A128 GLOBAL TRENDS IN TRAINING AND CREDENTIALING GUIDELINES FOR GASTROINTESTINAL (GI) ENDOSCOPY: A SYSTEMATIC REVIEW

Background

Credentialing in GI endoscopy is not a universally standardized process. National guidelines may provide a framework for local training, however in certain settings, training committees set minimal competency requirements that must be met before a clinician can be accredited to practice independently. There is a paucity of literature assessing the inter-societal and geographic variability in guidelines and training requirements in endoscopy.

Purpose

To systematically review the available credentialing guidelines proposed by different GI endoscopy societies and affiliated training committees internationally.

Method

We conducted a systematic review according to the PRISMA guidelines. A comprehensive literature search was performed for credentialing guidelines for GI endoscopy from inception until January 2022. Two reviewers screened and one reviewer abstracted data using a pre-defined data collection form.

Result(s)

From the 653 records obtained from our search, 20 credentialing guidelines from 12 different GI societies were ultimately included in the review. These guidelines encompassed the following procedures and outlined the following key-performance indicators; a) Colonoscopy: the recommended minimum number of procedures performed ranged from 150-275 with a minimum cecal intubation and adenoma detection rate of 85-90% and 20-30% respectively; b) EGD: the minimum number of procedures prior to credentialing ranged from 130-1000, the minimum duodenal intubation rate ranged from 95-100%, and the range for minimum number of upper GI bleeds managed was 20-45 (in addition to other procedural KPIs); c) ERCP: the recommended minimum number of procedures prior to credentialing ranged from 100-300 cases with a minimum selective duct cannulation rate of 80-90%. Guidelines for flexible sigmoidoscopy, EUS and capsule endoscopy were also obtained.

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Conclusion(s)

There is a general concordance amongst the various international GI societies with regards to minimum procedural volume and performance in key procedural tasks prior to credentialing, however the use of validated education assessment tools was lacking in the majority of guidelines. Additional KPI’s need to be explored for less routinely performed procedures such as EUS and capsule endoscopy.

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None

Disclosure of Interest

None Declared

A119 DEVELOPMENT AND EVALUATION OF LOW-COST GEL POLYPS FOR POLYPECTOMY SKILLS TRAINING IN NOVICE ENDOSCOPISTS

Background

Polypectomy is an essential skill for endoscopists to acquire. As polyps are encountered ad hoc during colonoscopies, exposure to polypectomy in clinical training may vary. There is a need to deliver a curriculum that standardizes exposure to polypectomy while remaining cost-effective for endoscopy programs worldwide.

Purpose

To develop low-cost simulated polyps that can be incorporated into endoscopic training programs, and to evaluate their perceived realism and useability for polypectomy training.

Method

We designed 3D molds based on the Paris classification, a validated rubric for polyp morphology. The polyps are depicted in Figure 1. Using low-cost materials, we created gel-based polyps compatible with physical colonic simulators. Current versions of the polyps were finalized based on visual realism and durability. Expert (performed >1000 procedures) and novice (<25 procedures) endoscopists were invited to perform simulated polypectomies and evaluate the realism of the polyps. Using a 7-point Likert scale (“strongly disagree” to “strongly agree”), we administered a survey adapted from the Direct Observed Polypectomy Skills (DOPyS) checklist to evaluate the polyps on practicality of design and useability for training. Additionally, the simulator’s resemblance to human polypectomy was assessed through a scale with 1 indicating “low resemblance” and 7 indicating “high resemblance”. The ease of identifying morphology was also evaluated, with 1 indicating “difficult” and 7 indicating “easy”.

Result(s)

The survey was completed by 11 expert endoscopists and 10 novices. The median score submitted by experts on the polyps’ useability in training the technique for mobilization of the polyp was 7 (IQR 6-7). Experts rated the simulator’s practicality in teaching cold snare or electrocautery techniques with a median score of 6 (IQR 6-7). Lastly, the ability of the simulator to develop skills in identifying and treating the residual polyp was assessed by expert endoscopists, giving it a median score of 6 (IQR 6-7). The simulators were tested on similarity to human polypectomy, with the median score of expert groups being 5 (IQR 5-6), and novice groups being 6 (IQR 6-6). Both groups were asked to rate if morphology could be identified using the simulator; the median score of expert groups being 6 (IQR 6-7), and 6.5 for novice endoscopists (IQR 5-7).

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Conclusion(s)

The development of simulated polyps with differing morphologies using low-cost and common materials with high realism is feasible. These polyps may potentially be integrated into different endoscopic training programs.

Please acknowledge all funding agencies by checking the applicable boxes below

None

Disclosure of Interest

A. Zhao: None Declared, N. Gimpaya: None Declared, J. Lisondra: None Declared, R. Fujiyoshi: None Declared, Y. Fujiyoshi: None Declared, R. Khan Grant / Research support from: Rishad Khan has received research grants from AbbVie (2018) and Ferring Pharmaceuticals (2019) and research funding from Pendopharm (2019). , D. Tham: None Declared, M. Scaffidi: None Declared, R. Bansal: None Declared, C. Walsh: None Declared, S. Grover Shareholder of: Samir C. Grover has equity in Volo Healthcare., Grant / Research support from: Samir C. Grover has received research grants and personal fees from AbbVie and Ferring Pharmaceuticals, personal fees from Takeda, education grants from Janssen.

A117 VALIDITY EVIDENCE FOR ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY COMPETENCY ASSESSMENT TOOLS: A SYSTEMATIC REVIEW

Background

Assessment of competence in endoscopic retrograde cholangiopancreatography (ERCP) is essential to ensure trainees possess the skills needed for independent practice. Traditionally, ERCP training has used the apprenticeship model, whereby novices learn skills under the supervision of an expert. A growing focus on procedural quality, however, has supported the implementation of competency-based medical education models which require documentation of a trainee’s competence for independent practice. Observational assessment tools with strong evidence of validity are critical to this process. Validity evidence supporting ERCP observational assessment tools has not been systematically evaluated.

Purpose

To conduct a systematic review of ERCP assessment tools and identify tools with strong evidence of validity using a unified validity evidence framework

Method

We conducted a systematic search using electronic databases and hand-searching from inception until August 2021 for studies evaluating observational assessment tools of ERCP performance. We used a unified validity framework to characterize validity evidence from five sources: content, response process, internal structure, relations to other variables, and consequences. Each domain was assigned a score of 0-3 (maximum score 15). We assessed educational utility and methodological quality using the Accreditation Council for Graduate Medical Education framework and the Medical Education Research Quality Instrument, respectively.

Result(s)

From 2769 records, we included 17 studies evaluating 7 assessment tools. Five tools were studied for clinical ERCP, one on simulated ERCP, and one on simulated and clinical ERCP. Validity evidence scores ranged from 2-12. The Bethesda ERCP Skills Assessment Tool (BESAT), ERCP Direct Observation of Procedural Skills Tool (ERCP DOPS), and The Endoscopic Ultrasound (EUS) and ERCP Skills Assessment Tool (TEESAT) had the strongest validity evidence with scores of 10, 12, and 11, respectively. Regarding educational utility, most tools were easy to use and interpret, and required minimal additional resources. Overall methodological quality was strong, with scores ranging from 10-12.5 (maximum 13.5).

Conclusion(s)

The BESAT, ERCP DOPS, and TEESAT have strong validity evidence compared to other assessments. Integrating tools into training may help drive learners’ development and support competency decision-making.

Please acknowledge all funding agencies by checking the applicable boxes below

CAG

Disclosure of Interest

None Declared

Isolation & identification of anti-inflammatory constituents of Randia dumetorum lamk. fruit: Potential beneficial effects against acute lung injury

ETHNOPHARMACOLOGICAL RELEVANCE

Randia dumetorum Lamk. is an Indian traditional medicinal plant that has been used for the treatment of various disorders including respiratory ailments.

AIM OF THE STUDY

In continuation of our recent report that the Ethanol soluble fraction (ESF) of Randia dumetorum fruit had potent anti-inflammatory activity against acute lung injury (ALI) in mice, the present work was undertaken to unveil the key bioactive constituents possessing anti-inflammatory action against ALI by employing bioactivity-guided fractionation of ESF.

MATERIAL AND METHODS

Different fractions/sub-fractions obtained by column chromatography of ESF were subjected to bioactivity studies by analyzing total and differential count, and protein content in broncho-alveolar lavage fluid (BALF) procured from mice. The most bioactive sub-fraction F3.2 was analyzed for the assessment of various inflammatory mediators using molecular techniques like ELISA, PCR, and western blotting. Further, an attempt was made to separate the key compounds in F3.2 using solvents of differential polarities; and isolated compounds were validated for their anti-inflammatory activity followed by their characterization using spectral techniques like ¹HNMR, ¹³CNMR, FT-IR, and ESIMS Mass Spectrometry.

RESULTS

The column chromatography of ESF yielded four fractions (F1, F2, F3, and F4) and data revealed that maximum activity resides in F3. Further fractionation of F3 yielded sub-fractions F3.1, F3.2, F3.3, and F3.4 which when tested for anti-inflammatory potential, showed F3.2 as the most active one. Moreover, the effect of F3.2 on oxidative stress parameters and inflammatory mediators analyzed via biochemical assays, PCR, and ELISA revealed the proficiency of this fraction in amelioration of ALI. F3.2 was then subjected to recrystallization using different solvents and two pure compounds were isolated which were characterized as D-Mannitol and Oleanolic acid (OA). D-Mannitol did not display any bioactivity, but OA showed potent anti-inflammatory activity.

CONCLUSION

Considering the ethnopharmacological role of R. dumetorum in respiratory ailments, OA as an aglycone moiety seems to be the main active principle possessing anti-inflammatory potential against ALI.

Synthesis of deoxy-Andrographolide Triazolyl Glycoconjugates for the Treatment of Alzheimer's Disease

A new andrographolide-based terminal alkyne 3 was synthesized in good yield from deoxy-andrographolide 2, obtained from a natural compound andrographolide 1, which in turn was isolated from the leaves of the plant Andrographis paniculata. Copper(I)-catalyzed azide-alkyne cycloaddition reaction of alkyne 3 with azido-sugars 4a-f furnished a library of andrographolide-fastened triazolyl glycoconjugates 5a-f in good yields. The structures of these semisynthetic andrographolide derivatives were established by Fourier transform infrared, NMR, and mass spectroscopy. The compounds 5a-f were further evaluated against Alzheimer's disease (AD) using a scopolamine (SCOP)-induced memory impairment mice model. It was observed that antioxidant and anticholinesterase properties of these compounds contribute significantly toward their remarkable potential to improve cognitive functioning.

Synthesis, In silico Studies and Pharmacological Evaluation of a New Series of Indanone Derivatives as Antiparkinsonian and Anti-Alzheimer’s Agents

Objective:

Parkinson’s disease (PD) and Alzheimer’s disease (AD) are the most common forms of neurodegenerative disorders. The aim of the current work is to study the potential of some new indanone derivatives for the treatment of these neurological disorders.

Methods:

A new series of 4-(2-oxo-2-aminoethoxy)-2-benzylidene substituted indanone derivatives have been synthesized and studied for anti-Parkinsonian and anti-Alzheimer’s effects. Substitution of different aminoalkyl functionalities at the para position of 2-benzylidene moiety of indanone ring resulted in the formation of potent anti-parkinsonian and anti-Alzheimer’s agents (5-10). The neuroprotective effects of newly synthesized compounds were evaluated using perphenazine (PPZ)-induced catatonia in rats and LPS-induced cognitive deficits in mice models. Further, in silico molecular modelling studies of the new indanone derivatives were performed by docking against the 3D structures of various neuroinflammatory mediators, such as interleukin-1β (IL-1β), tumor necrosis factor-α (TNF-β) and monoamine oxidase-B (MAO-B), to gain the mechanistic insights of their anti-Alzheimer’s and antiparkinsonian effects.

Results:

The newly synthesized indanone analogues 5-10 were found effective against PPZ-induced motor dysfunction and LPS-induced memory impairment in animal models. Among all the synthesized analogues, morpholine-substituted indanone 9 displayed maximum anti-parkinsonian activity, even better than the standard drug L-DOPA, while pyrrolidine and piperidine substituted analogues 5 and 6 were found to be the most potent anti-Alzheimer’s agents.

Conclusion:

The new 2-arylidene-1-indanone analogues show good potential as promising leads for designing compounds against Parkinson’s and Alzheimer’s diseases.

Outcomes of infective endocarditis in patients with and without pericardial effusion: a National Inpatient Sample study

Introduction

Pericardial effusion (PE) in patients with infective endocarditis (IE) has been shown to be an independent risk factor for severe complications, however no significant association with mortality has been established. Our study aims to study the significance of pericardial effusion in patients with IE.

Methods

We performed a retrospective analysis using the United States National Inpatient Sample (NIS) database to identify all the hospital admissions with IE using ICD 10 codes and divided them into two groups based on the presence of PE. The outcomes of interest were in-hospital mortality, in-hospital complications, need for cardiac surgery, and length of stay (LOS).

Results

A total of 381,300 patients were hospitalized from 2016 to 2019 with IE, of whom 10,370 developed PE. Mean age of patients in the PE group was 51 years and in non-PE group was 61 years with males and Caucasian race being predominant in both groups. PE group had higher rates of in-hospital death (12.7% vs 9%, P≤0.001) and longer in-hospital stay (12 days vs 7 days, P≤0.001) compared to non-PE group. The rates of cardiac surgery were higher in PE group (26.1% vs 8.4%, P≤0.001). The rates of heart failure, heart block, renal failure, cardiogenic shock, and embolic stroke were higher in PE group [Table 1].

Conclusion

Our study shows that presence of PE in patients with IE is a predictor for in-hospital mortality, length of stay, and need for cardiac surgery. Also, these patients are at higher risk for heart failure, heart block, cardiogenic shock and embolic stroke.

Funding Acknowledgement

Type of funding sources: None.

A Comprehensive Review on Steroidal Bioconjugates as Promising Leads in Drug Discovery

Ever increasing unmet medical requirements of the human race and the continuous fight for survival against variety of diseases give birth to novel molecules through research. As diseases evolve, different strategies are employed to counter the new challenges and to discover safer, more effective, and target-specific therapeutic agents. Among several novel approaches, bioconjugation, in which two chemical moieties are joined together to achieve noticeable results, has emerged as a simple and convenient technique for a medicinal chemist to obtain potent molecules. The steroid system has been extensively used as a privileged scaffold gifted with significantly diversified medicinal properties in the drug discovery and development process. Steroidal molecules are preferred for their rigidness and good ability to penetrate biological membranes. Slight alteration in the basic ring structure results in the formation of steroidal derivatives with a wide range of therapeutic activities. Steroids are not only active as such, conjugating them with various biologically active moieties results in increased lipophilicity, stability, and target specificity with decreased adverse effects. Thus, the steroid nucleus prominently behaves as a biological carrier for small molecules. The steroid bioconjugates offer several advantages such as synergistic activity with fewer side effects due to reduced dose and selective therapy. The steroidal bioconjugates have been widely explored for their usefulness against various disorders and have shown significant utility as anticancer, anti-inflammatory, anticoagulant, antimicrobial, insecticidal/pesticidal, antioxidant, and antiviral agents along with several other miscellaneous activities. This work provides a comprehensive review on the therapeutic progression of steroidal bioconjugates as medicinally active molecules. The review covers potential biological applications of steroidal bioconjugates and would benefit the wider scientific community in their drug discovery endeavors.

P-381 A novel natural cycle proliferative phase/progesterone replacement(NC/PR) protocol for endometrial preparation for frozen-thawed embryo transfer(FET) Can it improve pregnancy outcomes : a prospective comparative study

Study question

Can a novel protocol for endometrial preparation- NC/PR-FET, lead to better pregnancy outcomes than artificial cycle (AC)-FET, with similar ease of cycle monitoring and scheduling?

Summary answer

NC/PR-FET protocol gave comparable clinical pregnancy rates (CPR), significantly less early miscarriage rates (MR) and significantly more live birth rates (LBR) compared to AC-FET protocol.

What is known already

AC-FET is the most common protocol for endometrial preparation due to flexibility, easy monitoring, and high pregnancy rates albeit with evidence of higher obstetrical risks e.g., miscarriage, pre-eclampsia versus NC-FET. This risk could be due to suboptimal hormonal administration in AC-FET leading to impaired endometrial maturation, predecidualization, and altered endometrial function. Studies indicate, estradiol may have a stronger negative effect(versus progesterone) on the endometrial transcriptome. Hence, we studied a novel protocol with NC-estrogen (but with progesterone similar to AC-FET), for better endometrial maturation, predecidualization along with simple monitoring and flexible ET scheduling. Previously, a proof-of-concept case-series has been reported.

Study design, size, duration

The prospective comparative study was conducted at a tertiary center (Jan2019-Dec2021) with 126 patients (both autologous [AO] and donor oocytes [DO]):79 (AC-FET) and 47 (NC/PR-FET) with similar ICSI, vitrification, ET protocols. 2 or 3 Grade A cleavage stage embryos were transferred. CPR, implantation rates(IR), early MR (≤13 weeks, miscarriages/clinical pregnancies) and LBR (≥28 weeks, LBs/ETs) were compared. Serum progesterone was studied on day 5 post-ET. Antenatal care and most deliveries were at the same institute.

Participants/materials, setting, methods

Patients were non-smokers with normal hysteroscopy. In AC-FET, oral estradiol (6-8mg) was initiated from day 1-2 (for 10-17 days). In both groups, when endometrium ≥7mm and S.progesterone&lt;1ng/ml, intramuscular progesterone was initiated(daily till day 4 post-ET, then every 3rd day till week 8). ET was scheduled on day 4 of intramuscular progesterone, and concurrently, vaginal progesterone was added (till week 10). Chi-square, t-tests, and multiple regression was used for statistical analysis and 2-tailed P &lt;.05 indicated statistical significance.

Main results and the role of chance

Mean age and BMI were comparable in NC/PR-FET and AC-FET groups: 34.48±4.69 years vs. 33.58 ± 5.62 years (P =.35) and 26.27 ± 3.62 kg/m2 vs. 27.34 ± 4.61kg/m2 (P =.18) respectively. Similarly, the source of oocytes (%AO) and % singletons were also comparable in NC/PR-FET and AC-FET groups: 57.4% vs. 46.8% (P = .25), and 78.1% vs. 75% (P= .75) respectively. There were 3 ectopic pregnancies overall. The CPRs and IRs were comparable: 68.09% (NC/PR-FET) vs. 60.76% (AC-FET) (P=.41) and 32.30% (NC/PR-FET) vs. 28.96% (AC-FET) (P=.45) respectively.

The early MR was significantly more in AC-FET vs. NC/PR-FET: 29.17% vs. 6.25% (P =.012). Consequently, LBRs were significantly more in NC/PR-FET vs. AC-FET: 59.57% vs. 39.24% (P =.028). After adjusting for age, BMI, AO/DO, this difference remained significant (AOR 2.66; 95% CI 1.21-5.81; P =.014)

Mean serum progesterone was comparable in all patients in both groups: 38.50 ± 13.6ng/ml (NC/PR-FET) vs. 40.98 ± 28.64 ng/ml (AC-FET) (P =.57). Serum progesterone levels were also comparable in patients who were pregnant in both groups: 38.51 ± 14.79 (NC/PR-FET) vs. 42.25 ± 32.63 (AC-FET) (P =.53).Also, in the AC-FET group serum progesterone was comparable in patients who aborted,44.23 ± 31.60 vs. those who didn’t, 41.48 ± 33.44 (P =.79).

Limitations, reasons for caution

This was a single center study. Due to limited sample size, we could not control for many potential confounders (e.g., multiple pregnancies). For the same reason, we could not compare obstetrical risks as a study outcome.

Wider implications of the findings

This study shows significantly better pregnancy outcomes with a novel NC/PR-FET protocol vs. AC-FET. This needs to be validated in larger studies. Since suboptimal hormone administration in AC-FET could be causal factor for pre-eclampsia, larger studies can test if the NC/PR-FET protocol can lead to better obstetrical outcomes.

Trial registration number

not applicable

A89 PERCEPTIONS OF NON-TECHNICAL SKILLS IN GASTROINTESTINAL ENDOSCOPY: A THEMATIC ANALYSIS OF FOUR FOCUS GROUPS

Background

Nontechnical skills (NTS), which involve an individual’s cognitive, attitudinal, and social skills that supplement task expertise, are an essential component in the practice of gastrointestinal endoscopy. There is a growing body of literature that highlights the association between these skills and patient outcomes. To date, however, these skills have not been adequately defined within the context of gastrointestinal endoscopy.

Aims

To define the domain and corresponding characteristics of NTS in GI endoscopy.

Methods

We conducted a qualitative study at a tertiary-care academic center in Toronto, Ontario. Specifically, we held four focus groups with physician endoscopists, nurses who work in an endoscopy unit, and patients who have had previous endoscopies, in order to ascertain their input on the role of NTS in gastrointestinal endoscopy. The three groups were interviewed independently and there was one focus group of both physicians and nurses that was used for validation of our initial thematic framework. Data from the focus groups was collected using a combination of field notes and discussion transcriptions. Three authors independently generated codes from these data. Using these codes, a thematic network analysis was used to identify emerging themes. The primary outcome of this study was the development of a cohesive thematic network of NTS in endoscopy, including their characteristics and examples.

Results

The four focus groups included a total of 34 participants, including 15 physician endoscopists, 15 nurses, and 4 patients. Using thematic network analysis, we identified six dimensions of NTS using the first three focus groups: communication; professionalism; teamwork; leadership; decision-making; and situational awareness. Additional topics related to the practice and evaluation of NTS were identified. In particular, there is a degree of subjectivity in the appraisal of NTS due to the nuances among individual practice, aside from egregious errors of NTS (e.g. unprofessional behaviours). The use of video recordings was suggested as a way to capture signs of good NTS, such as appropriate levels of calmness during procedures and attention to patient comfort. Finally, patient involvement can be useful for evaluating communication and professionalism based on patient comprehension and the nature of the therapeutic relationship.

Conclusions

Our findings provide the first cohesive framework of NTS in gastrointestinal endoscopy that is anchored in real world experiences with relevant stakeholders – physicians, nurses, and patients. Future research should consolidate these findings into an assessment tool for NTS in order to evaluate and provide feedback to endoscopists who are both in training and in practice.

Funding Agencies

CAG

A25 CRITICAL APPRAISAL OF GI ENDOSCOPY CLINICAL PRACTICE GUIDELINES DURING THE COVID-19 PANDEMIC

Background

Clinical Practice Guidelines (CPGs) are integral during a pandemic, offering guidance to clinicians through uncertainty. Existing literature has established that the need for rapid publication of CPGs during previous infectious disease outbreaks resulted in less rigorous guidelines. CPGs were rapidly developed since the onset of the pandemic in December 2019, providing guidance in gastrointestinal (GI) endoscopy, an area where COVID-19 may pose risk of transmission.

Aims

To evaluate the quality of GI endoscopy guidelines developed during the COVID-19 pandemic and to compare these with (a) endoscopy CPGs developed prior to the pandemic; (b) CPGs for other endoscopic topics unrelated to COVID-19; and, (c) non-endoscopic CPGs published during the pandemic.

Methods

We systematically searched Medline, Embase and Scopus for CPGs published by GI societies from January 1, 2018 to December 31, 2020. A grey literature search was conducted. Two authors screened full-texts. In this interim analysis, CPGs were grouped based on publication year: before 2020, or 2020. Endoscopy CPGs published in 2020 were categorized as COVID or non-COVID related. Two authors independently assessed the CPGs using the AGREE II tool, consisting of six domains for evaluating guidelines. A domain score of 60 was set as a threshold to indicate good quality.

Results

There were 70 endoscopy guidelines and 27 CPGs focused on other GI topics. The mean overall scores were 69% (±12%) for endoscopy CPGs published before 2020 (n=28), and 51% (±23%) for CPGs published in 2020 (n=42). For individual AGREE II domains, mean scores for pre-2020 CPGs ranged from 33.11 (±17.39) in Applicability to 81.55 (±10.37) in Clarity of Presentation. For CPGs published during COVID-19, mean domain scores ranged from 34.18 (±10.52) in Applicability to 75.26 (±13.85) in Clarity of Presentation. 21 of 42 CPGs published in 2020 were related to COVID. Mean overall scores were 35% (±20%) for COVID-related CPGs and 67% (±13%) for non-COVID-19 CPGs. For COVID-19 CPGs, scores ranged from 27.88 (±20.31) in Rigour of Development to 69.58 (±10.81) in Scope and Purpose. For non-COVID CPGs, the scores ranged from 37.30 (±8.93) in Applicability to 84.52 (±5.93) in Clarity of Presentation.

Conclusions

The difference in overall scores between COVID-19 endoscopy CPGs and non-COVID endoscopy CPGs may suggest that the urgency to disseminate COVID-19 information decreased CPG quality or completeness of reporting. This interim analysis is limited by the lack of distinction between peer-reviewed CPGs and non-peer reviewed recommendations. Given the importance of CPGs in clinical decision making, it is important to ensure that the rapid development of guidelines does not compromise quality and rigour.

Funding Agencies

None

A99 PHARMACEUTICAL INDUSTRY FUNDING TO GASTROINTESTINAL PATIENT ADVOCACY ORGANIZATIONS

Background

Patient advocacy organizations (PAOs) are not-for-profit organizations that aim to support families and individuals afflicted by illnesses. PAOs play a significant role in guiding health policy, providing education to patients, lobbying, and supporting research. Previous studies have demonstrated that PAOs may receive financial payments from pharmaceutical and medical device manufacturers. This may create a risk of conflict of interest.

Aims

To assess the prevalence and transparency of financial donations from industry to gastrointestinal patient advocacy groups based in the United States (US).

Methods

We conducted a cross-sectional study to determine the prevalence of industry donations to PAOs. Data was extracted from the Kaiser Health News (KHN) Database, a database that tracked payments from pharmaceutical companies to PAOs in 2015. After an initial list of 1215 PAOs was obtained from the database, authors extracted the annual revenues, websites and mission statements for each PAO. Authors individually screened each organization’s mission statement and website to determine whether their primary scope of focus included gastroenterology. A final list of 11 PAOs with annual revenues surpassing $500,000 USD was included for descriptive analysis. From this list, the annual reports and websites of each group were reviewed to determine the extent of transparency of PAOs disclosing financial relationships with industry sponsors. The primary outcome of our study was the total amount of funding that each PAO received from pharmaceutical companies. The secondary outcome was the self-reported amount of funding stated on each PAO’s website and annual report.

Results

From our analysis of 11 PAOs, 9 (81%) organizations received payments from pharmaceutical companies. The median dollar value of donations received was $31,052 USD (IQR=$25 to $302,550). The total dollar value of donations received was $4,059,433 USD. Across the 9 PAOs that received donations, 5 (56%) organizations disclosed a financial relationship with a pharmaceutical company on their website and 2 (22%) disclosed the value of industry donations within a range. No group specified an exact amount of funding received.

Conclusions

Our results demonstrate that a majority of US based gastrointestinal PAOs receive funding from pharmaceutical companies. Furthermore, our results show that many PAOs that receive industry funding do not disclose this amount on their website or annual reports. Given their role in providing patient centered support, it is important for PAOs to disclose financial relationships with industry so as to not produce a conflict of interest.

Funding Agencies

None

Post-mating gene expression of Mexican fruit fly females: disentangling the effects of the male accessory glands

Mating has profound physiological and behavioural consequences for female insects. During copulation, female insects typically receive not only sperm, but a complex ejaculate containing hundreds of proteins and other molecules from male reproductive tissues, primarily the reproductive accessory glands. The post-mating phenotypes affected by male accessory gland (MAG) proteins include egg development, attraction to oviposition hosts, mating, attractiveness, sperm storage, feeding and lifespan. In the Mexican fruit fly, Anastrepha ludens, mating increases egg production and the latency to remating. However, previous studies have not found a clear relationship between injection of MAG products and oviposition or remating inhibition in this species. We used RNA-seq to study gene expression in mated, unmated and MAG-injected females to understand the potential mating- and MAG-regulated genes and pathways in A. ludens. Both mating and MAG-injection regulated transcripts and pathways related to egg development. Other transcripts regulated by mating included those with orthologs predicted to be involved in immune response, musculature and chemosensory perception, whereas those regulated by MAG-injection were predicted to be involved in translational control, sugar regulation, diet detoxification and lifespan determination. These results suggest new phenotypes that may be influenced by seminal fluid molecules in A. ludens. Understanding these influences is critical for developing novel tools to manage A. ludens.

Cardiac sympathetic denervation for catecholaminergic polymorphic ventricular tachycardia

Catecholaminergic polymorphic ventricular tachycardia (CPVT), a rare inheritable fatal arrhythmogenic disorder, is difficult to diagnose and is a challenge to manage. A 21-years-old man presented with recurrent exertional syncope and complex multifocal ventricular ectopy. CPVT was diagnosed based on the clinical criteria, despite the absence of some classical findings. The patient underwent cardiac sympathetic denervation (CSD) after lifestyle modification and pharmacological management were ineffective. CSD proved to be effective. The patient did not have any exertional symptoms or recurrence of syncope at follow-up period of 1 year. The present case report adds to the growing evidence in favour of CSD for CPVT.

Quantitative analysis of doxorubicin hydrochloride and arterolane maleate by mid IR spectroscopy using transmission and reflectance modes

Background

Environment-friendly fast and accurate mid-infrared spectroscopic methods have been developed for the quantitative analysis of doxorubicin hydrochloride (DOX) and arterolane maleate (ALM) in bulk and marketed formulations. Both transmittance and reflectance modes have been used for the analysis and a comparison has been drawn for better accuracy. The analytical methods were validated in accordance with International Council for Harmonisation (ICH) guidelines

Results

The proposed methods have been successfully developed and validated for the quantification of doxorubicin and arterolane maleate in solid bulk and dosage form. High recovery values in both the modes, while analysing DOX and ALM, indicated good accuracy of the methods. The methods showed excellent repeatability and intermediate precision [% RSD (Relative Standard Deviation < 2.0%]. The assay values of the drugs in solid dosage forms were also found close to the labelled claim.

Conclusion

The proposed Fourier transform infrared (FT-IR) spectroscopic methods were found to be specific, reproducible, valid and could be used as general methods for the quantification of most of the solid drug preparations such as tablets, capsules and powders.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13065-021-00752-3.

16-Substituted steroids alleviate LPS-induced neurodegenerative disorders in rats

The neuroprotective effects of some 16-substituted steroidal derivatives against the locomotive impairment and cognitive deficits in the lipopolysaccharide (LPS)-induced neuroinflammation model of rats have been investigated. The in vivo and in vitro evaluations include behavioural tests (actophotometer, block tests, Morris water maize and elevated plus maize), estimation of the biochemical parameters such as acetylcholinesterase, lipid peroxide, reactive oxygen, and nitric oxide species and molecular assays for the key proinflammatory mediators like Tumour Necrosis Factor alpha (TNF-α) and Interleukin 1 beta (IL- 1β) after 21 days of the treatment with the steroids. Behavioural and biochemical studies indicated impairment in the locomotor activity and cognitive dysfunction in rats after LPS treatment. In addition, higher levels of TNF-α and IL-1β in the blood serum of the rats were also noticed. However, significant alleviation of LPS-induced movement and memory disorders was observed in LPS-injected rats after treatment with 16-substituted steroidal derivatives 1-11. Furthermore the biochemical and molecular studies revealed suppression of oxidative and nitrosative stress, decreased acetylcholinesterase activity, and reduction of TNF-α and IL-1β levels after treatment with compounds 1-11. Among all the 16-substituted steroidal derivatives, the compounds 8 and 11 were found to be the most active neuroprotective agents and produced effects marginally better than standard drug dexamethasone.

A104 PREVALENCE OF GHOST-AUTHORSHIP IN INDUSTRY-SPONSORED CLINICAL TRIALS

Background

Ghost-authorship involves the exclusion of individuals who have made substantial contributions to the article from the author byline. Previous studies have found that ghost-authorship is highly prevalent in industry-sponsored clinical trials. Its prevalence, however, has yet to be investigated in trials of biologics in the management of inflammatory bowel disease (IBD).

Aims

To determine the prevalence of ghost-authorship in IBD biologic industry-sponsored clinical randomized controlled trials (RCTs).

Methods

Biologic medications indicated for ulcerative colitis (UC) or for Crohn’s disease (CD) were identified using the Food and Drug Agency (FDA) database. We identified the clinical trials on clinicaltrials.gov corresponding to the data presented at the time of FDA approval. Specifically, we included the first publication for each trial to report study results for our analysis. Two authors independently identified the presence of ghost-authorship, which we defined as the exclusion on the author byline of the included RCT publication of any individuals who assisted in the writing of the trial manuscript and/or performed the data analyses.

Results

We identified a total of 28 relevant RCTs on biologic medications (10 for UC and 18 for CD), which were matched to 20 publications. We found ghost-authorship in 70% of publications (n=14); 40% (n=8) involved manuscript and protocol writing assistance from sponsor staff; 35% (n=7) involved medical writers from external companies; 15% (n=3) involved both sponsor staff and medical writers assisting in manuscript writing; and 20% (n=4) involved individuals performing data analysis or interpretation.

Conclusions

We found that ghost-authorship in industry-sponsored IBD biologic clinical trials has a moderately high prevalence, with the most common being manuscript or protocol writing assistance. A lack of transparency regarding sponsor-affiliated and/or external contributors may negatively affect the trust placed in medical research. One limitation is that data was only extracted from publications. Further evidence on ghost-authorship may be found in study protocols and registrations, which will be investigated in the future.

Funding Agencies

None

A160 PREVALENCE OF OUTCOME SWITCHING AMONG PUBLISHED PHASE 3 INTERVENTIONAL TRIALS FOR INFLAMMATORY BOWEL DISEASE THERAPEUTICS

Background

Outcome switching is a well-described form of inconsistent reporting in randomized clinical trials (RCTs), wherein pre-specified primary and/or secondary outcomes are changed between trial registration and the publication of results without explanation. This is of particular concern, as the selective publication of results that are favorable will insert bias into the trial’s results and may cast doubt on the veracity of its findings. While it has been investigated in other disciplines, the prevalence of outcome switching has yet to be described among RCTs for inflammatory bowel disease (IBD).

Aims

To determine the prevalence of correctly reported pre-specified primary and secondary outcomes in published phase 3 interventional RCTs for IBD.

Methods

We identified all phase 3 interventional trials for IBD with published results using clinicaltrials.gov. We included all results with an associated publication that detailed the results of the trial. We excluded registrations if: only an abstract of the results was available; trial results were only published as a pooled analysis; multiple trial segments were reported collectively; or a publication of the results could not be identified through clinicaltrials.gov or a custom search.

Two reviewers extracted all pre-specified primary and secondary outcomes for each trial using the clinical trial registration page that was dated before the commencement of the trial. These outcomes were compared to the outcomes reported in the corresponding journal articles. Any discrepancies were noted, and additional outcomes were extracted.

Results

We identified a total of 88 phase 3 interventional RCTs for IBD, of which 57 were matched to independent publications of their results. All trials pre-specified a primary outcome, and 50 (87.7%) pre-specified secondary outcomes. 10 (17.5%) of trials did not report some or all primary outcomes, and 19 (33.3%) trials had a change or alteration to the primary outcome. Of the trials that pre-specified secondary outcomes, 16 (28.1%) did not report all pre-specified secondary outcomes. 49 (86.0%) trials added 6 (IQR: 2–8) unspecified secondary outcomes on average.

Conclusions

Many phase 3 interventional RCTs in IBD either did not report some or all primary outcomes, or altered the primary outcome. Trials routinely reported additional outcomes that were not pre-specified and failed to note that they were added post hoc. Based on these results, we recommend improvements in the reporting of pre-specified outcomes and higher fidelity in order to maintain confidence in trial results.

Funding Agencies

None

A70 PREVALENCE OF SELF-PUBLICATION AMONG EDITORIAL BOARD MEMBERS OF GASTROENTEROLOGY JOURNALS

Background

Editorial self-publication refers to the practice wherein editors publish research in journals to which they serve as editorial board members. The International Committee of Medical Journal Editors (ICMJE) has detailed recommendations against the practice of self-publication. There is evidence to suggest that editorial board membership may influence the decision to publish academic papers, which may contribute to publication bias. Despite this, there have been few attempts to characterize this practice in gastroenterology journals.

Aims

To determine the prevalence of original gastroenterology research articles published by editorial board members in their own journal.

Methods

We conducted a cross-sectional study to determine the prevalence of editorial board members publishing within their own journals. A list of the top 25 highest impact factor gastroenterology journals was created through InCites Journal reports. Journals were screened to determine eligibility based on whether their primary focus included gastroenterology research and whether archives with the names and affiliations of editorial board members were available. 10 journals were selected based on these criteria. For each journal, we extracted all original research articles published in 2019 using Web of Science (Clarivate Analytics ©). Articles classified as editorial material, meeting abstracts, reviews, and clinical practice guidelines were excluded. We cross-referenced the affiliations of all authors found in each publication with affiliations of editors disclosed on the journal website. For each editorial board member, we determined the number of publications within their own journal.

Results

We identified 844 editorial board members in the 10 journals included. Overall, 337 (39.9%) of the editors had a publication in their own journal, of which, 152 (18.0%) had more than one publication. Across all journals, the median number of editors with self-publication is 27 (IQR=20.3–49.8). The median number of editors with more than one self-publication is 16 (IQR=10.0–25.3). In total, 507 (60.1%) of all editors had no publications within their respective journals.

Conclusions

Despite recommendations against this practice, our results show a high number of research publications authored by editorial board members. These results demonstrate a potential risk for publication bias. However, this study was limited by the inability to investigate beyond the prevalence of self-publication. Furthermore, the explicit implications of our results remain unclear. Further research is required to evaluate factors such as disclosures and the review process associated with increased rates of self-publication as well as its impact on publication bias.

Funding Agencies

None

A89 CHARACTERISTICS AND CONFLICTS OF INTEREST AT FOOD AND DRUG ADMINISTRATION GASTROINTESTINAL DRUG ADVISORY COMMITTEE MEETINGS

Background

The United States Food and Drug Administration (FDA) Gastrointestinal Drug Advisory Committee (GIDAC) is involved in gastrointestinal drug application reviews. Characteristics and conflicts of interest (COI) in GIDAC meetings are not well described.

Aims

To analyze FDA GIDAC meetings and characteristics that predict recommendations.

Methods

This was a cross-sectional study of all publicly available GIDAC meetings where proposed medications were voted on from 1998–2018. Data were collected on individual meetings and individual voting members at meetings. Predefined predictor variables included type of medication, medication sponsor, primary efficacy studies, and voting member characteristics (e.g. committee membership, COI). Univariate analyses were conducted at per-meeting and per-vote levels to assess for predictors of committee recommendation and individual votes respectively.

Results

Thirty-four meetings with 476 individual votes from 1998–2018 were included. Twenty-three (68%) proposals were recommended for approval and 25 (74%) received FDA approval. Most proposals involved &gt;1 primary study (n=27, 79%). At least one voting member had a COI in 24 (71%) of 34 meetings. Twelve (35%) meetings had at least one sponsor COI. Among 476 individual votes, 74 (15.5%) involved a COI, with 33 (6.9%) sponsor COI. COI decreased significantly over time, with more COI in 1996–2000 and 2001–2005 compared to 2006–2010, 2011–2015, and 2016–2020 (p&lt;0.01). There were no significant associations between pre-defined predictors, including COI, and committee level recommendations or individual votes (p&gt;0.05 for all univariate analyses).

Conclusions

The GIDAC reviewed 34 proposals from 1998–2018. The majority were recommended for approval and later approved by the FDA, highlighting the GIDAC’s prominence in the regulatory process. COI are present among GIDAC panelists but decreasing over time and not associated with recommendations.

Funding Agencies

None

A77 A REUSABLE POLYCARBONATE BOX TO DECREASE DROPLET CONTAMINATION DURING UPPER ENDOSCOPY: A SIMULATION-BASED STUDY FOR THE COVID-19 PANDEMIC

Background

Upper gastrointestinal (GI) endoscopic procedures are aerosol-generating, increasing the risk of healthcare workers (HCW) contracting Coronavirus disease 2019 (COVID-19).

Aims

To present a polycarbonate box (EndoBox) designed for use in upper GI endoscopy and evaluate its impact on the contamination of endoscopy staff during simulated procedures.

Methods

Simulated gastroscopies were performed using an upper body simulator placed in left lateral decubitus (LLD) and supine positions. The endoscopist and assistant wore personal protective equipment. Droplet exposure was measured using fluorescent abiotic surrogate particles. Two blinded observers independently viewed images from each scenario to qualitatively evaluate contamination levels. The primary outcome was the level of HCW contamination by droplets generated from a simulated cough with and without the EndoBox on the upper body simulator. The endoscopist’s ergonomic behaviour was also assessed using the Rapid Upper Limb Assessment (RULA) tool.

Results

Without the EndoBox, there was a higher level of contamination on the endoscopist when the upper body simulator is in the LLD position. A higher level of contamination was observed on the assistant when the simulator is in supine position. With the EndoBox, the contamination levels on the endoscopy staff were lower in both LLD and supine scenarios. The endoscopist’s ergonomics were rated 2 to 3 on the RULA tool when using the EndoBox.

Conclusions

The EndoBox reduces macroscopic droplet contamination during simulated gastroscopy. The endoscopist’s risk of musculoskeletal injury remained in the low risk categories as assessed by the RULA tool. Another advantage of the EndoBox design is the arch extending from the bottom that allows for removal of the box without withdrawing the endoscope. This enables rapid access to the patient’s airway if they experience respiratory distress. This study was limited by an inability to assess microscopic contamination and contamination at the level of the port or buttons when suction is applied. Within these limitations, the EndoBox may be a useful adjunct to traditional personal protective equipment.

Funding Agencies

SMHA AFP COVID-Related Innovation Funds

A161 PREVALENCE OF FINANCIAL CONFLICTS OF INTEREST (FCOI) AMONG PROPENSITY-SCORE MATCHED RETROSPECTIVE STUDIES EVALUATING BIOLOGIC THERAPEUTICS FOR IBD

Background

Inflammatory Bowel Disease (IBD) studies have commonly relied on real-world evidence to evaluate different therapies. An emerging idea has been the use of propensity score matching as a statistical method to account for baseline characteristics in IBD patients. In retrospective studies, propensity score matching of patients helps reduce treatment assignment bias and mimic the effects of randomization. Recently, propensity-score matching has become an important tool in IBD studies comparing biologic therapeutics. Biologic medications are among the highest-grossing drugs worldwide, and their pharmaceutical producers make considerable payments to physicians to market them. In spite of this, there is a lack of evidence examining the role of undue industry influence among propensity-score matched comparative studies evaluating biologic therapeutics for IBD.

Aims

Given the documented association between IBD biologics and FCOI, we hypothesize a high burden of FCOI in propensity-score matched studies. The aim of this study was to evaluate the prevalence of disclosed & undisclosed financial conflicts of Interest (FCOI) in propensity-score matched comparison studies evaluating biologics for IBD.

Methods

We developed & ran a librarian-reviewed systematic search on EMBASE, MEDLINE, and Cochrane Library databases for all propensity-score matched retrospective studies comparing biologics for the treatment of IBD. Full-text retrieval & screening was performed on all studies in duplicate. 16 articles were identified. Industry payments to authors were only considered FCOI if they were made by a company producing a biologic that was included in the comparison study. Disclosed FCOI were identified by authors’ interests disclosures in full-texts. Any undisclosed FCOI among US authors were identified using the Centre for Medicare and Medicaid Services (CMS) Open Payments Database, which collects industry payments to physicians.

Results

Based on a preliminary analysis of 16 studies, there was at least one author with a relevant FCOI in 14 (88%) of the 16 studies. 14 studies (88%) had at least one disclosed FCOI, while 6 studies (37.5%) had at least one undisclosed FCOI. Among studies with disclosed FCOI, a mean of 40.2% (SD = 23.4%) of authors/study reported FCOI. Among studies with undisclosed FCOI, a mean of 18.8% (SD = 7.0%) of authors/study reported FCOI. The total dollar value of FCOIs was $1,974,328.3. The median conflict dollar value was $5,576.6 (IQR: $321.6 to $36,394.9).

Conclusions

We found a high burden of undisclosed FCOI (37.5%) among authors of propensity-score matched studies evaluating IBD biologics. Given the potential for undue industry influence stemming from such payments, authors should ensure better transparency with industry relationships.

Funding Agencies

None

A71 RECOMMENDATION REVERSALS IN GASTROENTEROLOGY CLINICAL PRACTICE GUIDELINES

Background

Clinical practice guidelines are evidence-based resources designed to inform clinical decision making. Often, superior evidence will support the inclusion of novel procedures and practices to replace older recommendations. Recommendation reversals occur when (a) superior quality evidence emerges to suggest the harm or non-beneficence of prior recommendations, and (b) that recommendation is not supplanted by a newer one.

Aims

The primary objective of this study was to describe the content, frequency and rationale for recommendation reversals in CPGs published by gastroenterological societies.

Methods

For this meta-epidemiologic study, we considered two criteria to define a recommendation reversal: (a) the more recent CPG makes a recommendation that contradicts a previously accepted practice; and (b) the prior recommendation is not replaced by any novel intervention. We searched CPGs published by 20 major GI societies from 1991- 2019. Guidelines were included if had at least two iterations with the same title and used a valid evidence rating system (such as GRADE). Explicit recommendations which reported definite levels of evidence and strength of recommendation were extracted.

Results

We identified 1022 clinical guidelines from GI societies over 28 years. 292 CPGs were included for data synthesis. 5985 explicit statements were extracted. 12 reversals were confirmed and are summarized in the Table. Six reversals (50.0%) occurred due to studies reporting non-beneficence and 3 (25.0%) occrred due to studies reporting harm. Three recommendations (25.0%) were reversed due to new clinical trials; 3 (25.0%) due to systematic reviews or meta-analyses; and 2 to conform with CPGs of other societies (16.7%).

Conclusions

We describe recommendation reversals made in gastroenterology CPGs, and the reasons thereof. Investigation of recommendation reversals allows for the identification of low-value medical practices. This reinforces the need for GI CPG committees to (1) iteratively review guidelines to re-evaluate recommendations made on low-quality evidence and; (2) refrain from making recommendations when evidence for the same is weak.

Funding Agencies

None

Is the right ventricular function affected by permanent pacemaker?

Funding Acknowledgements

Type of funding sources: None.

Background

The effect of right ventricular (RV) pacing on left ventricular (LV) function has been extensively evaluated, and so has the effect of the RV pacing lead on tricuspid valve function. However, the effects on RV function per se have not been evaluated systematically.

Purpose

We aimed to assess the RV dimensions and RV function six months after dual chamber pacemaker implantation

performed for atrioventricular (AV) block by detailed echocardiography, including three-dimensional (3D) echocardiography.

Method

All adult patients undergoing dual chamber pacemaker from January 2018 to March 2019 for symptomatic AV block with a structurally normal heart were included in the study. They underwent pre-procedure detailed echocardiography specifically directed at measuring RV dimensions and function [including 3D RV ejection fraction (EF)] and a repeat detailed echocardiogram at six-month follow-up, by the same echocardiographer. The echocardiographic parameters at baseline and after six-month follow-up were compared.

Results

All patients had more than 75% ventricular pacing in these six months. At six-month follow-up, there was no significant change in LVEF, while there was a mild decrease in RVEF as outlined in the Table 1. While there was some overlap between RVEF range of values at baseline and after six months, 23 (38.3%) patients showed a drop in RVEF by &gt;5%.

Conclusion

Our study shows a change in several RV function parameters in a majority of patients six months after

pacemaker implantation for AV block.

RV Function at six month follow-up Parameters Pre-procedure Six-Month Follow-up p value (Paired t-test) PASP (mm Hg) 20.2 ± 1.3 26.1 ± 12.2 &lt;0.001 FAC (%) 42.6 ± 3.4 39.4 ± 6 &lt;0.001 TAPSE (mm) 18.4 ±3.8 15.6 ± 4.7 &lt;0.001 RIMP 0.66 ± 0.09 0.61 ± 0.11 0.003 RV E/E’ 9.4 ± 2.1 7.7 ± 2.1 &lt;0.001 RV S’ 13.6 ± 2.4 10.7 ± 2.4 &lt;0.001 RVEF % [By 3D Echocardiography] 47.7± 5.1 44.9 ± 7.4 &lt;0.001 TR Jet Area (cm2) 0.03 ± 0.26 0.55 ± 0.96 &lt;0.001 RV= Right Ventricle; RA= Right Atrium; RVOT = Right Ventricular Outflow Tract; PASP = Pulmonary Artery Systolic Pressure; FAC= Fractional Area Change; TAPSE= Tricuspid Annular Plane Systolic Excursion; RIMP = Right Ventricular Index of Myocardial Performance; TR = Tricuspid Regurgitation S’ = Peak Systolic Annular Velocity; RVEF = Right Ventricular Ejection Fraction; 3D = Three Dimensional Abstract Figure. Change in RVEF in 6 months

Therapeutic progression of quinazolines as targeted chemotherapeutic agents

Presently cancer is a grave health issue with predominance beyond restrictions. It can affect any organ of the body. Most of the available chemotherapeutic drugs are highly toxic, not much selective and eventually lead to the development of resistance. Therefore, a target specific palliative approach for the treatment of cancer is required. Remarkable advancements in science have illuminated various molecular pathways responsible for cancer. This has resulted in abundant opportunities to develop targeted anticancer agents. Quinazoline nucleus is a privileged scaffold with significant diversified pharmacological activities. Numerous established anticancer quinazoline derivatives constitute a new class of chemotherapeutic agents which are found to act by inhibiting various protein kinases as well as other molecular targets. A recent update on various quinazoline derivatives acting on different types of molecular targets for the treatment of cancer has been compiled in this review. Brief SAR studies of quinazoline derivatives acting through different mechanisms of action have been highlighted. The comprehensive medicinal chemistry aspects of these agents in this review provide a panoramic view to the biologists as well as medicinal chemists working in this area and would assist them in their efforts to design and synthesize novel quinazoline based anticancer compounds.

Coronary artery bypass grafting versus percutaneous coronary intervention for left main disease in chronic kidney disease patients: a meta-analysis

Background

Limited data exist on the optimal revascularization strategy for patients with left main coronary artery disease (LMCAD) and chronic kidney disease (CKD). We conducted a meta-analysis to compare the outcomes of coronary artery bypass grafting (CABG) versus percutaneous coronary intervention (PCI) in this population.

Methods

Multiple electronic databases were queried for studies comparing CABG and PCI in CKD patients undergoing LMCAD (&gt;50% diameter stenosis) revascularization. CKD was defined as estimated glomerular filtration rate of &lt;60 ml/min/1.73 m2. The primary outcome was long-term major adverse cardiac and cerebrovascular events (MACCE), which was a composite of cardiovascular death, myocardial infarction (MI), stroke and repeat revascularization. Secondary outcomes included all-cause mortality, MI, stroke and repeat revascularization. Odds ratios (OR) and 95% confidence intervals (CI) were calculated. The analysis was performed using the DerSimonian and Laird random effect model.

Results

Six studies (4 observational, 2 randomized controlled trials) met inclusion criteria with a total of 2051 patients (CABG: 977, PCI: 1074). Patients undergoing CABG had a higher incidence of multi-vessel disease (74.7% vs 65.7%, p=0.01). At a mean follow-up of 3.4±1.1 years, MACCE was significantly lower in the CABG group (OR = 0.70, 95% CI 0.57–0.87; p=0.001) (Figure 1). The odds of MI or repeat revascularization were lower with CABG, whereas the odds of stroke were higher; no statistically-significant difference was seen in all-cause mortality.

Conclusion

This meta-analysis shows that CABG is associated with lower rates of MACCE and MI but with a higher rate of stroke compared to PCI in LMCAD patients with CKD.

Funding Acknowledgement

Type of funding source: None

A New Series of 1,3-Dimethylxanthine Based Adenosine A2A Receptor Antagonists as a Non-Dopaminergic Treatment of Parkinson's Disease

BACKGROUND

Adenosine receptors (AR) have emerged as competent and innovative nondopaminergic targets for the development of potential drug candidates and thus constitute an effective and safer treatment approach for Parkinson's disease (PD). Xanthine derivatives are considered as potential candidates for the treatment Parkinson's disease due to their potent A2A AR antagonistic properties.

OBJECTIVE

The objectives of the work are to study the impact of substituting N7-position of 8-m/pchloropropoxyphenylxanthine structure on in vitro binding affinity of compounds with various AR subtypes, in vivo antiparkinsonian activity and binding modes of newly synthesized xanthines with A2A AR in molecular docking studies.

METHODS

Several new 7-substituted 8-m/p-chloropropoxyphenylxanthine analogues have been prepared. Adenosine receptor binding assays were performed to study the binding interactions with various subtypes and perphenazine induced rat catatonia model was used for antiparkinsonian activity. Molecular docking studies were performed using Schrödinger molecular modeling interface.

RESULTS

8-para-substituted xanthine 9b bearing an N7-propyl substituent displayed the highest affinity towards A2A AR (Ki = 0.75 μM) with moderate selectivity versus other AR subtypes. 7-Propargyl analogue 9d produced significantly long-lasting antiparkinsonian effects and also produced potent and selective binding affinity towards A2A AR. In silico docking studies further highlighted the crucial structural components required to develop xanthine derived potential A2A AR ligands as antiparkinsonian agents.

CONCLUSION

A new series of 7-substituted 8-m/p-chloropropoxyphenylxanthines having good affinity for A2A AR and potent antiparkinsonian activity has been developed.

Case report: Xanthogranulomatous pyelonephritis masquerading as cystic renal cell carcinoma

Background: Xanthogranulomatous pyelonephritis (XGP) is a rare chronic bacterial inflammation of the renal parenchyma and is often a diagnostic dilemma.Case Presentation: We present a challenging case of a patient with XGP. Initially thought to have had renal cell cancer she was treated accordingly with a partial nephrectomy. However, on the final pathology, she was found to have XGP and required further antibiotic therapy and referral to the infectious disease service.Discussion: Management of XGP and diagnostic pitfalls are discussed.Conclusion: XGP is a diagnostic and therapeutic dilemma. Partial Nephrectomy may be appropriate in management of XGP in select cases.

28Impact of non-invasive rapid cardiac magnetic resonance for the assessment of cardiomyopathies in developing countries

Background

Cardiovascular mortality is higher in developing countries. Part of that is suboptimal testing. Cardiac magnetic resonance (CMR) is the gold standard for measuring structure, function of the heart and adds incremental value by imaging scarring and to assess iron level. Despite the existence of MRI units, CMR is identified as a complex test, with poor training and availability in developing countries.

Purpose

To assess the potential impact of a faster CMR protocol at a multicentre level in developing countries; implementing it with an education program, for the assessment cardiomyopathies.

Methods

An international partnership. A rapid CMR protocol for the evaluation of cardiac volumes, function and tissue characterization (Cardiac Iron T2* and LGE for scar) Figure 1a. We deployed the protocol as a multicentre study: Argentina, Peru, India and South Africa accompanied by a program of education. Pre-scan clinical information, scanning data: complications, image quality and post-scan follow-up of participants for the assessment on impact, between 3 to 24 months.

Results

510 scans (4 countries, 6 cities, 12 centres) were performed with the rapid CMR protocol. Contrast studies in 378 (74%). There were no scan-related complications. Quality of the studies was maintained in a high level as an average of 89%. 97% of studies responded referral's question. All patients with contrast CMR scan have had at least one 2D echocardiogram before CMR. Average scan duration was 21±6 mins for contrast studies and 12±3 for non-contrast T2* protocol. The most common underlying diagnoses were non-ischaemic cardiomyopathy in 73% of participants (including cardiac iron level assessment in 26%, HCM in 17%, DCM in 15%), 27% for ischaemic cardiomyopathy and 15% for other pathologies. 4 of the 12 participant centres started to incorporate CMR for the first time. Findings impacted management in 60% of patients, including new diagnosis in 21% of participants. See table 1, figure 1b. For just cardiac iron assessment: 1/3 of participants had iron deposited in the heart with 14% of patients in severe levels.

Conclusions

CMR can be delivered faster and easier. When this abbreviated protocol is enabled with education, it can be implemented in developing countries with existing technology. This protocol shows high quality exam, with an important impact on patient's management.

Characteristics and impact on management Contrast studies Non-contrast studies All patients (%) 378 (74) 132 (36) Age, mean (range) years 54 (16–93) 24 (13–41) Male (%) 151 (39) 64 (48) Pre-echocardiography exam (%) 370 (98) 42 (32) Scanning duration mean (SD) 21 (6) 12 (3) Good quality exam (%) 329 (87) 120 (91) Impact on management Total All patients (%) 510 (100) Completely new diagnosis (%) 105 (21) Change/Addition of Medication (%) 128 (25) Intervention/ Surgery (%) 31 (6) Invasive angiography/biopsy (%) 25 (5) Hospital discharge/admission (%) 15 (3) TOTAL 306 (60%) SD: Standard Deviation.

Acknowledgement/Funding

Global Engagement UCL, UK Foreign & Commonwealth Office and The Peruvian Scientific, Technological Development and Technological Innovation (FONDECYT)

16,17-N'-(alky/arylsulfonyl)pyrazoline substituted neuroprotective heterosteroids: Synthesis, molecular docking and preclinical efficacy/toxicity studies in rodents

The synthesis and neuroprotective efficacy and toxicity studies of a new series of 16,17-N'-(alkyl/arylsulfonyl)pyrazolinyl steroids is presented. Significant suppression of the overexpressed acetylcholinesterase and lipid peroxidation, marked reduction of nitrite, oxidative stress and TNF-α levels and noticeable improvement in cognitive and locomotor functions were observed after treatment with the newly synthesized steroids 2-4a-d in the LPS-treated animal models. Higher neuroprotective effects were produced by some of the pyrazolinyl steroids in comparison to the reference drugs celecoxib and dexamethasone. N'-(4-fluorobenzenesulfonyl) derivative 4c showed the most promising effects on all the analyzed parameters and is the most potent molecule among all compounds of this series. Acute toxicity studies on the most active steroids 2-4c at 50 mg/kg did not reveal any toxic effects on animals, however hepatitis and chronic nephritis were observed in histological examination of liver and kidney of mice after 28 days of treatment. The pyrazolinyl steroids 2-4a-d could be considered as promising candidates for the designing of novel multitarget-directed neuroprotectives for an effective therapy of AD and PD.

Papilloedema: diffusion-weighted imaging of optic nerve head

AIM

To establish the correlation between clinical grading of papilloedema and diffusion abnormalities of optic nerve head (ONH) on diffusion-weighted imaging (DWI).

MATERIALS AND METHODS

Brain magnetic resonance imaging (MRI), including readout segmented echo planar imaging-based DWI, was performed in 32 patients with papilloedema and the same number of age- and sex-matched controls. Clinical grading of papilloedema was done according to the modified Frisén scale. Two neuroradiologists independently evaluated the MRI for ONH hyperintensity and apparent diffusion coefficient (ADC) value of ONH. The comparison between papilloedema clinical grade and qualitative grade of ONH hyperintensity and its presence between cases and control groups were done using the Chi-square test and Fisher's exact test, respectively. The comparison between mean ADC value of ONH among different grades and between cases and controls were done using analysis of variance (ANOVA)-F-test and Student's t-test, respectively. Receiver operating characteristic (ROC) analysis was done to calculate a cut-off ADC value between the case and control groups.

RESULTS

Significant correlation between ONH hyperintensity and mean ADC value of ONH with clinical grades of papilloedema and between cases and control groups were found. ONH hyperintensity was found to be a highly sensitive (87.5% for both) and specific (specificity 97.1% and 98.6% for two observers) sign of papilloedema. A mean cut-off ONH ADC value was found to have high sensitivity (96.83%) and specificity (95.31%) to distinguish between the cases and controls.

CONCLUSIONS

Diffusion parameters of ONH have significant correlation with clinical grading of papilloedema and can serve as a surrogate marker for intracranial pressure.

Synthesis, biological evaluation and molecular modelling studies of 1,3,7,8-tetrasubstituted xanthines as potent and selective A2A AR ligands with in vivo efficacy against animal model of Parkinson's disease

In the present study, an attempt has been made to develop a new series of 1,3,7,8-tetrasubstituted xanthine based potent and selective AR ligands for the treatment of Parkinson's disease. Antagonistic interactions between dopamine and A_2A adenosine receptors serve as the basis for the development of AR antagonists as potential drug candidates for PD. All the synthesized compounds have been evaluated for their affinity toward AR subtypes using in vitro radioligand binding assays. 1,3-Dipropylxanthine 7a with a methyl substituent at N-7 position represents the most potent compound of the series and displayed highest affinity (A_2A, K_i = 0.108 µM), however incorporation of a propargyl group at 7-positon of the xanthine nucleus seems to be the most appropriate substitution to improve selectivity towards the A_2A subtype along with reasonable potency. Antiparkinsonian activity has been evaluated using perphenazine induced catatonia in rats. Most of the synthesized xanthines significantly lowered the catatonic score as compared to control and displayed antiparkinsonian effects comparable to standard drug. All the synthesized compounds were subjected to grid-based molecular docking studies to understand the key structural requirements for the development of new molecules well-endowed with intrinsic efficacy and selectivity as adenosine receptor ligands. In silico studies carried out on newly synthesized xanthines provided further support to the pharmacological results.

Isolation of a new flavonoid and waste to wealth recovery of 6-O-Ascorbyl Esters from Seeds of Aegle marmelos (family- Rutaceae)

Aegle marmelos is a plant species native to India. Commercially available food products such as jam, jelly, candy, squash etc. are prepared from ripe fruit pulp of A. marmelos. Ripe fruit processing accounts for 60% of whole fruit mass while 40% remains unutilized and generates waste (hard shell, pomace, fiber and seeds) on a massive scale which do not have high value applications. A new flavone 3,5,7-trihydroxy-2-(4'-hydroxy-3'-isopentyloxyphenyl-4H-chromen-4-one (5) in addition to the known compounds 1-4, has been isolated from seeds of A. marmelos. Also, compound 7-(3'-methylbut-2'-enyloxy)-2H-chromen-2-one (2) has been isolated for the first time from A. marmelos. The structure of compounds 1-5 was determined by spectral analysis (UV, IR, NMR, etc.). Additionally, the non-edible oil obtained from seeds was investigated for waste to wealth recovery of 6-O-ascorbyl esters in high regioselectivity via one step semi-synthetic approach in the presence of ascorbic acid and H₂SO₄ at ambient temperature.

Maternal and neonatal complications during pregnancy in women with epilepsy

Epilepsy is the commonest serious neurological problem faced by obstetricians and gynaecologists. Epidemiological studies estimate epilepsy to complicate 0.3–0.7% of all pregnancies.1 2 The importance of epilepsy in pregnancy lies in the fact that many women with epilepsy (WWE) have to go through their pregnancy while taking antiepileptic (AED) drugs. Both the seizures and AEDs can have harmful effects on the mother as well the foetus. Thus, during pregnancy, the clinician faces dual challenge of controlling seizures as well as preventing teratogenicity of AEDs.1 In this review we discuss the possible impact of seizures as well as AEDs on mother as well as the child. We try to answer some of the commonest questions which are relevant to successful management of pregnancy and ensuring birth of a healthy baby.

Microwave Mediated Synthesis and Analytical Method Development for the Estimation of Novel 1,4-Dihydropyridines in Bulk by RP-HPLC

The present work describes a rapid and green microwave mediated method for the synthesis and a simple and precise isocratic reverse phase HPLC method for the estimation of the biologically significant dihydropyridines. The conventional synthesis of these dihydropyridines has been previously reported from our lab. The analysis of a standard solution (1 mg/ml) was accomplished on a symmetry (4.6 mm I.D x 250 mm) C-18 column using mobile phase acetonitrile:water:triethylamine (TEA) (70:30:0.1 v/v/v) at a flow rate of 0.7 ml/min. Detection was monitored at 354 nm. The retention time for all the compounds was accomplished as less than 10 min. The compounds showed the linear response over the concentration range 10–100 µg/ml. The study is aimed to develop a rapid method for the quantification of these potent molecules. Various parameters like linearity (10–100 µg/ml), USP tailing and plate count were found to be satisfactory. The investigated parameters were studied with the freshly prepared solutions.

Diastereoselectivity in the Aza-Michael Reaction of Chiral α-Methylbenzylamines with α,β-Unsaturated Carbonyl Compounds

The aza-Michael reaction of (S)-(–)- and (R)-(+)-α-methylbenzylamines with trans-cinnamaldehyde and other α,β-unsaturated carbonyl compounds occurs with 52–98% diastereoselectivity (de); however, in the reaction with crotonaldehyde, the de is lower (20–38%). In the products obtained from the reaction with α,β-unsaturated aldehydes, the de could be determined on the basis of the relative intensities of the aldehydic protons of the two diastereomers. Theoretical investigations of the reaction of (S)-(–)-α-methylbenzylamine with trans-cinnamaldehyde at the DFT (B3LYP/6-31+G*) level reveal that the diastereomer formed from the attack of the amine on the Re face is thermodynamically more stable. The calculations also show that the aldehydic proton of this diastereomer is expected to be more deshielded, which on the basis of the 1H NMR spectrum is the major product.

Studies on 16,17-Pyrazoline Substituted Heterosteroids as Anti-Alzheimer and Anti-Parkinsonian Agents Using LPS Induced Neuroinflammation Models of Mice and Rats

Alzheimer's disease (AD) and Parkinson's disease (PD) are the most common forms of neurodegenerative disorders. Dehydroepiandrosterone (DHEA) has been reported as a neuroprotective steroid useful in the therapeutic management of neurodegenerative disorders such as AD and PD. Herein we report the synthesis and evaluation of a new series of 16,17-pyrazolinyl DHEA analogues 2-4a-d as neuroprotective agents using LPS-induced neuroinflammation animal models. Treatment with the pyrazoline substituted steroids considerably improved the LPS-induced learning, memory and movement deficits in animal models. Suppression of biochemical parameters of oxidative and nitrosative stress, acetylcholinesterase activity, and TNF-α levels was also observed. 16,17-Pyrazolinyl steroids 2c-4c substituted with a 4-pyridyl moiety at the 5-position of the heterocyclic ring were found to be the most potent agents and produced neuroprotective effects better than standard drugs celecoxib and dexamethasone. Of these pyrazoline substituted steroids, the N-acetyl analogue 3c displayed neuroprotective effects better than N-phenyl (4c), which in turn showed potency more than N-unsubstituted analogue 2c.

Tuberculosis and its Treatment: An Overview

Tuberculosis (TB) is a primordial infectious disease that mainly affects the lungs. M. tuberculosis (Mycobacterium tuberculosis) is the etiological agent of TB and currently more than one-third of the world population is suffering from TB. For the treatment of TB, administration of multiple antibiotics such as isoniazid, rifampicin, pyrazinamide and ethambutol is required for a long period of time to kill bacteria. However, antibiotic resistance is an emerging problem in multiple drug-resistant tuberculosis (MDR-TB) infections. World Health Organization (WHO) has developed a novel strategy called DOTS (directly observed treatment, short-course), in which specific combination of anti-TB drugs is given to control TB. In this review article we have focused on the comprehensive management of TB and have provided the valuable information about first and second line anti-TB drugs, DOTS and novel drug delivery systems to be used against M. tuberculosis. Important aspects related to new anti-TB drugs and vaccines in various stages of clinical development are also covered in this article.