Purchase intention towards dietary supplements during COVID-19 pandemic: consumers’ perspective

The consumption of dietary supplements (DSs) has been steadily increasing in the wake of the COVID-19 outbreak in most countries. Consumer purchase intention towards DSs is expected to be of concern to many companies in the pharmaceutical industry. This study extends the Theory of Planned Behaviour by adding health consciousness and perceived price in the model to investigate its effect on consumer purchase intention towards DSs during the COVID-19 outbreak. A questionnaire-based survey was distributed via an online survey to 207 respondents. Results from multiple regression analysis revealed that consumer attitudes, subjective norms, perceived behavioural control, and health consciousness contributed significantly to purchase intention towards DSs. Perceived price did not have an impact on intention. Further investigation revealed that favourable attitudes towards DSs were the most important contributor towards purchasing DSs during the COVID-19 pandemic.

Effect of Moringa olifera leaves on growth and gut microbiota of Nile tilapia (Oreochromis niloticus)

The study was conducted to evaluate the effect of Moringa olifera on the growth and gut health of Tilapia (Oreochromis niloticus). The feed having 30% crude protein was prepared as an experimental diet with 4%, 8% and 10% M. olifera leaf supplementation, respectively. The control diet was devoid of M. olifera leaves. The 10 weeks feeding trial was carried out on 60 fish in aquaria. Fish was fed @ 3% of body weight twice a day. Diet with the high level of inclusion of M. olifera leaves significantly increased the growth rate, Survival Rate (SR), Specific Growth Rate (SGR) and Feed Conversion Efficiency (FCE) in all treatment groups compared to the control group. Similarly, Feed Conversion Ratio (FCR) gradually decreased and found highly-significant. To check the gut health of the Tilapia, random samples were selected and dissected. Nutrient agar was used as culture media to check the growth of bacteria. Pour Plate Method was used for viable colonies count by colony counter. Through staining method, the different bacteria such as Escherichia coli, Salmonella, Shigella and Pseudomonas aeruginosa were identify abundantly in the intestine of control diet fish but less number present in treatment diets groups. These results showed that M. olifera leaves up to 10% of dietary protein can be used for Nile tilapia for significant growth and healthy gut microbiota of fish.

Statin induced myalgia on high intensity statin in patients with Acute Coronary Syndrome

Background

High intensity statins are recommended in patients with acute coronary syndrome. Statins inhibit atherosclerotic plaque formation in the coronary arteries and reducing the burden of ischemic heart disease, therefore decreasing the morbidity and mortality. Muscle symptoms are most common adverse effect of statins. Hence, the aim of this study is to determine the statin induced myalgia by the statin myalgia clinical score.

Purpose

To monitor the Statin induced myalgia on high intensity statin in patients with Acute Coronary Syndrome

Methods

This was an prospective observational study comprised of 418 patients with acute coronary syndrome who were commenced on high intensity statins (Rosuvastatin 20–40mg & Atorvastatin 40–80). These patients were followed at 4 weeks, 8 weeks and 12 weeks subsequently and the clinical myalgia score (SAMS-CI) was calculated at each visit to determine the statin induced myalgia. SAMS-CI was categorized as unlikely (2–6), possible (7–8) and probable (9–11)

Results

From 418 patients, 327 were males and 91 were females. Mean age was 55.6±11.14. Only 19 (7.63±1.8) patients developed muscle symptoms on high intensity statins (Rosuvastatin 20 mg and Atorvastatin 40 mg) on SAMS-CI Score. 5 patients were unlikely to develop myalgia on SAMS-CI and continued with the same dosage without any new symptoms. 6 patients were possible on SAMS-CI, therefore the dosage of these patients were decreased to moderate intensity statin (Rosuvastatin 10mg, Atorvastatin 20 mg), their symptoms were resolved and continued with the moderate intensity statins. Furthermore, Statin was hold in 8 patients in the probable category for 4 weeks until the resolution of symptoms followed by moderate intensity statins.

Conclusion

Statin induced myalgia is more reported in old aged and female patients. Most of the patients can better tolerate the lower range of high intensity statins with the similar benefits and should be prescribed in every patient

Funding Acknowledgement

Type of funding sources: None.

1599 Review of Telephone Consultations for Suspected Head and Neck Cancer Referrals During The COVID-19 Pandemic

Introduction

Pandemic COVID-19 necessitated a transformation in the delivery of healthcare. Telephone consultations were introduced to protect and progressively manage patients with minimal delay. This is a review of the effectiveness of these remote consultations for suspected 2-week wait (2ww) head and neck cancer referrals to a north London NHS teaching hospital Oral and Maxillofacial unit during the first official UK government lockdown from March - July 2020.

Method

Prospective electronic records of 176 consecutive 2ww referrals between March – July 2020 was assessed. Data analysed included initial telephone consultations, subsequent face-to-face (F2F) appointments, if required, the interval from telephone to F2F appointments and histopathological diagnoses.

Results

157 patients (n = 176) received an initial telephone call, of which 127 (80.9%) required a F2F consultation. The number of days between the initial telephone consultation and subsequent F2F assessment ranged from 0 to 141, with a mean of 11 and a median of 1. Notably, 31 patients (24.4%) were seen in person on the same day as their telephone consultation. Biopsies were indicated for 69 patients (54.3%) of which 9 (13.0%) were diagnosed as malignancies.

Conclusions

Whilst protecting patients from a pandemic is utmost, continuing care for non-pandemic conditions must be considered. It is even more important to manage 2ww referrals efficiently. These results indicate the majority of suspected cancer referrals warrant F2F assessment for a confident outcome. Despite reinstated, ongoing social restrictions, 2ww referrals are now being seen exclusively F2F, subject to patient choice. This information is useful for planning and strategizing services in a head and neck OMFS unit.

Limiting amino acids supplementation in low crude protein diets and their impacts on growth performance and carcass composition in Labeo rohita (rohu) adult fish

Ninety days study was conducted in hapas installed in earthen ponds. Fish of an average initial weight (220g) were evenly distributed in triplicate groups within fifteen hapas. Five experimental diets labeled as T1 (25% CP and NRC recommended amino acid level) as control diet, T2 (with 2% low protein and 5% amino acid supplementation), T3 (with 2% low protein and 10% amino acid supplementation), T4 (with 4% low protein and 10% amino acid supplementation) and T5 (with 4% low protein and 20% amino acid supplementation) were prepared. Fish were fed with @3% of their body weight twice a day at 10.00 & 16:00 hour. Significantly higher percent weight gain (420.18 ± 66.84a) and specific growth rate (13499.33±1273.54a) along with improved feed conversion ratio (1.29 ± 0.09b) and hundred percent survivals were recorded during the trial. Furthermore proximate analysis of meat showed significant improvement in the crude protein level (81.77 ± 0.19a) served with diet containing 20% limiting amino acids mixture. Therefore, limiting amino acids can be a source of cost effective feed and use safely in L. rohita diet.

Prevalence and determinants of stunting among preschool and school-going children in the flood-affected areas of Pakistan

Stunting is a significant public health problem in low- and middle-income countries. This study assessed the prevalence of stunting and associated risk factors of stunting among preschool and school-going children in flood-affected areas of Pakistan. A cross-sectional study was conducted by visiting 656 households through multi-stage sampling. Respondent's anthropometric measurements, socio-demographic information and sanitation facilities were explored. A logistic regression model was used to determine determinants of stunting, controlling for all possible confounders. The overall prevalence of stunting in children was 40.5%, among children 36.1% boys and 46.3% of girls were stunted. The prevalence of stunting in under-five children was 50.7%. Female children (OR=1.35, 95% CI:0.94-2.0), children aged 13-24 months (OR=6.5, 95% CI: 3.0-13.9), mothers aged 15-24 years (OR=4.4, 95% CI: 2.6-7.2), joint family (OR=2.1, 95% CI: 1.4-3.0) did not have access to improved drinking water (OR=3.3, 95% CI: 1.9-5.9), and the toilet facility (OR=2.8, 95% CI, 1.9-4.3), while the children from district Nowshera (OR=1.7, 95% CI: 0.9-3.2) were significantly (P<0.05) associated in univariate analysis. The regression model revealed that child age, maternal age, family type, quality of water, and toilet facility, were the significant (P<0.05) factors contributing to child stunting in the flood-hit areas. Identification of key factors might be helpful for policymakers in designing comprehensive community-based programs for the reduction of stunting in flood-affected areas. In disasters such as flood, the detrimental consequences of the stunting problem could be even more on children. Evidence-based education and care must be provided to the families in the flood-affected regions to reduce the stunting problem. The determinants of stunting should be targeted by making comprehensive policies regarding proper nutrition, livelihood, clean water, and sanitation facilities in flood-hit regions.

In vitro anthelmintic efficacy of Citrullus colocynthis (L.) Schrad on Haemonchus contortus

Ethno-veterinary medicinal studies associated with traditional uses of the flora of the Cholistan desert have shown that fruits of Citrullus colocynthis are used for the treatment of helminth infections. The present research was designed to evaluate the anthelmintic efficacy of C. colocynthis against H. contortus. The in vitro anthelmintic effects of aqueous-methanol and ethyl acetate fruit extracts of C. colocynthis against H. contortus were determined through egg hatch and adult motility assays. The effect of four serial dilutions of 25 mg/mL of each extract compared to levamisol (0.55 mg/mL) and oxfendazole (three serial dilutions of 25 µg/mL) were studied. Both ethyl acetate and aqueous-methanol extracts paralyzed all adult worms 4h and 8h post-exposure at a dose of 25 mg/mL each. In the egg hatch assay, about 83.67% and 80.67% of H. contortus eggs failed to hatch with the same dose (i.e. 25 mg/mL) of ethyl acetate and CAME extracts, respectively. The results of the present study strongly support fruit extracts of C. colocynthis as a promising alternative to synthetic drugs against H. contortus. These findings will lead to further in vivo studies to investigate the bio-availability of the active ingredients of the plant and the minimum non-lethal concentration required for treatment of haemonchosis in livestock. The anthelmintic effects of C. colocynthis might be attributed to the presence of phenolic acids.

OP0128 INTEGRATED LABORATORY ABNORMALITY PROFILES OF UPADACITINIB WITH UP TO 4.5 YEARS OF EXPOSURE IN PATIENTS WITH RHEUMATOID ARTHRITIS TREATED IN THE SELECT PHASE 3 PROGRAM

Background:

Upadacitinib (UPA) is an oral Janus kinase inhibitor approved for rheumatoid arthritis (RA). The safety and efficacy of UPA has been evaluated across a spectrum of patients (pts) with RA in the phase 3 SELECT clinical program.1,2

Objectives:

To describe long-term laboratory profiles (cutoff date: June 30, 2020) associated with exposure to UPA, adalimumab (ADA), and methotrexate (MTX) in pts with RA treated in the SELECT trials.

Methods:

Data were analyzed from 6 randomized controlled UPA RA trials.1,2 The proportions of pts experiencing potentially clinically significant laboratory changes at a single time point were summarized for the following groups: pooled UPA 15 mg once daily (QD; UPA15; 6 trials), pooled UPA 30 mg QD (UPA30; 4 trials), ADA 40 mg every other week (EOW; 1 trial), and MTX monotherapy (1 trial). Pts received UPA with/without background conventional synthetic disease-modifying antirheumatic drugs. Treatment-emergent adverse events are reported as exposure-adjusted event rates (events/100 pt-years [E/100 PY]). Toxicity was graded per OMERACT criteria, or NCI CTCAE for creatine phosphokinase (CPK) and creatinine.

Results:

4413 pts received ≥1 dose of UPA (UPA15, n=3209; UPA30, n=1204). Exposures were comparable between treatment groups (Table). Proportions of pts with Grade (Gr) 3 and 4 decreases in hemoglobin were highest with UPA30 and MTX (Table). Rates of anemia, as reported by the investigator, were comparable between UPA15, ADA, and MTX groups (Figure); the frequency of UPA-treated pts who discontinued due to anemia was low in all arms. Gr 3 and 4 decreases in neutrophils and lymphocytes with UPA were dose-dependent and higher vs ADA or MTX. Discontinuations due to neutropenia and lymphopenia were rare (<0.1%). Transaminase elevations were more frequent with UPA and MTX vs ADA; however, the proportion of pts who discontinued due to increases in alanine (ALT) or aspartate aminotransferase (AST) were comparable between UPA15 and ADA, and numerically higher with UPA30 and MTX. CPK elevations were more frequent with UPA (Figure). Most events were asymptomatic, and the 1 case of rhabdomyolysis in the UPA30 group was unrelated to study drug (attributed to influenza).

Table 1.

Pts with potentially clinically significant laboratory changes

Variable, n (%)MTX monotherapy (n=314; 637.4 PY)ADA 40 mg EOW (n=579; 1051.8 PY)UPA 15 mg QD (n=3209; 7023.8 PY)UPA 30 mg QD (n=1204; 3091.6 PY)Mean (SD) exposure, weeks106 (67)95 (70)114 (64)134 (66)Median (range) exposure, weeks144 (1, 221)118 (2, 231)136 (0, 232)160 (0, 231)Hemoglobin, g/LGr 3 (70–<80 or decreased 21–<30)28a (9.0)24b (4.2)254d (7.9)169f (14.2)Gr 4 (<70 or decreased ≥30)16a (5.1)16b (2.8)101d (3.2)78f (6.5)Neutrophils, 109/LGr 3 (0.5–<1.0)3a (1.0)3b (0.5)40d (1.2)37g (3.1)Gr 4 (<0.5)1a (0.3)1b (0.2)10d (0.3)5g (0.4)Lymphocytes, 109/LGr 3 (0.5–<1.0)74a (23.7)53b (9.2)802d (25.1)423g (35.5)Gr 4 (<0.5)5a (1.6)3b (0.5)75d (2.3)47g (3.9)ALT, U/LGr 3 (3.0–8.0 × ULN)26a (8.3)13c (2.3)152e (4.8)71h (5.9)Gr 4 (>8.0 × ULN)5a (1.6)4c (0.7)26e (0.8)10h (0.8)AST, U/LGr 3 (3.0–8.0 × ULN)15a (4.8)9c (1.6)101e (3.2)36h (3.0)Gr 4 (>8.0 × ULN)1a (0.3)5c (0.9)18e (0.6)8h (0.7)CPK, U/LGr 3 (>5.0–10.0 × ULN)2a (0.6)3c (0.5)65e (2.0)36i (3.0)Gr 4 (>10.0 × ULN)0a (0)3c (0.5)27e (0.8)15i (1.3)Creatinine, μmol/LGr 3 (>3.0–6.0 × ULN)0a (0)1c (0.2)3e (<0.1)2j (0.2)Gr 4 (>6.0 × ULN)0a (0)4c (0.7)8e (0.3)1j (<0.1)

an=312. bn=576. cn=577. dn=3201. en=3199. fn=1193. gn=1192. hn=1195. in=1196. jn=1197

ULN, upper limit of normal

Conclusion:

This long-term analysis of UPA-treated pts with RA showed dose-dependent relationships for several laboratory abnormalities. Incidences of these with UPA15 were typically higher than with ADA but similar to MTX, except for increased CPK elevations. Treatment discontinuations due to laboratory abnormalities were infrequent and similar across all treatment groups.

References:

[1]Tanaka Y. Mod Rheumatol 2020;30:779–87; 2. Rubbert-Roth A, et al. N Engl J Med 2020;383:1511–21.

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. No honoraria or payments were made for authorship. Medical writing support was provided by Russell Craddock, PhD, of 2 the Nth (Cheshire, UK), and was funded by AbbVie.

Disclosure of Interests:

Christina Charles-Schoeman Consultant of: AbbVie, Gilead, Pfizer, and Sanofi/Regeneron, Grant/research support from: AbbVie, Bristol-Myers Squibb, and Pfizer, Jon T Giles Consultant of: AbbVie, Bristol-Myers Squibb, Eli Lilly, Gilead, Pfizer, and UCB, Grant/research support from: Pfizer, Nancy Lane Consultant of: Amgen, Mallinckrodt, Pfizer, and Roche, Ernest Choy Speakers bureau: AbbVie, Amgen, Bristol-Myers Squibb, Chugai, Eli Lilly, Galapagos, Gilead, Janssen, Novartis, Pfizer, Regeneron, Roche, Sanofi, and UCB, Consultant of: AbbVie, Amgen, Biocon, Biogen, Chugai, Eli Lilly, Gilead, Janssen, Merck Serono, Novartis, Pfizer, Regeneron, Roche, R-Pharm, and Sanofi, Grant/research support from: Bio-Cancer, Biogen, Novartis, Pfizer, Roche, Sanofi, and UCB, Daniel Furst Speakers bureau: AbbVie, Continuing Medical Education, and Novartis, Consultant of: Actelion, Amgen, Bristol-Myers Squibb, Corbus, Galapagos, Novartis, and Pfizer, Grant/research support from: Actelion, Amgen, Bristol-Myers Squibb, Corbus, Galapagos, GSK, NIH, Novartis, Pfizer, Roche/Genentech, and Sanofi, Jiří Vencovský Speakers bureau: AbbVie, Biogen, MSD, Pfizer, Roche, Sanofi, and UCB, Consultant of: AbbVie, Boehringer Ingelheim, Eli Lilly, Gilead, and Octapharma, Anthony G Wilson: None declared, Gerd Rüdiger Burmester Speakers bureau: AbbVie, Eli Lilly, Gilead, Janssen, MSD, Pfizer, Roche, and UCB, Consultant of: AbbVie, Eli Lilly, Gilead, Janssen, MSD, Pfizer, Roche, and UCB, Tim Shaw Shareholder of: May own stock or options in AbbVie, Employee of: AbbVie, Yanna Song Shareholder of: May own stock or options in AbbVie, Employee of: AbbVie, Heidi Camp Shareholder of: May own stock or options in AbbVie, Employee of: AbbVie, Nasser Khan Shareholder of: May own stock or options in AbbVie, Employee of: AbbVie, Jillian Yee Shareholder of: May own stock or options in AbbVie, Employee of: AbbVie, Samuel Anyanwu Shareholder of: May own stock or options in AbbVie, Employee of: AbbVie, Iain McInnes Consultant of: AbbVie, Celgene, Janssen, Novartis, and UCB, Grant/research support from: Celgene, Janssen, Novartis, Pfizer, Roche, and UCB

POS0508 EVALUATION OF RESPONSE TO PNEUMOCOCCAL VACCINATION IN PATIENTS WITH RHEUMATOID ARTHRITIS RECEIVING UPADACITINIB: RESULTS FROM A PHASE 2 OPEN-LABEL EXTENSION STUDY

Background:

Pneumococcal vaccination is recommended in patients with RA who are receiving conventional synthetic/biologic DMARDs.1 Upadacitinib (UPA) is an oral Janus kinase (JAK) inhibitor engineered to have a greater selectivity for JAK1 versus JAK2, JAK3, and tyrosine kinase 2, and is approved for the treatment of RA.

Objectives:

The aim of this analysis was to assess the impact of long-term treatment with UPA + background MTX on immunologic responses to Prevnar 13® (Pneumococcal 13-valent Conjugate Vaccine [Diphtheria CRM197 Protein]; PCV13) in patients with RA enrolled in the ongoing Phase 2 open-label extension study BALANCE-EXTEND.

Methods:

Patients from BALANCE-EXTEND receiving PCV13 vaccination were required to be on UPA 15 mg once daily (QD) or 30 mg QD and background MTX for ≥4 weeks prior to, and after, PCV13 vaccination; MTX was not interrupted prior to vaccination. Vaccination antibody titers were collected pre-vaccination (Week 0) and post-vaccination (Weeks 4 and 12). The primary variable was the proportion of patients with satisfactory humoral response to PCV13 (≥2-fold increase in antibody concentration from pre-vaccination [Week 0] in ≥6/12 pneumococcal antigens [1, 3, 4, 5, 6B, 7F, 9V, 14, 18C, 19A, 19F, and 23F]) at 4 weeks post-vaccination.

Results:

Of 111 patients (UPA 15 mg, n=87; UPA 30 mg, n=24), 86% were female, most (98%) were white, and mean (standard deviation) age was 58.4 (12.0) years. Prior to vaccination, patients had a median (range) duration of RA of 9.3 (3.4–35.0) years and had been receiving UPA for a median (range) of 3.9 (3.0–4.9) years. All but 3 patients were taking concomitant MTX, and 44.1% were taking a CS (median daily dose, 5.0 mg). All 111 patients received PCV13, none discontinued UPA during the first 4 weeks, and blood samples were available from 83/23 and 79/22 patients in the UPA 15/30 mg groups at Weeks 4 and 12, respectively. At 4 weeks, satisfactory humoral response to PCV13 occurred in 67.5% (95% confidence interval [CI]: 57.4–77.5) and 56.5% (95% CI: 36.3–76.8) of patients receiving UPA 15 and 30 mg, respectively. At 12 weeks, satisfactory humoral response to PCV13 occurred in 64.6% (95% CI: 54.0–75.1) and 54.5% (95% CI: 33.7–75.4) of patients receiving UPA 15 and 30 mg, respectively (Figure 1). There was no clear difference in response between patients receiving and not receiving concomitant CS. Within 30 days post-vaccination, 2 adverse events (AEs) were considered as possibly related to UPA (1 case of diverticulitis, UPA 15 mg; 1 case of anemia, UPA 30 mg) and no serious AEs were reported (Table 1). Two patients experienced pyrexia and 1 subject each experienced vaccination-site pain and headache within 1 day post-vaccination (all in UPA 15 mg group).

Table 1.

Safety through 30 days post-PVC13 vaccination in UPA-treated patients

Event, n (%)UPA 15 mg QD (n=87)UPA 30 mg QD (n=24)Any AE15 (17.2)3 (12.5)Serious AE00AE leading to discontinuation of study drug00AE with reasonable possibility of being related to UPAa1 (1.1)b1 (4.2)cDeath00

aAs assessed by the investigator. bDiverticulitis. cAnemia.

AE, adverse event; PVC13, Pneumococcal 13-valent Conjugate Vaccine [Diphtheria CRM197 Protein]; QD, once daily; UPA, upadacitinib.

Conclusion:

Satisfactory humoral response to PCV13 at 4 weeks occurred in ~two-thirds of patients with RA receiving long-term treatment with UPA 15 mg QD + background MTX. This is broadly consistent with pneumococcal vaccine humoral responses observed in patients with RA treated with other JAK inhibitors, biologics, or placebo.2–4

References:

[1]Singh JA, et al. Arthritis Care Res 2016;68:1–25.

[2]Winthrop KL, et al. Arthritis Res Ther 2019;21:102.

[3]Bingham CO, et al. Ann Rheum Dis 2015;74:818–22.

[4]Winthrop KL, et al. Ann Rheum Dis 2016;75:687–95.

Acknowledgements:

AbbVie funded this study and participated in the study design, research, analysis, data collection, interpretation of data, reviewing, 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 Frances Smith, PhD, of 2 the Nth, which was funded by AbbVie.

Disclosure of Interests:

Kevin Winthrop Consultant of: AbbVie, Bristol-Myers Squibb, Eli Lilly, Galapagos, Gilead, Pfizer, Roche, and UCB., Grant/research support from: AbbVie, Bristol-Myers Squibb, Eli Lilly, Galapagos, Gilead, Pfizer, Roche, and UCB., Juan Ignacio Vargas Consultant of: AbbVie, Bristol-Myers Squibb, Eli Lilly, Galapagos, Gilead, Pfizer, Roche, and UCB, Grant/research support from: AbbVie, Bristol-Myers Squibb, Eli Lilly, Galapagos, Gilead, Pfizer, Roche, and UCB, Edit Drescher: None declared, CONRADO GARCIA GARCIA: None declared, Alan Friedman Shareholder of: AbbVie, Employee of: AbbVie, Jeffrey Enejosa Shareholder of: AbbVie, Employee of: AbbVie, Nasser Khan Shareholder of: AbbVie, Employee of: AbbVie, Yihan Li Shareholder of: AbbVie, Employee of: AbbVie, Justin Klaff Shareholder of: AbbVie, Employee of: AbbVie, Alan Kivitz Shareholder of: Amgen, Novartis, Gilead, GlaxoSmithKline, Pfizer Inc., and Sanofi, Speakers bureau: AbbVie, Celgene, Eli Lilly, Flexion, Genzyme, Horizon, Merck, Novartis, UCB, Pfizer Inc., Regeneron, Sanofi, and UCB, Consultant of: AbbVie, Boehringer Ingelheim, Genzyme, Gilead, Janssen, Pfizer Inc., Regeneron, Sanofi, SUN Pharma Advanced Research, and UCB

POS0655 LONG-TERM SAFETY AND EFFICACY OF UPADACITINIB IN PATIENTS WITH RHEUMATOID ARTHRITIS: 3-YEAR RESULTS FROM THE SELECT-EARLY STUDY

Background:

Upadacitinib (UPA), an oral Janus kinase inhibitor, demonstrated significant improvements in signs, symptoms, and structural inhibition as monotherapy (mono) vs methotrexate (MTX) in MTX-naïve patients (pts) with rheumatoid arthritis (RA) through 48 weeks (wks).1

Objectives:

To report the efficacy and safety of UPA vs MTX mono up to 156 wks in pts with RA from the ongoing long-term extension (LTE) of the SELECT-EARLY trial.

Methods:

During the 48-wk double-blind study period, pts were randomized to UPA 15 or 30 mg once daily (QD) or MTX (titrated to 20 mg/wk by Wk 8). At Wk 26, pts who did not achieve Clinical Disease Activity Index (CDAI) remission (≤2.8) and had <20% improvement from baseline in tender or swollen joint count received blinded rescue therapy (addition of MTX for UPA groups and UPA 15 or 30 mg for MTX group). In the LTE, pts received open-label treatment once the last pt reached Wk 48. Efficacy assessments up to Wk 156 were summarized by randomized group and included American College of Rheumatology (ACR) responses, remission and low disease activity (LDA) measures, and change in modified Total Sharp Score (mTSS; up to 96 wks). Treatment-emergent adverse events (AEs) per 100 pt-years (PY) for pts on continuous mono were summarized through 156 wks. Non-responder imputation was used for binary endpoints for missing data and when pts received rescue therapy or prematurely discontinued the study drug.

Results:

Of 945 pts randomized and treated, 775 entered the LTE on study drug (including 57 rescued pts; MTX, 33; UPA 15 mg, 17; UPA 30 mg, 7). Overall, 161 (21%) pts discontinued during the LTE. At Wk 156, higher proportions of pts randomized to UPA achieved a 20/50/70% improvement in ACR response (ACR20/50/70), LDA, and remission vs MTX (Figure 1). Change from baseline in mTSS at Wk 96 favored UPA vs MTX (data not shown). Most AEs were numerically more frequent with UPA 30 mg. The overall rate of serious infection was numerically higher with UPA vs MTX (Table 1). Herpes zoster (HZ), neutropenia, non-melanoma skin cancer (NMSC), and creatine phosphokinase (CPK) elevation were more frequent with UPA vs MTX. Two active tuberculosis (TB) events were reported in each UPA arm; 3 adjudicated gastrointestinal (GI) perforation events were observed in the UPA 30 mg arm. Adjudicated major adverse cardiovascular events (MACEs) or venous thromboembolic events (VTEs) were comparable across treatment arms.

Conclusion:

UPA monotherapy showed sustained clinically meaningful responses including remission vs MTX through Wk 156 but higher rates of several AEs, including HZ, neutropenia, and CPK elevations; no new safety risks were observed compared with previous results.1,2

References:

[1]van Vollenhoven R, et al. Ann Rheum Dis 2019;78:376–7; 2. Cohen SB, et al. Ann Rheum Dis 2020;annrheumdis-2020-218510.

Table 1.

Safety overview

E/100 PY (95% CI)MTX mono(n=314; PY=601.9)UPA 15 mg QD mono(n=317; PY=703.4)UPA 30 mg QD mono(n=314; PY=687.6)Any AE240.2(228.0, 252.9)268.0(256.0, 280.4)292.5(279.8, 305.5)Any serious AE10.8 (8.3, 13.8)12.2 (9.8, 15.1)16.3 (13.4, 19.6)Any AE leading to discontinuation of study drug6.5 (4.6, 8.9)7.3 (5.4, 9.5)7.7 (5.8, 10.1)Any deatha0.7 (0.2, 1.7)0.9 (0.3, 1.9)1.0 (0.4, 2.1)Serious infection2.5 (1.4, 4.1)3.3 (2.1, 4.9)4.4 (2.9, 6.2)Opportunistic infection excluding TB and HZ0.2 (0.0, 0.9)0.1 (0.0, 0.8)0.3 (0.0, 1.1)HZ0.8 (0.3, 1.9)4.5 (3.1, 6.4)4.7 (3.2, 6.6)Active TB00.3 (0.0, 1.0)0.3 (0.0, 1.1)NMSC00.4 (0.1, 1.2)1.0 (0.4, 2.1)Malignancy other than NMSC1.0 (0.4, 2.2)0.6 (0.2, 1.5)1.2 (0.5, 2.3)Hepatic disorder14.1 (11.3, 17.5)12.5 (10.0, 15.4)15.0 (12.2, 18.2)GI perforationb000.4 (0.1, 1.3)Neutropenia2.2 (1.2, 3.7)4.5 (3.1, 6.4)5.7 (4.0, 7.8)CPK elevation1.8 (0.9, 3.3)7.7 (5.8, 10.0)15.4 (12.6, 18.6)MACEb0.3 (0.0, 1.2)0.4 (0.1, 1.2)0.6 (0.2, 1.5)VTEb0.3 (0.0, 1.2)0.4 (0.1, 1.2)0.6 (0.2, 1.5)

Data were censored at the time of MTX or UPA addition for rescued pts

aIncludes treatment-emergent (≤30 days after the last dose of study drug) and non-treatment-emergent deaths. bAdjudicated

Acknowledgements:

AbbVie funded this study; contributed to its design; participated in data collection, analysis, and interpretation of the data; and in the writing, review, and approval of the abstract. No honoraria or payments were made for authorship. Medical writing support was provided by Russell Craddock, PhD, of 2 the Nth (Cheshire, UK), and was funded by AbbVie.

Disclosure of Interests:

Ronald van Vollenhoven Speakers bureau: AbbVie, AstraZeneca, Biotest, Bristol-Myers Squibb, Galapagos, Gilead, GSK, Janssen, Pfizer, Sanofi, Servier, UCB, and Viela Bio, Consultant of: AbbVie, AstraZeneca, Biogen, Biotest, Bristol-Myers Squibb, Galapagos, Gilead, GSK, Janssen, Pfizer, Sanofi, Servier, UCB, and Viela Bio, Grant/research support from: Bristol-Myers Squibb, GSK, Eli Lilly, Pfizer, Roche, and UCB, Tsutomu Takeuchi Speakers bureau: AbbVie, AYUMI, Bristol-Myers Squibb, Chugai, Daiichi Sankyo, Dainippon Sumitomo, Eisai, Gilead, Mitsubishi Tanabe, Novartis, Pfizer, and Sanofi, Consultant of: Astellas, Chugai, and Eli Lilly, Grant/research support from: AbbVie, Asahi Kasei, Astellas, Chugai, Daiichi Sankyo, Eisai, Mitsubishi Tanabe, Nippon Kayaku, Shionogi, Takeda, and UCB, Jacob Aelion Grant/research support from: AbbVie, Amgen, AstraZeneca, Bristol-Myers Squibb, Celgene, Eli Lilly, Galapagos/Gilead, Genentech, GSK, Horizon, Janssen, Mallinckrodt, Nektar, Nichi-Iko, Novartis, Pfizer, Regeneron, Roche, Sanofi, Selecta, and UCB, Nilmo Chávez Speakers bureau: AbbVie, Janssen, and Pfizer, Consultant of: AbbVie, Janssen, and Pfizer, Grant/research support from: AbbVie, Galapagos, Gilead, Pfizer, and Sanofi, Pablo Mannucci Walter Consultant of: AbbVie, Grant/research support from: AbbVie, Bristol-Myers Squibb, Eli Lilly, Genentech/Roche, GSK, Janssen, and UCB, Atul Singhal Consultant of: AbbVie, Aclaris, Amgen, AstraZeneca, Bristol-Myers Squibb, Eli Lilly, Gilead, Idorsia, Novartis, Oscotec, Pfizer, Regeneron, Roche/Genentech, Sanofi, Selecta, Takeda, UCB, and Viela Bio, Grant/research support from: AbbVie, Aclaris, Amgen, AstraZeneca, Bristol-Myers Squibb, Eli Lilly, Gilead, Idorsia, Novartis, Oscotec, Pfizer, Regeneron, Roche/Genentech, Sanofi, Selecta, Takeda, UCB, and Viela Bio, Jerzy Swierkot Speakers bureau: AbbVie, Accord, BMS, Janssen, MSD, Pfizer, Roche, Sandoz, and UCB, Consultant of: AbbVie, Accord, BMS, Janssen, MSD, Pfizer, Roche, Sandoz, and UCB, Grant/research support from: AbbVie, Accord, BMS, Janssen, MSD, Pfizer, Roche, Sandoz, and UCB, Alan Friedman Shareholder of: May own stock or options in AbbVie, Employee of: AbbVie, Nasser Khan Shareholder of: May own stocks or options in AbbVie, Employee of: AbbVie, Yihan Li Shareholder of: May own stocks or options in AbbVie, Employee of: AbbVie, Xianwei Bu Shareholder of: May own stocks or options in AbbVie, Employee of: AbbVie, Justin Klaff Shareholder of: May own stock or options in AbbVie, Employee of: AbbVie, Vibeke Strand Consultant of: AbbVie, Amgen, Arena, AstraZeneca, Bayer, Bristol-Myers Squibb, Boehringer Ingelheim, Celltrion, Eli Lilly, Genentech/Roche, Gilead, GSK, Ichnos, Inmedix, Janssen, Kiniksa, MSD, Myriad Genetics, Novartis, Pfizer, Regeneron, Sandoz, Sanofi, Setpoint, and UCB

POS0087 LONG-TERM SAFETY AND EFFICACY OF UPADACITINIB OR ADALIMUMAB IN PATIENTS WITH RHEUMATOID ARTHRITIS: RESULTS AT 3 YEARS FROM THE SELECT-COMPARE STUDY

Background:

In the SELECT-COMPARE study, the Janus kinase inhibitor, upadacitinib (UPA), demonstrated significant improvements in the signs and symptoms of rheumatoid arthritis (RA) when administered at 15 mg once daily (QD) on background methotrexate (MTX) compared with adalimumab (ADA) plus MTX at Week 12 that were maintained through 72 weeks in patients with prior inadequate response to MTX.1

Objectives:

To assess the long-term safety and efficacy of UPA vs ADA over 3 years in the ongoing long-term extension (LTE).

Methods:

Patients receiving background MTX were randomized 2:2:1 to UPA 15 mg QD, placebo (PBO), or ADA 40 mg every other week. Between Weeks 14-26, rescue was mandated for either lack of response (<20% improvement in tender or swollen joint counts: Weeks 14, 18, 22) or failure to achieve a targeted disease outcome (CDAI low disease activity: Week 26). Patients who completed the 48-week double-blind period could enter an LTE for up to 10 years total. This analysis describes patients through 3 years of treatment. Treatment-emergent adverse events (TEAEs) per 100 patient years (PY), including events of special interest (AESI), were summarized up to 3 years based on exposure to UPA and to ADA. Efficacy was analyzed by original randomized groups. Patients who were rescued or prematurely discontinued study drug were categorized as non-responders for visits after rescue or discontinuation. Descriptive analyses were performed without formal statistical comparisons.

Results:

In total, 651, 651, and 327 patients were randomized at baseline to receive UPA, PBO, and ADA, respectively. Between Weeks 14-26, 252 (39%) patients were rescued from UPA to ADA, 159 (49%) were rescued from ADA to UPA, and all PBO patients were switched to UPA by Week 26.1 A higher proportion of patients randomized to UPA completed 3 years without rescue compared to those randomized to ADA (47% vs 36%, respectively). UPA was generally well-tolerated as assessed by the rates of TEAEs, including serious AEs, AEs leading to discontinuation of study drug, and AESIs, including serious and opportunistic infections, malignancies, adjudicated major adverse cardiac events or venous thromboembolism; Figure 1). Consistent with previous analyses, the event rates of AESIs were generally comparable between the UPA and ADA groups, while herpes zoster, lymphopenia, hepatic disorder, and CPK elevation were reported at higher rates with UPA. Consistent with earlier time points, greater proportions of patients randomized to UPA achieved low disease activity and remission at 3 years based on CDAI, as well as DAS28(CRP) ≤3.2 or <2.6, compared with patients randomized to ADA (Table 1).

Conclusion:

The safety profile of UPA was consistent with the results reported previously and with the integrated Phase 3 safety analysis.1,2 Higher levels of clinical response continued to be observed with UPA vs ADA through 3 years of treatment.

References:

[1]Fleischmann R, et al. Ann Rheum Dis 2020;79:323.

[2]Cohen SB, et al. Ann Rheum Dis 2020; doi: 10.1136/annrheumdis-2020-218510.

Table 1.

Efficacy Endpoints at 3 Years (NRI)

Endpoints, % (95% CI)UPA 15 mg QDN=651*ADA 40 mg EOWN=327*CDAI ≤1039 (36, 43)29 (24, 34)CDAI ≤2.824 (21, 28)17 (12, 21)DAS28(CRP) ≤3.237 (33, 41)26 (21, 31)DAS28(CRP) <2.632 (29, 36)22 (17, 26)

ADA, adalimumab; CI, confidence interval; DAS28(CRP), Disease Activity Score for 28-joints C-Reactive Protein; CDAI, clinical disease activity index; EOW, every other week; NRI, non-responder imputation; QD, once daily; UPA, upadacitinib.

*Patients who were rescued prior to/at Week 26 were considered non-responders. 252/651 and 159/327 patients were rescued of those randomized to UPA and ADA, respectively.

Acknowledgements:

AbbVie and the authors thank the patients, trial sites, and investigators who participated in this clinical trial. AbbVie, Inc was the trial sponsor, contributed to trial design, data collection, analysis & interpretation, and to writing, reviewing, and approval of final version. No honoraria or payments were made for authorship. The authors thank Dr. Tim Shaw of AbbVie Inc. for his support with the interpretation of the data. Medical writing support was provided by Ramona Vladea, PhD, of AbbVie, Inc.

Disclosure of Interests:

Roy Fleischmann Consultant of: AbbVie, Amgen, Bristol-Myers Squibb, Eli Lilly, GSK, Janssen, Novartis, Pfizer Inc, Sanofi-Aventis, and UCB, Grant/research support from: AbbVie, Amgen, Boehringer Ingelheim, Bristol-Myers Squibb, Celgene, Eli Lilly, Genentech, Janssen, Novartis, Pfizer Inc, Regeneron, Roche, Sanofi-Aventis and UCB, Eduardo Mysler Consultant of: AbbVie, AstraZeneca, Lilly, Pfizer, Roche, BMS, Sandoz, GSK, Janssen, Grant/research support from: AbbVie, AstraZeneca, Lilly, Pfizer, Roche, BMS, Sandoz, GSK, Janssen, Louis Bessette Consultant of: Amgen, BMS, Janssen, Roche, UCB, AbbVie, Pfizer, Merck, Celgene, Sanofi, Eli Lilly, Novartis, Gilead, Grant/research support from: Amgen, BMS, Janssen, Roche, UCB, AbbVie, Pfizer, Merck, Celgene, Sanofi, Eli Lilly, Novartis, Gilead, Charles Peterfy Shareholder of: Spire Sciences, Inc, Speakers bureau: Amgen, Bristol-Myers Squibb, Consultant of: Aclaris, Centrexion, Daiichi Sankyo, EMD, Serono, Five Prime, Flexion Therapeutics, Genentech, Gilead, GlaxoSmithKline, Istresso, Eli Lilly, Myriad Genetics, Novartis, Roche, SetPoint, Sorrento, UCB, Employee of: Spire Sciences, Inc, Patrick Durez Speakers bureau: BMS, Sanofi, Eli Lilly, Celltrion, Yoshiya Tanaka Speakers bureau: Daiichi-Sankyo, Astellas, Chugai, Eli Lilly, Pfizer, AbbVie, YL Biologics, Bristol-Myers, Takeda, Mitsubishi-Tanabe, Novartis, Eisai, Janssen, Teijin, Consultant of: Daiichi-Sankyo, Astellas, Chugai, Eli Lilly, Pfizer, AbbVie, YL Biologics, Bristol-Myers, Takeda, Mitsubishi-Tanabe, Novartis, Eisai, Janssen, Teijin, Grant/research support from: Asahi-kasei, Mitsubishi-Tanabe, Chugai, Takeda, Sanofi, Bristol-Myers, UCB, Daiichi-Sankyo, Eisai, Ono, Jerzy Swierkot Speakers bureau: AbbVie, Sandoz, Pfizer, Roche, BMS, UCB, MSD, Accord, Janssen, Consultant of: AbbVie, Sandoz, Pfizer, Roche, BMS, UCB, MSD, Accord, Janssen, Grant/research support from: AbbVie, Sandoz, Pfizer, Roche, BMS, UCB, MSD, Accord, Janssen, Nasser Khan Shareholder of: AbbVie, Employee of: AbbVie, Xianwei Bu Shareholder of: AbbVie, Employee of: AbbVie, Yihan Li Shareholder of: AbbVie, Employee of: AbbVie, In-Ho Song Shareholder of: AbbVie, Employee of: AbbVie.

Magnetic resonance imaging features of dermatofibrosarcoma protuberans; what the surgeon should know: a case series

Dermatofibrosarcoma protuberans (DFSP) is a rare, slow-growing, spindle cell neoplasm with low to intermediate grade malignant potential, commonly found in young and middle-aged adults, more in males than females. DFSP mostly originates in the dermis; rarely, it may be located in the deeper tissues without dermal involvement. Typically, DFSP appears as a multinodular mass, which then spreads into the subcutaneous tissues and muscle; it rarely dedifferentiates to high-grade fibrosarcoma, and more rarely, it may metastasise. We describe magnetic resonance imaging (MRI) features in three female patients with histologically proven DFSP and review the literature.

Observations during the COVID-19 pandemic in chronic heart failure patients with complex devices in a tertiary care cardiac centre using the HeartLogic software

Funding Acknowledgements

Type of funding sources: None.

Introduction

Decompensation of heart failure leading (HF) to hospitalisation is the single most important drain on healthcare resources when managing patients with left ventricular systolic dysfunction. Cardiac resynchronisation therapy with/without defibrillators (CRT-P/D) decreases hospitalisation due to HF and improves survival while implantable cardiac defibrillators (ICD"s) have a favourable effect on the former. Proprietary software algorithms embedded in these complex devices give an early warning to clinicians when decompensation of HF is imminent allowing preventative action to be undertaken.

HeartLogic (HL) is one such new algorithm in Boston Scientific CRT-D/ICD devices using multiple sensors to track 5 physiological parameters, combining them into one composite Index, with an Alert being triggered if the Index is >16. The COVID-19 pandemic, due to multiple reasons, resulted in a significant decrease in availability of routine HF services in the United Kingdom, especially during the initial lockdown period from 23rd March to 1st July 2020.

Aim

To assess the impact of the COVID-19 pandemic, using HL, in patients with HF and complex devices. 

Materials and Methods

Retrospective analysis of patients in a tertiary care cardiac centre in whom the HL software had been activated in March/April 2019 (n = 49) and comparison of those with (Group A n = 21) and without (Group B n = 28) an Alert (HLA) during the COVID-19 pandemic. 

Results (Table): Whole cohort n = 49. Age:  72 ± 12 years, Median: 75, Range: 36-95. 36/49 (73.5%) males. Type of device implanted: Resonate X4 CRT-D: 28/49 (57.1%); Momentum CRT-D: 8/49 (16.3%); Resonate ICD: 13/49 (26.5%). Ischaemic aetiology of HF: 35/49 (71.4%), Total duration of HL monitoring: 632 ± 7 days (median: 632; range: 626-672).  There was no difference in the age, gender, and type of device implanted between Group A and Group B. Over nearly ∼1 year of monitoring in each of the groups, Group A had more unstable HF with 10/21 (47.6%) having their first HLA during the pandemic. Multiple HLA"s, longer period in HLA and those with ischaemic aetiology of HF were higher in Group A. 17/40 (42.5%) HLA"s in Group A were within the first lockdown period (March - July). 24/28 (85.7%) patients in Group B had no HLA"s either before or during the pandemic. There was no difference in the HLA score between Groups A and B.

Conclusion

In this limited group of patients with a medium term follow-up, using the HeartLogic software, patients with ischaemic aetiology of HF and those with more HLA"s prior to the pandemic did worse than those who no HLA"s. First HLA"s, multiple alerts and longer duration of alerts in this group of patients suggests a lack of access to adequate HF services during the pandemic. It has implications with regard to how HF services are configured in future whenever resources are constrained.

Food handlers: an important reservoir of protozoans and helminth parasites of public health importance

Food handlers plays a primary role in the transmission of pathogenically important protozoans and helminth parasites. This study was aimed to evaluate the prevalence of intestinal pathogenic protozoans and helminth parasites among food handlers in and around University of Malakand, Lower Dir, Pakistan. Stool samples were collected from 642 food handlers (all of male) in a cross-sectional study from January to November, 2017. Wet Mount Techniques and concentration methods by using salt and formol-ether solutions. Three hundred and eighty four cases (59.8%) were found infected with one more parasites. Most of the individuals were found infected with helminth (47.6%) as compared to intestinal protozoans (0.93%). Seventy two cases (11.2%) of the cases presented mixed infection with both intestinal protozoan and helminth parasites. The order of prevalence for intestinal helminth was Ancylostoma duodenale (n = 258, 40.1%), followed by Taeniasa ginata (n=96, 14.9%) Ascaris lumbricoides (n = 54, 8.40%) and Trichuris trichura (n=30, 4.60%). For intestinal protozoa, Entamoeba histolytica/dispar (n = 36, 5.64%) was the only protozoan detected. Mono-parasitism was higher than poly-parasitism. Family size income and education level were the factors significantly (P<0.05) associated in the parasites prevalence. Current research showed that IPIs are primarily the foodborne pathogens still an important public health problem in Pakistan. Effective control programs on parasitic diseases transfer and their associated factors are recommended.

Pinworm infection in school children of four districts of Malakand region, Khyber Pakhtunkhwa, Pakistan

Illnesses caused by human pinworm remains a pediatric health problem in developing nations including Pakistan. This study aimed to investigate the prevalence of Enterobius vermicularis in school children of four districts in Malakand region, Pakistan. Four hundred faecal specimens were screened from May 2014 to July 2017 using normal saline and Lugol Iodine solution. Twenty three (5.75%) individuals were found infected with E. vermicularis. Five children (1.25%) were infected with only E. vermicularis and eighteen (4.5%) were mixed with other helminths. E. vermicularis 23 (5.75%), hookworm 11 (2.75%), Ascaris lumbricoides 5 (1.25%), Taenia saginata 2 (0.5%) and Trichuris trichuira 4 (1%) were detected. Age wise 5-8 years were more parasitized followed by 13-15 and 9-12 years of age (0.0296, P<0.05). Male children were highly (0.06700, P<0.05) infected than female. Children in Malakand district were found more infected followed by Dir Upper, similar infection rate was noted in children of districts Lower Dir and Swat (0.0192, P<0.05). Children in primary level were highly (0.0013, P<0.05) infected than those of middle and high levels. Enterobiosis is still the most common parasitic diseases in children. Studies on enterobiosis should be conducted time by time to recognize the hazardous of such parasitic infection in remote areas of the country.

822 Lessons Learnt During the COVID-19 Pandemic on Emergency Surgical Admissions in A District General Hospital

Introduction

Coronavirus disease (COVID-19) is an acute severe respiratory distress syndrome which resulted in an unprecedented impact on NHS service provision. We aimed to assess the impact of COVID-19 on general surgical services in a district general hospital.

Method

Electronic health care record data was retrospectively collected from 6th of April to 6th of May for both 2019 and 2020.

Results

Despite fewer referrals and admissions in 2020 (133 vs 177 admissions in 2019), there were more failed discharges (29 vs 17 in 2019) and higher associated costs. Higher numbers of biliary related pathologies and pancreatitis (50 in 2020 vs 25 in 2019), and fewer complaints of non-specific abdominal pain (10 in 2020 vs 22 in 2019) were observed. The use of outpatient investigations decreased by approximately 40% in 2020; however, utilisation of inpatient investigations was comparable.

Conclusions

Better utilisation of outpatient investigations and virtual clinic services may surmount pressures from further peaks of COVID-19. The increase in biliary related cases and pancreatitis may be consequent upon lifestyle changes during lockdown. This merits further investigation and if appropriate, public health intervention. In the absence of an efficacious vaccine, further research would be essential to streamline general surgical services based on clinical risk stratification.

258 Increase in Cycling Injuries During COVID-19: Unintended Consequences of Lockdown Restrictions in The United Kingdom

Introduction

Higher number of cycling injuries were observed during the COVID-19 period in the United Kingdom at our institution. Many were serious injuries requiring hospitalisation and some requiring surgery. We investigated whether the lockdown led to a legitimate increase in incidence of cycling related injuries, resulting in a higher number of aerosol generating procedures (AGPs). This would assess whether the guidance on exercise during lockdown was appropriate, shaping future regulation in the case of cyclical lockdowns.

Method

Records were screened retrospectively for cycling related injuries between April 1st and May 12th (lockdown) 2020 and for same period in 2019 as a control group. Injury severity, distribution and number of surgical procedures resulting from these were assessed.

Results

The proportion of injuries due to cycling rose threefold (n = 55) during the COVID-19 lockdown. Injuries included fractures, soft tissue injuries and mixed injuries. An increase in the number of operative procedures (n = 13) and AGPs was also noted.

Conclusions

Vague guidance and allowance of one form of outdoor exercise per day may have unintentionally contributed to rise in cycling injuries as many took to cycling for recreation. To make the guidance appropriate, usual forms of exercise should be encouraged, risk taking behaviours discouraged and safe cycling practices endorsed.

Key Considerations for Policymakers-Iodized Salt as a Vehicle for Iron Fortification: Current Evidence, Challenges, and Knowledge Gaps

Could DFS help prevent iron deficiency and anemia? Studies in controlled settings (efficacy) demonstrate that double-fortified salt (DFS; iron added to iodized salt) reduces the prevalence of anemia and iron deficiency anemia. Studies in program settings (effectiveness) are limited and reported differing levels of DFS coverage, resulting in mixed evidence of impact on anemia. What iron formulations are available and how do they affect iodized salt? Ferrous sulfate and encapsulated ferrous fumarate (both with various enhancers and/or coating materials) are the main iron formulations currently in use for DFS. Adding iron to iodized salt may lead to adverse changes in the product, specifically discoloration and losses in iodine content. These changes are greatest when the iodized salt used in DFS production is of low quality (e.g., contain impurities, has high moisture, and is of large crystal size). DFS requires iodized salt of the highest quality and a high-quality iron formulation in order to minimize adverse sensory changes and iodine losses. Appropriate packaging of iodized salt is also important to prevent losses. What is known about the minimum requirements to manufacture DFS? DFS producers must use high-quality refined iodized salt meeting the minimum standards for DFS production (which is higher than standards for salt intended for iodization alone), and an iron formulation for which there are rigid quality-assurance measures to ensure consistent quality and blending techniques. The actual proportion of iodized salt meeting the stringent requirements necessary for DFS production is unclear, but likely to be low in many countries, especially those with fragmented salt industries and a low proportion of industrially produced salt. What are the financial implications of adding iron to iodized salt? As a result of higher input costs both for input salt and the iron compound, DFS is more expensive to produce than iodized salt and thus has a higher production cost. Various grades of iodized salt are produced and consumed in different sectors of the market. Experience in India indicates that, on average, producing DFS costs 31-40 US dollars/metric ton or 0.03-0.04 US dollars/kg more than high-quality refined iodized salt. The exact impact of this production-level cost difference on profit margins and consumer price is specific to the conditions of different salt markets. Factors such as transport costs, customary wholesale and retail mark-ups, and taxes all vary greatly and need to be assessed on a case by case basis. Is DFS in alignment with salt-reduction efforts? The WHO has long recognized that salt iodization is an important public health intervention to achieve optimal iodine nutrition and is compatible with salt-reduction goals. Fortification of salt (with any nutrient) should not be used to justify or encourage an increase in salt intake to the public. Any effort to expand salt fortification to other nutrients should be done in close consultation with WHO and those working on salt reduction. What has been the experience with DFS delivery under different platforms? To date, DFS has been introduced into the retail market and in social safety net (primarily in India) programs, but sensory changes in DFS have been raised as concerns. The higher price for DFS has limited expansion in the retail market. In social safety net programs where the cost of DFS is subsidized for beneficiaries, programs must consider long-term resourcing for sustainability. Overall: The optimal production and delivery of DFS are still under development, as many challenges need to be overcome. There is a beneficial impact on hemoglobin in efficacy trials. Thus, if those conditions can be replicated in programs or the technology can be adapted to better fit current production and delivery realities, DFS may provide an effective contribution in countries that need additional food-fortification vehicles to improve iron intake.

Current and future best practice in imaging, staging, and response assessment for Non-Hodgkin's lymphomas: the Specialist Integrated Haematological Malignancy Imaging Reporting (SIHMIR) paradigm shift

Non-Hodgkin's lymphoma (NHL) encompasses over 40 different haematological malignancies, including low and high-grade neoplasms, such as follicular lymphoma (FL) and diffuse large B-cell lymphoma (DLBCL) respectively. A key clinical issue in the context of NHL is delayed and inaccurate diagnosis, which contributes adversely to patient morbidity and mortality. This article will address relevant imaging aspects, with particular reference to advancements in NHL imaging, including computed tomography (CT), integrated positron-emission tomography (PET)-CT, and magnetic resonance imaging (MRI). We provide multiparametric (anato-functional) imaging display items, including histological correlation. We will also introduce our original concept of "Specialist Integrated Haematological Malignancy Imaging Reporting" (SIHMIR), a paradigm shift in lymphoma radiology.

Effect of differential music tempo on post-exercise cardiovascular recovery parameters in hypertensive individuals: a randomised control trial

Hypertensive individuals tend to have autonomic dysfunction indicated by sympathetic dominance or delayed parasympathetic reactivation. A complimentary therapy such as music following exercise is considered to be beneficial in improving autonomic recovery. The purpose of this study was to assess the effect of differential music tempo on post-exercise cardiovascular recovery parameters in hypertensive individuals. Thirty hypertensive individuals were recruited for the present study which were randomly allocated to no music (n=10), slow music (n=10) and fast music (n=10) group. Participants in all three groups were subjected to submaximal exercise bout by Harvard step test. The cardiovascular recovery parameters i.e. heart rate recovery (HRR), blood pressure recovery (BPR) and rating of perceived exertion recovery (RPER) were assessed in all three groups after 1 min, 2 min and 3 min following termination of exercise. A significant decline was observed in HRR (P=0.002) and RPER (P=0.008) following exercise in slow music group as compared to fast and no music while no significant differences were observed in BPR between the three groups. The study concluded that music accelerates post-exercise recovery and slow music has greater effect as compared to fast or no music. These findings may have potential implications in the cardiovascular recovery dynamics in hypertensive individuals participating in submaximal exercise.

Anorectal Malformations and Associated Anomalies in Children

Anorectal malformations (ARM) incorporate a broad spectrum of diseases, can affect both sexes, and involve the distal anus and rectum as well as the uro-genital tracts. Defects range from the minor which can be treated easily with an excellent outcome, to those are complex and often associated with other anomalies are difficult to manage with poor functional prognosis. This study was done to observe the hospital incidence of Anorectal malformations, frequency of types, sex distribution and spectrum of associations with ARM. The effects of presence of associated anomalies on morbidity and mortality also observed. Detailed history, clinical examinations and relevant investigations were performed for the primary and as well as the associated anomalies. A total of 80 patients were admitted in the department of pediatric surgery in Mymensingh Medical College Hospital during the period of June 2016 to May 2017. Age of the patients was ranging from 1-180 days with the mean age of 0.49±1.002 months. Male: Female ratio was 1.6: 1. Among them 48(60%) were high and 32(40%) were low variety of ARM. In male 37(46.2%) had high and 13(13.7%) were low variety whereas in female 11(13.7%) were high and 19(23.7%) had low ARM. Associated anomalies were seen in 25(31.2%) patient -18 in males and 7 in females; 20 in high and 5 in low ARM. Associated anomalies were uro-genital 11(13.8%), cardiovascular 10(12.5%), vertebral 4(5%), limb defects 3(3.5%) and others 2(2.5%). Four patients have more than one anomaly. Anorectal malformations occur more in boys than girls. Males were more likely to have high lesions and without fistula was the common defect. Low variety ARM were found more in females with Anovestibular fistula is the commonest defect. The most common associated anomalies were recto urinary fistula (13.8%). Associations were more in high than low ARM but not significant (p>0.05). Post operative complications were more in high ARM in both sexes with associated anomalies. The effects of types and associations on morbidity and mortality were significantly different (p<0.05).