Efficacy of different surgical treatments for management of anal fistula: a network meta-analysis

PURPOSE

Currently, the anal fistula treatment which optimises healing and preserves bowel continence remains unclear. The aim of our study was to compare the relative efficacy of different surgical treatments for AF through a network meta-analysis.

METHODS

Systematic searches of MEDLINE, EMBASE and CENTRAL databases up to October 2022 identified randomised controlled trials (RCTs) comparing surgical treatments for anal fistulae. Fistulae were classified as simple (inter-sphincteric or low trans-sphincteric fistulae crossing less than 30% of the external anal sphincter (EAS)) and complex (high trans-sphincteric fistulae involving more than 30% of the EAS). Treatments evaluated in only one trial were excluded from the primary analyses to minimise bias. The primary outcomes were rates of success in achieving AF healing and bowel incontinence.

RESULTS

Fifty-two RCTs were included. Of the 14 treatments considered, there were no significant differences regarding short-term (6 months or less postoperatively) and long-term (more than 6 months postoperatively) success rates between any of the treatments in patients with both simple and complex anal fistula. Ligation of the inter-sphincteric fistula tract (LIFT) ranked best for minimising bowel incontinence in simple (99.1% of comparisons; 3 trials, n = 70 patients) and complex anal fistula (86.2% of comparisons; 3 trials, n = 102 patients).

CONCLUSIONS

There is insufficient evidence in existing RCTs to recommend one treatment over another regarding their short and long-term efficacy in successfully facilitating healing of both simple and complex anal fistulae. However, LIFT appears to be associated with the least impairment of bowel continence, irrespective of AF classification.

Efficacy and Safety of Stempeucel in Osteoarthritis of the Knee: A Phase 3 Randomized, Double-Blind, Multicenter, Placebo-Controlled Study

BACKGROUND

Osteoarthritis is a chronic, progressive, and degenerative condition with limited therapy options. Recently, biologic therapies have been an evolving option for the management of osteoarthritis.

PURPOSE

To assess whether allogenic mesenchymal stromal cells (MSCs) have the potential to improve functional parameters and induce cartilage regeneration in patients with osteoarthritis.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

A total of 146 patients with grade 2 and 3 osteoarthritis were randomized to either an MSC group or placebo group with a ratio of 1:1. There were 73 patients per group who received either a single intra-articular injection of bone marrow-derived MSCs (BMMSCs; 25 million cells) or placebo, followed by 20 mg per 2 mL of hyaluronic acid under ultrasound guidance. The primary endpoint was the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) total score. The secondary endpoints were WOMAC subscores for pain, stiffness, and physical function; the visual analog scale score for pain; and magnetic resonance imaging findings using T2 mapping and cartilage volume.

RESULTS

Overall, 65 patients from the BMMSC group and 68 patients from the placebo group completed 12-month follow-up. The BMMSC group showed significant improvements in the WOMAC total score compared with the placebo group at 6 and 12 months (percentage change: -23.64% [95% CI, -32.88 to -14.40] at 6 months and -45.60% [95% CI, -55.97 to -35.23] at 12 months P < .001; percentage change, -44.3%). BMMSCs significantly improved WOMAC pain, stiffness, and physical function subscores as well as visual analog scale scores at 6 and 12 months (P < .001). T2 mapping showed that there was no worsening of deep cartilage in the medial femorotibial compartment of the knee in the BMMSC group at 12-month follow-up, whereas in the placebo group, there was significant and gradual worsening of cartilage (P < .001). Cartilage volume did not change significantly in the BMMSC group. There were 5 adverse events that were possibly/probably related to the study drug and consisted of injection-site swelling and pain, which improved within a few days.

CONCLUSION

In this small randomized trial, BMMSCs proved to be safe and effective for the treatment of grade 2 and 3 osteoarthritis. The intervention was simple and easy to administer, provided sustained relief of pain and stiffness, improved physical function, and prevented worsening of cartilage quality for ≥12 months.

REGISTRATION

CTRI/2018/09/015785 (National Institutes of Health and Clinical Trials Registry-India).

Label extension, single-arm, phase III study shows efficacy and safety of stempeucel® in patients with critical limb ischemia due to atherosclerotic peripheral arterial disease

BACKGROUND

Peripheral arterial disease (PAD) of lower extremities comprises a clinical spectrum that extends from asymptomatic patients to critical limb ischemia (CLI) patients. 10% to 40% of the patients are at the risk of primary amputation. This study was planned in "no-option" patients of CLI due to atherosclerotic PAD to assess the efficacy and safety of pooled, allogeneic, adult human bone marrow-derived mesenchymal stromal cells which is already approved for marketing in India for CLI due to Buerger's disease.

METHODS

This was a single-arm, multi-centric, phase III study where mesenchymal stromal cells was injected as 2 million cells/kg body weight in the calf muscle and around the ulcer. Twenty-four patients of lower extremity CLI due to PAD with Rutherford III-5 or III-6 and ankle-brachial pressure index ≤ 0.6 and having have at least one ulcer with area between 0.5 and 10 cm² were included in the study. These patients were evaluated over 12 months from drug administration.

RESULTS

Over a period of 12 months, statistical significant reduction of rest pain and ulcer size along with improvement in ankle-brachial pressure index and ankle systolic was observed. The quality of life of patients improved together with increase in total walking distance and major amputation-free survival time.

CONCLUSION

Mesenchymal stromal cells may be a feasible option to treat "no-option" patients with atherosclerotic PAD. Trial registration This study is registered prospectively in National Institutes of Health and Clinical Trials Registry-India (CTRI) website: CTRI/2018/06/014436. Registered 6th June 2018. http://ctri.nic.in/Clinicaltrials/pmaindet2.php?trialid=24050&EncHid=&userName=stempeutics .

Double C-2 like domain beta (DOC2B) induces calcium dependent oxidative stress to promote lipotoxicity and mitochondrial dysfunction for its tumor suppressive function

Mitochondria are biosynthetic and bioenergetic organelles that regulate many biological processes, including metabolism, oxidative stress, and cell death. Cervical cancer (CC) cells show impairments in mitochondrial structure and function and are linked with cancer progression. DOC2B is a tumor suppressor with anti-proliferative, anti-migratory, anti-invasive, and anti-metastatic function in CC. For the first time, we demonstrated the role of the DOC2B-mitochondrial axis with tumor growth regulatory functions in CC. We used DOC2B overexpression and knockdown model systems to show that DOC2B is localized to mitochondria and induces Ca²⁺-mediated lipotoxicity. DOC2B expression induced mitochondrial morphological changes with the subsequent reduction in mitochondrial DNA copy number, mitochondrial mass, and mitochondrial membrane potential. Intracellular and mitochondrial Ca²⁺, intracellular O^.-₂, and ATP levels were substantially elevated in the presence of DOC2B. DOC2B manipulation reduced glucose uptake, lactate production, and mitochondrial complex-IV activity. The presence of DOC2B significantly reduced the proteins associated with mitochondrial structure and biogenesis with the concomitant activation of AMPK signaling. Augmented lipid peroxidation (LPO) in the presence of DOC2B was a Ca²⁺-dependent process. Our findings demonstrated that DOC2B promotes lipid accumulation, oxidative stress, and LPO through intracellular Ca²⁺ overload, which may contribute to mitochondrial dysfunction and tumor-suppressive properties of DOC2B. We propose that the DOC2B-Ca²⁺-oxidative stress-LPO-mitochondrial axis could be targeted for confining CC. Further, the induction of lipotoxicity in tumor cells by activating DOC2B could serve as a novel therapeutic approach in CC.

The effect of hemoglobin level on the prognostic value of peak exercise oxygen uptake differs between obese and non-obese patients with heart failure

Funding Acknowledgements

Type of funding sources: None.

Background

Obesity and low hemoglobin content (Hgb &lt;13 and &lt;12 g/dL, men/women, respectively) are commonly observed in patients with heart failure and reduced ejection fraction (HFrEF). This overlap typically yields reductions in peak exercise oxygen uptake (V̇O2peak) which exceed those observed in both non-obese and obese patients exhibiting normal Hgb levels. However, when matched for body size, non-obese patients exhibiting low Hgb levels also demonstrate worse V̇O2peak impairment than normal Hgb level counterparts. To date, it is unclear whether the effect of Hgb level on V̇O2peak also affects the association between V̇O2peak and mortality risk in both non-obese and obese patients.

Purpose

To assess whether V̇O2peak that is predictive of mortality risk is directly impacted by Hgb level regardless of whether a patient is non-obese or obese.

Methods

Adults with HFrEF (n=346; LVEF ≤40%; 76% men) completed cardiopulmonary exercise testing (CPET) as part of routine clinical management. The majority of patients performed Naughton or Modified Naughton CPET protocols. Patients with a BMI ≥30 kg/m2 were classified as obese (n=135; 81% men). Patients were followed up to one-year for the endpoint of all-cause mortality.

Results

Age (63±7 vs 61±8 yrs), total body weight (77±13 vs 107±15 kg), BMI (25.2±3.0 vs 34.5±4.0 kg/m2), and Hgb (12.6±1.8 vs 13.1±1.8 g/dL) differed between non-obese and obese patients (all P&lt;0.01), respectively. There were no significant differences between non-obese and obese patients for % men (73 vs 81 %), % ischemic etiology (46 vs 42 %), and LVEF (23±8 vs 24±9 % (all P&gt;0.05), respectively. Peak exercise RER (1.13±0.12 vs 1.10±0.11), V̇O2peak (13.0±3.8 vs 11.9±3.3 mL/kg/min), and absolute V̇O2peak (1.01±0.37 vs 1.28±0.40 L/min) differed between non-obese and obese patients (all P&lt;0.02), respectively. Over the 1-year tracking period, 25 and 13 deaths were observed and crude survival was 85% and 88% in non-obese and obese patients (Log-rank, P=0.465), respectively. In obese patients, V̇O2peak and Hgb interacted (χ2=4.855, P=0.028), resulting in up to a 22% reduction in all-cause mortality risk per 1.0 mL/kg/min rise in V̇O2peak for Hgb levels ≤13.1 g/dL. In non-obese patients, V̇O2peak and Hgb did not interact (χ2=0.001, P=0.977), and when Hgb was removed from the Cox regression, this resulted in up to a 29% reduction in all-cause mortality risk per 1.0 mL/kg/min rise in V̇O2peak (χ2=23.618, P&lt;0.001).

Conclusion

Demonstrating low Hgb and V̇O2peak levels yields comparable effects on all-cause mortality risk in non-obese and obese patients. However, at normal Hgb levels, V̇O2peak loses prognostic value in the obese, suggesting for these patients other CPET variables should be used to complement V̇O2peak when CPET is built into risk stratification models.

Interventional treatments for prolapsing haemorrhoids: network meta-analysis

Background

Multiple treatments for early–moderate grade symptomatic haemorrhoids currently exist, each associated with their respective efficacy, complications, and risks. The aim of this study was to compare the relative clinical outcomes and effectiveness of interventional treatments for grade II–III haemorrhoids.

Methods

A systematic review was conducted according to PRISMA criteria for all the RCTs published between 1980 and 2020; manuscripts were identified using the MEDLINE, Embase, and CENTRAL databases. Inclusion criteria were RCTs comparing procedural interventions for grade II–III haemorrhoids. Primary outcomes of interest were: symptom recurrence at a minimum follow-up of 6 weeks, postprocedural pain measured on a visual analogue scale (VAS) on day 1, and postprocedural complications (bleeding, urinary retention, and bowel incontinence). After bias assessment and heterogeneity analysis, a Bayesian network meta-analysis was performed.

Results

Seventy-nine RCTs were identified, including 9232 patients. Fourteen different treatments were analysed in the network meta-analysis. Overall, there were 59 RCTs (73 per cent) judged as being at high risk of bias, and the greatest risk was in the domain measurement of outcome. Variable amounts of heterogeneity were detected in direct treatment comparisons, in particular for symptom recurrence and postprocedural pain. Recurrence of haemorrhoidal symptoms was reported by 54 studies, involving 7026 patients and 14 treatments. Closed haemorrhoidectomy had the lowest recurrence risk, followed by open haemorrhoidectomy, suture ligation with mucopexy, stapled haemorrhoidopexy, and Doppler-guided haemorrhoid artery ligation (DG-HAL) with mucopexy. Pain was reported in 34 studies involving 3812 patients and 11 treatments. Direct current electrotherapy, DG-HAL with mucopexy, and infrared coagulation yielded the lowest pain scores. Postprocedural bleeding was recorded in 46 studies involving 5696 patients and 14 treatments. Open haemorrhoidectomy had the greatest risk of postprocedural bleeding, followed by stapled haemorrhoidopexy and closed haemorrhoidectomy. Urinary retention was reported in 30 studies comparing 10 treatments involving 3116 participants. Open haemorrhoidectomy and stapled haemorrhoidopexy had significantly higher odds of urinary retention than rubber band ligation and DG-HAL with mucopexy. Nine studies reported bowel incontinence comparing five treatments involving 1269 participants. Open haemorrhoidectomy and stapled haemorrhoidopexy had the highest probability of bowel incontinence.

Conclusion

Open and closed haemorrhoidectomy, and stapled haemorrhoidopexy were associated with worse pain, and more postprocedural bleeding, urinary retention, and bowel incontinence, but had the lowest rates of symptom recurrence. The risks and benefits of each treatment should be discussed with patients before a decision is made.

Health Locus of Control: A Determinant of Oral Health among Tobacco users in Rural India

Purpose: The concept of health locus of control is important because of its relation with health attitudes, behavior and coping styles. This study was done to compare the locus of control orientation and oral health status of tobacco users with that of non-tobacco users. Method: This cross-sectional study was conducted on rural population in southern Indian state. All the participants were interviewed to gather data on their socio-demographic correlates, oral health related behavior and health locus of control with the help of a pre-tested questionnaire. Clinical examination was done using WHO oral health assessment form (1997).Main outcome measures were Locus of Control, Oral Health (dental caries status and periodontal status). Results: Tobacco users were found to score lower on the dimension of Internality and higher on the Chance dimension compared to non-tobacco users. The prevalence and severity of periodontal disease was significantly higher in tobacco users than non-tobacco users irrespective of age and socioeconomic strata. Conclusion: It was also concluded that non-tobacco users had internal orientation to health locus of control thereby being important behavioral factor controlling health in this group.Findings also demonstrated significant association between tobacco usage and adverse periodontal health.

A study of second to fourth digit ratio in relation to verbal and numerical intelligence among medical students

Introduction and Aim: Prenatal androgens are believed to be one of the probable etiological factors influencing intellectual development of an individual. In-utero testosterone exposure has been thought to affect the digit ratio which is the ratio of lengths of index finger and ring finger (2D:4D). In the present work we intended to study the correlation of 2D:4D with numerical and verbal intelligence believed to be variable among genders. The aim of our study was to find the association of 2D:4D with Verbal Intelligence and Numerical Intelligence in a sample of medical students.                                Materials and Methods: This study was conducted in a sample of medical students. 44 female and 44 male students participated in the study. 2D:4D measurements were made using standard procedure after which the participants completed a questionnaire containing 20 questions each to test numerical and verbal intelligence.   Results: In this study, Males were found to have a lower 2D:4D when compared to females. Individuals with lower 2D:4D in their right-hand were seen to have lower verbal intelligence and higher numerical intelligence thus suggesting that males are born with  better numerical intelligence and females with greater verbal intelligence.   Conclusion: Digit ratio can be considered as a valuable indicator of individual differences in terms of intelligence, although the exact role of testosterone on brain to cause variation in these cognitive domains is yet to be clearly understood.

Impact of gastric resection and enteric anastomotic configuration on delayed gastric emptying after pancreaticoduodenectomy: a network meta-analysis of randomized trials

Introduction

Delayed gastric emptying (DGE) is frequent after pancreaticoduodenectomy (PD). Several RCTs have explored operative strategies to minimize DGE, however, the optimal combination of gastric resection approach, anastomotic route, configuration and the use of enteroenterostomy remains unclear.

Methods

MEDLINE, Embase and CENTRAL databases were systematically searched for RCTs comparing gastric resection (classic Whipple, pylorus-resecting, pylorus-preserving), anastomotic route (antecolic, retrocolic), configuration (loop gastroenterostomy/Billroth II, Roux-en-Y), and use of enteroenterostomy (Braun). A random-effects, Bayesian network meta-analysis with non-informative priors was conducted to determine the optimal combination of approaches to PD for minimizing DGE.

Results

Twenty-four RCTs, including 2526 patients and 14 approaches were included. There was some heterogeneity, although inconsistency was low. The overall incidence of DGE was 25.6 per cent (647 patients). Pylorus-resecting, antecolic, Billroth II with Braun enteroenterostomy was associated with the lowest rates of DGE and ranked the best in 35 per cent of comparisons. Classic Whipple, retrocolic, Billroth II with Braun ranked the worst for DGE in 32 per cent of comparisons. Pairwise meta-analysis of retrocolic versus antecolic route for gastrojejunostomy found increased risk of DGE with the retrocolic route (odds ratio 2.10, 95 per cent credibility interval (cr.i.) 0.92 to 4.70). Pairwise meta-analysis of enteroenterostomy found a trend towards lower DGE rates when this was used (odds ratio 1.90, 95 per cent cr.i. 0.92 to 3.90). Having a Braun enteroenterostomy ranked the best in 96 per cent of comparisons.

Conclusion

Based on existing RCT evidence, a pylorus-resecting, antecolic, Billroth II with Braun enteroenterostomy seems to be associated with the lowest rates of DGE.

Preregistration

PROSPERO submitted 23 December 2020. CRD42021227637

Optimization of culture conditions for human bone marrow-derived mesenchymal stromal cell expansion in macrocarrier-based Tide Motion system

BACKGROUND

With high cell doses required for mesenchymal stromal cell (MSC) clinical trials, there is a need to upgrade technologies that facilitate efficient scale up of MSCs for cell therapy. Conventional expansion with 2D culture vessels becomes the bottleneck when large cell dosages are required. Tide Motion bioreactors offer a robust, scalable platform using BioNOC II macrocarriers developed for the production of adherent cells.

METHODS

We evaluated the growth and expansion of bone marrow-derived MSCs (BM-MSCs) on the macrocarrier-based culture system by optimizing key parameters such as cell seeding densities, culturing conditions, and harvesting procedures to achieve optimal cell growth. BM-MSCs expanded in conventional 2D adherent cultures were seeded into BioNOC II macrocarriers and grown in serum-containing or serum-free medium.

RESULTS

BM-MSCs attained a maximum cell density of 0.49 ± 0.07 × 10⁶ cells/carrier after 12 days of culture in BioNOC II macrocarriers with cell viability > 86% while retaining MSC specific characteristics such as surface marker expression, tri-lineage differentiation potential, immunosuppressive properties, and potency.

CONCLUSION

These results reveal the feasibility of BM-MSC expansion in the scalable macrocarrier-based Tide Motion system both under serum and serum-free conditions and represent an important step for the large-scale production system of BM-MSC based cellular therapies.

Novel bioactive formulation derived from the conditioned medium of mesenchymal stromal cells reduces under-eye dark circles in human volunteers

BACKGROUND

Under-eye dark circles are a common condition observed in dermatology practice. Mesenchymal stromal cell-derived conditioned medium (MSC-CM) contains an array of growth factors and cytokines reported to promote periorbital rejuvenation and may be useful in removing the dark circle around the eyes.

AIMS

The aim of the present study was to evaluate the safety and efficacy of developed bioactive formulation containing mesenchymal stromal cell-derived conditioned medium in reducing the under-eye dark circles.

PATIENTS/METHODS

We tested the safety profile of MSC-CM along with antioxidants, in vitro using human melanocytes cultures. The bioactive formulation containing MSC-CM was developed and tested for physicochemical parameters. The dermatological safety was evaluated by primary irritant patch-test under complete occlusion on healthy human subjects. To elucidate its safety and efficacy, monocentric, open-label, single-arm study was carried out in 20 Indian female subjects for the duration of 12 weeks. Parameters such as eye puffiness, radiance, skin smoothness, even skin tone, periorbital fine lines and wrinkles, crow's feet, whitening, pigmentation, skin tightening, and refreshing/soothing effect were used to investigate the rejuvenating property of the bioactive formulation.

RESULTS

Mesenchymal stromal cell-derived conditioned medium along with antioxidants decreased the melanin content compared to the CM alone in the melanocyte cultures. Besides, the bioactive formulation was safe and emerged as a non-irritant product. Improvement in the majority of the clinical parameters assessed through efficacy study was observed within 4 weeks of topical application of the formulation twice daily, and showed continued improvement for 12 weeks as evaluated by the dermatologists as well as self-assessment by the subjects.

CONCLUSION

The bioactive formulation containing MSC-CM was safe and effective in reducing the under-eye dark circles and was beneficial in improving the overall appearance of the eye area.

Metastatic suppression by DOC2B is mediated by inhibition of epithelial-mesenchymal transition and induction of senescence

Senescence induction and epithelial-mesenchymal transition (EMT) events are the opposite sides of the spectrum of cancer phenotypes. The key molecules involved in these processes may get influenced or altered by genetic and epigenetic changes during tumor progression. Double C2-like domain beta (DOC2B), an intracellular vesicle trafficking protein of the double C2 protein family, plays a critical role in exocytosis, neurotransmitter release, and intracellular vesicle trafficking. DOC2B is repressed by DNA promoter hypermethylation and functions as a tumor growth regulator in cervical cancer. To date, the molecular mechanisms of DOC2B in cervical cancer progression and metastasis is elusive. Herein, the biological functions and molecular mechanisms regulated by DOC2B and its impact on senescence and EMT are described. DOC2B inhibition promotes proliferation, growth, and migration by relieving G0/G1-S arrest, actin remodeling, and anoikis resistance in Cal27 cells. It enhanced tumor growth and liver metastasis in nude mice with the concomitant increase in metastasis-associated CD55 and CD61 expression. Inhibition of EMT and promotion of senescence by DOC2B is a calcium-dependent process and accompanied by calcium-mediated interaction between DOC2B and CDH1. In addition, we have identified several EMT and senescence regulators as targets of DOC2B. We show that DOC2B may act as a metastatic suppressor by inhibiting EMT through induction of senescence via DOC2B-calcium-EMT-senescence axis.

ZNF471 modulates EMT and functions as methylation regulated tumor suppressor with diagnostic and prognostic significance in cervical cancer

Cervical cancer (CC) is a leading cause of cancer-related death among women in developing countries. However, the underlying mechanisms and molecular targets for therapy remain to be fully understood. We investigated the epigenetic regulation, biological functions, and clinical utility of zinc-finger protein 471 (ZNF471) in CC. Analysis of cervical tissues and five independent public datasets of CC showed significant hypermethylation of the ZNF471 gene promoter. In CC cell lines, promoter DNA methylation was inversely correlated with ZNF471 expression. The sensitivity and specificity of the ZNF471 hypermethylation for squamous intraepithelial lesion (SIL) vs tumor and normal vs tumor was above 85% with AUC of 0.937. High methylation and low ZNF471 expression predicted poor overall and recurrence-free survival. We identified -686 to +114 bp as ZNF471 promoter, regulated by methylation using transient transfection and luciferase assays. The promoter CpG site methylation of ZNF471 was significantly different among cancer types and tumor grades. Gal4-based heterologous luciferase reporter gene assays revealed that ZNF471 acts as a transcriptional repressor. The retroviral mediated overexpression of ZNF471 in SiHa and CaSki cells inhibited growth, proliferation, cell migration, invasion; delayed cell cycle progression in vitro by increasing cell doubling time; and reduced tumor growth in vivo in nude mice. ZNF471 overexpression inhibited key members of epithelial-mesenchymal transition (EMT), Wnt, and PI3K-AKT signaling pathways. ZNF471 inhibited EMT by directly targeting vimentin as analyzed by bioinformatic analysis, ChIP-PCR, and western blotting. Thus, ZNF471 CpG specific promoter methylation may determine the prognosis of CC and could function as a potential tumor suppressor by targeting EMT signaling.

Role of amino terminal substitutions in the pharmacological, rewarding and psychostimulant profiles of novel synthetic cathinones

The emergence of new synthetic cathinones continues to be a matter of public health concern. In fact, they are quickly replaced by new structurally related alternatives. The main goal of the present study was to characterize the pharmacological profile, the psychostimulant and rewarding properties of novel cathinones (pentedrone, N-ethyl-pentedrone, α-PVP, N,N-diethyl-pentedrone and α-PpVP) which only differs in their amino terminal substitution. Rat synaptosomes were used for [³H]dopamine uptake experiments. HEK293 transfected cells (hDAT, hSERT, hOCT; human dopamine, serotonin and organic cation transporter) were also used for [³H]monoamine uptake and transporter binding assays. Molecular docking was used to investigate the effect of the amino substitutions on the biological activity. Hyperlocomotion and conditioned place preference paradigm were used in order to study the psychostimulant and rewarding effects in mice. All compounds tested are potent inhibitors of DAT with very low affinity for SERT, hOCT-2 and -3, and their potency for inhibiting DAT increased when the amino-substituent expanded from a methyl to either an ethyl-, a pyrrolidine- or a piperidine-ring. Regarding the in vivo results, all the compounds induced an increase in locomotor activity and possess rewarding properties. Results also showed a significant correlation between predicted binding affinities by molecular docking and affinity constants (Ki) for hDAT as well as the cLogP of their amino-substituent with their hDAT/hSERT ratios. Our study demonstrates the role of the amino-substituent in the pharmacological profile of novel synthetic cathinones as well as their potency inhibiting DA uptake and ability to induce psychostimulant and rewarding effects in mice.

Prevalence, Extent, and Severity of Oral Health Impacts Among Adults in Rural Karnataka, India

INTRODUCTION

Oral health affects quality of life. Many studies have investigated the factors associated with oral health-related quality of life (OHRQoL). Little is known about OHRQoL of adults living in rural and remote areas of India, where many have lower levels of education and limited availability of oral health care services.

OBJECTIVES

To determine the prevalence, extent, and severity of OHRQoL impacts associated with psychosocial factors, functional dentition, and patterns of dental visits among rural Indian adults between the ages of 35 and 54 y.

METHODS

A cross-sectional study was conducted with a multistage stratified sampling strategy targeting 35- to 54-year-olds. Interviews and oral examinations were performed to collect data on sociodemographic variables, Oral Health Impact Profile-14 (OHIP-14), patterns of dental visits, stress, tobacco and alcohol use, and dentition status. Univariate, bivariate, and multivariable analyses were done to determine the factors associated with prevalence, extent, and severity of OHIP-14 using SAS version 9.3.

RESULTS

There were 873 participants. Prevalence, extent, and severity of OHIP-14 were 13.4%, 0.5 (0.4-0.7), and 11.8 (11.2-12.5), respectively. The OHIP-14 impacts reported were not severe and mostly affected physical functioning. Levels of education, income, and number of functional teeth (FT) were inversely associated and last dental visit within the previous year was positively associated with prevalence, extent, and severity of OHIP-14. The prevalence of 1 or more oral health impacts was nearly 13% among rural middle-aged adults in India.

CONCLUSIONS

Low socioeconomic conditions, dental visits, and FT ≤19 were positively associated with prevalence, extent, and severity of oral health impacts.

KNOWLEDGE TRANSFER STATEMENT

This article provides data regarding OHRQoL of people in rural areas of a developing country. The study was intended to determine the factors associated with OHRQoL in rural people who are less educated and living in areas with minimal oral health care facilities. The findings of this study could potentially facilitate further research and health promotional activities for rural people of developing countries.

A nanocomposite hydrogel delivery system for mesenchymal stromal cell secretome

Background

Mesenchymal stromal cell conditioned medium (MSC-CM) contains a cocktail of bioactive factors that act synergistically to induce therapeutic effects. This has been clearly demonstrated by in vivo applications of MSC-CM, but the establishment of controlled delivery systems is an unmet requirement for clinical translation.

Methods

We developed a nanocomposite-hydrogel (NP-H) comprised of poly-L-lactide nanoparticles (NPs) embedded in gelatin/hyaluronic acid (Gel/HA) hydrogel as a delivery vehicle for MSC-CM. First, we optimized the culture conditions for bone marrow-derived MSCs using serum-containing medium (SCM) and serum-free medium (SFM) and characterized the corresponding CM (serum-containing conditioned medium (ScCM) and serum-free conditioned medium (SfCM), respectively) for its potency and xeno markers. Then we prepared a composite matrix followed by physiochemical characterization and functional assays were performed.

Results

Nanocomposite hydrogel displayed an even distribution of NPs along with high porosity (> 60%) and swelling ratios > 1500%, while its protein release pattern corresponded to a mix of degradation and diffusion kinetics. Functional evaluation of the composites was determined using MSCs and human fibroblasts (HFFs). The cells seeded directly onto the composites displayed increasing metabolic activities over time, with ScCM-NP-H groups having maximum activity. The cells treated in vitro with 5% and 10% extracts of ScCM-NP-H and SfCM-NP-H exhibited a dose- and duration-dependent response. Cell activities reduced considerably for all groups, except 10% ScCM-NP-H, which displayed a significant increase over time.

Conclusion

We observed that sustained release of MSC-CM is required to prevent dose-dependent cytotoxicity. The proposed nanocomposite hydrogel for MSC-CM delivery can open up a new array for its clinical application.

0809 A Randomized Double-blind, Placebo Controlled Trial With Cross-over, To Assess The Efficacy Of Correcting Vitamin D Deficiency In Improving The Symptoms Of Restless Legs Syndrome (RLS)

Introduction

Recent studies have shown an association of low Vitamin D levels and severity of RLS symptoms. However, effect of treatment of Vit D deficiency on RLS symptoms was not reported, nor were other exacerbating factors for RLS such as iron deficiency or OSA addressed in prior studies, but have been addressed in our study.

Methods

This is an ongoing study at the JFKMC Sleep Clinic. Eligible Patients with RLS include those with vitamin D 25,hydroxy deficiency (&lt;20 ng/ml), or insufficiency (&lt;30 ng/ml). Such patients will be enrolled in the study after comorbid conditions like iron deficiency and OSA have been adequately corrected. Randomization of the patients will be done by the JFK pharmacy so the patient and provider are blinded to the substance. Substance A or B could be either Vitamin D3 Capsule 50,000 IU, or placebo. Each patient takes A for 6 weeks and then crosses over to B for 6 weeks. Weekly iRLS questionnaires will be collected. Actiwatch Device, to assess activity count per minute, will be worn on the ankle at night for one week time periods: at baseline, at end of 6 weeks of taking A and then at the end of 6 weeks of taking B. Vitamin D levels will also be assessed after each course of supplementation and correlated with subjective and objective findings.

Results

Between July 7, 2019 to current, 50 consecutive patients seen in sleep clinic with RLS were assessed for vitamin D levels. Ages ranged from 23-86 years. 27 patients were female (54%). Two patients met inclusion criteria and have started their 13-week study.

Conclusion

This study will help to establish the role of Vitamin D deficiency as a risk factor for RLS, independent of ferritin levels, and comorbid OSA, in affected individuals. This may help to discover a potentially treatable form of RLS.

Support

No financial support.

1149 A Pilot Quality Improvement (QI) Study To Assess Whether Bilevel Positive Airway Pressure (bipap) Support In Acute Ischemic Stroke Patients With Sleep Disordered Breathing, Can Improve Neurological Recovery During Acute Stroke Care

Introduction

Obstructive sleep apnea (OSA) has been associated with adverse outcomes in patients with stroke. While data is limited, it suggests that treatment of OSA may improve neurological recovery. With this quality improvement (QI) project, we aim to develop an interprofessional-team workflow process for screening and correction of OSA in acute ischemic stroke, with the goal to improve outcomes of neurological recovery.

Methods

This is an ongoing study to screen all eligible patients admitted to JFK Medical Center stroke unit, with MRI-proven Supratentorial acute ischemic stroke. The patients are screened using an overnight Pulse Oximetry test. A 3% oxygen desaturation index (ODI) of ≥10/hr or 4% ODI of ≥ 5/hr is considered at high risk for OSA. Such Patients will receive nocturnal Auto-adjusting BIPAP therapy during their acute care stay, for up to 5 days, for at least 4 hours per night. Eligible Patients who refused BiPAP therapy or were non-compliant will be considered as a controls. Baseline NIH stroke scale (NIHSS), and bilateral MCA mean flow velocity (MFV) in the morning, by transcranial doppler (TCD) will be assessed at baseline for cases and controls, and after BiPAP therapy, for the case group. The two groups of patients will also be compared in terms of Modified Rankin Scale at time of discharge and at phone follow-up after 6 weeks.

Results

Between Oct 17th, 2019 to current, 15 patients were admitted to the stroke unit with MRI confirmed stroke. Ages ranged from 34 - 88 years (average age 66.5 years). 8 patients (60%) were female. Of those, 6 patients consented to being screened for OSA. Of these, 1 had 4%ODI &gt;5/hr, and therefore received treatment with BIPAP. However, compliance was &lt; 4 hrs on 2 consecutive nights.

Conclusion

This is ongoing QI project and results will be available after few more months of continued recruitment.

Support

Auto-adjusting BIPAP machines were provided by RESMED.

The association of dietary patterns and carotid intima-media thickness: A synthesis of current evidence

AIMS

Dietary pattern (DP) analysis has emerged as a holistic method to understand the effects of food intake on health outcomes. Though dietary intake has been associated with cardiovascular disease, the association of DPs and carotid intima-media thickness (CIMT), a robust early marker of cardiovascular disease progression has not been comprehensively investigated. This study systematically explores the association of a posteriori and a priori DPs and CIMT.

DATA SYNTHESIS

Through a systematic search of MEDLINE, CINAHL, and Web of Science, twenty studies that derived DPs using a posteriori or a priori methods with CIMT as an outcome were included. Four cross-sectional studies and 1 cohort paper reported a statistically significant association between increased consumption of 'unhealthy' foods (i.e processed meat, soda drinks and refined grain) and increased CIMT. While four cross-sectional studies reported a statistically significant association of DPs characterized by increased consumption of 'healthy' foods (i.e fruit and vegetables, fish) and decreased CIMT. DPs derived from each study varied depending on derivation method, study design and use of dietary data collection method.

CONCLUSION

Findings from this review are generally supportive of a trend between DPs with higher consumption of 'healthy' foods and lower consumption of 'unhealthy' foods and decreased CIMT; however, the association was largely not statistically significant. Evidence was overwhelmingly heterogeneous due to differences seen in DPs based on location and culture, sample characteristics and adjustment for confounders. Long-term prospective observational and interventional studies with standardized sample selection and dietary data collection are needed to significantly establish the role of DPs on CIMT.

P5239Cost-effectiveness of direct oral anticoagulants for cancer-associated venous thromboembolism

Background

Direct oral anticoagulants (DOACs) are at least as effective as low-molecular weight heparins (LMWH) at preventing recurrence after cancer-associated venous thromboembolism (CA-VTE). DOACs are also oral and far less costly, but they may confer a higher bleeding risk than LMWH.

Purpose

To estimate the cost-effectiveness of DOACs and LMWHs for CA-VTE.

Methods

We developed a health state transition model to estimate recurrent VTE, bleeding events, quality-adjusted life years (QALY), and direct healthcare costs (2018 United States dollars) associated with DOACs vs. LMWH use. The model had four states: (1) long-term anticoagulation (first 3 months after VTE), (2) extended anticoagulation (more than 3 months after VTE), (3) off anticoagulants, and (4) death. We used a United States healthcare sector perspective, 3-month cycle length, and 1-year time horizon. Event probabilities were derived from the Hokusai Cancer VTE trial and other literature. Event and medication costs were obtained from national sources. We used a threshold of less than $50,000 per QALY gained to define cost-effectiveness.

Results

Compared to LMWH, DOACs were less costly (mean costs: $8,477 vs. $33,917 per year) and similarly effective (mean QALY: 0.616 vs. 0.622). The incremental cost-effectiveness ratio was $4,479,374 per QALY gained with LMWH, indicating that DOACs are cost-effective (Table 1). In threshold analyses, LMWH therapy only became cost-effective when DOAC recurrent VTE risk increased to at least 72% (relative risk vs. LMWH, 6.19) or DOAC clinically relevant bleeding increased to at least 39% (relative risk vs. LMWH, 10.09).

Scenarios Recurrent VTE, % Major bleed, % Mean difference DOAC − LMW ICER DOAC LMWH Relative Risk DOAC LMWH Relative Risk Cost QALY Base case 8.1 11.6 0.71 6.8 4.0 1.75 −$25,440 (−26,496, −24,274) −0.006 (−0.019, 0.008) $4,479,374 DOAC outcome rate threshold at which LMWH becomes cost-effective*   Recurrent VTE 71.5 11.7 6.19 – – – −$6,064 (−7,534, −4,627) −0.121 (−0.136, −0.108) $49,886   Major Bleed – – – 38.9 4.0 10.09 −$2,192 (−3,400, −704) −0.044 (−0.056, −0.030) $49,878 DOAC = direct oral anticoagulant, ICER = incremental cost-effectiveness ratio, LMWH = low-molecular-weight heparin, VTE = venous thromboembolism. Values are mean (95% Uncertainty Interval). Uncertainty was derived from 1,000 stochastic model iterations. *Represents the minimum increased risk with DOAC that would result in LMWH achieving an ICER <$50K per QALY gained.

Conclusion

In this simulation study, DOACs were a cost-effective oral alternative to LMWH for the treatment of CA-VTE. For LMWH to be cost-effective, DOAC event rates needed to be far higher than what is likely to be observed in clinical practice.

Acknowledgement/Funding

Agency for Health Research and Quality R18HS026156

Gene promoter-associated CpG island hypermethylation in squamous cell carcinoma of the tongue

The present study was undertaken to explore and validate novel hypermethylated DNA regions in squamous cell carcinoma of the tongue (SCCT). Genome-wide methylation changes were identified by differential methylation hybridization (DMH) microarray and validated by bisulfite genome sequencing (BGS). The results were compared against datasets from The Cancer Genome Atlas head and neck squamous cell carcinoma (TCGA-HNSCC), Gene Expression Omnibus (GSE26549), and ArrayExpress (E-MTAB-1328). DMH identified 116 hypomethylated and 241 hypermethylated regions. Of the latter, 24 were localized to promoter or 5'-UTR regions. By BGS, promoter sequences of DAPK1, LRPPRC, RAB6C, and ZNF471 were significantly hypermethylated in tumors when compared with matched normal tissues (P < 0.0001). A TCGA-HNSCC dataset (516 cases of cancer and 50 normal tissue samples) further confirmed hypermethylation of DAPK1, RAB6C, and ZNF471. Sensitivity and specificity of methylation markers for a diagnosis of cancer were in the range of 70-100% in our study and from TCGA-HNSCC datasets, with an area under curve (AUC) of 0.83 and above. Kaplan-Meier survival analysis of TCGA-HNSCC expression data revealed that patients with low expressions of DAPK1, RAB6C, and ZNF471 showed poorer survival than patients with high expression (P = 0.02). Human papillomavirus (HPV) was found in 55% of cases, HPV16 being the predominant genotype. DAPK1 immunohistochemical staining was lower in SCCT than in normal buccal epithelial cells. This is the first study to report hypermethylation of LRPPRC, RAB6C, and ZNF471 in SCCT and its diagnostic and prognostic potentials in a specific head and neck squamous cell carcinoma.