Pharmacokinetics/pharmacodynamics of ivosidenib in advanced IDH1-mutant cholangiocarcinoma: findings from the phase III ClarIDHy study

PURPOSE

Report pharmacokinetic (PK)/pharmacodynamic (PD) findings from the phase III ClarIDHy study and any association between PK/PD parameters and treatment outcomes in this population.

METHODS

Patients with mutant isocitrate dehydrogenase 1 (mIDH1) advanced cholangiocarcinoma were randomized at a 2:1 ratio to receive ivosidenib or matched placebo. Crossover from placebo to ivosidenib was permitted at radiographic disease progression. Blood samples for PK/PD analyses, a secondary endpoint, were collected pre-dose and up to 4 h post-dose on day (D) 1 of cycles (C) 1 - 2, pre-dose and 2 h post-dose on D15 of C1 - 2, and pre-dose on D1 from C3 onwards. Plasma ivosidenib and D-2-hydroxyglutarate (2-HG) were measured using liquid chromatography-tandem mass spectrometry. All clinical responses were centrally reviewed previously.

RESULTS

PK/PD analysis was available for samples from 156 ivosidenib-treated patients. Ivosidenib was absorbed rapidly following single and multiple oral doses (time of maximum observed plasma concentration [Tmax] of 2.63 and 2.07 h, respectively). Ivosidenib exposure was higher at C2D1 than after a single dose, with low accumulation. In ivosidenib-treated patients, mean plasma 2-HG concentration was reduced from 1108 ng/mL at baseline to 97.7 ng/mL at C2D1, close to levels previously observed in healthy individuals. An average 2-HG inhibition of 75.0% was observed at steady state. No plasma 2-HG decreases were seen with placebo. Plasma 2-HG reductions were observed in ivosidenib-treated patients irrespective of best overall response (progressive disease, or partial response and stable disease).

CONCLUSION

Once-daily ivosidenib 500 mg has a favorable PK/PD profile, attesting the 2-HG reduction mechanism of action and, thus, positive outcomes in treated patients with advanced mIDH1 cholangiocarcinoma.

CLINICAL TRIAL REGISTRATION

NCT02989857 Registered February 20, 2017.

Final phase I substudy results of ivosidenib in patients with mutant IDH1 relapsed/refractory myelodysplastic syndrome

Ivosidenib is a first-in-class mutant isocitrate dehydrogenase 1 (mIDH1) inhibitor and has shown efficacy and tolerability in patients with advanced mIDH1 hematologic malignancies, leading to approval in front-line and relapsed/refractory (R/R) mIDH1 AML populations. We report final data from a phase I single-arm substudy (NCT02074839) of patients with R/R mIDH1 MDS following failure of standard-of-care therapies. Oral ivosidenib was taken once daily on days 1-28 in 28-day cycles. Primary objectives were to determine safety, tolerability, and clinical activity. The primary efficacy endpoint was the complete remission + partial remission (CR+PR) rate. Nineteen patients were enrolled; 18 were included in the efficacy analysis. Treatment-related adverse events occurred in eight (42.1%) patients, including a grade 1 QT interval prolongation in one (5.3%) patient and grade 2 differentiation syndrome in two (10.5%) patients. Rates of CR+PR and objective response (CR +PR+marrow CR) were 38.9% (95% confidence interval [CI]: 17.3, 64.3) and 83.3% (95% CI: 58.6, 96.4), respectively. Kaplan-Meier estimates showed a 68.6% probability of patients in CR achieving a remission duration of >=5 years, and a median OS of 35.7 months. Of note, 71.4% and 75.0% baseline red blood cell (RBC) and platelet transfusion-dependent patients, respectively, became transfusion independent (TI; no transfusion >=56 days); 81.8% and 100% of baseline RBC and platelet TI patients, respectively, remained TI. One (5.3%) patient proceeded to a hematopoietic stem cell transplant by data cut-off. In conclusion, ivosidenib is clinically active, with durable remissions and a manageable safety profile observed in patients with mIDH1 R/R MDS.

Evaluation of Antimicrobial Efficacy and Clinical Outcomes of Triphala and 2.5% Sodium Hypochlorite as Intraradicular Irrigants in Pulpectomy of Primary Teeth

A natural irrigation solution with a broad spectrum of antimicrobial coverage, triphala was selected for the pulpectomy procedure. Because of its natural ingredients, it is well-known for promoting tissue healing. It also supposedly has certain additional qualities as compared to usual irrigation solutions that are made chemically. Although 2.5% NaOCl is thought to be perfect since it meets most of the requirements for an irrigation solution but it cannot be optimized for pulpectomy procedure. Primary teeth that were recommended for pulpectomy underwent this randomized controlled experiment. Two groups of eighty-four primary teeth were randomly assigned to receive irrigations: triphala in Group A; 2.5% Sodium hypochlorite in Group B. Sample were taken from infected primary root canals. A sterile test tube with bhi broth as the transport media was used to collect pre- and post-irrigation samples using sterile absorbent paper tips. On agar media, microorganisms were cultivated and their mean colony count was assessed. Following the procedure, the patient's follow-up visits at one, two and three months were used to evaluate the clinical result. The post-microbial colony count was dramatically reduced (p<0.001) by both irrigation treatments. Triphala in Group A is demonstrating desirable efficacy. Clinical success was found satisfactory in both the groups studied (p<0.001). But statistically significant difference was not found (p=0.175). Considering undesirable properties of sodium hypochlorite triphala can be a better alternative as a root canal irrigants in pulpectomy of primary teeth.

Efficacy of therapeutically administered gepotidacin in a rabbit model of inhalational anthrax

Bacillus anthracis is a Gram-positive Centers for Disease Control and Prevention category "A" biothreat pathogen. Without early treatment, inhalation of anthrax spores with progression to inhalational anthrax disease is associated with high fatality rates. Gepotidacin is a novel first-in-class triazaacenaphthylene antibiotic that inhibits bacterial DNA replication by a distinct mechanism of action and is being evaluated for use against biothreat and conventional pathogens. Gepotidacin selectively inhibits bacterial DNA replication via a unique binding mode and has in vitro activity against a collection of B. anthracis isolates including antibacterial-resistant strains, with the MIC90 ranging from 0.5 to 1 µg/mL. In vivo activity of gepotidacin was also evaluated in the New Zealand White rabbit model of inhalational anthrax. The primary endpoint was survival, with survival duration and bacterial clearance as secondary endpoints. The trigger for treatment was the presence of anthrax protective antigen in serum. New Zealand White rabbits were dosed intravenously for 5 days with saline or gepotidacin at 114 mg/kg/d to simulate a dosing regimen of 1,000 mg intravenous (i.v.) three times a day (TID) in humans. Gepotidacin provided a survival benefit compared to saline control, with 91% survival (P-value: 0.0001). All control animals succumbed to anthrax and were found to be blood- and organ culture-positive for B. anthracis. The novel mode of action, in vitro microbiology, preclinical safety, and animal model efficacy data, which were generated in line with Food and Drug Administration Animal Rule, support gepotidacin as a potential treatment for anthrax in an emergency biothreat situation.

Adverse Events of SARS-CoV-2 Therapy: A Pharmacovigilance Study of the FAERS Database

BACKGROUND

Over the past 2 years of the several strategies recommended to help fight COVID-19, nirmatrelvir/ritonavir is a novel drug shown in the EPIC-HR phase 2 to 3 clinical trial to lower COVID-19-related death or hospitalization at day 28 when compared with placebo.

OBJECTIVE

Our study's aim was to explore the reported adverse events (AEs) associated with nirmatrelvir/ritonavir use for COVID-19.

METHOD

We conducted a retrospective analysis using the FDA Adverse Event Reporting System (FAERS) database for AEs, listing nirmatrelvir/ritonavir as the primary drug between January and June 2022. The primary outcome was the incidence of reported AEs associated with nirmatrelvir/ritonavir. The OpenFDA database was queried using Python 3.10 to collect the AEs and Stata 17 was used to analyze the database. Adverse events were analyzed by associated medication, with "Covid-19" excluded.

RESULTS

A total of 8098 reports were identified between January and June 2022. Most reported complaints in the AE system were COVID-19 and disease recurrence. The most common symptomatic AEs were dysgeusia, diarrhea, cough, fatigue, and headache. Event rates significantly rose between April and May. Disease recurrence and dysgeusia were the most commonly reported complaints for the top 8 concomitant drugs identified. Cardiac arrest, tremor, akathisia, and death were reported in 1, 3, 67, and 5 cases, respectively.

CONCLUSIONS AND RELEVANCE

This is the first retrospective study done on reported AEs associated with nirmatrelvir/ritonavir use for COVID-19. COVID-19 and disease recurrence were the most reported AEs. Further monitoring of the FAERS database is warranted to periodically reassess the safety profile of this medication.

Sex-based differences in left ventricular assist device clinical outcomes

BACKGROUND

Heart failure (HF) continues to be a significant public health issue, posing a heightened risk of morbidity and mortality for both genders. Despite the widespread use of left ventricular assist device (LVAD), the influence of gender differences on clinical outcomes following implantation remains unclear.

OBJECTIVES

We investigated the impact of gender differences on readmission rates and other outcomes following LVAD implantation in patients admitted with advanced HF.

METHODS

We conducted a retrospective study of patients who underwent LVAD implantation for advanced HF between 2014 and 2020, using the Nationwide Readmissions Database. Our study cohort was divided into male and female patients. The primary outcome was 30-day readmission (30-dr), while secondary outcomes were inpatient mortality, length of stay (LOS), procedural complication rates, and periadmission rates. Multivariate linear, Cox, and logistic regression analyses were performed.

RESULTS

During the study period, 11,492 patients with advanced HF who had LVAD placement were identified. Of these, 22% (n = 2532) were females and 78% (n = 8960) were males. The mean age was 53.9 ± 10.8 years for females and 56.3 ± 10.5 years for males (adjusted Wald test, p < 0.01). Readmissions were higher in females (21% vs. 17%, p = 0.02) when compared to males. Cox regression analysis showed higher readmission events (hazard ratio: 1.24, 95% confidence interval: 1.01-1.52, p = 0.03) in females when compared to males. Inpatient mortality, LOS, and most procedural complication rates were not statistically significantly different between the two groups (p > 0.05, all).

CONCLUSION

Women experienced higher readmission rates and were more likely to be readmitted multiple times after LVAD implantation when compared to their male counterparts. However, there were no significant sex-based differences in inpatient mortality, LOS, and nearly all procedural complication rates. These findings suggest that female patients may require closer monitoring and targeted interventions to reduce readmission rates.

Dimeric 3,5-Bis(benzylidene)-4-piperidones: Tumor-Selective Cytotoxicity and Structure-Activity Relationships

Background: The objective of this study is to find novel antineoplastic agents that display greater toxicity to malignant cells than to neoplasms. In addition, the mechanisms of action of representative compounds are sought. This report describes the cytotoxicity of a number of dimers of 3,5-bis(benzylidene)-4-piperidones against human malignant cells (promyelocytic leukemia HL-60 and squamous cell carcinoma HSC-2, HSC-3, and HSC-4). Methods: Tumor specificity was evaluated by the selectivity index (SI), that is the ratio of the mean CC50 for human non-malignant oral cells (gingival fibroblasts, pulp cells, periodontal ligament fibroblasts) to that for malignant cells. Results: The compounds were highly toxic to human malignant cells. On the other hand, these molecules were less toxic to human non-malignant cells. In particular, a potent lead molecule, 3b, was identified. A QSAR study revealed that the placement of electron-releasing and hydrophilic substituents into the aryl rings led to increases in cytotoxic potencies. The modes of action of a lead compound discovered in this study designated 3b were the activation of caspases-3 and -7, as well as causing PARP1 cleavage and G2 arrest, followed by sub-G1 accumulation in the cell cycle. This compound also depolarized the mitochondrial membrane and generated reactive oxygen species in human colon carcinoma HCT116 cells. In conclusion, this study has revealed that, in general, the compounds described in this report are tumor-selective cytotoxins.

Self-removal of catheter after robot-assisted radical prostatectomy: a feasibility study

Self-removal of urinary catheter as an option after robot-assisted radical prostatectomy (RARP) has never been explored in literature. We report the feasibility and outcome of the first study of this novel concept in our hospital. We conducted a prospective audit of self-TWOC (trial without catheter) in men who underwent consecutive RARP in our centre between April 2022 and September 2022. Men who had self-TWOC filled a questionnaire about the outcomes of self-TWOC. Carbon footprint and carbon offset for each hospital TWOC avoided were calculated. Of the 129 who underwent self-TWOC, 112 filled the questionnaire and were hence included in the final analysis. Self-TWOC was successful in all the 112 (100%) men in the study. 99.1% of men were satisfied with self-TWOC at home. We managed to avoid 79.6 ± 36.72 km of travel and 77 min of travel time for every self-TWOC. This also saved 85£/patient on clinic expenses and fuel cost savings of 9.87-15.99£ per patient depending on car engine size/type. The carbon footprint calculated was 20 kg CO2 assuming average engine sized diesel/petrol cars and 10 kg CO2 for an average UK petrol hybrid car. The calculated carbon offset per patient for diesel/petrol cars: 0.32£, petrol hybrid: 0.16£. Self-TWOC for 80-160 patients will save the carbon emissions equivalent to that of a passenger on a London-New York Trans-Atlantic flight. Self-TWOC is safe, affordable and is sustainable to the environment. Widespread acceptance of this practice change will be a small, but steady step towards greener health systems across the world.

Impact of Frailty on Left Ventricular Assist Device Clinical Outcomes

Frailty is a clinical syndrome prevalent in older adults and carries poor outcomes in patients with heart failure. We investigated the impact of frailty on left ventricular assist device (LVAD) clinical outcomes. The Nationwide Readmission Database was used to retrospectively identify patients with a primary diagnosis of heart failure who underwent LVAD implantation during their hospitalization from 2014 to 2020. Patients were categorized into frail and nonfrail groups using the Hospital Frailty Risk Score. Cox and logistic regression were used to predict the impact of frailty on inpatient mortality, 30-day readmissions, length of stay, and discharge to a skilled nursing facility. LVADs were implanted in 11,465 patients who met the inclusion criteria. There was more LVAD use in patients who were identified as frail (81.6% vs 18.4%, p <0.001). The Cox regression analyses revealed that LVAD insertion was not associated with increased inpatient mortality in frail patients (hazard ratio 1.15, 95% confidence interval 0.81 to 1.65, p = 0.427). Frail patients also did not experience a higher likelihood of readmissions within 30 days (hazard ratio 1.15, 95% confidence interval 0.91 to 1.44, p = 0.239). LVAD implantation did not result in a significant increase in inpatient mortality or readmission rates in frail patients compared with nonfrail patients. These data support continued LVAD use in this high-risk patient population.

Urban-rural difference in factors associated with childhood functional difficulty in Bangladesh: a cross-sectional study

Objective

Early childhood functional difficulty poses a substantial worldwide public health challenge, leading to adverse effects on children's quality of life and overall productivity. Moreover, it represents a significant social and economic problem in Bangladesh. Therefore, the current study aimed to identify factors contributing to childhood functional difficulty in Bangladesh within the context of urban-rural areas.

Methods

A nationally representative cross-sectional survey data from Multiple Indicator Cluster Survey (MICS), 2019 in Bangladesh was used in this study. Chi-square test and multivariable logistic regression analyses were carried out to identify factors associated with childhood functional difficulty.

Results

Functional difficulties were found in approximately 3.3% of children 2-4 years of age in urban areas and 2.5% in rural areas. Having a mother with functional difficulties and undernutrition were identified as significant factors common in both urban and rural areas. Further, mothers who had no formal education (AOR = 2.76, 95%CI = 1.18-6.45) and experienced infant death (AOR = 1.94, 95%CI = 1.01-3.70) were identified as significant factors of functional difficulty in urban areas. On the other hand, in rural areas, no access to mass media, children with acute respiratory infection (ARI) (AOR = 2.13, 95%CI = 1.39-3.28), female sex (AOR = 0.69, 95%CI = 0.53-0.91), child undernutrition (AOR = 1.73, 95%CI = 1.32-2.27) and poorer socio-economic status (AOR = 1.95, 95%CI = 1.08-3.55) were found significant factors.

Conclusion

Functional difficulty was found to be present in one out of every 35 children age 2 to 4 years in Bangladesh. Childhood functional difficulties were reported slightly higher in urban areas as compared to rural areas. Reducing childhood difficulties in urban areas demands comprehensive strategies: quality healthcare, inclusive education, community support, better information systems, and collaboration. To achieve urban-rural parity in child health, address disparities in economic development, healthcare, and education, especially for girls.

Metastatic Endocrine Mucin-Producing Sweat Gland Carcinoma to the Lung: A Case Report

Endocrine mucin-producing sweat gland carcinoma (EMPSGC) is a rare, low-grade neuroendocrine neoplasm previously believed to be indolent in nature. There have only previously been six reported cases of metastases and none of thoracic structures. This case shows a metastatic EMPSGC in a 72-year-old male with a complex oncologic history and is the first reported case of metastases to the lung. As increased recognition of this entity continues to grow, it is important to consider it as part of the differential in mucinous and/or neuroendocrine neoplasms for appropriate management. This case adds to the oncologic literature by demonstrating a rare cutaneous neoplasm and emphasizing its metastatic potential.

The Utilization of 15-Minute Multidisciplinary Rounds to Reduce Length of Stay in Patients under Observation Status

With the recent change to value-based care, institutions have struggled with the appropriate management of patients under observation. Observation status can have a huge impact on hospital and patient expenses. Institutions have implemented specialized observation units to provide better care for these patients. Starting in January 2020, coinciding with the initiation of daily multidisciplinary rounds, our study focused on patients aged 18 and older admitted to our hospital under observation status. Efforts were built upon prior initiatives at Jersey Shore University Medical Center (JSUMC) to optimize patient care and length of stay (LOS) reduction. The central intervention revolved around the establishment of daily "Observation Huddles"-succinct rounds led by hospital leaders to harmonize care for patients under observation. The primary aim was to assess the impact of daily multidisciplinary rounds (MDR) on LOS, while our secondary aim involved identifying specific barriers and interventions that contributed to the observed reduction. Our study revealed a 9-h reduction in observation time, resulting in approximately USD 187.50 saved per patient. When accounting for the period spanning 2020 to 2022, potential savings totaled USD 828,187.50 in 2020, USD 1,046,062.50 in 2021, and USD 1,243,562.50 in 2022. MDR for observation patients led to a reduction in LOS from 29 h to 20 h (p < 0.001).

Chronic Pancreatitis-Induced Thrombosis of Celiac and Superior Mesenteric Artery

Every year, nearly 60,000 hospitalizations occur in the United States due to chronic pancreatitis (CP). CP can cause severe chronic abdominal pain, pancreatic insufficiency, and increased risk of pancreatic cancer. While venous thrombotic complications are common, arterial thrombotic events are rarely reported in CP. This report describes a case of a 43-year-old female who presented with severe worsening abdominal pain due to CP. Diagnostic imaging disclosed thrombosis of superior mesenteric artery (SMA) and celiac artery (CA) with acute bowel wall changes reflecting ischemic changes, resulting in acute-on-chronic mesenteric ischemia. Endovascular stent placement relieved the ischemia with the resolution of pain. Arterial thrombosis should be considered as a diagnostic possibility when patients with CP present with a significant change in symptoms. Importantly, the case demonstrates that endovascular treatment with stent placement can relieve ischemia and resolve symptoms in patients with CP.

Demographic and Clinical Characteristics of Persons With Spinal Cord Injury in Bangladesh: Database for the International Spinal Cord Injury Community Survey 2023

The study aims to explore the demographic and clinical characteristics of persons with spinal cord injury (SCI) in Bangladesh. A total of 3035 persons with SCI spanning from 2018 to 2022 were included in this cross-sectional study. Information about demographic and clinical variables was obtained from the medical records and verified through telephone calls to ensure accuracy and consistency. Approximately half (48.30%) of the study participants were located in Dhaka Division. The average age of persons with SCI was 38.3 years, with a standard deviation of 15.9 years, and the largest proportion (33.4%) fell within the age range of 18-30 years. Males outnumbered females by nearly 2.5 times. In the study, 59.6% had suffered traumatic injuries, whereas 40.4% had SCI attributable to disease-related causes; 58.1% were diagnosed with tetraplegia and 40.1% with paraplegia. Fall from height (42.1%) and road traffic trauma (27%) were the most common causes of traumatic injuries. Degenerative myelopathy (41.1%) was the most frequent cause of non-traumatic SCI, followed by tumors (27.7%) and tuberculosis (TB; 14.8%). Both traumatic (58.3%) and degenerative (56.7%) causes of SCI commonly affected the cervical spine, whereas TB (24.4%) and tumors (47.5%) had a higher incidence of affecting the dorsal spine. In the absence of a registry or national database for patients with SCI in Bangladesh, this study would serve as representative data for future studies.

Probiotics and Fecal Transplant: An Intervention in Delaying Chronic Kidney Disease Progression?

Chronic kidney disease (CKD) is a global health challenge affecting nearly 700 million people worldwide. In the United States alone, the Medicare costs for CKD management has reached nearly USD 80 billion per year. While reversing CKD may be possible in the future, current strategies aim to slow its progression. For the most part, current management strategies have focused on employing Renin Angiotensin Aldosterone (RAS) inhibitors and optimizing blood pressure and diabetes mellitus control. Emerging data are showing that a disruption of the gut-kidney axis has a significant impact on delaying CKD progression. Recent investigations have documented promising results in using microbiota-based interventions to better manage CKD. This review will summarize the current evidence and explore future possibilities on the use of probiotics, prebiotics, synbiotics, and fecal microbial transplant to reduce CKD progression.

Fulminant Presentation of Budd-Chiari Syndrome Secondary to COVID-19 Infection

Budd-Chiari syndrome (BCS) is a rare condition characterized by the obstruction of hepatic venous outflow. It is estimated to affect 1 in 100,000 people worldwide. In cases of new BCS, inherited and acquired hypercoagulability states must be evaluated. Coronavirus disease 2019 (COVID-19) can induce a hypercoagulable state because of its extensive inflammatory response, and while it has been reported to cause portal vein thrombosis, it rarely causes BCS. This article presents a case of a 22-year-old man who developed fulminant symptoms and was subsequently diagnosed with BCS and portal vein thrombosis secondary to COVID-19 infection, after ruling out other inherited and acquired causes of BCS. In addition, a literature review is provided to understand the presentation and management of such patients. Although most patients improve with medical management, this article emphasizes the consideration of liver transplant for patients who do not improve.

Body Mass Index versus Waist Circumference in Predicting Insulin Resistance in Infertile Women with Polycystic Ovary Syndrome

Weight management is central to the treatment of infertile women with polycystic ovary syndrome. Both body mass index and waist circumference are measures of obesity. The objective of the study was to examine the clinical importance of waist circumference and body mass index in predicting insulin resistance. The cross-sectional study involved a total of 126 consecutive infertile women with polycystic ovary syndrome attending the Infertility unit of the Department of Obstetrics and Gynaecology of Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh from January 2017 to December 2017. The anthropometric measurements like weight, height and waist circumference were made and body mass index and waist hip ratio were calculated. Fasting insulin and fasting plasma glucose were estimated in early follicular phase of menstrual cycle. Insulin resistance was calculated with HOMA-IR. Body mass index and waist circumference were examined for clinical prediction of insulin resistance by ROC curve analysis. The mean age was 25.56±3.90 years. Mean body mass index was 26.79±3.25, mean waist circumference was 90.9±9.4cm. By body mass index thresholds, 47.9% of the women were overweight, 39.7% of the women were obese. By waist circumference threshold, 80.2% of the women were centrally obese. Body mass index and waist circumference, both had significant correlation with hyperinsuliaemia. When body mass index and waist circumference were examined for predicting insulin resistance by sensitivity, specificity, positive likelihood ratio and negative likelihood ratio, waist circumference appeared to have moderate clinical importance compared to the negligible role of body mass index. Waist circumference may be a better predictor of insulin resistance than body mass index in infertile women with polycystic ovary syndrome.

Water structure modification by d-(+)-glucose at different concentrations and temperatures-effect of mutarotation

Water structure modification by carbohydrates is essential both in chemistry and life processes and in particular, molecular level interaction of glucose with water is very important. With a view to developing a fundamental knowledge base, thermodynamic parameters derived from measurements of density, viscosity, and refractive index have been analyzed to investigate how d-(+)-glucose alters the structure of water at various concentrations and temperatures. The nature and extent of the interactions have been investigated using apparent molar volume, Jones-Dole constants, changes in free energy (ΔG), changes in entropy (ΔS), and changes in enthalpy (ΔH) for viscous flow. Using measurements from dynamic light scattering (DLS), the sizes of the aggregates were studied. The kinetics of mutarotation have been investigated using polarimetry and the structural effect on water during mutarotation between α-d-glucose and β-d-glucose with time has been explored by near-infrared (NIR) spectroscopy. The spectroscopic results were examined using difference spectroscopy and two-dimensional correlation spectroscopy (2DCOS). The absorption bands of water shift to a higher wavenumber irrespective of the concentration of the solution with time due to the enhancement of the cleavage of hydrogen bonding in water. At high temperatures, three bands in the region 7100-7350 cm^-1 are attributed to the first overtones of the hydrogen-bonded -O-H stretching vibration. Refractive index values indicate an increase in the density of the anomer solutions with time, suggesting an increase in free water concentration. These results provide evidence for more than one water molecule being involved in the mechanism of mutarotation and propose a concerted mechanism for proton transfer.

A Rare Case of COVID-19 Vaccination-Induced Cholangiopathic Liver Injury

Drug-induced liver injury is a serious adverse drug reaction that can result in acute liver injury or cholestatic injury affecting the bile ducts, known as cholangiopathic liver injury (CLI). Although CLI is not as familiar as the hepatocellular pattern, emerging evidence suggests that it may occur after coronavirus disease 2019 (COVID-19) vaccination. This case report focuses on an 89-year-old woman who developed CLI after receiving the tozinameran COVID-19 vaccine. The main aim of this report was to raise awareness of the possibility of developing CLI after COVID-19 vaccination and to underscore the critical significance of promptly identifying and managing this infrequent but severe side effect.

Unique Variant of Zieve Syndrome With a Normal Reticulocyte Count

Zieve syndrome is a rare diagnosis seen in patients with chronic alcohol use which consists of a distinct clinical triad of hyperlipidemia, hemolytic anemia, and jaundice. Patients typically have an elevated reticulocyte count due to the hemolytic nature of the anemia. We present the case of a 44-year-old female who was discovered to have an unusual variant of Zieve syndrome with a normal reticulocyte count, which was believed to be due to suppression of bone marrow from excessive alcohol consumption. She was treated with steroids and complete alcohol cessation, with remarkable improvement on subsequent follow-up. An exhaustive literature review of 31 documented cases of Zieve syndrome was conducted to better understand the clinical presentation and overall prognosis of these patients. This case report and literature review aimed to improve patient outcomes through increased recognition of this underrecognized syndrome.

Efficacy of Intravenously Administered Gepotidacin in Cynomolgus Macaques following a Francisella tularensis Inhalational Challenge

Francisella tularensis (F. tularensis) is a Centers for Disease Control (CDC) category "A" Gram-negative biothreat pathogen. Inhalation of F. tularensis can cause pneumonia and respiratory failure and is associated with high mortality rates without early treatment. Gepotidacin is a novel, first-in-class triazaacenaphthylene antibiotic that inhibits bacterial DNA replication by a distinct mechanism of action. Gepotidacin selectively inhibits bacterial DNA replication via a unique binding mode, has activity against multidrug-resistant target pathogens, and has demonstrated in vitro activity against diverse collections of F. tularensis isolates (MIC₉₀ of 0.5 to 1 μg/mL). Gepotidacin was evaluated in the cynomolgus macaque model of inhalational tularemia, using the SCHU S4 strain, with treatment initiated after exposure and sustained fever. Macaques were dosed via intravenous (i.v.) infusion with saline or gepotidacin at 72 mg/kg/day to support a human i.v. infusion dosing regimen of 1,000 mg three times daily. The primary study endpoint was survival, with survival duration and bacterial clearance as secondary endpoints. Gepotidacin treatment resulted in 100% survival compared to 12.5% in the saline-treated control group (P < 0.0001) at Day 43 postinhalational challenge. All gepotidacin-treated animals were blood and organ culture negative for F. tularensis at the end of the study. In contrast, none of the saline control animals were blood and organ culture negative. Gepotoidacin's novel mechanism of action and the efficacy data reported here (aligned with the Food and Drug Administration Animal Rule) support gepotidacin as a potential treatment for pneumonic tularemia in an emergency biothreat situation.

Identification of Variants and Mutational Analyses of Cardiac Myosin-binding Protein C (MYBPC3) Gene of Adult Bangladeshi Patients with Hypertrophic Cardiomyopathy

Hypertrophic cardiomyopathy (HCM) is the most prevalent genetic hereditary cardiomyopathy characterized by sudden cardiac death. Mutations in the MYBPC3 gene are often the most prevalent genetic abnormality in HCM with a prevalence ranging from 20.0 to 42.0%. The mutation spectrum is available for different countries, but such studies are lacking in the Asian population including Bangladeshi patients. A cross-sectional descriptive study was conducted for mutation analysis of the whole MYBPC3 gene on a cohort of 75 HCM Bengali Bangladeshi probands through Next Generation Sequencing at the Genetic Research Lab of Bangabandhu Sheikh Mujib Medical University from 2016 to 2019. The structural and functional impact of the mutations was further analyzed by in silico process. We analyzed the data and found 103 variants in 102 locations in the MYBPC3 gene. Variants were identified in both the coding region and the non-coding region. We found one possibly novel variant in the MYBPC3 gene. The findings of this research will help to develop a genetic database of HCM which will help in the early diagnosis and proper management of HCM patients in Bangladesh. One pathogenic splice donor variant (47356592 C >T) was found in the intronic region. Among the variants in the coding region, one missense mutation was pathogenic (NP₋000247.2: p.Asp770Asn) which was found in seven patients and another one is of conflicting interpretations of pathogenicity (NP₋000247.2: p.Ser217Gly) which was found in two patients. We have identified one in-frame deletion (NP₋000247.2: p.Ala433del) that is possible a novel variant responsible for the development of HCM.

Matrix in Medicine: Health Consequences of Mutant Cartilage Oligomeric Matrix Protein and its relationship to abnormal growth and to joint degeneration

Cartilage oligomeric matrix protein (COMP), an extracellular matrix protein, has been shown to enhance proliferation and mechanical integrity in the matrix, supporting functions of the growth plate and articular cartilage. Mutations in COMP cause pseudoachondroplasia (PSACH), a severe dwarfing condition associated with premature joint degeneration and significant lifelong joint pain. The MT (mutant)-COMP mouse mimics PSACH with decreased limb growth, early joint degeneration and pain. Ablation of endoplasmic reticulum stress CHOP signaling eliminated pain and prevented joint degeneration. The health effects of mutant COMP are discussed in relation to cellular/chondrocyte stress in the growth plate, articular cartilage and nearby tissues, and the implications for therapeutic approaches. There are many similarities between osteoarthritis and mutant-COMP protein-induced joint degeneration, suggesting that the relevance of findings in the joints may extend beyond PSACH to idiopathic primary OA.

Dose selection for a phase III study evaluating gepotidacin (GSK2140944) in the treatment of uncomplicated urogenital gonorrhoea

BACKGROUND

Gepotidacin is a novel, first-in-class triazaacenaphthylene antibiotic that inhibits bacterial DNA replication by a distinct mechanism of action and is active against most strains of Neisseria gonorrhoeae (N. gonorrhoeae). Phase II data suggested higher exposures were needed for efficacy and to suppress resistance development. A translational approach using in vitro pharmacokinetic/pharmacodynamic (PK/PD) and clinical data was used to select a gepotidacin dose for a phase III study. In this narrative review of previously shown data, we summarise how a translational approach based on in vitro PK/PD and population PK modelling and simulation data was undertaken to select a dosing regimen for the ongoing phase III gepotidacin study in participants with uncomplicated urogenital gonorrhoea.

METHODS

For dose selection, prior in vitro minimum inhibitory concentrations (MICs) and PK/PD data were available. PK modelling was conducted to determine a dose that would limit plasma concentrations to less than 14 µg/mL (as concentrations above this are associated with QT prolongation and effects associated with acetylcholinesterase inhibition) while maintaining ≥90% probability of target attainment (PTA) for efficacy and resistance suppression against N. gonorrhoeae isolates with gepotidacin MICs ≤1 µg/mL.

RESULTS

Two 3000 mg gepotidacin doses, administered 10-12 hours apart, resulted in PTA of ≥97.5% and ≥91.7% for gepotidacin MICs ≤1 µg/mL for the ratio of the area under the free drug plasma concentration-time curve over 24 hours to the MIC (fAUC_0-24/MIC) efficacy, and resistance suppression targets of 40 and 46, respectively, but limited the occurrence of maximum plasma concentrations ≥14 µg/mL.

CONCLUSIONS

Two gepotidacin 3000 mg oral doses 10-12 hours apart provide ~2-fold higher systemic exposures, increase efficacy for higher gepotidacin MIC N. gonorrhoeae isolates, reduce resistance potential and limit plasma concentrations of potential safety concern, compared with higher doses.

Early outcome of radiculopathy with local application of steroid in perineural space in lumbar discectomy

Lumbar disc herniation resulting in compression and inflammation of nerve roots causes low back pain and radiculopathy. Per-operative use of steroids may help reduce inflammatory reaction and scar formation, causing less postoperative pain. The study aimed to assess the early outcome of radiculopathy with local application of steroids in peri-neural space after lumbar discectomy. This experimental study was carried out in the Department of Neurosurgery of the National Institute of Neuroscience and Hospital (NINS&H), Dhaka from March 2019 to August 2020. A total of 68 patients operated for prolapsed lumbar intervertebral disc (PLID) at L4/L5 and /or L5/S1 levels were divided into two groups. Patients who did not receive steroids (n=34) and those who received steroids (n=34) in peri-neural space were considered group A and group B, respectively. Patients were examined on the 1st, 2nd and 14th postoperative days to measure the pain intensity by the Visual Analogue Scale (VAS). Pre-operatively mean (standard deviation, sd) VAS was 7.41 (1.28) in Group A and 7.91 (0.9) in Group B (p-value >.05). Mean (sd) improvement of pain intensity on day 1, was 58.82 (17.55)% in Group A and 70.59 (12.26)% in Group B from pre-operative VAS. On day 2, 71.69 (12.43)% improvement was seen in Group A and 79.78 (9.74)% in Group B. On day 14, 75.37 (9.96)% improvement was seen in Group A and 83.46 (7.36)% in Group B from pre-operative. The improvements of VAS in all 1st, 2nd and 14th days were statistically significant (p-value <.05) between the two groups. Local application of steroids in peri-neural space found effective in reducing early postoperative radiculopathy following lumbar discectomy. BSMMU J 2022; 15(2): 107-109

Pharmacokinetic, Safety, and Tolerability Evaluations of Gepotidacin (GSK2140944) in Healthy Japanese Participants

Gepotidacin is a novel, bactericidal, first-in-class triazaacenaphthylene antibiotic in late-phase development for uncomplicated urinary tract infection and uncomplicated urogenital gonorrhea. Two clinical studies were conducted to assess the pharmacokinetics (PK) and interethnic comparisons of oral gepotidacin (free-base and to-be-marketed mesylate formulations) administered as single doses ranging from 1500 to 3000 mg in fed and fasted states, and as 2 × 3000-mg doses given 12 hours apart under fed conditions in healthy participants of Japanese ancestry. Dose proportionality was observed in plasma exposures, and comparable area under the concentration-time curve (AUC) and maximum concentration were observed in fed and fasted states. Interethnic comparisons for Japanese versus non-Japanese participant data showed slightly higher plasma maximum concentration (7%-30%) yet similar plasma AUCs; slightly lower urine AUCs (11%-18%) were observed. The slightly higher plasma exposures in healthy Japanese versus White participants in the same study were attributed to lower mean body weights (64 kg versus ≈80 kg). Adverse events were primarily gastrointestinal, and when administered with food, gastrointestinal tolerability was improved. Overall, the gepotidacin PK and safety-risk profiles in healthy Japanese support potential evaluation of the global clinical doses in future studies.

1526. Time from last COVID-19 vaccination’s impact on rapidity of viral culture conversion following SARS-CoV-2 infection: a prospective cohort study

Background

Vaccination is a fundamental element of pandemic control; however, insufficient data exists on vaccine’s impact on SARS-CoV-2 viral dynamics. We aimed to evaluate the relationship between time to negative viral culture conversion after diagnosis and time since most recent COVID-19 vaccination.

Scatterplot illustrating relationship between time from last dose of a COVID-19 vaccine and time to culture conversion. Both participants who only received their initial series of COVID-19 vaccination and those who received a COVID-19 vaccine booster dose were included. The black solid line shows the best fit for the Spearman correlation model; Gray shading denotes 95% confidence interval around this estimate. Spearman correlation coefficient, R, and p-value were estimates for the model.

Scatterplot illustrating relationship between time since completion of initial COVID-19 vaccine series and time to culture conversion among un-boosted participants. The vaccine type received has also been designated by plot labels. The black solid line shows the best fit for the Spearman correlation model; gray shading denotes 95% confidence interval around this estimate. Spearman correlation coefficient, R, and p-value were estimates for the model.

Methods

CoViD Post-vax is longitudinal cohort study collecting baseline clinical questionnaires, and daily anterior nasal swabs and symptom screens on enrolled Boston University SARS-CoV-2 PCR-positive cases detected through a serial screening testing program or symptomatic testing. Data was collected from November 2021 to March 2022. Participants were excluded from analysis if they lacked at least one positive culture or did not culture convert during their study involvement. Scatter plots comparing time to culture conversion to time from initial vaccine series were created. We calculated spearman correlation coefficients to determine the relationship between time to culture conversion and time from last vaccination for all participants, those who completed the initial vaccine series (unboosted), and those who were boosted.

Scatterplot illustrating relationship between time since receiving a booster COVID-19 vaccine dose and time to culture conversion among boosted participants. The vaccine type received has also been designated by plot labels. The black solid line shows the best fit for the Spearman correlation model; Gray shading denotes 95% confidence interval around this estimate. Spearman correlation coefficient, R, and p-value were estimates for the model.

Results

Of 54 CoViD Post-Vax participants included in this analysis, the mean age was 21 years (SD=2) and culture conversion occurred after a median of 4 days (IQR=3–5.75). There was no association between time to culture conversion and time since last dose of a COVID-19 vaccination (R= -0.13, p= .34). When stratified by vaccination status, there was no association between time to culture conversion and time since initial COVID-19 vaccine series (R= -0.25, p= .21, n=26) or time since COVID-19 booster vaccination (R= -0.24, p= .22, n=28).

Conclusion

Our results show no significant relationship between time to culture conversion and time since most recent dose of COVID-19 vaccination in an initially culture positive, young, University-based cohort. More work needs to be done to understand the impact of symptom severity, disease burden, SARS-CoV-2 variants, and COVID-19 vaccine status on duration of transmissible SARS-CoV-2 infection.

Disclosures

Catherine M. Klapperich, Ph.D., BioSens8, LLC: Ownership Interest.

313. Performance of Rapid Diagnostic Testing at Days 4-6 from Diagnosis: Implications for Discharge from Isolation on a University Campus

Background

Omicron rapidly replaced delta as the predominant strain causing COVID-19 related illness in the United States (US) in December 2021, the same month the US CDC reduced the recommended isolation period from 10 to 5 days for asymptomatic individuals or those with resolving symptoms. New evidence suggests some asymptomatic individuals with omicron remain culture positive beyond 5 days from diagnosis. We sought to evaluate the performance of a SARS-CoV-2 antigen rapid diagnostic test (RDT) in predicting persistent potential for transmission at the end of a five-day isolation period among young, fully vaccinated individuals in a university community setting.

Methods

A subgroup of participants enrolled in a longitudinal COVID-19 cohort were asked to self-perform RDTs on days 4 to 6 from diagnostic test date in addition to a separate self-collected anterior nasal swab used for culture and RT-PCR, and a daily symptom screen (15 COVID-19 symptom questions on a 4-point scale). We calculated the daily and overall sensitivity and specificity of the RDTs in comparison to SARS-CoV-2 culture result. We also compared the N1 cycle threshold (CT) values and symptom score on each day of the study by RDT results.

Results

Of 23 participants, the mean age was 20 years, all had completed their primary COVID-19 vaccine series, and 13 (65.0%) had received a booster vaccine (Table 1). Compared to culture, sensitivity and specificity of the RDTs were 100% and 62% respectively (Table 2). Compared to participants with negative RDTs, median CT values were lower in those with positive RDTs on each day of the study (Figure 1). Participants who had positive RDTs on all three days had higher symptom scores (Figure 2) than those without.

Conclusion

RDTs have a high sensitivity in detecting culture positive SARS-CoV-2 on Days 4 to 6 from initial diagnostic test. However, the high false positive rate of 38% means that over a third of culture negative individuals will stay in isolation longer than necessary if RDTs are used in test to release from isolation protocols. Viral loads (CT values) and symptom scores were higher for participants with persistently positive RDT result. An approach that uses a combination of RDTs, CT values and symptom score may prove useful in guiding isolation duration.

Disclosures

Davidson H. Hamer, MD, Trinity Biotech: Advisor/Consultant Catherine M. Klapperich, Ph.D., BioSens8, LLC: Ownership Interest.

Short Term Visual and Refractive Outcome following Surgical Intervention for Posterior Capsule Opacification (PCO) in Children in a Tertiary Eye Hospital

BACKGROUND

PCO occurs commonly postoperatively following cataract extraction in children, obscuring vision as did the initial cataract. It may require a second surgical procedure when it is dense. It is expected that this results in restoration of vision and it is important to ascertain that this is the case as well as to examine any significant changes in refraction thereafter.

METHODS

A retrospective observational study extracting demographic and clinical information from case notes of patients who had membranectomy and/or capsule polishing between October 2017 and September 2018.

RESULTS

57 eyes of 51 patients were enrolled. There was a 2:1 male: female ratio. Mean age at cataract surgery was 6.33± 3.59years whilst that for PCO surgery was 9.68±3.89years. Postoperative visual acuity (by WHO definition) was good (between 6/6 and 6/18) in 33.3%, compared to 8.8% preoperatively. Whereas presenting visual acuity was poor (<6/60) in 61.4% preoperatively, this reduced to 30% postoperatively. Visual outcome was influenced by age at cataract surgery, age at PCO surgery, interval between cataract and PCO surgery and type of cataract. Children >8 years of age at time of PCO surgery had a greater proportion of good post-operative best corrected visual acuity (BCVA) (52.6%), whilst 75% of children younger than 8years at time of surgery turned out with poor BCVA after surgery. Developmental cataracts proportionately had the best outcome of visual acuity. There was a range of refractive shift of +0.25D to - 5.25D with a mean myopic shift of -1.51D following membranectomy. CONCLUSION: There was a good proportion of children with significant improvement in visual acuity on the short term, and a mild myopic shift following membranectomy.

A Rare and Unusual Cause of Ischemic Stroke to Be Aware of

Congenital absence of an internal carotid artery (ICA) is an extremely rare vascular anomaly. This case report presents an instance of right ICA agenesis to highlight the importance of early identification of this anomaly and its impact on disease presentation and complications. With transient ischemic attack (TIA), cerebrovascular accident (CVA), and cerebral aneurysms being among the chief presenting scenarios or course of the anomaly, it is important to have a high level of suspicion for these in patients with known ICA agenesis. Understanding the underlying development of this vasculature and its impact on cerebral circulation aids in identifying possible findings on imaging. This case report aims to delineate the pathophysiology of ICA agenesis, recognition of the vasculature that contributes to the anomaly, different presentations of the disease, complications, and obstacles in management.

Design of Two Phase III, Randomized, Multicenter Studies Comparing Gepotidacin with Nitrofurantoin for the Treatment of Uncomplicated Urinary Tract Infection in Female Participants

BACKGROUND

Uncomplicated urinary tract infections (uUTIs) are among the most common community-acquired infections for women worldwide. Treatment options are increasingly limited by antibiotic resistance; novel oral antibiotics are urgently needed. Gepotidacin is a novel, bactericidal, first-in-class triazaacenaphthylene antibiotic that inhibits bacterial deoxyribonucleic acid (DNA) replication by a distinct mechanism of action, which confers activity against most strains of target pathogens, such as Escherichia coli and Staphylococcus saprophyticus, including those resistant to current antibiotics. Here, we describe the designs of two near-identical phase III clinical trials (EAGLE-2 and EAGLE-3) evaluating gepotidacin for the treatment of uUTI.

METHODS

These are phase III, randomized, multicenter, parallel-group, double-blind, double-dummy, comparator-controlled, noninferiority studies, comparing the efficacy and safety of gepotidacin to nitrofurantoin in the treatment of uUTI. Eligible participants are women aged ≥ 12 years with ≥ 2 uUTI symptoms, randomized (1:1) to receive oral gepotidacin (1500 mg) plus placebo or nitrofurantoin (100 mg) plus placebo, twice daily for 5 days. The primary therapeutic endpoint is composite clinical and microbiological efficacy, with noninferiority comparisons made in individuals with a qualifying (≥ 10⁵ colony-forming units/mL urine) nitrofurantoin-susceptible uropathogen.

RESULTS

These trials were designed in accordance with US Food and Drug Administration (2019) and European Medicines Agency (2018) guidance, particularly the composite endpoint and microbiological evaluability requirements. Across the trials ~ 5000 participants are planned to be enrolled from > 200 centers globally.

CONCLUSIONS

Gepotidacin represents an important potential treatment option being evaluated to address the need for novel oral antibiotics to treat uUTI. These trials are registered at ClinicalTrials.gov ( https://clinicaltrials.gov/ ) where the full protocols can be accessed under trial IDs: NCT04020341 (EAGLE-2) and NCT04187144 (EAGLE-3).

Relationship of Conduction Defects and In-Hospital Outcome after Acute ST Segment Elevation Myocardial Infarction

The presence of conduction defects complicating acute myocardial infarction (MI) is relatively frequent and is associated with increased short and long term mortality. Thrombolytic therapy has been established to reduce the mortality in acute MI, however its role in reducing the incidence of conduction defects is less clearly defined. Morbidity and mortality associated with conduction defects also remain unchanged. This study was aimed to assess the correlation between conduction defects and adverse in-hospital outcome of patients with acute ST segment elevation MI. This cross sectional descriptive type of observational study was conducted among 100 purposively selected patients with acute ST segment elevation MI in the coronary care unit (CCU) of Mymensingh Medical College Hospital, Bangladesh from June 2012 to March 2013. The patients were divided into two groups depending on the presence or absence of conduction defects namely Group A- 40 patients with conduction defects and Group B- 60 patients without conduction defects. Highest number of the patients (36.0%) was in the age group of 45-55 years. In case of inferior MI, age groups 45-55 years and 55-65 years had equal number of patients (30.4%). Only 2.0% patients were in age group of 75-85 years and this group had only inferior MI. Total number of female patients were 16(16.0%). Female patients had more inferior MI (17.4%) than anterior MI (15.9%). Number of MI patients was slightly more in inferior MI (46.0%) than anterior MI (44.0%). Group B had equal number of patients in both anterior and inferior MI. Conduction defects were more common in inferior MI (43.5%) than anterior MI (40.9%). Atrio-ventricular conduction defects were more common in inferior MI whereas intra-ventricular conduction defects were more common in anterior MI. Complete heart block (CHB) was more prevalent in inferior MI. Complications were more common in Group A (65.0%) than Group B (18.3%). In terms of complications the difference between two groups were significant (p<0.001). Group A showed higher rate of mortality (20.0%) than Group B (3.3%). In cases of anterior MI difference in mortality between Group A and Group B was highly significant (p<0.001). Conduction defects in the setting of acute MI are a common finding. Atrio-ventricular conduction defects occur more frequently in inferior MI whereas intra-ventricular conduction defects were more frequently encountered in anterior MI. Patients with conduction defects had more complications than those without conduction defects. Presence of conduction defects significantly increases the mortality of patients with anterior MI.

Pharmacokinetics, safety, and tolerability of gepotidacin administered as single or repeat ascending doses, in healthy adults and elderly subjects

Gepotidacin, a novel, first-in-class triazaacenaphthylene antibiotic, inhibits bacterial DNA replication by a distinct mechanism of action. We report the pharmacokinetics (PKs), safety, and tolerability of gepotidacin following single or multiple ascending doses. Studies 1 and 2 were randomized, single-blind, placebo-controlled trials in healthy adults aged 18-60 years, who received single (study 1 [NCT02202187]; 100-3000 mg) or repeat (study 2 [NCT01706315]; 400 mg twice daily to 2000 mg thrice daily) ascending doses of gepotidacin. Study 3 (NCT02045849) was an open-label, three-part, study in healthy adults; here, we report on part 3, a two-period, repeat-dose, crossover study. Healthy elderly participants received repeat 1500 mg gepotidacin twice daily with or without a moderate-fat meal. Primary end points were PKs (studies 1 and 2) and safety (studies 1 and 3 part 3). Gepotidacin PK parameters were comparable across all ages and were dose proportional. In all studies, gepotidacin was readily absorbed with median time to maximum concentration observed ranging from 1.0 to 4.0 h across all doses. Median apparent terminal phase half-life was consistent across studies and doses (range: 5.97-19.2 h). Steady-state was achieved following repeated dosing for 3-5 days; gepotidacin PK parameters were time invariant after repeated oral dosing. A moderate-fat meal did not affect gepotidacin PK parameters. Gepotidacin was generally well-tolerated, with no drug-related serious adverse events reported. Collectively, these PK and safety data across a wide range of doses in healthy participants aged greater than or equal to 18 years support the development of gepotidacin in further clinical studies.

SP11.7 Cost-effectiveness of carotid endarterectomy in symptomatic patients

Aims

In recent years, improvements in medical therapy for stroke prevention have emerged. Recent analyses of medically treated cohorts have suggested that early rates of stroke may have reduced, whilst reports for safety of carotid surgery have also shown improvements. Since the effectiveness of carotid surgery versus medical therapy was established in 1990s, it is important to evaluate whether surgery remains cost-effective.

Methods

A decision model was developed to estimate the lifetime costs and utilities of modern medical therapy with and without carotid endarterectomy in patients with symptomatic stenosis from perspective of the UK National Health Service. The base-case population consisted of adults 65 years of age with 70–99% stenosis. Costs and utilities were obtained from National Health Service tariffs and the literature. Univariate and probabilistic sensitivity analyses were carried out. Data on surgical safety was taken from the 2020 National Vascular Registry Report. Data on modern medical therapy was taken from Fisch et al. 2020.

Results

In the base-case scenario, the 5-year absolute risk reduction with endarterectomy was 5%, and incremental cost-effectiveness ratio was £23,632 per quality adjusted life year. Surgery was more cost-effective if performed rapidly after presentation. In patients with 50–69% stenosis, surgery appeared clinically ineffective.

Conclusion

In symptomatic patients with 70–99% stenosis, carotid endarterectomy would remain cost-effective if performed rapidly after presentation. Surgery may have lost clinical efficacy in those with moderate stenosis. However, these results are uncertain because of limited data on modern medical therapy. A new randomised controlled trial of surgery versus modern medical therapy is needed.

Estimation of Serum Lipid Profile among Patients Admitted with Myocardial Infarction in a Tertiary Level Hospital of Bangladesh

Different studies worldwide showed that dyslipidaemia is involved in the pathogenesis of ischemic heart diseases (IHD). This cross sectional descriptive type of observational study was carried out at Mymensingh Medical College Hospital during the period of six months from January 2021 to September 2021 to estimate the lipid profile among patients admitted in the coronary care unit (CCU) with myocardial infarction (MI). Data were collected from purposively selected 343 patients with MI by face to face interview and laboratory investigations using a case record form. Informed written consent of participants was taken prior to interview. Data were analyzed by using SPSS version 21.0. The study results revealed that mean age of the patients with myocardial infarction was 53.16 years with a standard deviation of 11.68 years. Majority of them (284, 82.8%) were male and the remaining (59, 17.2%) were female. Proportion of risk factors for ischaemic heart disease (IHD) were estimated and found that 244(71.1%) patients were smoker; 150(43.7%) had hypertension and 110(32.2%) had family history of IHD. Ninety nine (28.9%) patents were obese with BMI ≥25kg/m². Eighty three (24.2%) patients had diabetes mellitus; 66(19.2%) lead sedentary life and 61(17.8%) patients with myocardial infarction had dyslipidaemia. Mean LDL of patients with myocardial infarction was 103.65±39.73mg/dl; mean total cholesterol (TC) was 189.44±45.41mg/dl; mean TG was 243.11±205.19mg/dl and mean HDL was 39.29±8.98mg/dl. LDL was increased in 10(2.9%) patients; total cholesterol was raised in 121 (35.3%) patients and TG was raised in 195(56.9%) patients. HDL was raised in 26(7.6%) patients and it was lowered in 57(16.6%) patients. Mean LDL, TC, TG and HDL of younger (≤45 years) and older (>45 years) patients were compared and t-test showed no significant difference (p>0.05). Similarly mean LDL, TC, TG and HDL of male and female were compared and again t-test showed no significant difference (p>0.05). Though the pattern of lipid profile was found similar in younger and older patients and in males and females, a significant number of patients (61, 17.8%) with MI had dyslipidaemia which should be address by dietary and lifestyle modification.

Dichloroacetyl Amides of 3,5-Bis(benzylidene)-4-piperidones Displaying Greater Toxicity to Neoplasms than to Non-Malignant Cells

A series of 3,5-bis(benzylidene)-1-dichloroacetyl-4-piperidones 1a–l was evaluated against Ca9-22, HSC-2, HSC-3, and HSC-4 squamous cell carcinomas. Virtually all of the compounds displayed potent cytotoxicity, with 83% of the CC₅₀ values being submicromolar and several CC₅₀ values being in the double digit nanomolar range. The compounds were appreciably less toxic to human HGF, HPLF, and HPC non-malignant cells, which led to some noteworthy selectivity index (SI) figures. From these studies, 1d,g,k emerged as the lead molecules in terms of their potencies and SI values. A Quantitative Structure-Activity Relationship (QSAR) study revealed that cytotoxic potencies and potency–selectivity expression figures increased when the magnitude of the sigma values in the aryl rings was elevated. The modes of action of the representative cytotoxins in Ca9-22 cells were found to include G2/M arrest and stimulation of the cells to undergo mitosis and cause poly(ADP-ribose) polymerase (PARP) and procaspase 3 cleavage.

Gepotidacin is efficacious in a nonhuman primate model of pneumonic plague

Gepotidacin is a first-in-class triazaacenaphthylene antibacterial agent that selectively inhibits bacterial DNA gyrase and topoisomerase IV through a unique binding mode and has the potential to treat a number of bacterial diseases. Development of this new agent to treat pneumonic plague caused by Yersinia pestis depends on the U.S. Food and Drug Administration Animal Rule testing pathway, as testing in humans is not feasible. Here, preclinical studies were conducted in the African green monkey (AGM) inhalational model of pneumonic plague to test the efficacy of gepotidacin. AGMs infected with Y. pestis were dosed intravenously with gepotidacin (48, 36, or 28 milligrams/kilogram per day) for 10 days to provide a plasma concentration that would support a rationale for a 1000 mg twice or thrice daily intravenous dose in humans or saline as a control. The primary end point was AGM survival with predefined euthanasia criteria. Secondary end points included survival duration and bacterial clearance. Gepotidacin showed activity in vitro against diverse Y. pestis isolates including antibiotic-resistant strains. All control animals in the inhalational plague studies succumbed to plague and were blood culture and organ culture positive for Y. pestis. Gepotidacin provided a 75 to 100% survival benefit with all dose regimens. All surviving animals were blood culture and organ culture negative for Y. pestis. Our randomized, controlled efficacy trials in the AGM pneumonic plague nonhuman primate model together with the in vitro Y. pestis susceptibility data support the use of gepotidacin as a treatment for pneumonic plague caused by Y. pestis.

Cytotoxic benzylidene hydrazides of terephthalic acid and related compounds

The present investigation involved the synthesis of a number of novel benzylidene hydrazides as candidate cytotoxic agents. The preparation of these compounds from terephthalic acid and isophthalic acid proceeded satisfactorily. However, the reaction of phthalic acid hydrazide with various aryl aldehydes was unsuccessful in general. Some of the unexpected products were identified. The shapes and also the distances between the centers of the aryl rings designated B and C of three representative compounds 1b, 2b and 3b were determined. The compounds designated 1a-e, 2a-e and 3b were screened against human HCT116 and HT29 colon cancer cells as well as human CRL1790 non-malignant colon cells which revealed the tumor-selective toxicity displayed by these compounds.

Pharmacokinetic/Pharmacodynamic Evaluation of Ivosidenib or Enasidenib Combined With Intensive Induction and Consolidation Chemotherapy in Patients With Newly Diagnosed IDH1/2-Mutant Acute Myeloid Leukemia

Mutant isocitrate dehydrogenase 1/2 (mIDH1/2) proteins catalyze production of the oncometabolite D-2-hydroxyglutarate (2-HG). Ivosidenib and enasidenib are oral inhibitors of mIDH1 and mIDH2, respectively. An open-label phase 1 study is evaluating the safety and efficacy of ivosidenib or enasidenib combined with intensive induction and consolidation chemotherapy in adult patients with newly diagnosed mIDH1/2 acute myeloid leukemia (AML; NCT02632708). In this population, we characterized the pharmacokinetics (PK), pharmacodynamics (PD), and PK/PD relationships for ivosidenib and enasidenib. Patients received continuous oral ivosidenib 500 mg once daily or enasidenib 100 mg once daily combined with chemotherapy. Serial blood samples were collected for measurement of the concentrations of the mIDH inhibitors. 2-HG concentrations were measured in both plasma and bone marrow aspirates. Samples were collected from 60 patients receiving ivosidenib and 91 receiving enasidenib. For both drugs, exposures at steady state were higher than after single doses, with mean accumulation ratios (based on area under the plasma concentration-time curve from time 0 to 24 hours) of 2.35 and 8.25 for ivosidenib and enasidenib, respectively. Mean plasma 2-HG concentrations were elevated at baseline. After multiple ivosidenib or enasidenib doses, mean trough plasma 2-HG concentrations decreased to levels observed in healthy individuals and were maintained with continued dosing. There was a corresponding reduction in bone marrow 2-HG concentrations. When combined with intensive chemotherapy in patients with newly diagnosed mIDH1/2 AML, ivosidenib and enasidenib demonstrated PK/PD profiles similar to those when they are given as single agents. These findings support the dosing of ivosidenib or enasidenib in combination with intensive chemotherapy for the treatment of patients with newly diagnosed mIDH1/2 AML.

The perplexing postsurgical complication of carotid-jugular fistula: A bitter experience

Background:

Vascular injuries occur in approximately 25% of all penetrating neck traumas, with carotid artery injuries being particularly lethal. Penetrating neck injuries are potentially fatal. Vascular injuries occur in approximately 25% of cases, which can lead to the formation of arteriovenous fistulas.

Case Description:

The authors present a case of delayed open surgery to repair a carotid-jugular fistula that resulted in an unprecedented complication, as well as a brief review of the condition’s diagnosis and treatment options.

Conclusion:

This case report suggests us that, penetrating neck injuries should be thoroughly evaluated for arteriovenous fistulae. To avoid complications, common carotid-jugular fistulas must be treated as soon as possible. Postoperative complications can be effectively managed with prompt action.

A review on carbon fiber-reinforced hierarchical composites: mechanical performance, manufacturing process, structural applications and allied challenges

The utilization of carbonaceous reinforcement-based polymer matrix composites in structural applications has become a hot topic in composite research. Although conventional carbon fiber-reinforced polymer composites (CFRPs) have revolutionized the composite industry by offering unparalleled features, they are often plagued with a weak interface and lack of toughness. However, the promising aspects of carbon fiber-based fiber hybrid composites and hierarchical composites can compensate for these setbacks. This review provides a meticulous landscape and recent progress of polymer matrix-based different carbonaceous (carbon fiber, carbon nanotube, graphene, and nanodiamond) fillers reinforced composites’ mechanical properties. First, the mechanical performance of neat CFRP was exhaustively analyzed, attributing parameters were listed down, and CFRPs’ mechanical performance barriers were clearly outlined. Here, short carbon fiber-reinforced thermoplastic composite was distinguished as a prospective material. Second, the strategic advantages of fiber hybrid composites over conventional CFRP were elucidated. Third, the mechanical performance of hierarchical composites based on carbon nanotube (1D), graphene (2D) and nanodiamond (0D) was expounded and evaluated against neat CFRP. Fourth, the review comprehensively discussed different fabrication methods, categorized them according to performance and suggested potential future directions. From here, the review sorted out three-dimensional printing (3DP) as the most futuristic fabrication method and thoroughly delivered its pros and cons in the context of the aforementioned carbonaceous materials. To conclude, the structural applications, current challenges and future prospects pertinent to these carbonaceous fillers reinforced composite materials were elaborated.

1115. Evaluation of Gepotidacin (GSK2140944) Pharmacokinetics and Food Effect in Japanese Subjects

Background

Gepotidacin, a novel, first-in-class triazaacenaphthylene antibiotic, inhibits bacterial replication and has in vitro and in vivo activity against key pathogens, including drug-resistant strains, associated with a range of infections. Gepotidacin is currently in Phase 3 clinical studies for the treatment of uncomplicated urinary tract infections and gonorrhea. This study (NCT02853435) was designed to assess gepotidacin pharmacokinetics (PK) in Japanese subjects (fasted and fed).

Methods

A tablet formulation of 750 mg gepotidacin free base was used in the study, which was conducted in two parts: Part 1, gepotidacin PK was assessed following 1500 and 3000 mg single oral doses in the fasted state; and Part 2, gepotidacin PK was assessed following 1500, 2250, and 3000 mg single oral doses in the fed state. Serial blood and urine samples were collected in both study parts.

Results

Part 1: The area under the plasma drug concentration-time curve from time 0 to infinity (AUC_[0–∞]) and maximum observed concentration (C_max) were slightly higher in Japanese subjects than in Caucasian subjects at the same dose levels and with the same formulation. Following gepotidacin dosing in the fasted state, the 1500 mg dose was tolerated, while the 3000 mg dose was poorly tolerated with mild or moderate gastro-intestinal adverse effects (GI AEs) reported by most subjects shortly after being dosed. Part 2: PK was linear with doses in the range of 1500–3000 mg. Administration of gepotidacin 3000 mg tablets in the fed state slightly reduced C_max and slightly increased AUC at the 3000 mg dose level. The 1500 and 2250 mg doses were tolerated while the 3000 mg dose was better tolerated compared to the fasted state with fewer and short-lived GI AEs, mostly mild in intensity. After oral administration of 1500–3000 mg, high urine drug concentrations were achieved, remaining above the minimum inhibitory concentration of 4 μg/mL for up to 24 hours.

Conclusion

The PK of gepotidacin following administration of a single oral dose to Japanese subjects was linear from 1500–3000 mg and food decreased C_max without impact on exposure (AUC). Administration of gepotidacin with food resulted in an improved GI tolerability profile at the higher dose tested in Japanese subjects.

Disclosures

Mohammad Hossain, PhD, GlaxoSmithKline plc. (Employee, Shareholder, Former employee of and past/current shareholder in GlaxoSmithKline plc.) Courtney Tiffany, BSc, GlaxoSmithKline plc. (Employee, Shareholder, Former employee of and past/current shareholder in GlaxoSmithKline plc.) Aline Barth, MSC;PHD, GlaxoSmithKline plc. (Employee, Shareholder, Employee of and shareholder in GlaxoSmithKline plc.) Aparna Raychaudhuri, Ph.D., GlaxoSmithKline plc. (Employee, Shareholder, Former employee of and past/current shareholder in GlaxoSmithKline plc.) Etienne F. Dumont, MD, GlaxoSmithKline plc. (Employee, Shareholder, Former employee of and shareholder in GlaxoSmithKline plc.)

Eculizumab as a Treatment for Hyper-Haemolytic and Aplastic Crisis in Sickle Cell Disease

Background

Patients with sickle cell disease can experience various crises including sequestration crisis, haemolytic crisis and aplastic crisis. Due to alloantibody formation, transfusion alloantibodies can cause a haemolytic crisis. Treatment involves avoiding packed red blood cell transfusions, as well as intravenous immunoglobulin, steroids and eculizumab to decrease the chances of haemolysis.

Case description

We report the case of a 42-year-old man who was found to have worsening anaemia after packed red blood cell transfusion with evidence suggestive of haemolytic crisis. Due to reticulocytopenia, aplastic crisis was also suspected and later confirmed via parvovirus IgG and IgM titres. The patient did not improve with steroid and intravenous immunoglobulin therapy and was treated with eculizumab as a salvage therapy.

Conclusion

Concurrent hyper-haemolytic crisis and aplastic crisis should be suspected in patients with features of haemolysis and reticulocytopenia. Prompt recognition and treatment with eculizumab are paramount in those who fail steroid and intravenous immunoglobulin treatment.

LEARNING POINTS

Treatment of hyper-haemolytic and aplastic crisis in sickle cell disease with eculizumab offers therapeutic benefit.A high index of suspicion for hyper-haemolytic crisis and aplastic crisis should be maintained in those with haemolytic features as well as reticulocytopenia in the setting of sickle cell disease.

Numerical investigation on effect of particle aspect ratio on the dynamical behaviour of ellipsoidal particle flow

Flow of ellipsoidal particles in a modal shear cell was investigated at the microdynamic level based on discrete element method simulations. In a stress-controlled double-shear condition, the flow was studied by varying the aspect ratio of ellipsoidal particles and comparing with the flow of spherical particle assembly in terms of some key properties, including particle alignment, linear velocity, angular velocity, porosity, contact force and contact energy. It was found that particle elongation impacts the rotational displacement around the axis perpendicular to the shear direction, which causes that the ellipsoidal particles with higher elongation are more aligned with the direction of the shear velocity, with more uniform force network. This then affects other particle properties. The fluctuation of linear velocity and the angular velocity decreases with an increase in particle aspect ratio, although the particle elongation does not significantly affect the flow velocity gradient. There is a reduction in both normal and tangential forces per contact with an increase of particle elongation. Due to the variation of the particle alignment with elongation, the standard deviation of the contact energies increases and then reduces when an increase in particle aspect ratio occurs, and on contrary, the porosity has an opposite variation trend.

Streptococcus anginosus Empyema Induced by Dental Abscess: A Case Report

Streptococcus anginosus is a gram-positive catalase-negative cocci and commensal flora of the oropharynx and gastrointestinal tract. Streptococcus anginosus is known to be highly virulent and known to cause invasive pyogenic infection which may necessitate emergent surgical treatment. We present a case of a 53-year-old female with dental caries and uncontrolled diabetes mellitus who presented with progressive shortness of breath for 1 week. A computed tomography scan of the chest showed a loculated empyema which was treated with emergent video-assisted thoracoscopic surgery. Pleural fluid culture as well as sputum cultures grew Streptococcus anginosus. The patient was treated intravenous cephalosporins and discharged on oral antibiotics after 14 days with outpatient dental follow-up and improvement of symptoms.