in CVS-exposed males. Overall, these data suggest that neonatal paternal experience, sex, and chronic stress contribute to exploratory behavior, cognition, and stress hormone concentrations in a biparental species.

Numerical solutions to Giovannini’s QCD parton branching processes

In 1979, Giovannini [1] formulated multiparticle production as a manifestation of four QCD processes: A: g → gg (gluon bremsstrahlung), A-: q → qg (quark bremsstrahlung), B: g → qq (quark pair creation) and C: g → ggg (four-gluon vertex). At present, only approximate solutions exist, such as the Generalized Multiplicity Distribution (GMD) which excludes pro- cesses B and C [2, 3]. These approximate solutions have been very successful in describing charged particle multiplicities at lower energies, at least until the appearance of a shoulder-like structure at √s ≈ 200 GeV and 900 GeV first reported by the UA5 collaboration [4], also known as “KNO-scaling violation”. Here, we extend the work of Sakai [5] and attempt a numerical solution that incorporates all four QCD processes, and see if the addition of processes B and C can explain the shoulder-like structure.

The most useful cranial ultrasound predictor of neurodevelopmental outcome at 2 years for preterm infants

AIM

To determine the most important cranial ultrasound predictors of abnormality associated with neurodevelopmental outcome at 2 years of age in preterm infants.

MATERIALS AND METHODS

A total of 343 preterm infants born between 2005 and 2010 and cared for in KK Women's and Children's Hospital, a tertiary paediatric hospital, with birth weight ≤1,250 g were assessed in this retrospective study. Serial cranial ultrasound examinations were examined for intraventricular haemorrhage and cystic periventricular leukomalacia. Ventricular-brain ratio on term equivalent cranial ultrasound was measured. Neurodevelopmental outcome was assessed by the performance on Bayley Scales of Infant and Toddler Development, 3^rd edition (Bayley-III) at 2 years corrected age. Mental delay was defined as having a combined Bayley-III score (the average of cognitive and language scores) <80.

RESULTS

The mean cognitive, language, and motor scores on Bayley-III in this cohort were 93±15, 83±18, and 92±15, respectively. Twenty-six percent of the preterm infants had mental delay and 4% had cerebral palsy. Ventricular-brain ratio >0.35 was the most significant factor associated with mental delay (odds ratio 5.28, 95% CI: 1.49-18.71, p=0.01). Other significant risk factors for mental delay were male gender, postnatal steroids, and necrotising enterocolitis, whereas maternal tertiary education was a protective factor against adverse outcome.

CONCLUSION

Ventricular-brain ratio >0.35 on term-equivalent cranial ultrasound in preterm infants is the strongest predictor for mental delay on Bayley score at 2 years of age.

Vestibular Incision Subperiosteal Tunnel Access with Titanium-Prepared Platelet-Rich Fibrin - A Golden Approach for Treating Multiple Recession Defects in Esthetic Zone

Gingival recession is defined as apical migration of marginal gingival tissue causing the exposure of root surface. Abnormal brushing techniques, trauma, anatomical presence of tooth, caries, and improper oral hygiene measures are some of the problems leading to gingival recession. Several treatment modalities such as coronary advanced flaps and free gingival grafts have been used for the treatment of gingival recession defects and showed good results. However, while treating multiple gingival recessions, some new treatment modalities were introduced in literature. Vestibular incision subperiosteal tunnel access (VISTA) as a minimally invasive technique for root coverage was introduced with various advantages such as no secondary surgical site needed for harvestment of donor tissue and it provides excellent esthetic results with decreased patient morbidity. The present case report emphasizes on the treatment of multiple gingival recessions in the maxillary anterior teeth region using VISTA with titanium-prepared platelet-rich fibrin.

A comparison of lancets and evaluation of various manoeuvres in reducing finger prick pain during pre-donation haemoglobin estimation

OBJECTIVES

Three different types of lancets have been compared to identify and implement the one that causes the least pain. Simple manoeuvres during the lancing procedure have been evaluated to determine their effectiveness in reducing the intensity of perceived pain.

BACKGROUND

Pre-donation haemoglobin estimation is performed by pricking the donor's finger with a lancet. Pain associated with the procedure causes fear and anxiety, which dissuades the donors from donating blood.

METHODS

In 100 subjects, finger prick was performed using three different lancets, and the subjects were asked to score their pain on a numerical rating scale (NRS). A further 150 blood donors were subjected to routine finger pricking for Hb estimation and were asked to score their pain on an NRS. After 15 min, they underwent a second prick with application of a manoeuvre (breath holding, coughing trick or looking away) and again marked their pain scores on the NRS.

RESULTS

Participants reported the least pain scores with lancing devices that have a spring mechanism to retract the lancets soon after penetration into the skin. Breath holding and the cough trick manoeuvre reduced the perceived pain scores significantly.

CONCLUSION

Lancing devices merit consideration for routine use, and a simple manoeuvre may be applied to reduce perceived pain.

Laying the Foundation of Medical Professionalism among Pre-clinical Students: Importance of Reflection

This article was migrated. The article was not marked as recommended. Introduction: The escalating problem of unprofessionalism calls for 'teaching' medical professionalism in a more explicit manner. Early clinical exposure (ECE) presents the issues pertaining to medical professionalism to the students and reflection note writing evokes critical process of thought and analysis required for learning. The two, therefore, may be used for teaching medical professionalism. Methods:Two hundred students of Ist MBBS were taken for ECE to a medical intensive care unit (ICU). There, the students observed different ongoing activities and critical patients, a doctor discussed some cases with them and they also interacted with the relatives of patients admitted in the ICU. Thereafter, students wrote a 'reflection' note describing what did you see? so what? and now what? Students were given an Objective Structured Clinical Examinations (OSCE), one before the ECE and one after it, for assessing any change in their professional behaviour.Analysis of reflection notes was done thematically and of OSCE scores using paired t-test (p<0.05). Results: The analysis of reflection notes revealed the budding of different elements of professionalism among the students. Post-visit OSCE scores also showed significant improvement. Conclusion: Incorporation of reflection with ECE is helpful in laying the foundation of medical professionalism among pre-clinical students.