Aerosol drug therapy in critically ill patients (Aero-in-ICU study): A multicentre prospective observational cohort study

BACKGROUND

In recent years, a significant understanding of delivering optimal aerosol therapy and the availability of various drugs and devices have led to an increase in its use in clinical practice. There are only a few studies available regarding their use in critically ill patients from a few parts of the world. We aimed to study the practice pattern of aerosol therapy in critically ill patients from Indian intensive care units (ICUs).

METHODS

After ethical approval, this multi-centric prospective observational study was performed over a study period of four weeks. Newly admitted adult patients considered who had an artificial airway and/or ventilation (including non-invasive). Patients were followed up for the next 14 days or until ICU discharge/death (whichever came first) for details of each aerosol therapy, including ongoing respiratory support, drug type, and aerosol-generating device.

RESULTS

From the nine participating centers across India, 218 patients were enrolled. Of 218 enrolled patients, 72.48% received 4884 aerosols with 30.91 ± 27.15 (95%CI: 26.6-35.1) aerosols per patient over 1108 patient days. Approximately 62.7% during IMV, 30.2% during NIV, 2.3% in spontaneously breathing patients with an artificial airway during weaning, and 4.7% were given without an artificial airway after weaning or decannulation. In 59%, a single drug was used, and bronchodilators were the most frequent. The jet nebulizer was the most common, followed by the ultrasonic and vibrating mesh aerosol generator. The ventilator setting was changed in only 6.6% of the aerosol sessions with IMV and none with NIV.

CONCLUSION

Aerosol therapy is frequently used with a wide variation in practices; bronchodilators are the most commonly used drugs, and jet nebulizers are the most widely used.

Evaluation of Diagnostic Performance of Line Probe Assay on Smear-Negative Samples of Pulmonary Tuberculosis

BACKGROUND

This study aims to compare the performance of line probe assay (LPA) on smear-negative samples with that of smear-positive samples for diagnosing pulmonary tuberculosis (PTB) and first-line drug sensitivity testing (FL DST).

METHODS

A total of 196 sputum samples including both smear-positive (112) and negative (84) samples of patients suspected of PTB were subjected to LPA for TB detection and FL DST. TB culture followed by MPT 64 Ag was done and conventional FL DST was performed on all culture-positive isolates. Results of LPA on smear-negative were compared with smear-positive samples.

RESULTS

The LPA confirmed the diagnosis of PTB in 104/112 smear-positive cases but in only 36/84 smear-negative cases. The assay had 47.36%, 72.72%, and 88.88% sensitivity and 86.96%, 95.23%, and 95.65% specificity in smear-negative cases compared to 89.09%, 95.83%, and 98.07% sensitivity and 100%, 98.36%, and 98.24% specificity in smear-positive cases for detecting Mycobacterium tuberculosis (MTB), rifampicin (RMP) resistance, and isoniazid (INH) resistance, respectively.

CONCLUSION

LPA performance was better on smear-positive than smear-negative sputum samples. Further larger studies are needed to justify the use of LPA on smear-negative pulmonary samples for diagnosis.

Remifentanil for tracheal intubation without neuromuscular blocking drugs in adult patients: a systematic review and meta-analysis

There is increasing interest in the use of short-acting opioids such as remifentanil to facilitate tracheal intubation. The aim of this systematic review was to determine the efficacy and safety of remifentanil for tracheal intubation compared with neuromuscular blocking drugs in adult patients. We conducted a systematic search for randomised controlled trials evaluating remifentanil for tracheal intubation. Primary outcomes included tracheal intubation conditions and adverse events. Twenty-one studies evaluating 1945 participants were included in the analysis. Use of remifentanil (1.5-4.0 μg.kg-1 ) showed no evidence of a difference in tracheal intubation success rate compared with neuromuscular blocking drugs (risk ratio (95%CI) 0.97 (0.94-1.01); six studies; 1232 participants; I2 28%; p = 0.16; moderate-certainty evidence). Compared with neuromuscular blocking drugs, the use of remifentanil (2.0-4.0 μg.kg-1 ) makes little to no difference in terms of producing excellent tracheal intubation conditions (risk ratio (95%CI) 1.16 (0.72-1.87); two studies; 121 participants; I2 31%, p = 0.54; moderate-certainty of evidence). There was no evidence of an effect between remifentanil (2.0-4.0 μg.kg-1 ) and neuromuscular blocking drugs for bradycardia (risk ratio (95%CI) 0.44 (0.01-13.90); two studies; 997 participants; I2 81%; p = 0.64) and hypotension (risk ratio (95%CI) 1.05 (0.44-2.49); three studies; 1071 participants; I2 92%; p = 0.92). However, the evidence for these two outcomes was judged to be of very low-certainty. We conclude that remifentanil may be used as an alternative drug for tracheal intubation in cases where neuromuscular blocking drugs are best avoided, but more studies are required to evaluate the haemodynamic adverse events of remifentanil at different doses.

Silent choker: Unveiling tracheal stenosis as an atypical manifestation of mucormycosis

Airway mucormycosis is a fatal opportunistic infection typically seen in immunocompromised individuals. In this case report, we present an unusual instance of tracheal stenosis in a patient with diabetes mellitus who had recently recovered from coronavirus 2019 (COVID-19). Our patient was a 69-year-old male with poorly controlled type-II diabetes mellitus, on oral hypoglycemic agents, who had successfully completed treatment for COVID-19. Approximately one month later, he developed a cough, fever and breathlessness. Several factors, including advanced age, history of smoking and tobacco chewing, the nodular appearance of the trachea on bronchoscopy, hypermetabolic wall of the trachea on positron emission tomography scan and dysplasia on biopsy, initially raised suspicion of malignancy. However, repeated biopsies from multiple sites confirmed the diagnosis of tracheal mucormycosis. The patient was treated with amphotericin-B and posaconazole. We extensively reviewed the literature and found only 14 reported cases to discuss compared to ours.

Is scolding analogous to positive end-expiratory pressure (PEEP)?

N/A

Clinical and ultrasonographic assessment of airway indices among non-pregnant, normotensive pregnant and pre-eclamptic patients: a prospective observational study

BACKGROUND

Prediction of a difficult airway is of paramount importance for an anaesthesiologist. Various anatomical and physiological factors contribute to a difficult airway in pregnant females, especially those with pre-eclampsia. The aim of the study was to assess airway indices using both routinely used clinical methods and ultrasound.

METHODS

Fifty-five non-pregnant females, 55 normotensive pregnant females and 55 females with pre-eclampsia were included in this prospective study. Clinical airway assessment was the modified Mallampati score, thyromental distance, hyomental distance, hyomental distance ratio, chest circumference, neck circumference and chest-to-neck circumference ratio. Sonographic assessment included tongue width, tongue volume, anterior neck soft tissue thickness at the level of hyoid, epiglottis and vocal cords, subglottic diameter, ratio of pre-epiglottic space to anterior, posterior and midpoint of anterior and posterior vocal folds.

RESULTS

Several significant differences were observed between pregnant and non-pregnant females, with additional changes in pre-eclamptic females. These included clinical parameters such as the modified Mallampati score and sonographic measurements of tongue width, tongue volume, subglottic diameter, anterior neck soft tissue thickness at the level of hyoid, epiglottis and vocal cords, and the ratio of pre-epiglottic space to anterior, posterior and midpoint of anterior and posterior vocal folds.

CONCLUSION

Routinely used clinical methods of airway assessment lack sensitivity and specificity. Ultrasound can visualise anatomical structures in the supraglottic and subglottic views and is encouraging as an airway assessment tool.

'Vaccinate my village' strategy in Malawi: an effort to boost COVID-19 vaccination

OBJECTIVES

To boost COVID-19 vaccine uptake, an innovative 'vaccinate my village' (VMV) strategy using door-to-door vaccination by Health Surveillance Assistants (HSA) was adopted. In this study, we assessed the impact of the 'vaccinate my village' strategy on COVID-19 vaccine uptake.

METHODS

This was a cross-sectional review of the data on COVID-19 vaccination obtained from the Ministry of Health, Malawi, from 11 March 2021 to September 2022.

RESULTS

From March 2021-4 September 2022,091,551 COVID-19 vaccine doses were administered, out of which 2,253,546 were administered over just six months as a part of VMV as compared to 1,838,005 doses were administered over 13 months as a part of other strategies. The proportion of Malawi's population receiving at least one dose of the COVID-19 vaccine increased substantially from 4.66 to 15.4 with the implementation of the VMV strategy (p = 0.0001). District-wise coverage of the COVID-19 vaccine also increased significantly after its implementation (p = 0.0001).

CONCLUSIONS

Door-to-door vaccination involving HSAs benefitted the COVID-19 vaccination program in Malawi by ensuring accessibility, availability, and acceptability.

Key lessons learned from the immunization supply chain of Malawi, an African country using EVM2.0

Objectives

A country’s immunization system's effectiveness depends on its supply chain's efficacy. To assess the challenges of maintaining an efficient vaccine supply chain, Malawi conducted its assessment using The EVM2.0 tool (Effective Vaccine Management).

Methods

It is a cross-sectional study in which all EVM requirements were assessed between September and October 2021. Data were collected from eighty-two randomly selected sites using the site selection tool of the EVM. Data were entered into the EVM assessment tool 2.0 version 1.12 for analysis. This tool generates performance indicators and criteria scores for assessed sites, compared with a WHO minimum score of 80%.

Results

Overall criteria scores across all levels of the immunization supply chain showed a statistically significant mean difference of 5.92 (t = 2.58, P = 0.02). Comparative overall mean criteria scores across different levels of the immunization supply chain showed no statistically significant difference for primary (p = 0.76), sub-national (p = 0.69), and lowest distribution stores (p = 0.12). However, a substantial gap was found in the overall mean scores of the health facility’s service point (SP) (t = 4.12, P = 0.001). The overall category scores across all immunization supply chain levels did not show a statistically significant difference. However, among individual category scores, Infrastructure (76 %), Equipment (67 %), Policies and procedures (62 %), Financial (47 %), and Resources (64 %) were found to be below the WHO minimum score.

Conclusion

Though the 2021 Malawi EVM assessment findings are promising, they still identified the gaps to be improved to ensure the vaccine availability in the right amount, at the right time, and at the right cost.

The 50-Year Journey of Lung Cancer Screening: A Narrative Review

Early diagnosis and treatment are associated with better outcomes in oncology. We reviewed the existing literature using the search terms “low dose computed tomography” and “lung cancer screening” for systematic reviews, metanalyses, and randomized as well as non-randomized clinical trials in PubMed from January 1, 1963 to April 30, 2022. The studies were heterogeneous and included people with different age groups, smoking histories, and other specific risk scores for lung cancer screening. Based on the available evidence, almost all the guidelines recommend screening for lung cancer by annual low dose CT (LDCT) in populations over 50 to 55 years of age, who are either current smokers or have left smoking less than 15 years back with more than 20 to 30 pack-years of smoking. “LDCT screening” can reduce lung cancer mortality if carried out judiciously in countries with adequate resources and infrastructure.

COVID-19 vaccine express strategy in Malawi: An effort to reach the un-reach

Objectives

To establish the impact of “Covid-19 Vaccination express” (CVE) on vaccine uptake in Malawi

Design

Retrospective cross-sectional study to compare the daily vaccine administration rate in CVE and routine covid vaccination (RCV). RCV data was collected from March 2021 to October 2021. The data regarding CVE was collected from 5 November 2021 to 31 December 2021. Data was collected regarding (1) the total number and type of vaccine doses administered and (2) Demographic details like age, gender, occupation, presence of comorbidities, the first dose, or the second dose of the people who received a vaccine.

Results

From March-December 2021, a total of 1,866,623 COVID-19 vaccine doses were administered, out of which 1,290,145 doses were administered at a mean daily vaccination rate of 1854 (95% CI: 1292-2415) doses as a part of RCV, and 576,478 doses were administered at a mean daily vaccination rate of 3312 (95% CI: 2377-4248) doses as a part of CVE.

Comparing the mean daily doses (Astra Zeneca, AZ doses 1 & 2) administered in the CVE and RCV showed that the mean daily doses of AZ vaccine administered were significantly higher in the CVE (p<0.05).

Conclusion

CVE successfully increased the uptake of the Covid-19 vaccine.

LB0004 EFFICACY AND SAFETY OF DEUCRAVACITINIB, AN ORAL, SELECTIVE, ALLOSTERIC TYK2 INHIBITOR, IN PATIENTS WITH ACTIVE SYSTEMIC LUPUS ERYTHEMATOSUS: A PHASE 2, RANDOMIZED, DOUBLE-BLIND, PLACEBO-CONTROLLED STUDY

Background

Tyrosine kinase 2 (TYK2) mediates signaling of Type I interferons, IL-23, and IL-12, key cytokines involved in lupus pathogenesis. Deucravacitinib (DEUC) is an oral, selective, allosteric TYK2 inhibitor with a unique mechanism of action, distinct from Janus kinase (JAK) 1/2/3 inhibitors, and has shown efficacy in psoriasis and psoriatic arthritis.

Objectives

Assess efficacy and safety of DEUC in patients with active systemic lupus erythematosus (SLE).

Methods

This was a 48-week (wk), randomized, double-blind, placebo (PBO)-controlled, phase 2 trial (NCT03252587). Eligible patients met SLICC criteria, were seropositive (ANA/anti-dsDNA/anti-Sm), and had a SLEDAI-2K score ≥6 and ≥1 BILAG index A or >2 BILAG B manifestations from the musculoskeletal or mucocutaneous domain. Patients on standard background medications were randomized 1:1:1:1 to PBO or DEUC (3 mg BID, 6 mg BID, 12 mg QD). Oral corticosteroid tapering to 7.5 mg/day was required from wks 8-20; further tapering was optional from wks 32-40. The primary endpoint was the proportion of patients achieving SRI(4) at wk 32. Key secondary endpoints at wk 48 included SRI(4), BICLA, LLDAS, CLASI-50, and change from baseline in active (tender and swollen) joint count.

Results

A total of 363 patients were randomized, with baseline demographic and disease characteristics similar across treatment groups. Of randomized patients, 275 (76%) completed 48 wks of treatment. The primary endpoint at wk 32 was met, with significantly greater proportion of patients in DEUC 3 mg BID and 6 mg BID groups vs PBO achieving SRI(4) responses (PBO: 34.4%; DEUC 3 mg BID: 58.2%, P=0.0006; DEUC 6 mg BID: 49.5%, P=0.021; DEUC 12 mg QD: 44.9%, P=0.078). SRI(4) response was sustained across all DEUC groups up to 48 wks (Figure 1). At wk 48, the DEUC 3 mg BID group demonstrated statistical significance in BICLA, LLDAS, CLASI-50, and active joint count, and the two other DEUC groups demonstrated clinically meaningful differences vs PBO (Figure 1). Rates of adverse events (AEs), serious AEs, and AEs of interest were similar between DEUC and PBO groups (Table 1). Most common AEs (≥10%) with DEUC were upper respiratory tract infection, nasopharyngitis, headache, and urinary tract infection. No deaths, major cardiac events, thrombotic events, systemic opportunistic infections, or active tuberculosis occurred. Malignancies were rare with similar rates across all groups. No meaningful abnormalities in mean levels of hematology and chemistry laboratory parameters were observed.

Table 1.

Summary of Adverse Events Through Week 48

AE, na(%)Placebo n = 90DEUC 3 mg BID n = 91DEUC 6 mg BID n = 93DEUC 12 mg QD n = 89AE79 (87.8)85 (93.4)81 (87.1)75 (84.3)SAE11 (12.2)7 (7.7)8 (8.6)7 (7.9)AEs leading to treatment discontinuation3 (3.3)8 (8.8)6 (6.5)11 (12.4)Skin-related AEsb12 (13.3)15 (16.5)32 (34.4)30 (33.7)Overall infections/infestations48 (53.3)60 (65.9)60 (64.5)45 (50.6)Serious infections/infestations1 (1.1)1 (1.1)2 (2.2)1 (1.1)Infections of interest Tuberculosis0000 Herpes zosterc4 (4.4)3 (3.3)3 (3.2)2 (2.2) Influenza1 (1.1)3 (3.3)1 (1.1)3 (3.4) COVID-193 (3.3)3 (3.3)5 (5.4)3 (3.4)Malignancy events1 (1.1)d1 (1.1)e01 (1.1)fMACE0000Thrombotic events0000

an is the number of patients who experienced an event. bIncludes (≤8.6% in any arm) acne, rash, dermatitis acneiform, pruritus, skin lesion, urticaria. cIncludes herpes zoster, herpes ophthalmic, genital herpes zoster. dBasal cell carcinoma. eBreast carcinoma. fVaginal squamous cell carcinoma.

AE, adverse event; COVID-19, coronavirus disease 2019; DEUC, deucravacitinib; MACE, major adverse cardiac events; SAE, serious adverse event.

Conclusion

In patients with active SLE, DEUC showed statistically significant and sustained clinical efficacy in SRI(4), improvement across multiple composite and organ-specific measures up to 48 wks, and was well tolerated. DEUC shows promise as a novel therapy for SLE and warrants further investigation in phase 3 trials.

Acknowledgements

This study was sponsored by Bristol Myers Squibb. Professional medical writing assistance was provided by Julianne Hatfield, PhD at Peloton Advantage, LLC, an OPEN Health company, Parsippany, NJ, USA, and funded by Bristol Myers Squibb. The authors acknowledge Christina Crater, MD, who was employed by Bristol Myers Squibb at the time the study was conducted, for contributions to study conduct.

Disclosure of Interests

Eric Morand Consultant of: AstraZeneca, Bristol Myers Squibb, Biogen, Eli Lilly, EMD Serono, Genentech, Servier, and Novartis , Grant/research support from: AbbVie, Amgen, AstraZeneca, Bristol Myers Squibb, Biogen, Eli Lilly, EMD Serono, Genentech, Janssen, and UCB , Marilyn Pike Consultant of: AstraZeneca, Bristol Myers Squibb, and Pfizer, Joan T. Merrill Consultant of: UCB, GlaxoSmithKline, AbbVie, EMD Serono, Remegen, Celgene/Bristol Myers Squibb, AstraZeneca, Amgen, Janssen, Lilly, Genentech, Aurinia, Astellas, Alexion, Sanofi, Zenas, and Provention , Grant/research support from: GlaxoSmithKline and AstraZeneca , Ronald van Vollenhoven Consultant of: UCB, Pfizer, AbbVie, AstraZeneca, Biogen, Biotest, Celgene, Galapagos, Gilead, Janssen, Servier, Paid instructor for: Roche, Pfizer, Speakers bureau: UCB, Pfizer, AbbVie, Galapagos, Janssen, Grant/research support from: Bristol Myers Squibb, GlaxoSmithKline, Eli Lilly, UCB, , Victoria P. Werth Consultant of: Celgene, Medimmune, Resolve, Genentech, Idera, Janssen, Lilly, Biogen, Bristol Myers Squibb, Gilead, Amgen, Medscape, Nektar, Incyte, EMD Serono, CSL Behring, Principia, Crisalis, Viela Bio, Argenx, Kirin, AstraZeneca, AbbVie, GSK, AstraZeneca, Cugene, UCB, Corcept, Beacon Bioscience , Grant/research support from: Celgene, Janssen, Biogen, Gilead, AstraZeneca, Viela, Amgen, Lupus Research Alliance/BMS , Coburn Hobar Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Nikolay Delev Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Vaishali Shah Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Brian Sharkey Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Thomas Wegman Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Ian Catlett Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Subhashis Banerjee Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Shalabh Singhal Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb

POS0198 EFFICACY AND SAFETY OF DEUCRAVACITINIB, AN ORAL, SELECTIVE TYROSINE KINASE 2 INHIBITOR, IN PATIENTS WITH ACTIVE PSORIATIC ARTHRITIS: RESULTS FROM A PHASE 2, RANDOMIZED, DOUBLE-BLIND, PLACEBO-CONTROLLED TRIAL

Background:

Tyrosine kinase 2 (TYK2) is an intracellular kinase that mediates signaling by key cytokines involved in psoriatic arthritis (PsA) and plaque psoriasis (PsO) pathogenesis. Deucravacitinib is a novel oral agent that selectively inhibits TYK2 via an allosteric mechanism by binding to the nonconserved regulatory domain of the kinase. A previous Phase 2 trial in PsO had demonstrated that deucravacitinib was efficacious and well tolerated, with no laboratory abnormalities observed.

Objectives:

To evaluate the efficacy and safety of deucravacitinib in active PsA.

Methods:

This is an ongoing, 1-year, randomized, double-blind, placebo (PBO)-controlled (initial 16 weeks), multiregional, Phase 2 trial (NCT03881059). Eligible patients had a PsA diagnosis for ≥6 months, met CASPAR criteria, and had active disease with ≥3 tender and ≥3 swollen joints, C-reactive protein ≥3 mg/L (ULN, 5 mg/L), and ≥1 psoriatic lesion (≥2 cm). Patients had failed or were intolerant to ≥1 nonsteroidal anti-inflammatory drug, corticosteroid, conventional synthetic disease-modifying antirheumatic drug (csDMARD), and/or 1 TNF inhibitor (TNFi; ≤30%). Patients were randomized 1:1:1 to deucravacitinib 6 mg once daily (QD) or 12 mg QD, or PBO. The primary endpoint was achievement of ACR 20 response at Week 16. Additional endpoints included the proportion of patients achieving ACR 50/70 response, Health Assessment Questionnaire-Disability Index (HAQ-DI) response (≥0.35 improvement from baseline), enthesitis resolution (Leeds Index score of 0), minimal disease activity, change from baseline in SF-36 physical component score (SF-36 PCS) and mental component score (SF-36 MCS), Psoriasis Area and Severity Index (PASI) 75 response, adverse events (AEs), and laboratory parameters.

Results:

Of 203 patients randomized, 180 (89%) completed 16 weeks of treatment (deucravacitinib 6 mg QD, 63/70 [90%]; deucravacitinib 12 mg QD, 59/67 [88%]; PBO, 58/66 [88%]). Demographic and baseline disease characteristics were similar across groups. Mean age was 49.8 years, 51% of patients were female, median PsA duration was 4.5 years, 66% of patients used csDMARDs at baseline and throughout the study, and 15% had used a TNFi. This study met its primary endpoint, with deucravacitinib 6 mg and 12 mg QD demonstrating significantly higher ACR 20 responses versus PBO at Week 16 (Figure 1). Additional endpoints were also met with deucravacitinib versus PBO (Figure 1). Adjusted mean changes from baseline in SF-36 PCS and SF-36 MCS at Week 16, respectively, were significantly higher in the deucravacitinib 6 mg QD group (5.6 vs 2.3, P=0.0062; 3.6 vs 0.7, P=0.0211) and 12 mg QD group (5.8 vs 2.3, P=0.0042; 3.5 vs 0.7, P=0.0263) compared with PBO. PASI 75 responses were also significantly higher in the deucravacitinib groups (P≤0.0136 vs PBO). The most common AEs in the deucravacitinib 6 mg/12 mg/PBO groups, respectively, during the 16-week treatment period were nasopharyngitis (5.7%/17.9%/7.6%), sinusitis (0%/7.5%/0%), headache (7.1%/1.5%/4.5%), and rash (4.3%/6.0%/0%). No serious AEs, herpes zoster infections, opportunistic infections, or thrombotic events were reported in deucravacitinib-treated patients during this period. Additionally, no significant changes from baseline in hematologic parameters (lymphocytes, neutrophils, platelets, and hemoglobin) or serum lipids were observed with deucravacitinib treatment.

Conclusion:

Deucravacitinib was efficacious versus PBO over 16 weeks in patients with active PsA. Treatment was generally well tolerated and the safety and laboratory parameter profile of deucravacitinib was consistent with that observed in an earlier Phase 2 PsO trial.

Acknowledgements:

This study was sponsored by Bristol Myers Squibb. Professional medical writing assistance was provided by Peloton Advantage, LLC, an OPEN Health company, and funded by Bristol Myers Squibb.

Disclosure of Interests:

Philip J Mease Consultant of: AbbVie, Amgen, Boehringer Ingelheim, Bristol Myers Squibb, Eli Lilly, Galapagos, Gilead, GlaxoSmithKline, Janssen, Novartis, Pfizer, SUN Pharma, UCB, Grant/research support from: AbbVie, Amgen, Boehringer Ingelheim, Bristol Myers Squibb, Eli Lilly, Galapagos, Gilead, GlaxoSmithKline, Janssen, Novartis, Pfizer, SUN Pharma, UCB, Atul Deodhar Consultant of: AbbVie, Amgen, Boehringer Ingelheim, Bristol Myers Squibb, Celgene, Eli Lilly, Galapagos, Glaxo Smith & Kline, Janssen, Novartis, Pfizer, UCB, Grant/research support from: AbbVie, Eli Lilly, Glaxo Smith & Kline, Novartis, Pfizer, UCB, Désirée van der Heijde Consultant of: AbbVie, Amgen, Astellas, AstraZeneca, Bayer, Bristol Myers Squibb, Boehringer Ingelheim, Celgene, Cyxone, Daiichi, Eisai, Eli Lilly, Galapagos, Gilead, GlaxoSmithKline, Janssen, Merck, Novartis, Pfizer, Regeneron, Roche, Sanofi, Takeda, UCB Pharma, Frank Behrens Consultant of: Pfizer, AbbVie, Sanofi, Lilly, Novartis, Genzyme, Boehringer, Janssen, MSD, Celgene, Roche, Chugai, Bristol Myers Squibb, UCB Pharma, Grant/research support from: Pfizer, Janssen, Chugai, Celgene, Roche, Alan Kivitz Shareholder of: Pfizer, Sanofi, GlaxoSmithKline, Gilead Sciences, Inc., Novartis, Paid Consultant: AbbVie, Boehringer Ingelheim, Flexion, Janssen, Pfizer, Sanofi, Regeneron, SUN Pharma Advanced Research, Gilead Sciences, Inc., Speakers bureau: Celgene, Merck, Lilly, Novartis, Pfizer, Sanofi, Genzyme, Flexion, AbbVie, Jonghyeon Kim Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Shalabh Singhal Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Miroslawa Nowak Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Subhashis Banerjee Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb

Optimisation of modification parameters for amaranth starch for the development of pudding and study of the quality traits of developed pudding

Amaranth is considered to be a part of “superfood”, however, due to multiple restricting properties, its functionality in the food industry is still not explored to its fullest. The present study investigated the effect of almond gum concentration (3–10 g), temperature (50–90 °C), and quantity of water (30–70 mL) on the functional properties of amaranth starch. A central composite rotatable design (CCRD) showed that the 6.9 g of almond gum, 64.43 mL of water, and temperature maintained at 90 °C, were the optimised conditions to attain 16.77 g g−1 of swelling power, 12.97% of solubility index, and 20.13% freeze-thaw stability. Moreover, the modified amaranth starch was further employed to develop pudding as a value-added product. The findings concluded that the developed pudding using modified amaranth starch exhibited enhanced sensorial attributes due to an increase in cohesiveness, chewiness, and resilience of starch gel.

Evidence-based decision making and covid-19: what a posteriori probability distributions speak

Background: In the absence of any pharmaceutical interventions, the management of the COVID-19 pandemic is based on public health measures. The present study fosters evidence-based decision making by estimating various “a posteriori probability distributions" from COVID-19 patients.  Methods: In this retrospective observational study, 987 RT-PCR positive COVID-19 patients from SMS Medical College, Jaipur, India, were enrolled after approval of the institutional ethics committee. The data regarding age, gender, and outcome were collected. The univariate and bivariate distributions of COVID-19 cases with respect to age, gender, and outcome were estimated. The age distribution of COVID-19 cases was compared with the general population's age distribution using the goodness of fit c2 test. The independence of attributes in bivariate distributions was evaluated using the chi-square test for independence. Results: The age group ‘25-29’ has shown highest probability of COVID-19 cases (P [25-29] = 0.14, 95% CI: 0.12- 0.16). The men (P [Male] = 0.62, 95%CI: 0.59-0.65) were dominant sufferers. The most common outcome was recovery (P [Recovered] = 0.79, 95%CI: 0.76-0.81) followed by admitted cases (P [Active]= 0.13, 95%CI: 0.11-0.15) and death (P [Death] = 0.08, 95%CI: 0.06-0.10). The age distribution of COVID-19 cases differs significantly from the age distribution of the general population (c2  =399.04, P < 0.001). The bivariate distribution of COVID-19 across age and outcome was not independent (c2 =106.21, df = 32, P < 0.001). Conclusion: The knowledge of disease frequency patterns helps in the optimum allocation of limited resources and manpower. The study provides information to various epidemiological models for further analysis.

Patient Flow Dynamics in Hospital Systems During Times of COVID-19: Cox Proportional Hazard Regression Analysis

Objectives: The present study is aimed at estimating patient flow dynamic parameters and requirement for hospital beds. Second, the effects of age and gender on parameters were evaluated.

Patients and Methods: In this retrospective cohort study, 987 COVID-19 patients were enrolled from SMS Medical College, Jaipur (Rajasthan, India). The survival analysis was carried out from February 29 through May 19, 2020, for two hazards: Hazard 1 was hospital discharge, and Hazard 2 was hospital death. The starting point for survival analysis of the two hazards was considered to be hospital admission. The survival curves were estimated and additional effects of age and gender were evaluated using Cox proportional hazard regression analysis.

Results: The Kaplan Meier estimates of lengths of hospital stay (median = 10 days, IQR = 5–15 days) and median survival rate (more than 60 days due to a large amount of censored data) were obtained. The Cox model for Hazard 1 showed no significant effect of age and gender on duration of hospital stay. Similarly, the Cox model 2 showed no significant difference of age and gender on survival rate. The case fatality rate of 8.1%, recovery rate of 78.8%, mortality rate of 0.10 per 100 person-days, and hospital admission rate of 0.35 per 100,000 person-days were estimated.

Conclusion: The study estimates hospital bed requirements based on median length of hospital stay and hospital admission rate. Furthermore, the study concludes there are no effects of age and gender on average length of hospital stay and no effects of age and gender on survival time in above-60 age groups.

High burden of cardiometabolic risk factors in spouses of Indian women with hyperglycaemia in pregnancy

AIM

To evaluate the burden and association of cardiometabolic risk factors in the spouses of women with and without hyperglycaemia in pregnancy.

METHODS

Women with (n = 204) and without (n = 197) hyperglycaemia in pregnancy, along with their spouses, participated in this cross-sectional study. The hyperglycaemia in pregnancy group included women with gestational diabetes and diabetes in pregnancy. A detailed questionnaire was completed for all participants (men and women), documenting relevant personal and medical history, along with biochemical investigations (men).

RESULTS

A total of 401 couples were evaluated at the time point during the pregnancy of 24.7 ± 5.2 gestational weeks (mean ± sd). Dysglycaemia (prediabetes or diabetes), overweight/obesity (BMI ≥25 kg/m² ) and metabolic syndrome were detected in 120 (58.9%), 123 (60.3%) and 98 spouses (48.3%) of women with hyperglycaemia in pregnancy, respectively. In the fully adjusted model, an increased risk of dysglycaemia [odds ratio 1.43 (95% CI 0.95-2.17); P = 0.088], overweight/obesity [odds ratio 1.49 (95% CI 0.98-2.27); P = 0.064] and metabolic syndrome [odds ratio 2.00 (95% CI 1.30-3.07); P = 0.001] was seen in the spouses of women with hyperglycaemia in pregnancy. The prevalence of these metabolic conditions was higher in spouses of women with diabetes in pregnancy compared to spouses of women with gestational diabetes mellitus.

CONCLUSIONS

A high burden of cardiometabolic risk factors was observed in the spouses of women with hyperglycaemia in pregnancy. The opportunity provided by pregnancy could be used by the healthcare system not only to improve the health of the woman and her offspring, but also her spouse.

Logistic regression analysis to predict mortality risk in COVID-19 patients from routine hematologic parameters

Background: The triage of coronavirus-19 patients into various strata based on some prognostic indicator might prove a utilitarian strategy in the management of epidemic. The goal of health-care facilities is optimization of the use of medical resources. The present study aimed to develop a predictor model of mortality risk from routine hematologic parameters. Patients and Methods: In this retrospective case–control study, seventy survivors (n = 47) and nonsurvivors (n = 23) were enrolled who were laboratory-confirmed coronavirus disease 2019 (COVID-19) cases from SMS Medical College, Jaipur (Rajasthan, India). The clinical and routine blood profile of the survivors and nonsurvivors was recorded. A logistic regression model was fitted with step-wise method to the above dataset with dependent variable such as survivor or nonsurvivor and independent variables such as age, sex, symptoms, random blood glucose, and complete blood count. The best model was selected on the basis of Akaike information criterion. Results: It was observed that differential neutrophil count (%) and random blood sugar (RBS in mg/dL) are the statistically significant regressors (P < 0.05). The performance metrics of the model with 5-fold cross-validation showed area under the receiver operating characteristic curve, sensitivity, specificity, and validation accuracy to be 0.95, 90%, 92%, and 70%, respectively. The cutoff probability comes out at 0.30 for the outcome (nonsurvivor as success). Conclusion: The study concludes that differential neutrophil count and RBS levels can be used as early screening tools of mortality risk in COVID-19 patients and they assist in further patient management.

Brivaracetam efficacy and tolerability in clinical practice: A UK-based retrospective multicenter service evaluation

PURPOSE

This multicenter service evaluation explores the efficacy and tolerability of brivaracetam (BRV) in an unselected, consecutive population in 'real-life' clinical settings.

METHOD

We retrospectively collected data from patient records at 11 UK hospitals and epilepsy centers. Consecutive patients prescribed BRV with at least 3 months of follow-up (FU) were included. Apart from reporting effectiveness and tolerability of BRV across the whole cohort, we compared treatment outcomes depending on previous levetiracetam use (LEV+ versus LEV-), comorbid learning disability (LD+ versus LD-), and epilepsy syndrome (focal versus generalized epilepsy).

RESULTS

Two hundred and ninety patients (46% male, median age: 38 years, range: 15 to 77) with ≥3 months of FU were included. The median duration of BRV exposure was 12 months (range: 1 day to 72 months). Overall BRV retention was 71.1%. While 56.1% of patients improved in terms of seizure frequency category (daily, weekly, monthly, yearly seizures), 23.1% did not improve on this measure and 20.8% deteriorated. In terms of seizure frequency, 21% of patients experienced a ≥50% reduction, with 7.0% of all patients becoming seizure-free. Treatment-emergent adverse events (AEs) were reported by 107 (36.9%) patients, but there were no serious AEs. The commonest AEs were sedation/fatigue (18.3%), mood changes (9.0%), and irritability/aggression (4.8%). There were no significant differences in drug retention, seizure frequency outcomes, or AEs between the LEV+ and LEV- subgroups, or between patients with generalized or focal epilepsies. Although 15.5% of patients in the LD+ group achieved a ≥50% reduction, this rate was lower than in the LD- group.

CONCLUSIONS

This 'real-life' evaluation suggests that reductions in seizure frequency can be achieved with BRV in patients with highly refractory epilepsy. Brivaracetam may be a useful treatment option in patients who have previously failed to respond to or tolerate LEV, those with LD, or (off-label) those with generalized epilepsies.

International Nosocomial Infection Control Consortium (INICC) report, data summary of 45 countries for 2012-2017: Device-associated module

BACKGROUND

We report the results of International Nosocomial Infection Control Consortium (INICC) surveillance study from January 2012 to December 2017 in 523 intensive care units (ICUs) in 45 countries from Latin America, Europe, Eastern Mediterranean, Southeast Asia, and Western Pacific.

METHODS

During the 6-year study period, prospective data from 532,483 ICU patients hospitalized in 242 hospitals, for an aggregate of 2,197,304 patient days, were collected through the INICC Surveillance Online System (ISOS). The Centers for Disease Control and Prevention-National Healthcare Safety Network (CDC-NHSN) definitions for device-associated health care-associated infection (DA-HAI) were applied.

RESULTS

Although device use in INICC ICUs was similar to that reported from CDC-NHSN ICUs, DA-HAI rates were higher in the INICC ICUs: in the medical-surgical ICUs, the pooled central line-associated bloodstream infection rate was higher (5.05 vs 0.8 per 1,000 central line-days); the ventilator-associated pneumonia rate was also higher (14.1 vs 0.9 per 1,000 ventilator-days,), as well as the rate of catheter-associated urinary tract infection (5.1 vs 1.7 per 1,000 catheter-days). From blood cultures samples, frequencies of resistance, such as of Pseudomonas aeruginosa to piperacillin-tazobactam (33.0% vs 18.3%), were also higher.

CONCLUSIONS

Despite a significant trend toward the reduction in INICC ICUs, DA-HAI rates are still much higher compared with CDC-NHSN's ICUs representing the developed world. It is INICC's main goal to provide basic and cost-effective resources, through the INICC Surveillance Online System to tackle the burden of DA-HAIs effectively.

Granulicatella adiacens abscess: Two rare cases and review

Granulicatella adiacens is a nutritionally variant streptococcus species. These bacteria are rarely isolated in the laboratory due to their fastidious growth requirements. These have been mostly reported from bloodstream infections, infective endocarditis, infections of orbit, nasolacrimal duct and breast implants. Here, we are reporting two cases of subcutaneous abscesses caused by G. adiacens. In first case, it was isolated from abscess around elbow joint and second case was a suprapatellar abscess. We have also reviewed the published data concerning diagnosis and antimicrobial susceptibility pattern of Granulicatella infections and included some Indian cases.

Visits for Nontraumatic Dental Conditions in Ontario's Health Care System

BACKGROUND

Physicians' offices and emergency departments (EDs) are not suited for addressing nontraumatic dental conditions (NTDCs); however, significant numbers of people in Canada, including Ontario, visit such settings for their dental complaints. Also, people sometimes visit hospitals for day surgery to get their complicated dental conditions treated. This reflects the inefficient usage of the health care system and gaps in accessing timely dental care.

METHODS

We assessed trends in the burden of NTDCs in Ontario by estimating the visits made for such conditions to physicians, EDs, and hospitals for day surgery. Aggregate data for years 2001 to 2015 were retrieved from Intellihealth Ontario. Descriptive analysis was conducted to calculate rates of visits as stratified by sex, age groups (0 to 6, 7 to 18, 19 to 64, and ≥65 y), and jurisdictions (public health unit level).

RESULTS

On average, 70,274 visits to physicians, 51,861 to EDs, and 13,889 to hospital day surgery are made each year in Ontario for NTDCs, which costs approximately CAN$29 million. Children aged 0 to 6 y visit more than their counterparts. Statistically significant increasing trends for physician and ED visits were observed over the years. Analyses show large variations in rates of visits across public health units, with higher rates in rural communities.

CONCLUSION

A large number of visits for NTDCs, with jurisdictional variations, were consistently made to nondental health care settings in Ontario over the last 15 y. Central- and local-level policy options for optimizing resources and health care system use are required.

KNOWLEDGE TRANSFER STATEMENT

The findings of this study will provide oral and general health professionals a comprehensive understanding about the ineffective usage of a health care system for nontraumatic dental conditions. Quantifying the burden and associated dollars spent will promote crucial policy discussions to explore the possible options for providing emergency and essential dental services for all Canadians and possible equitable options to enhance access to dental care for vulnerable populations in Canadian society.

Swallow-induced esophageal shortening in patients without hiatal hernia is associated with gastroesophageal reflux

Longitudinal esophageal body shortening with swallow-induced peristalsis has been reported in healthy individuals. Esophageal shortening is immediately followed by esophageal re-elongation, and the lower esophageal sphincter (LES) returns to the baseline position. High-resolution manometry (HRM) allows for objective assessment of extent of shortening and duration of shortening. In patients without hiatal hernia at rest, swallow-induced esophageal shortening can lead to transient hiatal hernia (tHH) which at times may persist after the completion of swallow. This manometric finding has not been investigated in the literature, but a question arises whether this swallow-induced transient herniation can effect on the likelihood of gastroesophageal reflux. This study aims to assess the relationship between gastroesophageal reflux and the subtypes of swallow-induced esophageal shortening, i.e. tHH and non-tHH, in patients without hiatal hernia at rest. After Institutional Review Board (IRB) approval, we queried a prospectively maintained database to identify patients who underwent HRM evaluation and 24-hour pH study between January to December 2015. Patients with type-I esophagogastric junction (EGJ) morphology (i.e. no hiatal hernia) according to the Chicago classification v3.0 were included. The patterns of the esophageal shortening with swallows were divided into two subtypes, i.e. tHH and non-tHH. tHH was defined as an EGJ double high-pressure zones (≥1 cm) at the second inspiration after the termination of swallow-induced esophageal body contraction. The number of episodes of tHH was counted per 10 swallows and tHH size was measured for each patient. In total, 41 patients with EGJ morphology Type-I met the inclusion criteria. The mean age was 47.2 years, 35 patients (85.4%) were women, and the mean body mass index was 33.9 kg/m2. The mean number of tHH episodes was 3 out of 10 swallows; mean maximal tHH size was 1.3 cm. Patients who had tHH in ≥3 out of 10 swallows (n = 16; 39.0%) were more likely to have abnormal DeMeester scores than patients with <3 swallows (56% vs. 28%; P = 0.070). Patients with maximal tHH ≥2 cm in at least 1 swallow (n = 17; 41.5%) were more likely to experience pathological reflux than patients with maximal tHH <2 cm (59% vs. 25%; P = 0.029). In conclusion, we showed that, in a subset of patients with Type-I EGJ morphology, swallowing induced transient EGJ double high-pressure zones (≥1 cm) after peristalsis. We have named this new manometric finding the swallow-induced tHH. A high prevalence of pathological reflux disease was observed in patients with maximal tHH ≥2 cm. The degree of swallow-induced tHH could be an early indicator of lower esophageal sphincter dysfunction in patients without manometric hiatal hernia.

Abstract P6-13-08: A novel comparative analysis approach to personalize chemotherapy dose in early breast cancer

Background: Worldwide, body surface area [BSA] is used to calculate chemotherapy dose. The BSA formula was originally developed in 1916, derived from height and weight, with no consideration of other patient characteristics. Most chemotherapy agents have a narrow therapeutic index and are distributed in lean body mass [LBM], leading to under- or over-dosing and deleterious effects to major organs when body composition is not considered. To date, while experts worldwide acknowledge the limitations and risks of BSA dosing, no practical approach to personalizing chemotherapy dose has been developed. Ideally, body composition would be assessed by tests already routinely performed, avoiding unnecessary radiation exposure, clinic visits, discomfort to the patient, and cost. The majority of patients undergo cardiac imaging prior to chemotherapy. We hypothesized that clinical parameters routinely performed prior to chemotherapy could predict LBM in early breast cancer patients.

Method: Early stage breast cancer patients (n = 45) enrolled in the Multidisciplinary Team Intervention in Cardio-Oncology (TITAN) study underwent pre-treatment cardiac MRI, body composition (iDEXA) and laboratory (complete blood cell count and chemistry). Cardiac MRI and iDEXA are considered 'gold standard' imaging modalities, the accuracy of which allow for significantly reduced sample size.

Our modeling approach, which is novel in this area, aimed to select the best combination of parameters with the most predictive ability of total lean mass (iDEXA). The parameters included in study are: cardiac MRI metrics (LV mass, cardiac output), and laboratory parameters associated with major organ function (albumin, creatinine, bilirubin). All parameters were tested using univariate, multivariate and subset selection approach. Akaike's Information Criterion (AIC) was used to measure model quality, with lower AIC values indicating closer prediction.

Results: The univariate analysis of each parameter independently showed LV mass is most predictive with AIC 857.8, while combination of all parameter in multivariate fashion show improvement in prediction with AIC 851. The subset selection approach shows, Adjusted R2 with 4 parameters had AIC 849.14, Schwartz's information criterion (BIC) with 2 parameters had AIC 849.66 and Mallows' C Selection (Cp) model with 3 parameters had the least AIC 848.71 value (P &lt; 0.001).

Conclusion: Our comparative analysis showed that the Cp model with 3 parameters (LV mass, cardiac output and bilirubin) has high prediction ability of LBM. This model will form the basis of a personalized formula for chemotherapy dose calculation. We expect this work to result in optimal cancer-specific outcomes while reducing short and long-term toxicities associated with necessary chemotherapy.

Citation Format: Perri MD, Singhal S, Hegadoren K, Norris C, Mackey J, Paterson I, Pituskin E. A novel comparative analysis approach to personalize chemotherapy dose in early breast cancer [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P6-13-08.