Climate change and healthy ageing: An assessment of the impact of climate hazards on older people

Background

Climate change not only directly impacts older people's longevity but also healthy ageing, which is the process of maintaining physical and mental capacities while optimising functional abilities. The urgency to address both population ageing and climate change necessitates a rethink and assessment of the impact of climate change on older people. This includes identifying what can be done to anticipate, mitigate and adapt to climate change and engage older persons.

Methods

A review of climate change and healthy ageing forms the basis of evidence in this report. We developed a comprehensive search to assess current literature, combining terms related to ageing and climate change across four major data sets and assessing articles published up to the end of 2021.

Results

We summarised the current and future impact of climate change on older people and developed a framework identifying climate change impacts on older persons, recognising social and environmental determinants of healthy ageing. Major hazards and some key exposure pathways include extreme temperatures, wildfire, drought, flooding, storm and sea level rise, air quality, climate-sensitive infectious diseases, food and water insecurities, health and social care system displacement, migration, and relocation. Strategies to address climate change require interventions to improve systems and infrastructure to reduce vulnerability and increase resilience. As a heterogeneous group, older people's perceptions of climate change should be integrated into climate activism. Increasing climate change literacy among older people and enabling them to promote intergenerational dialogue will drive the development and implementation of equitable solutions. Pathways may operate via direct or indirect exposures, requiring longitudinal studies that enable assessment of exposures and outcomes at multiple time points, and analyses of cumulative impacts of hazards across the life course.

Conclusions

The lack of systematic reviews and primary research on the impact of most climate hazards, except for heat, on older people is apparent. Future research should include outcomes beyond mortality and morbidity and assess how older people interact with their environment by focusing on their capacities and optimising abilities for being and doing what they value.

Microbiological Characteristics and Resistance Patterns in a Neonatal Intensive Care Unit: A Retrospective Surveillance Study

BACKGROUND AND OBJECTIVE

This study aims to assess the prevalence and antimicrobial susceptibility patterns of bacterial infections associated with both early-onset sepsis (EOS) and late-onset sepsis (LOS).

METHODOLOGY

This descriptive retrospective surveillance research was conducted on all neonates admitted to the neonatal ICU with bacterial sepsis, where positive cultures were isolated from sterile sites (either cerebrospinal fluid or blood) at Tawam Hospital, Al Ain, Emirate of Abu Dhabi, UAE, from January 2012 and December 2021. Antimicrobial susceptibility analysis was performed.

RESULTS

The incidence of LOS (94.43%) was higher compared to EOS (5.56%). The most prevalent isolates (59.2%) were gram-positive bacteria, with gram-negative bacteria accounting for 40.8%. The leading isolates included coagulase-negative Staphylococci (CONS, 40.98%), Klebsiella (16.04%), Staphylococcus aureus (8.46%), Escherichia coli (8.24%), Pseudomonas (7.57%), and Group B Streptococcus (GBS, 5.12%). CONS were predominant in LOS cases (42.9%), while GBS was the main pathogen in EOS cases (44%).

CONCLUSIONS

We observed reduced resistance levels of CONS against ampicillin, benzylpenicillin, clindamycin, erythromycin, fusidic acid, gentamicin, oxacillin, rifampicin, and trimethoprim/sulfa. S. aureus exhibited increased resistance to erythromycin, fusidic acid, gentamicin, and levofloxacin, while E. coli demonstrated decreased resistance against cephalothin, gentamicin, and trimethoprim/sulfa. The antibiotics currently employed empirically appear to provide adequate coverage against the most prevalent bacteria causing early- and late-onset neonatal infections.

SMT-738: a novel small-molecule inhibitor of bacterial lipoprotein transport targeting Enterobacteriaceae

Carbapenem-resistant Enterobacteriaceae (CREs) are described by the Centers for Disease Control as an urgent threat, and there is a critical need for new therapeutic agents able to treat infections caused by these pathogens. Herein, we describe the microbiological profile, the mechanism f action, and the in vitro safety as well as the pharmacokinetic (PK)/PD profile of SMT-738, a small molecule belonging to a new chemical class. SMT-738 is active against Enterobacterales [including multi-drug-resistant Escherichia coli with 90% of isolates having a minimum inhibitory concentration (MIC90) of 1 µg/mL and Klebsiella pneumoniae 2 µg/mL] and inactive against a broad panel of Gram-negative and Gram-positive pathogens. SMT-738 displays rapid bactericidal activity (2-4 h) and has a low propensity for resistance development (less than ~10-9). Characterization of resistant mutants following exposure to SMT-738 identified mutations within the lipoprotein transport complex (LolCDE), a clinically unexploited and essential bacterial molecular target in Gram-negative bacteria. SMT-738 has a promising in vitro toxicology profile. Furthermore, PK studies demonstrated that when dosed intravenously, SMT-738 maintained exposure levels across infection sites (bloodstream/urinary tract/lung). Proof-of-concept studies across multiple murine in vivo infection models (bloodstream/pneumonia/urinary tract) demonstrated that SMT-738 significantly reduced the bacterial burden compared to baseline and vehicle control. SMT-738 represents a promising novel drug candidate being developed to address clinically challenging serious life-threatening infections caused by highly resistant Enterobacteriaceae including CRE.

Clustering by multiple long-term conditions and social care needs: a cross-sectional study among 10 026 older adults in England

BACKGROUND   : People with multiple long-term conditions (MLTC) face health and social care challenges. This study aimed to classify people by MLTC and social care needs (SCN) into distinct clusters and quantify the association between derived clusters and care outcomes. METHODS : A cross-sectional study was conducted using the English Longitudinal Study of Ageing, including people with up to 10 MLTC. Self-reported SCN was assessed through 13 measures of difficulty with activities of daily living, 10 measures of mobility difficulties and whether health status was limiting earning capability. Latent class analysis was performed to identify clusters. Multivariable logistic regression quantified associations between derived MLTC/SCN clusters, all-cause mortality and nursing home admission. RESULTS: Our study included 9171 people at baseline with a mean age of 66.3 years; 44.5% were men. Nearly 70.8% had two or more MLTC, the most frequent being hypertension, arthritis and cardiovascular disease. We identified five distinct clusters classified as high SCN/MLTC through to low SCN/MLTC clusters. The high SCN/MLTC included mainly women aged 70-79 years who were white and educated to the upper secondary level. This cluster was significantly associated with higher nursing home admission (OR=8.71; 95% CI: 4.22 to 18). We found no association between clusters and all-cause mortality. CONCLUSIONS: We have highlighted those at risk of worse care outcomes, including nursing home admission. Distinct clusters of individuals with shared sociodemographic characteristics can help identify at-risk individuals with MLTC and SCN at primary care level.

Factors associated with multimorbidity in England: an analysis of the English Longitudinal Study of Ageing

BACKGROUND

Multimorbidity, defined as the presence of two or more long-term conditions, is a growing public health challenge, especially in terms of prevention and accumulation of long-term conditions among particular population cohorts. To date, efforts to understand multimorbidity has focused mainly on specific disease combinations, with little known about the sociodemographic factors associated with it. The study aimed to assess the factors associated with multimorbidity in England.

METHODS

A cross-sectional study was conducted using the English Longitudinal Study of Ageing (ELSA), a dataset of people aged 50 years and older. The study identified ten long-term conditions from waves 2 to 9. Wave 2 to 9 were conducted between June 2004 to July 2005, May 2006 to August 2007, May 2008 to July 2009, June 2010 to July 2011, May 2012 to June 2013, June 2014 to May 2015, May 2016 to June 2017 and June 2018 to July 2019, respectively. The study included people with two or more long-term conditions. We identified the number of long-term conditions and multimorbidity, and we examined their association with age, gender, ethnicity, marital status, employment status, education, weekly contact with relative, and feeling lonely, sad or depressed using multinomial logistic regression.

FINDINGS

Of 16 731 people recruited from wave 2 to wave 9, we identified 10 026 people with multimorbidity aged 50 years and older. The majority had two conditions (39%) and were female (55%), aged 50-69 years (32%), of white ethnicity (96%), married (69%) and unemployed (65·3%). The adjusted odds ratio (aOR) of having more than two long-term conditions increased with age, after adjusting for sex and ethnicity (≥5 conditions: aOR 12·89, 95% CI 2·23-3·76). Being female was associated with an increased risk of having more than two long-term conditions (≥5 conditions: aOR 1·21, 1·04-1·42). Similarly, being separated, divorced, or widowed were associated with having more than two long-term conditions (≥5 conditions: aOR 1·45, 1·21-1·74). Not owning a home was independently associated with more than two long-term conditions (≥5 conditions: aOR 1·59, 1·35-1·88).

INTERPRETATION

The current analysis used only ten long-term conditions that were available in the ELSA data, so a different association might have arisen if other conditions had been considered. Our findings provide insights into which particular groups of the multimorbid population could be the target of preventive public health strategies and wider clinical and social care interventions in England to reduce the burden of multimorbidity.

FUNDING

National Institute for Health and Care Research (NIHR).

Wheat Water-Soluble Carbohydrate Remobilisation under Water Deficit by 1-FEH w3

Fructan 1-exohydrolase (1-FEH) is one of the major enzymes in water-soluble carbohydrate (WSC) remobilisation for grains in wheat. We investigated the functional role of 1-FEH w1, w2, and w3 isoforms in WSC remobilisation under post-anthesis water deficit using mutation lines derived from the Australian wheat variety Chara. F1 seeds, developed by backcrossing the 1-FEH w1, w2, and w3 mutation lines with Chara, were genotyped using the Infinium 90K SNP iSelect platform to characterise the mutated region. Putative deletions were identified in FEH mutation lines encompassing the FEH genomic regions. Mapping analysis demonstrated that mutations affected significantly longer regions than the target FEH gene regions. Functional roles of the non-target genes were carried out utilising bioinformatics and confirmed that the non-target genes were unlikely to confound the effects considered to be due to the influence of 1-FEH gene functions. Glasshouse experiments revealed that the 1-FEH w3 mutation line had a slower degradation and remobilisation of fructans than the 1-FEH w2 and w1 mutation lines and Chara, which reduced grain filling and grain yield. Thus, 1-FEH w3 plays a vital role in reducing yield loss under drought. This insight into the distinct role of the 1-FEH isoforms provides new gene targets for water-deficit-tolerant wheat breeding.

Clinical learning environments across two different healthcare settings using the undergraduate clinical education environment measure

BACKGROUND

The clinical placements of our medical students are almost equally distributed across private and public sectors. This study aims to assess medical students' perceptions of their Clinical learning Environment (CLE) across these two different healthcare settings, using the Undergraduate Clinical Education Environment Measure (UCEEM).

METHODS

76 undergraduate medical students (Year 5 and 6), were invited to participate. Data were collected using an online UCEEM with additional questions related to demographics and case load exposure. The UCEEM consists of two overarching domains of experiential learning and social participation, with four subdomains of learning opportunities, preparedness, workplace interaction, and inclusion.

RESULTS

38 questionnaires were received. Of 225 responses to the individual UCEEM items, 51 (22.6%) scored a mean of ≥ 4 (range 4-4.5, representing strong areas), 31 (13.7%) scored a mean of ≤ 3 (range 2.1-3, needing attention) and 143 (63.6%) scored a mean of 3.1-3.9 (areas that could be improved). The majority (63%) of the case load exposure responses scored a mean of ≥ 4 (range 4-4.5). Compared to the private sittings, there is a significant reduction in total UCEEM (p = 0.008), preparedness for student entry (p = 0.003), and overarching dimension of social participation (p = 0.000) scores for the public sector. Similarly, both workplace interaction patterns and student inclusion and equal treatment scored significantly lower for the public sector (p = 0.000 and p = 0.011 respectively). Two out of three case load exposure items scored significantly higher for the public sector (p = 0.000).

DISCUSSION

The students' CLE perceptions were generally positive. The lower UCEEM ratings in the public sector items were related to student entry preparedness, workplace interactions, student inclusiveness and workforce equity of treatment. In contrast the students were exposed to more variety and larger number of patients in the public sector. These differences indicated some significantly different learning environments between the two sectors.

Clustering populations by health and social care with multiple long-term conditions: a cohort study - the English Longitudinal Study of Ageing (ELSA)

BACKGROUND

The integration of health and social care services is a potential solution for improving care, despite monetary constraints and increasing demand. How two or more multiple long-term conditions (MLTC) cluster, interact and associate with socioeconomic factors, and affect access to unscheduled primary healthcare services is understudied.

AIM

To cluster an MLTC population by health and social care, examine clusters, and quantify associations with health outcomes.

METHOD

A retrospective cohort study was conducted using the ELSA database (2002 to 2019) on 19802 participants aged ≥50 years. Ten major health conditions, and social care need, including difficulty in activities of daily living (ADL) and mobility, for example, were used to cluster MLTC by latent class modelling. Multivariate logistic regression models were used to establish further association.

RESULTS

The mean age of the participants at baseline (wave 2) was about 66 years and 55% of participants were female, with more than 60% developing MLTC in their lifetime (waves 2 to 9). Of the five distinct latent clusters, cluster 5 was the most significant cluster composed of lung diseases, stroke, dementia, and high ADL and mobility difficulty scores. The majority of the participants were aged 70-79 years, female, and married. The odds of having a longer nursing home stay were 8.97 (95% confidence interval = 4.36 to 18.45), and death was 10% higher in this cluster compared to the highest probability cluster 4 in the maximally adjusted regression model.

CONCLUSION

This study identified MLTC clusters by social care need with the highest primary care demand. Targeting clinical practice to prevent MLTC progression for these groups may lessen future pressures on primary care demand.

Trajectories of multiple long-term conditions and mortality in older adults: A retrospective cohort study using English Longitudinal Study of Ageing (ELSA)

Objectives

To classify older adults with MLTC into clusters based on accumulating conditions as trajectories over time, characterise clusters and quantify associations between derived clusters and all-cause mortality.

Design

We conducted a retrospective cohort study using the English Longitudinal Study of Ageing (ELSA) over nine years (n=15,091 aged 50 years and older). Group-based trajectory modelling was used to classify people into MLTC clusters based on accumulating conditions over time. Derived clusters were used to quantify the associations between MLTC trajectory memberships, sociodemographic characteristics, and all-cause mortality.

Results

Five distinct clusters of MLTC trajectories were identified and characterised as: "no-LTC" (18.57%), "single-LTC" (31.21%), "evolving MLTC" (25.82%), "moderate MLTC" (17.12%), and "high MLTC" (7.27%). Increasing age was consistently associated with an increased number of MLTC. Female sex (aOR = 1.13; 95%CI 1.01 to 1.27) and ethnic minority (aOR = 2.04; 95%CI 1.40 to 3.00) were associated with the "moderate MLTC" and "high MLTC" clusters, respectively. Higher education and paid employment were associated with a lower likelihood of progression over time towards an increased number of MLTC. All the clusters had higher all-cause mortality than the "no-LTC" cluster.

Conclusions

The development of MLTC and the increase in the number of conditions over time follow distinct trajectories. These are determined by non-modifiable (age, sex, ethnicity) and modifiable factors (education and employment). Stratifying risk through clustering will enable practitioners to identify older adults with a higher likelihood of worsening MLTC over time to tailor effective interventions.

Consumer attitude toward Halal food in the case of the United Kingdom: the role of product attributes and marketing stimuli

The Halal market in the United Kingdom is worth $4.5 billion and is anticipated to grow at a rate of 5% each year. In the United Kingdom, there is a growing demand for Halal food, which has resulted in the formation of various unregulated Halal Certification Bodies. In the halal food market, the problem of halal authenticity has recently become a serious concern. The purpose of the paper was to determine the effect of product attributes and marketing stimuli on customer attitudes toward halal food among Muslim customers in the U.K. A cross-sectional study was adopted for this study. The sample of the study included the Muslim customers who have consumed halal food in the U.K. The authors used a survey method to collect the quantitative data. A total of 384 responses were received and data were analysed using SPSS. The findings of the study revealed that product attributes such as country of origin have a significantly greater influence on the customer attitude towards halal food compared to other product attributes. The findings further showed that marketing stimuli such as sales’ location impact on customer attitude however advertisement did not have any impact on customer attitude towards halal food. The finding held perspectives from Muslim customers in the U.K and contributes to the stimulus-organism-response theory by incorporating product attributes and marketing as stimulus factors that affect the internal psychological state i.e., customer’s attitude in the case of the U.K. The implication of this study was to recommend Halal enterprises import halal food from Islamic countries for U.K customers, research the strategic location and select the hypermarkets, that handle halal food with care.

National audit of non-melanoma skin cancer excisions performed by plastic surgery in the UK

A national, multi-centre audit of non-melanoma skin cancer excisions by plastic surgery.

Adult outcomes of complex pulmonary atresia, ventricular septal defect and major aortopulmonary collaterals following repair during childhood, a single centre experience

Background

Complex pulmonary atresia with a ventricular septal defect and major aortopulmonary collateral arteries (PA VSD MAPCA) is a rare and complex form of congenital heart disease. Staged surgical palliation is carried out in childhood, and in expert centres, is associated with good medium term survival. Adult outcomes following transition to adult care are not known.

Purpose

To establish adult outcomes of PA VSD MAPCA following repair during childhood in our institution

Methods

Review of clinical records for outcome data including life status, NYHA class, employment status, re-intervention in adult life, arrhythmia, pregnancy, exercise capacity and mode of death, where known. We predefined our population into two groups based on their status at transition to adult care, A) complete repair with RV-PA conduit and VSD closed and B) repaired but VSD left open.

Results

188 patients from our series have transitioned to adult services. As many were tertiary referrals (nationally and internationally) the local follow up population was 53 adults (54.7% male), mean age of those alive under follow up is 27.2±6.5 years, with a mean follow up of 25.3±6.1 years. There were 43 in group A and 10 in group B. Mortality in the total population was 18.9% (10/53), group A (16.3%), group B (30.0%), mean age at death 37.5±10.3 years and 29.9±8.4 years, 6/10 deaths were sudden. 22.6% of the whole group had DiGeorge/22q11 microdeletion, with a learning deficit in 32.7% of the cohort, where this could be assessed. Reinterventions included RV-PA conduit change, coil occlusion, pacemaker implantation, ICD implantation and ablation procedures, overall 39.6% underwent reintervention in adult life. Pregnancy occurred in 33.3% of 24 female patients. 50% of individuals were found to have undertaken some form of paid work and of these 11.5% had DiGeorge.

Conclusions

Complex PA VSD MAPCA is associated with good late survival with late attrition including sudden death and heart failure. 22q11 is associated with learning deficit and consequent lack of employment. Non 22q11 have good educational outcomes and there is less observed deficit regarding employment. Successful pregnancy is possible within this population.

Funding Acknowledgement

Type of funding sources: None.

The Impact of Living with INOCA

Background

There is limited literature available on the impact of myocardial ischemia but no obstructive coronary arteries (INOCA) on patients' lives.

Purpose

We sought to determine how INOCA impacts the physical, social, and mental health of persons with this diagnosis.

Methods

A survey was made available to all members of the patient support group from INOCA International over a 3-month time period. Fitness was estimated using the Duke Activity Status Index (DASI), assessing levels of activities performed prior to the onset of INOCA symptoms, and after the diagnosis of INOCA. The formula to estimate fitness in metabolic equivalents (METs) = 0.43 × DASI + 9.6 / 3.5

Results

A total of 297 patients with INOCA responded to the survey; 91.2% were women. The most common diagnosis was coronary microvascular dysfunction (64.3%) and coronary artery spasm (50.5%) (Table 1). 34.4% reported living with symptoms for ≥3 years before their diagnosis of INOCA was made. 77.8% who had been told their symptoms were not cardiac. The symptoms the respondents experienced were numerous, but 92.9% reported symptoms of chest pain, pressure, or discomfort. Fitness levels prior to the onset of INOCA symptoms were significantly higher compared to after diagnosed with INOCA (8.6±1.8 METs vs 5.6±1.8 METs; P<0.0001). Most respondents reported an adverse impact on their home life (80.5%), social life (80.1%), mental health (70.4%), outlook on life (69.7%), sex life (55.9%), and their partner/spouse relationship (53.9%). Work life was also affected once living with INOCA: approximately three-quarters had reduced their work hours or stopping work completely, 47.5% retired early, and 38.4% applied for disability. While living with INOCA, for each 1-MET decrease in fitness, there was a loss of 3.0±0.6 days/months of physical health, 1.8±0.6 days/month of mental health, and 2.9±0.7 days/months of inability to perform recreational activities (p<0.0001) (Figure 1).

Conclusions

Living with INOCA has significant impact on physical, mental and social health. Significant physical fitness declines are seen in those living with INOCA and are lower in those experiencing any adverse impact of living with INOCA. Additionally, the impact of INOCA on the ability to work has important economic consequences to both the patient and society. Increased recognition of the impact of INOCA on these aspects of health need to be recognized and further work is needed to better diagnosis and treat the symptoms of INOCA to improve the quality of life, cardiovascular outcomes, and overall health of this frequently encountered cardiovascular disorder.

Funding Acknowledgement

Type of funding sources: None.

Comparative Study between Acacia Nilotica versus Povidone Iodine in Topical Treatment of Omphalocele Major

Well established and common practice in conservative management of omphalocele major is escharotics therapy with different topical agents. Among them mercurochrome, alcohol, silver salts, povidone iodine, acacia nilotca paste are commonly used. It is a comparative study between application of acacia nilotica paste and povidone iodine solution as a primary non surgical treatment of omphalocele major regarding efficacy and safety of these two topical agents. A double blind randomized controlled study was conducted at the department of Paediatric Surgery, Mymensingh Medical College Hospital, Mymensingh, Bangladesh from July 2016 to June 2019. In this study 20 cases of omphalocele major and randomly divided into two equal groups. Group A and Group B treated with acacia nilotica paste and povidone iodine solution respectively. Gastroschisis, ruptured-omphalocele major or omphalocele minor excluded in this study. The size of the fascial defect in cm, time required for full oral feeding tolerance and duration of hospital stay were evaluating parameters. Patients with Group A tolerated full oral feeding earlier, shorter total hospital stay duration and low mortality rate than those from Group B. Application of acacia nilotica is a safe and effective treatment of omphalocele major regarding rapid full oral feeding tolerance, shorter hospital stay and low mortality rate.

363 A Comparative Analysis of Night-Time General Surgical Training

Aim

The aim of surgical training is to ensure trainees acquire competencies to perform as a Day 1 Consultant. The last decade has seen the introduction of European Working Time Directive, NELA guidelines and the revised Junior Doctor Contract. All of these, as well as the COVID 19 pandemic, have caused concerns regarding training. Our aim was to examine any changes to night-time on call activity during this time.

Method

We retrospectively analysed prospectively collected data from 2011, 2018, and 2021, in a busy District General Hospital. The data collection period was 31 days, looking at night-time (8pm to 8am) operative experience, supervision, and non-operative activity. A regression analysis was conducted to compare outcomes. A qualitative survey was used to assess attitudes and confidence.

Results

On average, trainees spent 11% of their time operating independently, 2% operating supervised, 11% attending trauma-calls and 73% clerking/non-educational activities. There was a significant difference between the hours spent on operative versus non-operative activity (P 0.00046) with no differences over the years. Junior trainees did not feel confident operating at night and only 33% of all trainees found night-time training effective.

Conclusions

Nightshifts comprise a substantial proportion of potential training opportunities and managing the unselected emergency take is one of the Capabilities in Practice. Effective solutions must be implemented to help improve night-time surgical experience and confidence in order for this time to be effective for training of both operative and non-operative competency attainment.

Awareness, Social Media, Ethnicity and Religion: are they Responsible for Vaccination Hesitancy? A Systematic Review with Annotated Bibliography

Vaccination is not only a medical term rather it is framed under socio-cultural perspectives and debates as well. Human history is full of illnesses caused bacteria and viruses killing millions of people including children and adults. Technological development in the health sector enabled to combat pathogenic illnesses through different methods whereby vaccination is one of them. However, it is a dilemma that vaccination has faced many barriers including logistical but most importantly sociocultural and religious. In 2019, WHO revealed vaccine hesitancy as a leading threat to health throughout the globe even in the top 10. This study looks to analyze peer reviewed literature to explore barriers to vaccination. Methodologically, this is desk research and systematic review. Numerous databases were searched with key words and purposively studies were selected for this study. A total of 17 most relevant studies were sampled. Findings show that there are four major factors hindering vaccination. 1st cultural and ethnic background matters whereby religion and the belief system are predominant factors. 2nd awareness and educational variables are also there, for instance, it is noted that many people are not aware of vaccination process specifically in case of HPV vaccination. 3rd social media plays a pivotal role whereby misinformation internalizes negative attitudes and misperceptions about vaccines. 4th social media is a key dimension whereby disinformation and misinformation are communicated through platforms whereby some are intentionally circulated. It is suggested that culturally relativism perspective can be helpful in increasing vaccination percentages. It pertains to intervention through culturally approved methods, for example, sensitizing the ethnic backgrounds through their leadership. In addition, vaccination tracking, media campaigns, focus on school level education to include health related course can be helpful.

Spreading Terrorism, Militancy, and Radicalization in Malakand Division Khyber Pakhtunkhwa Pakistan: An Analysis of the Economic Factors

The current study is to analyze the causes of militancy, terrorism, and radicalization where multifarious factors are contributing towards spreading such behavior. However, the study is delimited to focus on the economic factors, including poverty, unemployment and other such factors that lead towards militancy, terrorism, and radical behavior in society. The field information was collected from 200 respondents using purposive sampling technique with stratified approach from 3 strata of the society including businessmen, teachers and clergy or religious class of age 20 and above. The data was collected through a structured interview schedule, and the analysis was made in the form of tables, discussion and the findings have been verified through chi-square test. The findings show that militancy, terrorism, and radicalization have their roots in deep rooted poverty, unemployment, and lack of other life facilities in the area. The study suggests proper planning for provision of jobs, equal distribution of resources among people and provision of life facilities to the masses.

POS0685 LONG-TERM SAFETY AND EFFICACY OF UPADACITINIB IN PATIENTS WITH RHEUMATOID ARTHRITIS: FINAL RESULTS FROM THE BALANCE-EXTEND OPEN-LABEL EXTENSION STUDY

Background

Upadacitinib (UPA) was previously evaluated in two Phase 2, randomized, controlled trials (RCTs) in patients (pts) with rheumatoid arthritis (RA) and inadequate response to tumor necrosis factor inhibitors (BALANCE-1) or methotrexate (BALANCE-2).

Objectives

To assess the final safety and efficacy of UPA in BALANCE-EXTEND, a 312-week open-label extension (OLE) enrolling pts who completed either BALANCE-1 or BALANCE-2.

Methods

All pts initially received UPA 6 mg twice daily (BID). Increase to 12 mg BID was required for pts with <20% improvement in swollen or tender joint counts (S/TJC) at Week 6 or 12, and permitted for those not achieving Clinical Disease Activity Index (CDAI) low disease activity (LDA). Pts with <20% improvement in SJC or TJC 6 weeks after escalation, or at any two consecutive visits, discontinued. Return to 6 mg BID was permitted for safety or tolerability reasons. After January 2017, the 6 and 12 mg BID doses were replaced by 15 and 30 mg once-daily (QD) extended-release equivalents. As-observed efficacy data are shown at Week 312 for three subgroups: pts who received 6 mg BID/15 mg QD throughout (“Never titrated”), those titrated up to 12 mg BID/30 mg QD for efficacy (“Titrated up”), and those titrated up to 12 BID/30 mg QD and then back to 6 mg BID/15 mg QD due to safety concerns (“Titrated up and down”). Exposure-adjusted adverse events (EAERs) per 100 patient-years (PY) of exposure were summarized from OLE Day 1 in all pts who received UPA (Any UPA).

Results

Overall, 493 pts entered the OLE, receiving UPA for ≤6.2 years (Never titrated, n=306; Titrated up, n=149; Titrated up and down, n=38), and 270 pts (54.8%) discontinued, mostly due to withdrawal of consent (16.8%; n=83) or AEs (14.6%; n=72). Mean (standard deviation) duration of UPA exposure was 3.8 (2.4) years (range <1–6.2 years); cumulative exposure was 1863 PY. The AE profile in pts receiving UPA 15 mg was generally similar to the Any UPA population, and to that observed in the Phase 3 UPA 15 mg clinical trial population (Table 1). Efficacy was maintained to Week 312, with 84.5% and 86.6% of pts in the Never titrated group achieving DAS28-CRP ≤3.2 and CDAI LDA, respectively (Figure 1).

Table 1.

Summary of AEs in pts who received UPA 6 mg BID/15 mg QD in the OLE and in the UPA 15 mg Phase 3 study program

BALANCE-EXTEND (UPA 6 mg BID/15 mg QD)UPA 15 mg – Phase 3 programbEvents/100 PY (95 CI)aEvents/100 PY (95% CI)aN=493, PY=1277N=3209, PY=9079Any AE138.4 (132.0, 145.0)205.5 (202.5, 208.5)Any SAE7.9 (6.4, 9.6)12.4 (11.7, 13.2)AE leading to discontinuation4.2 (3.2, 5.5)4.9 (4.4, 5.3)Death0.4 (0.1, 0.9)0.5 (0.4, 0.7)cInfection49.2 (45.5, 53.2)63.9 (62.3, 65.6) Serious infection1.4 (0.8, 2.2)2.8 (2.4, 3.1) Opportunistic infection0.2 (0.0, 0.6)0.3 (0.2, 0.4) Herpes zoster2.0 (1.3, 3.0)3.0 (2.6, 3.3)Anemia1.1 (0.6, 1.8)3.0 (2.7, 3.4)Neutropenia1.3 (0.8, 2.1)2.1 (1.8, 2.5)Lymphopenia1.7 (1.1, 2.6)1.7 (1.4, 1.9)Gastrointestinal perforation0<0.1 (0.0, 0.1)Any malignancy1.2 (0.7, 1.9)1.1 (0.9, 1.4)Non-melanoma skin cancer (NMSC)0.4 (0.1, 0.9)0.4 (0.3, 0.5) Excluding NMSC0.8 (0.4, 1.4)0.7 (0.6, 0.9)Creatinine phosphokinase elevation3.4 (2.5, 4.6)4.4 (4.0, 4.9)Hepatic disorder4.1 (3.0, 5.3)10.2 (9.5, 10.8)Venous thromboembolism0.5 (0.2, 1.0)0.4 (0.3, 0.6)Major adverse cardiovascular event0.5 (0.2, 1.0)0.4 (0.3, 0.5)

aMultiple events occurring in the same pts are counted in the calculation of events/100 PY. bCut-off, June 30, 2021. cBased on 9080 PY.

Conclusion

In this OLE, UPA treatment over ~312 weeks showed sustained long-term efficacy in pts with RA who had completed Phase 2 RCTs. Overall safety results showed that UPA was well tolerated over time; the types and frequencies of AEs were consistent with those in pts with similar populations of moderately to severely active RA receiving Janus kinase inhibitors.

Acknowledgements

AbbVie funded this study; contributed to its design; participated in data collection, analysis, and interpretation of the data; and participated in the writing, review, and approval of the abstract. AbbVie and the authors thank all study investigators for their contributions and the patients who participated in this study. No honoraria or payments were made for authorship. Medical writing support was provided by Dan Booth, PhD, of 2 the Nth (Cheshire, UK), and was funded by AbbVie.

Disclosure of Interests

Alan Kivitz Shareholder of: Amgen, Gilead, GlaxoSmithKline, Novartis, Pfizer, and Sanofi (stocks or options), Consultant of: AbbVie, Amgen, Boehringer Ingelheim, Eli Lilly, Flexion, Genzyme, Gilead, Horizon, Janssen, Merck, Novartis, Pfizer, Regeneron, Sanofi, Sanofi Aventis, SUN Pharma Advanced Research, and UCB, Grant/research support from: AbbVie (his institution received fees for his role as a Principal Investigator in the study), Alvin F. Wells Consultant of: AbbVie, Juan Ignacio Vargas Consultant of: AbbVie, Grant/research support from: AbbVie (as a Principal Investigator in the study), Herbert S.B. Baraf Consultant of: Gilead and Janssen, Grant/research support from: AbbVie, Eli Lilly, Genentech, Gilead, and Janssen, Maureen Rischmueller Consultant of: AbbVie, Bristol-Myers Squibb, CSL Behring, Eli Lilly, Gilead Sciences, Janssen Global Services, Pfizer, Sanofi US Services, and UCB Biosciences, Grant/research support from: AbbVie, Amgen, Bristol-Myers Squibb, Eli Lilly, Janssen Global Services, Novartis, Pfizer, Sanofi Pasteur Biologics, and UCB Biosciences, Justin Klaff Shareholder of: AbbVie (may own stocks or options), Employee of: AbbVie, Nasser Khan Shareholder of: AbbVie (may own stocks or options), Employee of: AbbVie, Yihan Li Shareholder of: AbbVie (may own stocks or options), Employee of: AbbVie, Kyle Carter Shareholder of: AbbVie (may own stocks or options), Employee of: AbbVie, Alan Friedman Shareholder of: AbbVie (may own stocks or options), Employee of: AbbVie, Patrick Durez Speakers bureau: Eli Lilly and Galapagos

AB0652 Prevalence of Interstitial lung disease and pulmonary arterial hypertension in systemic sclerosis patients cohort at a rheumatology referral centre in the United Arab Emirates

Background

Scleroderma, also known as Systemic Sclerosis (SSc), is a connective tissue disease that affects multiple organ systems, including the cardiovascular and respiratory systems, namely, pulmonary arterial hypertension (PAH) and interstitial lung disease (ILD) as the leading causes of death in this patient population.

Objectives

The purpose of this study is to determine the prevalence of PAH and ILD in a cohort of patients diagnosed with SSc.

Methods

We performed a retrospective chart review of clinical characteristics of all patients diagnosed with SSc Cleveland Clinic Abu Dhabi between April 2015 and April 2020. PAH was estimated by echocardiographic findings and diagnosed based on right heart catheterization (RHC) using 2019 World Symposium on Pulmonary Hypertension. The CT scan of the chest was read by a board-certified radiologist in chest radiology.

Results

Fifty individuals were diagnosed with SSc, with 46% having diffuse cutaneous systemic sclerosis and 54% having limited cutaneous systemic sclerosis. The majority of the patients (88%) were female, with a mean age of 41 ±13 years. The average period from presentation to diagnosis was 5 ±5.4 years. The majority of the cohort (86%) were from the United Arab Emirates. The average BMI was 26.0 kg/m2. Patients’ most prevalent symptoms are fatigue (80%), gastrointestinal symptoms (72%) followed by shortness of breath (58%) and cough (50%). Twenty-six out of fifty patients (52%) underwent a CT chest scan, with 19 (38%) having ILD. Eight patients had more than 30% fibrotic alterations, four patients had 10-30% fibrotic changes, and seven patients had less than 10% fibrotic abnormalities. Patients with more than 10% fibrotic changes were more likely to have usual interstitial pneumonia, whereas those with less than 10% fibrotic changes were more likely to have none specific fibrosis. The majority of patients (92%) had echocardiogram. All except one patient had a normal ejection fraction, and five had grade 1 left ventricular diastolic dysfunction. Five patients were described as having mild, 1 moderate and 2 severe PAH. Only 4 patients underwent RHC. One patient had group II PAH based on elevated wedge pressure. One had group 1 PAH with systemic sclerosis as the only cause for her PAH and two patients had group III PAH due to having more than 30 % pulmonary fibrosis and severe restrictive defect on spirometry. Therefore, the precapillary PAH prevalence was 6% (3/50).

Conclusion

While the prevalence of pulmonary fibrosis in our SSc patients reflects what has been reported in the literature, the prevalence of PAH is significantly lower than the reported 15-20%.1 This is likely due to underdiagnosis of PAH considering the number of years of systemic sclerosis diagnosis on presentation to our clinic. A systematic approach is needed to assess for the presence and severity of PAH using tools as in Detect algorithm which has been validated and commonly used in Europe and North America to screen for PAH.2 Validation of such algorithm is likely needed in middle eastern population before it is universally adopted.

References

[1]Screening for pulmonary arterial hypertension in an unselected prospective systemic sclerosis cohort. Vandecasteele E, Eur Respir J. 2017;49(5) Epub 2017 May 11.

[2]Evidence-based detection of pulmonary arterial hypertension in systemic sclerosis: the DETECT study, Coghlan et al. Ann Rheum Dis 2014;73:1340–1349. doi:10.1136/annrheumdis-2013-203301.

Disclosure of Interests

None declared

POS0540 CLINICAL OUTCOMES ASSOCIATED WITH GLUCOCORTICOID DISCONTINUATION AMONG PATIENTS WITH RHEUMATOID ARTHRITIS RECEIVING UPADACITINIB OR ADALIMUMAB

Background

Patients (pts) with rheumatoid arthritis (RA) are often administered glucocorticoids (GCs) as bridging therapy when initiating or adjusting disease-modifying antirheumatic drugs (DMARDs). Due to their systemic effects, short-term use of GCs at the lowest possible dose is recommended with rapid tapering.1

Objectives

We describe GC discontinuation patterns and the associated clinical outcomes in pts with RA receiving upadacitinib (UPA) or adalimumab (ADA).

Methods

SELECT-COMPARE is a randomized phase 3 trial of UPA vs placebo and ADA with a 48-week (wk) double-blind treatment period and a 10-year long-term extension in pts with RA receiving concomitant methotrexate (MTX) who had an inadequate response to MTX.2 Background GCs (≤10 mg/day prednisone or equivalent) were permitted and could be tapered or discontinued starting at wk 26 per physician discretion. This post hoc analysis included pts who received ≥1 dose of UPA 15 mg once daily or ADA 40 mg every other wk while on concomitant GCs at baseline. The proportion of pts with disease worsening (Clinical Disease Activity Index [CDAI] >2 and Disease Activity Score 28-joint count C-reactive protein [DAS28-CRP] >0.6) following GC discontinuation through follow-up is described. Maintenance of clinical response, including remission and low disease activity based on CDAI ≤2.8 and ≤10, respectively, as well as DAS28-CRP <2.6 and ≤3.2, were assessed among pts who discontinued GCs. Adverse events (AEs) were assessed before and after GC discontinuation through follow-up. Data were analyzed descriptively.

Results

Of 1,629 pts randomized, 978 (60%) used GCs at baseline; 128 (13%) discontinued use at/after wk 26 (UPA, n=97; ADA, n=31). Baseline demographics and clinical characteristics were broadly similar between pts who continued or discontinued GCs. Median follow-up time after GC discontinuation was 60 wks for UPA and 84 wks for ADA. At the time of GC discontinuation, a numerically higher proportion of pts treated with UPA vs ADA were in disease control (CDAI ≤2.8: 55% vs 32%; CDAI ≤10: 85% vs 68%; DAS28-CRP <2.6: 71% vs 48%; DAS28-CRP ≤3.2: 87% vs 62%) (Table 1). Few pts receiving UPA experienced disease worsening following GC discontinuation (1% CDAI increase >2; 7% DAS28-CRP increase >0.6) and none on ADA (Table 1). At 6 months follow-up after GC discontinuation, most pts treated with UPA and ADA maintained CDAI ≤2.8 (74% vs 88%) and ≤10 (92% vs 95%) and DAS28-CRP <2.6 (89% vs 85%) and ≤3.2 (91% vs 94%), respectively (Table 1). GCs were reintroduced (albeit usually temporarily) in 14% of pts on UPA and 19% on ADA (Figure 1). AEs were generally similar across treatment groups. Rates of serious infection before and after GC discontinuation were 0.8 (95% CI 0.0–4.2) and 1.5 (0.2–5.4) events per 100 patient-years (E/100 PY) for UPA and 7.7 (1.6–22.4) and 0 E/100 PY for ADA, respectively. Interpretation of results is limited by small pt numbers and different exposure times.

Table 1.

Clinical outcomes of pts who discontinued GCs at/after wk 26

n/N (%)Pts who discontinued GCs N=128UPAn=97ADAn=31CDAI≤10 at discontinuation79/93 (85%)21/31 (68%) Maintained at 6 months post discontinuationa61/66 (92%)18/19 (95%)≤2.8 at withdrawal51/93 (55%)10/31 (32%) Maintained at 6 months post discontinuationa32/43 (74%)7/8 (88%)Increase >2 any visit after withdrawal1/93 (1%)0DAS28-CRP≤3.2 at withdrawal78/90 (87%)18/29 (62%) Maintained at 6 months post discontinuationa58/64 (91%)15/16 (94%)<2.6 at withdrawal64/90 (71%)14/29 (48%) Maintained at 6 months post discontinuationa47/53 (89%)11/13 (85%)Increase >0.6 any visit after withdrawal6/92 (7%)0

aAs a proportion of pts achieving outcome at GC discontinuation and with observed data 6 months post GC discontinuation.

Conclusion

In pts who achieved disease control and discontinued GCs, disease control was maintained in almost all without worsening disease activity over time following GC discontinuation.

Conclusion

In pts who achieved disease control and discontinued GCs, disease control was maintained in almost all without worsening disease activity over time following GC discontinuation.

References

[1]Smolen JS, et al. Ann Rheum Dis. 2020;79:685–99.

[2]Fleischmann R, et al. Ann Rheum Dis. 2019;78:1454–62.

Acknowledgements

AbbVie funded this study and participated in the study design, research, analysis, data collection, interpretation of data, review, and approval of the publication. All authors had access to relevant data and participated in the drafting, review, and approval of this publication. No honoraria or payments were made for authorship. Medical writing assistance was provided by Julia Zolotarjova, MSc, MWC of AbbVie Inc.

Disclosure of Interests

Roy M. Fleischmann Consultant of: AbbVie, Amgen, BMS, Galvani, Gilead, GSK, Janssen, Eli Lilly, Novartis, Pfizer, and UCB, Grant/research support from: AbbVie, Amgen, Astra-Zeneca, BMS, Flexion, Galvani, Gilead, GSK, Janssen, Eli Lilly, Novartis, Noven, Pfizer, Samumed, Selecta, Teva, UCB, Viela, and Vorso., Bernard Combe Speakers bureau: AbbVie, BMS, Celltrion, Eli Lilly, Gilead-Galapagos, Janssen, Merck Sharp & Dohme, Novartis, Pfizer, and Roche-Chugai, Consultant of: AbbVie, BMS, Celltrion, Eli Lilly, Gilead-Galapagos, Janssen, Merck Sharp & Dohme, Novartis, Pfizer, and Roche-Chugai, Grant/research support from: Pfizer and Roche-Chugai, Andrew Ostor Consultant of: AbbVie, BMS, Eli Lilly, Gilead, Janssen, Novartis, Paradigm, Pfizer, Roche, and UCB., Cesar Francisco Pacheco Tena Consultant of: AbbVie, Astra-Zeneca, Eli Lilly, Gilead, Janssen, Pfizer, Roche, R-Pharm, Sanofi Regeneron, and UCB., Grant/research support from: AbbVie, Astra-Zeneca, Eli Lilly, Gilead, Janssen, Pfizer, Roche, R-Pharm, Sanofi Regeneron, and UCB., Nasser Khan Shareholder of: May own AbbVie stock or stock options, Employee of: AbbVie, Jessica Suboticki Shareholder of: May own AbbVie stock or stock options, Employee of: AbbVie, Anna Shmagel Shareholder of: May own AbbVie stock or stock options, Employee of: AbbVie, Yanna Song Shareholder of: May own AbbVie stock or stock options, Employee of: AbbVie, Ivan Lagunes-Galindo Shareholder of: May own AbbVie stock or stock options, Employee of: AbbVie, Gerd Rüdiger Burmester Speakers bureau: AbbVie, Eli Lilly, Galapagos, Gilead, Janssen, MSD, Pfizer, Roche, Sanofi, and UCB., Consultant of: AbbVie, Eli Lilly, Galapagos, Gilead, Janssen, MSD, Pfizer, Roche, Sanofi, and UCB.

Vector engineering, strategies and targets in cancer gene therapy

Understanding the molecular basis of disease and the design of rationally designed molecular therapies has been the holy grail in the management of human cancers. Gene-based therapies are an important avenue for achieving a possible cure. Focused research in the last three decades has provided significant clues to optimize the potential of cancer gene therapy. The development of gene therapies with a high potential to kill the target cells at the lowest effective dose possible, the development of vectors with significant ability to target cancer-associated antigen, the application of adjunct therapies to target dysregulated microRNA, and embracing a hybrid strategy with a combination of gene therapy and low-dose chemotherapy in a disease-specific manner will be pivotal. This article outlines the advances and challenges in the field with emphasis on the biology and scope of vectors used for gene transfer, newer targets identified, and their outcome in preclinical and clinical studies.

Cambridge hybrid closed-loop algorithm in children and adolescents with type 1 diabetes: a multicentre 6-month randomised controlled trial

BACKGROUND

Closed-loop insulin delivery systems have the potential to address suboptimal glucose control in children and adolescents with type 1 diabetes. We compared safety and efficacy of the Cambridge hybrid closed-loop algorithm with usual care over 6 months in this population.

METHODS

In a multicentre, multinational, parallel randomised controlled trial, participants aged 6-18 years using insulin pump therapy were recruited at seven UK and five US paediatric diabetes centres. Key inclusion criteria were diagnosis of type 1 diabetes for at least 12 months, insulin pump therapy for at least 3 months, and screening HbA1c levels between 53 and 86 mmol/mol (7·0-10·0%). Using block randomisation and central randomisation software, we randomly assigned participants to either closed-loop insulin delivery (closed-loop group) or to usual care with insulin pump therapy (control group) for 6 months. Randomisation was stratified at each centre by local baseline HbA1c. The Cambridge closed-loop algorithm running on a smartphone was used with either (1) a modified Medtronic 640G pump, Medtronic Guardian 3 sensor, and Medtronic prototype phone enclosure (FlorenceM configuration), or (2) a Sooil Dana RS pump and Dexcom G6 sensor (CamAPS FX configuration). The primary endpoint was change in HbA1c at 6 months combining data from both configurations. The primary analysis was done in all randomised patients (intention to treat). Trial registration ClinicalTrials.gov, NCT02925299.

FINDINGS

Of 147 people initially screened, 133 participants (mean age 13·0 years [SD 2·8]; 57% female, 43% male) were randomly assigned to either the closed-loop group (n=65) or the control group (n=68). Mean baseline HbA1c was 8·2% (SD 0·7) in the closed-loop group and 8·3% (0·7) in the control group. At 6 months, HbA1c was lower in the closed-loop group than in the control group (between-group difference -3·5 mmol/mol (95% CI -6·5 to -0·5 [-0·32 percentage points, -0·59 to -0·04]; p=0·023). Closed-loop usage was low with FlorenceM due to failing phone enclosures (median 40% [IQR 26-53]), but consistently high with CamAPS FX (93% [88-96]), impacting efficacy. A total of 155 adverse events occurred after randomisation (67 in the closed-loop group, 88 in the control group), including seven severe hypoglycaemia events (four in the closed-loop group, three in the control group), two diabetic ketoacidosis events (both in the closed-loop group), and two non-treatment-related serious adverse events. There were 23 reportable hyperglycaemia events (11 in the closed-loop group, 12 in the control group), which did not meet criteria for diabetic ketoacidosis.

INTERPRETATION

The Cambridge hybrid closed-loop algorithm had an acceptable safety profile, and improved glycaemic control in children and adolescents with type 1 diabetes. To ensure optimal efficacy of the closed-loop system, usage needs to be consistently high, as demonstrated with CamAPS FX.

FUNDING

National Institute of Diabetes and Digestive and Kidney Diseases.

Linking COVID-19 with Suicide: Suggestions for Future Research

COVID-19 has impacted the world socio-economically. Unemployment, poverty, social stigma, social isolation, domestic violence and mental illnesses are the notable social issues related to COVID-19 pandemic. Framed under a review based approach, the current study searches for the link between COVID-19 pandemic and an increased vulnerability to suicide across the globe. Linking the current situation with researched determinants of suicide shows that COVID-19 pandemic is exacerbating various socio-economic and psychological causes of suicide. In near future or even during the pandemic, suicide will be a key challenge for the public health sector across the globe. Besides, future research suggestions are given in light of the discussion in order to provide an impetus to researching the impact of the COVID-19 pandemic on suicide.

Phytochemical screening and evaluation of antioxidant, total phenolic and flavonoid contents in various weed plants associated with wheat crops

This study explores the antioxidant activity, phytochemical screening, total phenolic and flavonoids contents in the extracts of four locally available weeds plants namely Convolvulus arvensis, Chenopodium murale, Avena fatua and Phalaris minor with different solvents. The antioxidant activities of these extracts were determined via various in-vitro methods such as total antioxidant activity (TAA), reducing power (RP), DPPH (2,2-Diphenyl-1-Picrylhydrazyl) free radical scavenging and hydrogen peroxide scavenging assays. Phytochemical screening was performed both qualitatively as well as quantitatively. Total phenolic content (TPC) and total flavonoid content (TFC) were determined through Folin- Ciocalteu reagent and aluminium chloride methods respectively. Methanol-chloroform solvent showed the presence of a high amount of TPC in milligram of gallic acid equivalent per gram of dry weight (mg of GAE/g of DW) in the extracts of all weeds. Their descending sequence was Avena fatua (74.09) ˃ Phalaris minor (65.66) ˃ Chenopodium murale (64.04) ˃ Convolvulus arvensis (61.905), while, chloroform solvent found to be best solvent for the extraction of TFC. Methanol-chloroform solvent was also found to be best solvent for TAA (Total antioxidant activity assay) which showed values in milligram of ascorbic acid equivalent per gram of dry weight (mg of AAE /g of DW), for DPPH scavenging activity, reducing power (antioxidant activity) and hydrogen peroxide scavenging activity. Phytochemical screening indicated the presence of polyphenols, flavonoids, tannins, saponins, alkaloids and glycosides in these weeds.

Radiology of Castleman disease: the pivotal role of imaging in diagnosis, staging, and response assessment of this rare entity

Castleman Disease (CD) is a rare entity that typically presents as an enhancing nodal mass in the mediastinum or head and neck region on computed tomography (CT). It may manifest as unicentric or multicentric regions of lymph node enlargement. A key clinical issue in the context of CD is delayed diagnosis, which contributes adversely to patient outcome, given that accurate diagnosis facilitates earlier treatment of this curable disease. This article will address relevant imaging aspects, with reference to typical and atypical imaging features of CD, illustrated using examples from our specialist centre; the imaging journey for patients with CD; and will provide practical pointers to radiologists in differentiating CD from other benign and malignant causes of enhancing lymphadenopathy, including lymphoma and neoplastic adenopathy. We will also review current classification tools and staging challenges with reference to World Health Organization guidelines, International Working Group guidelines as well as the Lugano classification. Finally, we will discuss the potential role of additional imaging techniques in CD, highlighting novel imaging methods and expanded utilities from our specialist centre.

The association of preoperative dialysis with troponin trends and short term outcomes among advanced kidney disease patients undergoing coronary artery bypass grafting

Funding Acknowledgements

Type of funding sources: None.

Introduction

Coronary artery disease continues to be the leading cause of death in patients with stage IV-V chronic kidney disease (CKD IV-V). However, the prognosis and early outcomes for advanced CKD patients undergoing coronary artery bypass grafting (CAB) worsen as the estimated glomerular filtration rate (eGFR) deteriorates. Therefore, we compared postoperative clinical outcomes and troponin trends in patients having advanced CKD according to preoperative dialysis status in a single centre experience.

Methods

A total of 51 patients with CKD IV and V who underwent CAB between 2016-2021 were included in the study. Data on patient characteristics and postoperative outcomes were collected retrospectively, and independently for our Society of Thoracic Surgeons database. Characteristics were compared between patients having CKD IV vs. CKD V. The differences in postoperative cardiac troponin trends and outcomes were evaluated between patients who did vs. did not undergo preoperative dialysis. The statistical analysis was conducted applying appropriate parametric or non-parametric (for skewed variables) testing methods, and a p value &lt; 0.05 was considered to be statistically significant.

Results

47% (24) of subjects had CKD IV, while the rest featured CKD V. Patients with CKD IV tended to be older (61.8 ± 9.2 vs. 56.3 ± 11.5 years, p = 0.07), more obese (BMI: 31.4 ± 6.8, 27.4 ± 4.9 kg/m2, p = 0.02) and had significantly higher preoperative GFR (23 ± 4.9 vs. 9 ± 3.3 mL/min, p &lt; 0.001) (Table.1). When comparing patients who underwent preoperative dialysis vs. those who did not, troponin levels were the highest at 18h postoperative in both groups, however, troponin levels were comparable between both groups at all time points (Table.2). Although, there was no difference in hospital length of stay and mortality between these groups, patients who did not undergo preoperative dialysis had longer intensive care unit length of stay (ICU LOS).

Conclusion

In this single centre experience preoperative dialysis was not associated with a significant difference in trends of postoperative cardiac enzymes. Although preoperative dialysis was associated with shorter ICU LOS, complex pre-procedural surgical risk assessment remains paramount in reducing complications and mortality in this high-risk population. Abstract Figure.  Abstract Figure.

A randomised controlled trial of a novel tramadol chewable tablet: pharmacokinetics and tolerability in children

Tramadol is a bitter atypical opioid analgesic drug and is prescribed to treat postoperative pain in children. However, in many countries there is no licensed paediatric tramadol formulation available. We have formulated a novel chewable chocolate-based drug delivery system for the administration of tramadol to children. This pilot, single-centre, open-label, randomised clinical study assessed the taste tolerability and comparative population pharmacokinetics of the novel tramadol chewable tablet against a compounded tramadol hydrochloride oral liquid, at a dose of 1 mg.kg^-1 . A 5-point facial hedonic scale was used by the children, parents and nurses to assess tolerability. One hundred and forty-one children aged 3-16 years were given tramadol 30 min before general anaesthesia. Blood samples were taken following the induction of anaesthesia and for up to 5 h following tramadol administration. Tramadol and its active metabolite O-desmethyltramadol were analysed using reversed-phase high-performance liquid chromatography. A population pharmacokinetic model was built using non-linear mixed effects modelling. The relative bioavailability for the tablet was 1.25 times higher (95%CI 1.16-1.35) than for tramadol hydrochloride oral liquid, while the absorption rate constant for the tablet was significantly lower (1.97 h^-1 vs. 3.34 h^-1 , p < 0.001). Larger inter-individual variability in absorption rates were observed with the liquid tramadol. The tramadol chewable tablet was more acceptable in taste to children when assessed by the children, parents and nurses (all p < 0.001). We conclude that the novel tramadol chewable tablet has favourable acceptability and more reliable relative bioavailability in children compared with tramadol hydrochloride oral liquid.

Sublethal toxicity of carbofuran in cattle egret (Bubulcus ibis coromandus): hematological, biochemical, and histopathological alterations

This study was aimed to investigate Carbofuran (CF)-induced pathological changes in cattle egret. Two hundred cattle egrets were reared and equally divided into four groups and given different CF concentrations (0.03 mg/L, 0.02 mg/L, 0.01 mg/L and 0 mg/L (control group)). Hematology, serum biochemistry, histopathology, and immunological markers were studied. Our results confirm that CF induces anemic conditions, leukocytosis, elevated liver enzymatic activity, and alterations in renal biomarkers. Moreover, specific microscopic lesions such as multifocal necrosis, pyknotic nuclei, hemorrhages, congestion, and inflammatory cell proliferation were observed in the liver, kidney, spleen, and thymus. These findings suggest that CF can induce harmful effects, so the application of this pesticide in the field must be strictly monitored to mitigate the possibility of exposure to non-target species.

Environmental sustainability assessment of wooden furniture produced in Pakistan

Life cycle assessment was carried out for a conventional wooden furniture set produced in Mardan division of the Khyber Pakhtunkhwa province of Pakistan during 2018-19. Primary data regarding inputs and outputs were collected through questionnaire surveys from 100 conventional wooden furniture set manufacturers, 50 in district Mardan and 50 in district Swabi. In the present study, cradle-to-gate life cycle assessment approach was applied for a functional unit of one conventional wooden furniture set. Production weighted average data were modelled in the environmental impacts modelling software i.e., SimaPro v.8.5. The results showed that textile used in sofa set, wood preservative for polishing and preventing insects attack and petrol used in generator had the highest contribution to all the environmental impact categories evaluated. Total cumulative energy demand for wooden furniture set manufactured was 30,005 MJ with most of the energy acquired from non-renewable fossil fuel resources.

Vitamin K Deficiency in the Setting of Blenderized Tube Feeding Regimen in a Teenager: A Case Report

Vitamin K acts a cofactor for the gamma-carboxylation of several proteins in the coagulation cascade. The clinical spectrum of vitamin K deficiency (VKD) can be asymptomatic to a significant bleeding. VKD is classically seen in newborns. However, this can manifest later in patients with risks such as sub-optimal nutrition, fat malabsorption, medications including antibiotics. A 17-year-old male with spinal muscular atrophy (SMA) Type 1, tracheostomy with ventilator dependent, gastrostomy tube feeding was seen by the gastroenterologist following treatment for small intestinal bacterial overgrowth (SIBO). Investigations showed coagulopathy following which he was transferred to the Pediatric ICU. Labs revealed prothrombin time (PT) 114 s [Normal 9.4-12.5 s], INR (International normalized ratio) 12.6 [Normal < 1.1] and partial thromboplastin time (PTT) 90 s [Normal 25.1-36.5 s]. Mixing studies and coagulation assays were consistent with VKD (low Factor VII and Factor IX with normal Factor V). His home blenderized feeding regimen met the caloric requirement but not the adequate intake (AI) values for vitamin K and other minerals. He received intravenous vitamin K (phytonadione) for five consecutive days with resolution of the coagulopathy (PT 13.2 s, PTT 37.1 s, INR 1.2). The patient was discharged on enteral vitamin K and additional supplements following dietary review by a nutritionist. Clinicians should be cognizant of VKD in patients on blenderized tube feeds which may not meet the adequate intake (AI) goals. In patients who are not receiving nutritionally complete formulas or receiving inadequate volumes, it is important to monitor macro and micronutrients.

Assessment of initial vancomycin trough levels and risk factors of vancomycin-induced nephrotoxicity in neonates

OBJECTIVES

Vancomycin is a glycopeptide antibiotic commonly used in neonatal intensive care units (NICUs) to treat late onset sepsis. It is recommended that vancomycin trough levels at steady state following intermittent dosing regimen be maintained at 10-20 mg/L, which is largely dependent on the type of infection. Our objective is to assess the ability of initial vancomycin dosing regimens to obtain target trough levels and to assess the percentage and risk factors associated with the development of acute kidney injury (AKI) while on vancomycin.

METHODS

This is a retrospective review of all NICU patients admitted between January 2016 and December 2017 who received vancomycin according to the NeoFax at either 10 mg/kg/dose (low-dose group, LDG) or 15 mg/kg/dose (high-dose group, HDG), with a frequency based on the postmenstrual age (PMA) and postnatal age (PNA). Both regimens were compared by their ability to attain target trough levels and the episodes of vancomycin-induced AKI. Other outcomes included identification of risk factors associated with the development of vancomycin-induced nephrotoxicity.

RESULTS

Of 182 patients evaluated, 44 (24%) were in the LDG and 138 patients (76%) were in the HDG. Ninety-one patients (50%) attained target trough levels of 10-20 mg/L. Among these and according to patients' PMA, 48% in the HDG versus 7% in the LDG in PMA ≤29 weeks and 69% in the HDG versus 18% in the LDG in PMA 30-36 weeks attained target trough levels (p=0.006 and p<0.001, respectively). According to PNA, 47% in the HDG versus none in the LDG in patients <7 days old and 61% in the HDG versus 10% in the LDG in patients aged 8-14 days attained target trough levels (p=0.025 and p=0.016, respectively). A total of 14% developed AKI in the LDG vs 7% in the HDG (p=0.225). Only PMA ≤29 weeks (OR, 4.5, 95% CI 1.5 to 13), vancomycin trough levels >20 mg/L (OR 5.1, 95% CI 1.5 to 17), hypotension (OR 11.02, 95% CI 3.5 to 34) and furosemide (OR 4.4, 95% CI 1.4 to 13.5) were significantly associated with vancomycin-induced AKI in our NICU.

CONCLUSION

Vancomycin dosing in neonates according to the NeoFax did not provide sufficient attainment of target trough levels (10-20 mg/L). However, using the higher dosing range at 15 mg/kg/dose was more likely to reach target levels, with no measured increased risk of nephrotoxicity. Extreme premature neonates, supratherapeutic vancomycin trough levels, hypotension and furosemide use are associated with an increased incidence of vancomycin-induced nephrotoxicity.

Performance evaluation of the commercial aquafeeds available in the market of Pakistan on Channa marulius (Sole)

The present study aimed to determine the effect of different levels of protein on the growth, body composition, amino acid profile and serology of Channa marulius fingerlings. The experiment was conducted in ten happas installed in earthen ponds, each stocked with 10 fishes for 90 days. Four commercial fish feeds having 25%, 30%, 32% and 40% crude protein (CP) levels were fed to fish at 3% of their wet body weight three times a day. The results of the study revealed that highest weight gain, feed conversion ratio and survival rate were observed in 30% protein feed. Meanwhile, moisture content was higher in fish fed with 30% CP feed while highest crude protein was recorded in 40% CP fed fish. Lowest fat content was observed in 32% CP feed. Amino acid profile of fish revealed better results in 30% CP feed. Total protein, glucose and globulin were also highest in fish feeding 30% CP feed, while albumin was highest in 40% CP feed. It is concluded that 30% CP feed showed better results in terms of growth, amino acid profile and serological parameters without effecting fish body composition.

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

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

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

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

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

Background

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

Purpose

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

Methods

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

Results

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

Conclusion

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

Funding Acknowledgement

Type of funding sources: None.

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

Introduction

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

Method

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

Results

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

Conclusions

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

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

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

Implementation of a pooled surveillance testing program for asymptomatic SARS-CoV-2 infections in K-12 schools and universities

BACKGROUND

The negative impact of continued school closures during the height of the COVID-19 pandemic warrants the establishment of cost-effective strategies for surveillance and screening to safely reopen and monitor for potential in-school transmission. Here, we present a novel approach to increase the availability of repetitive and routine COVID-19 testing that may ultimately reduce the overall viral burden in the community.

METHODS

We implemented a testing program using the SalivaClear࣪ pooled surveillance method that included students, faculty and staff from K-12 schools (student age range 5-18 years) and universities (student age range >18 years) across the country (Mirimus Clinical Labs, Brooklyn, NY). The data analysis was performed using descriptive statistics, kappa agreement, and outlier detection analysis.

FINDINGS

From August 27, 2020 until January 13, 2021, 253,406 saliva specimens were self-collected from students, faculty and staff from 93 K-12 schools and 18 universities. Pool sizes of up to 24 samples were tested over a 20-week period. Pooled testing did not significantly alter the sensitivity of the molecular assay in terms of both qualitative (100% detection rate on both pooled and individual samples) and quantitative (comparable cycle threshold (Ct) values between pooled and individual samples) measures. The detection of SARS-CoV-2 in saliva was comparable to the nasopharyngeal swab. Pooling samples substantially reduced the costs associated with PCR testing and allowed schools to rapidly assess transmission and adjust prevention protocols as necessary. In one instance, in-school transmission of the virus was determined within the main office and led to review and revision of heating, ventilating and air-conditioning systems.

INTERPRETATION

By establishing low-cost, weekly testing of students and faculty, pooled saliva analysis for the presence of SARS-CoV-2 enabled schools to determine whether transmission had occurred, make data-driven decisions, and adjust safety protocols. We provide strong evidence that pooled testing may be a fundamental component to the reopening of schools by minimizing the risk of in-school transmission among students and faculty.

FUNDING

Skoll Foundation generously provided funding to Mobilizing Foundation and Mirimus for these studies.

Implementation of a pooled surveillance testing program for asymptomatic SARS-CoV-2 infections in K-12 schools and universities

BACKGROUND

The negative impact of continued school closures during the height of the COVID-19 pandemic warrants the establishment of cost-effective strategies for surveillance and screening to safely reopen and monitor for potential in-school transmission. Here, we present a novel approach to increase the availability of repetitive and routine COVID-19 testing that may ultimately reduce the overall viral burden in the community.

METHODS

We implemented a testing program using the SalivaClear࣪ pooled surveillance method that included students, faculty and staff from K-12 schools (student age range 5-18 years) and universities (student age range >18 years) across the country (Mirimus Clinical Labs, Brooklyn, NY). The data analysis was performed using descriptive statistics, kappa agreement, and outlier detection analysis.

FINDINGS

From August 27, 2020 until January 13, 2021, 253,406 saliva specimens were self-collected from students, faculty and staff from 93 K-12 schools and 18 universities. Pool sizes of up to 24 samples were tested over a 20-week period. Pooled testing did not significantly alter the sensitivity of the molecular assay in terms of both qualitative (100% detection rate on both pooled and individual samples) and quantitative (comparable cycle threshold (Ct) values between pooled and individual samples) measures. The detection of SARS-CoV-2 in saliva was comparable to the nasopharyngeal swab. Pooling samples substantially reduced the costs associated with PCR testing and allowed schools to rapidly assess transmission and adjust prevention protocols as necessary. In one instance, in-school transmission of the virus was determined within the main office and led to review and revision of heating, ventilating and air-conditioning systems.

INTERPRETATION

By establishing low-cost, weekly testing of students and faculty, pooled saliva analysis for the presence of SARS-CoV-2 enabled schools to determine whether transmission had occurred, make data-driven decisions, and adjust safety protocols. We provide strong evidence that pooled testing may be a fundamental component to the reopening of schools by minimizing the risk of in-school transmission among students and faculty.

FUNDING

Skoll Foundation generously provided funding to Mobilizing Foundation and Mirimus for these studies.

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

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

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

Background:

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

Objectives:

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

Methods:

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

Results:

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

Table 1.

Pts with potentially clinically significant laboratory changes

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

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

ULN, upper limit of normal

Conclusion:

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

References:

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

Acknowledgements:

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

Disclosure of Interests:

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