A176 ASSOCIATIONS OF ANTIBIOTICS, HORMONAL THERAPIES, ORAL CONTRACEPTIVES, AND LONG-TERM NSAIDS WITH INFLAMMATORY BOWEL DISEASE: RESULTS FROM THE PROSPECTIVE URBAN RURAL EPIDEMIOLOGY (PURE) STUDY

Background

The pathogenesis of inflammatory bowel disease (IBD) which includes Crohn’s disease (CD) and ulcerative colitis (UC), is believed to involve activation of the intestinal immune system in response to the gut microbiome among genetically susceptible hosts. IBD has been historically regarded as a disease of developed nations, though in the past two decades there has been a reported shift in the epidemiological pattern of disease. High-income nations with known high prevalence of disease are seeing a stabilization of incident cases, while a rapid rise of incident IBD is being observed in developing nations. This suggests that environmental exposures may play a role in mediating the risk of developing IBD. The potential environmental determinants of IBD across various regions is vast, though medications have been increasingly recognized as one broad category of risk factors.

Purpose

Several medications have been considered to contribute to the etiology of IBD. This study assessed the association between medication use and risk of developing IBD using the Prospective Urban Rural Epidemiology (PURE) cohort.

Method

This was a prospective cohort study of 133,137 individuals between the ages of 20-80 from 24 countries. Country-specific validated questionnaires documented baseline and follow-up medication use. Participants were followed prospectively at least every 3 years. The main outcome was development of IBD, including CD and UC. Short-term (baseline but not follow-up use) and long-term use (baseline and subsequent follow-up use) was evaluated. Results are presented as adjusted odds ratios (aOR) with 95% confidence intervals (CI).

Result(s)

During the median follow-up of 11.0 years [interquartile range (IQR) 9.2-12.2], we recorded 571 incident cases of IBD (143 CD and 428 UC). Higher risk of incident IBD was associated with baseline antibiotic use [aOR: 2.81 (95% CI: 1.67-4.73), p=0.0001] and hormonal medication use [aOR: 4.43 (95% CI: 1.78-11.01), p=0.001]. Among females, previous or current oral contraceptive use was also associated with IBD development [aOR: 2.17 (95% CI: 1.70-2.77), p=5.02E-10]. NSAID users were also observed to have increased risk of IBD [aOR: 1.80 (95% CI: 1.23-2.64), p=0.002], which was driven by long-term users [aOR: 5.58 (95% CI: 2.26-13.80), p<0.001]. All significant results were consistent in direction for CD and UC with low heterogeneity.

Conclusion(s)

Antibiotics, hormonal medications, oral contraceptives, and long-term NSAID use were associated with increased odds of incident IBD after adjustment for covariates.

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Salim Yusuf is supported by the Heart & Stroke Foundation/Marion W. Burke Chair in Cardiovascular Disease. The PURE Study is an investigator-initiated study funded by the Population Health Research Institute, the Canadian Institutes of Health Research (CIHR), Heart and Stroke Foundation of Ontario, support from CIHR’s Strategy for Patient Oriented Research (SPOR) through the Ontario SPOR Support Unit, as well as the Ontario Ministry of Health and Long-Term Care and through unrestricted grants from several pharmaceutical companies, with major contributions from AstraZeneca (Canada), Sanofi-Aventis (France and Canada), Boehringer Ingelheim (Germany and Canada), Servier, and GlaxoSmithkline, and additional contributions from Novartis and King Pharma and from various national or local organisations in participating countries; these include: Argentina: Fundacion ECLA; Bangladesh: Independent University, Bangladesh and Mitra and Associates; Brazil: Unilever Health Institute, Brazil; Canada: Public Health Agency of Canada and Champlain Cardiovascular Disease Prevention Network; Chile: Universidad de la Frontera; China: National Center for Cardiovascular Diseases; Colombia: Colciencias, grant number 6566-04-18062; India: Indian Council of Medical Research; Malaysia: Ministry of Science, Technology and Innovation of Malaysia, grant numbers 100 -IRDC/BIOTEK 16/6/21 (13/2007) and 07-05-IFN-BPH 010, Ministry of Higher Education of Malaysia grant number 600 -RMI/LRGS/5/3 (2/2011), Universiti Teknologi MARA, Universiti Kebangsaan Malaysia (UKM-Hejim-Komuniti-15-2010); occupied Palestinian territory: the UN Relief and Works Agency for Palestine Refugees in the Near East, occupied Palestinian territory; International Development Research Centre, Canada; Philippines: Philippine Council for Health Research & Development; Poland: Polish Ministry of Science and Higher Education grant number 290/W-PURE/2008/0, Wroclaw Medical University; Saudi Arabia: the Deanship of Scientific Research at King Saud University, Riyadh, Saudi Arabia (research group number RG -1436-013); South Africa: the North-West University, SANPAD (SA and Netherlands Programme for Alternative Development), National Research Foundation, Medical Research Council of SA, The SA Sugar Association (SASA), Faculty of Community and Health Sciences (UWC); Sweden: grants from the Swedish state under the Agreement concerning research and education of doctors; the Swedish Heart and Lung Foundation; the Swedish Research Council; the Swedish Council for Health, Working Life and Welfare, King Gustaf V’s and Queen Victoria Freemasons Foundation, AFA Insurance, Swedish Council for Working Life and Social Research, Swedish Research Council for Environment, Agricultural Sciences and Spatial Planning, grant from the Swedish State under the Läkar Utbildnings Avtalet agreement, and grant from the Västra Götaland Region; Turkey: Metabolic Syndrome Society, AstraZeneca, Turkey, Sanofi Aventis, Turkey; United Arab Emirates (UAE): Sheikh Hamdan Bin Rashid Al Maktoum Award For Medical Sciences and Dubai Health Authority, Dubai UAE.

Disclosure of Interest

C. Pray: None Declared, N. Narula Grant / Research support from: Neeraj Narula holds a McMaster University Department of Medicine Internal Career Award. Neeraj Narula has received honoraria from Janssen, Abbvie, Takeda, Pfizer, Merck, and Ferring, E. C. Wong: None Declared, J. K. Marshall Grant / Research support from: John K. Marshall has received honoraria from Janssen, AbbVie, Allergan, Bristol-Meyer-Squibb, Ferring, Janssen, Lilly, Lupin, Merck, Pfizer, Pharmascience, Roche, Shire, Takeda and Teva., S. Rangarajan: None Declared, S. Islam: None Declared, A. Bahonar: None Declared, K. F. Alhabib: None Declared, A. Kontsevaya: None Declared, F. Ariffin: None Declared, H. U. Co: None Declared, W. Al Sharief: None Declared, A. Szuba: None Declared, A. Wielgosz: None Declared, M. L. Diaz: None Declared, R. Yusuf: None Declared, L. Kruger: None Declared, B. Soman: None Declared, Y. Li: None Declared, C. Wang: None Declared, L. Yin: None Declared, M. Erkin: None Declared, F. Lanas: None Declared, K. Davletov: None Declared, A. Rosengren: None Declared, P. Lopez-Jaramillo: None Declared, R. Khatib: None Declared, A. Oguz: None Declared, R. Iqbal: None Declared, K. Yeates: None Declared, Á. Avezum: None Declared, W. Reinisch Consultant of: Speaker for Abbott Laboratories, Abbvie, Aesca, Aptalis, Astellas, Centocor, Celltrion, Danone Austria, Elan, Falk Pharma GmbH, Ferring, Immundiagnostik, Mitsubishi Tanabe Pharma Corporation, MSD, Otsuka, PDL, Pharmacosmos, PLS Education, Schering-Plough, Shire, Takeda, Therakos, Vifor, Yakult, Consultant for Abbott Laboratories, Abbvie, Aesca, Algernon, Amgen, AM Pharma, AMT, AOP Orphan, Arena Pharmaceuticals, Astellas, Astra Zeneca, Avaxia, Roland Berger GmBH, Bioclinica, Biogen IDEC, Boehringer-Ingelheim, Bristol-Myers Squibb, Cellerix, Chemocentryx, Celgene, Centocor, Celltrion, Covance, Danone Austria, DSM, Elan, Eli Lilly, Ernest & Young, Falk Pharma GmbH, Ferring, Galapagos, Genentech, Gilead, Grünenthal, ICON, Index Pharma, Inova, Janssen, Johnson & Johnson, Kyowa Hakko Kirin Pharma, Lipid Therapeutics, LivaNova, Mallinckrodt, Medahead, MedImmune, Millenium, Mitsubishi Tanabe Pharma Corporation, MSD, Nash Pharmaceuticals, Nestle, Nippon Kayaku, Novartis, Ocera, Omass, Otsuka, Parexel, PDL, Periconsulting, Pharmacosmos, Philip Morris Institute, Pfizer, Procter & Gamble, Prometheus, Protagonist, Provention, Robarts Clinical Trial, Sandoz, Schering-Plough, Second Genome, Seres Therapeutics, Setpointmedical, Sigmoid, Sublimity, Takeda, Therakos, Theravance, Tigenix, UCB, Vifor, Zealand, Zyngenia, and 4SC, Advisory board member for Abbott Laboratories, Abbvie, Aesca, Amgen, AM Pharma, Astellas, Astra Zeneca, Avaxia, Biogen IDEC, Boehringer-Ingelheim, Bristol-Myers Squibb, Cellerix, Chemocentryx, Celgene, Centocor, Celltrion, Danone Austria, DSM, Elan, Ferring, Galapagos, Genentech, Grünenthal, Inova, Janssen, Johnson & Johnson, Kyowa Hakko Kirin Pharma, Lipid Therapeutics, MedImmune, Millenium, Mitsubishi Tanabe Pharma Corporation, MSD, Nestle, Novartis, Ocera, Otsuka, PDL, Pharmacosmos, Pfizer, Procter & Gamble, Prometheus, Sandoz, Schering-Plough, Second Genome, Setpointmedical, Takeda, Therakos, Tigenix, UCB, Zealand, Zyngenia, and 4SC, P. Moayyedi: None Declared, S. Yusuf: None Declared

Efficacy of Fluoride Varnish with Casein Phosphopeptide and Amorphous Calcium Phosphate vs Fluoride Varnish in Prevention of White Spots Lesion in fixed Orthodontic Patients: In Vivo Study

AIM

The aim of the study is to compare the in vivo efficiency of Michigan (MI) varnish containing casein phosphopeptide (CPP) and amorphous calcium phosphate (ACP) and Fluoritop containing sodium fluoride (5% NaF) in the prevention and remineralization of white spot lesions (WSLs) around orthodontic brackets at days 28 and 56 after bonding.

MATERIALS AND METHODS

A total of 30 patients were selected and divided into two groups I (MI varnish) II (Fluoritop varnish) of 15 patients in each group. All the patients were bonded and then varnish was applied around the brackets. Right-side upper and lower first premolar teeth were taken as the control group and left-side upper and lower first premolar teeth as the experimental group. Also, 14, 24 teeth were extracted on day 28 after bonding and 34, 44 teeth after day 56 of bonding. Samples were collected and sent to laboratory for evaluation of surface microhardness (SMH).

RESULTS

Based on the statistics results, there was a significant decrease in demineralization and an increase in remineralization of WSLs after the application of varnish. No statistical significance was found between the effectiveness of MI varnish and Fluoritop except in the cervical region.

CONCLUSION

Through our study, we concluded that no statistical significance was found between the effectiveness of MI varnish and Fluoritop except in the cervical region where MI varnish was found to be more effective than Fluoritop in preventing WSLs.

CLINICAL SIGNIFICANCE

The results from the above study concluded that CPP-ACP varnish can be an effective method in preventing WSLs in patients undergoing fixed orthodontic treatment.

Effect of Frequency of Micro-osteoperforation on Miniscrew- supported Canine Retraction: A Single-centered, Split-mouth Randomized Controlled Trial

AIM

The present study aimed at evaluating the increase in the rate of tooth movement by increasing the number and frequency of micro-osteoperforations (MOPs).

MATERIALS AND METHODS

The study was a single-center, split-mouth, randomized controlled trial. A total of 20 patients were included in the study who had fully erupted maxillary canines with class I molar canine relationship and a bimaxillary protrusion that required the removal of both maxillary and mandibular first premolars. Out of 80 samples, the experimental and controlled groups were randomly assigned. The experimental group received five MOPs in the extracted site of the first premolar before retraction, at 28th day and 56th day. The control group received no MOPs. The rate of tooth movement was measured on 28th, 56th, and 84th day on both the experimental and control sides.

RESULTS

In maxillary dentition, the canine on the MOP side moved by 0.65 ± 0.21 mm, 0.74 ± 0.23 mm, and 0.87 ± 0.27 mm during 28th, 56th, and 84th day, respectively, whereas in control side the rate of tooth movement was 0.37 ± 0.09 mm, 0.43 ± 0.11 mm, and 0.47 ± 0.11 mm during 28th, 56th and 84th day, respectively, which was statistically significant (p-value = 0.000). In mandibular dentition, the canine on the MOP site has moved by 0.57 ± 0.12 mm, 0.68 ± 0.21 mm, and 0.67 ± 0.10 mm during 28th, 56th, and 84th day, respectively, whereas in control side the rate of the tooth movement was 0.34 ± 0.08 mm, 0.40 ± 0.15 mm, and 0.40 ± 0.13 mm during 28th, 56th, and 84th day, respectively, which was statistically significant.

CONCLUSION

Micro-osteoperforations effectively increased the rate of tooth movement. Overall, MOPs increased the rate of canine retraction by 2-fold when compared with the control group.

CLINICAL SIGNIFICANCE

Micro-osteoperforation is a proven methodology to increase the rate of tooth movement and decrease the treatment time. However, it is important to repeat the procedure during every activation to increase its effectiveness.

A quantitative study to explore functional outcomes following laparoscopic ventral mesh rectopexy for rectal prolapse

INTRODUCTION

Rectal prolapse is a life-altering problem and laparoscopic ventral mesh rectopexy (LVMR) is emerging as the surgical intervention of choice. However, the literature is ambiguous on its effect on bowel function and sparse as regards bladder and sexual function. This study assesses short-term functional outcomes following LVMR.

MATERIALS AND METHODS

This quantitative retrospective study with a pretest-post-test design included 130 adults who had undergone LVMR from October 2010 to December 2018 in a tertiary centre. Analysis with paired-samples t-test and Wilcoxon matched pairs test was done using SPSS (v26).

RESULTS

The median age was 58 years (interquartile range, 48-74 years); 123 (94.6%) were female. The median length of stay was two days (interquartile range, 1-2 days). A total of 104 (80%) sets of medical notes were reviewed. One patient had recurrence of rectal prolapse. Synthetic mesh was used in 24 patients (23.1%) and biological mesh in 80 (76.9%). One patient had extrusion of a synthetic mesh and required surgery; 31(23.8%) completed the Electronic Patient Assessment Questionnaire for Pelvic Floor. Overall, the improvement in bladder function was not statistically significant (p = 0.670). A statistically significant improvement was seen for all bowel symptoms (p = 0.002) excluding constipation (p = 0.295). Irritable bowel symptoms associated with rectal prolapse improved significantly following LVMR (p = 0.001). Vaginal prolapse (p < 0.0005), dyspareunia (p = 0.001) and bowel symptoms affecting sexual intercourse (p = 0.01) improved, but improvement in overall sexual function was not statistically significant (p = 0.081).

CONCLUSIONS

LVMR improves bowel function overall, although it can worsen constipation. It has the potential to improve sexual function but makes negligible difference to bladder function.

195 Surgical Education Runs A-MOOC!

Aim

This study aims to review the available surgical Massive Open Online Course (MOOCs), to assess their scope, users, function and to use a quality assurance score to assess whether they are of sufficient quality. Understanding gaps will aid development of future surgical MOOCs.

Introduction

MOOCs have been changing the fabric of medical education over the last ten years1. They are perceived to be disruptive in their dismantling of the traditional methods of content delivery. Their offer of remote but flexible access and visually appealing content has been an integral part of their success.

Method

We scrutinised publicly accessible websites offering MOOCs using the search terms “surgery” and “surgical”. Thirty-eight of the 234 MOOCs found were deemed relevant and analysed further. Each MOOC was ranked into categories (not achieved, partially achieved, largely achieved, fully achieved) for standards set out by a validated OpenUp education tool.

Results

Only 34.2% of MOOCs were suitable for patients or relatives. The average cost of accessing a course (and certificate if available) is £50.39. Only 5.26% courses met the minimum recommended 25-hour study time. Only 5.26% MOOCs provided different learning pathways with different activities with a range of difficulties. An astounding 34.2% of MOOCs did not achieve providing reliable and fair assessments and providing regular feedback to students.

Conclusions

Not many high-quality surgical MOOCs exist. There is scope to produce more MOOCs aimed at patients and medical students, to reduce the cost of accessing the course and to improve how the courses are designed and assessed.

Correlation of Infrazygomatic Bone Thickness With Cervical Vertebrae Maturation Stages

Anchorage is one of the most important consideration in the field of orthodontics to achieve a desired tooth movement. In order to eliminate the undesirable side effects such as anchorage loss, skeletal anchorage systems such as mini-implants have been introduced in orthodontics.

Aim:

To evaluate the bone thickness of the infrazygomatic crest in different cervical vertebrae maturation index (CVMI) and to compare it between male and female subjects, by using cone beam computerized tomography (CBCT) imaging.

Materials and Methods:

A retrospective study was conducted using CBCT images of 60 patients in the age group of 8–25 years. Cervical vertebra maturation was analyzed using Hassel–Farmann index and divided into 6 groups (n = 10/group). The infrazygomatic crest was divided into horizontal and vertical planes. The horizontal plane passed through the most inferior border of the zygomatic process of maxilla and the vertical plane passed through the most anterior point of the infratemporal fossa parallel to midsagittal plane. Five parallel lines were drawn at 2 mm interval in both horizontal and vertical planes (HB+2, HB+4, HB+6, HB+8, and HB+10) (V-2, V-4, V-6, V-8, and V-10). The bone thickness was measured at the point of intersection of these lines.

Results:

According to Kruskal–Wallis analysis, statistically significant difference in infrazygomatic crest (IZC) bone thickness was seen in various CVMI stages ( P = .001). Maximum bone thickness was 11 mm and minimum bone thickness was 1 mm. No significant difference was observed between male and female populations.

Conclusion:

Thus, the superolateral area in infrazygomatic crest is the most appropriate site for miniscrew insertion in all age groups.

Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study

BACKGROUND

This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery.

METHODS

This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery.

RESULTS

A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21; P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498).

CONCLUSION

There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.

COX-2-derived prostaglandins as mediators of the deleterious effects of nicotine in chronic kidney disease

Tobacco smoking has been identified as a risk factor in the progression of chronic kidney disease (CKD). In previous studies, we showed that nicotine induces cyclooxygenase (COX)-2 expression in vivo and in vitro and that the administration of nicotine in vivo worsens the severity of renal injury in a model of subtotal renal ablation. In the present study, we tested the role of COX-2-derived prostaglandins on the deleterious effects of nicotine in CKD. Sham and 5/6 nephrectomy (5/6Nx) rats received tap water or nicotine (100 μg/mL) in the drinking water for 12 wk. Additional groups also systemically received the COX-2 inhibitor NS-398 (1.5 mg·kg^-1·day^-1 via osmotic minipump). The administration of nicotine worsened renal injury and proteinuria in 5/6Nx rats and increased proteinuria in sham rats. 5/6Nx rats had increased cortical production of the prostaglandins PGE₂, PGI₂, PGD₂, and PGF_2α and of thromboxane A₂. In these rats, nicotine reduced the production of all prostaglandins examined except thromboxane A₂. Treatment with the COX-2 inhibitor NS-398 resulted in complete inhibition of all prostaglandins studied and ameliorated renal injury and proteinuria in 5/6Nx rats on nicotine but not in 5/6 Nx rats on tap water. Nicotine also reduced the expression of megalin in all groups examined, and this was partially prevented by COX-2 inhibition. In the present study, we showed that in CKD, nicotine worsens renal injury at least in part by producing an imbalance in the production of prostaglandins. This imbalance in the production of prostaglandins likely plays a role in the deleterious effects of smoking on the progression of CKD.

No UHC without medicines: out-of-pocket payments for non-communicable diseases in 18 countries

Background

In 2014 the United Nations agreed on a goal to reduce premature mortality from NCDs by improving financial risk protection. We are far from achieving this: households with NCDs are at an increased risk of catastrophic health spending and impoverishment, particularly in lower middle- and low-income countries. There is a need to better understand the drivers of health spending among households with NCDs, to inform interventions aimed at achieving universal health coverage.

Methods

Using data from the Prospective Urban and Rural Epidemiology Study, we analyse out-of-pocket expenditure (OOP) among households with NCDs (cancer, cardiovascular disease, hypertension, diabetes, respiratory disease or kidney disease) in 18 countries: Canada, Sweden, Brazil, Chile, Malaysia, Poland, South Africa, Turkey, China, the Philippines, Colombia, Iran, the Occupied Palestinian Territory (OPT), Bangladesh, India, Pakistan, Zimbabwe and Tanzania.

Results

The leading driver of OOP on health care in almost all countries included is medicine. For example, the monthly OOP on medicines among NCD households in Iran, where roughly 18% of NCD households experience catastrophic spending, is USD 13.50, representing 36% of OOP on health. In Brazil this figure is USD 25.85, representing 46% of OOP on health. A large proportion of OOP is also made up by consultation fees, particularly in Sub-Saharan African countries. In Poland, 63% of OOP on health is spent on alternative medicine consultation fees.

Conclusions

Our findings echo the message shared by the Director General of the World Health Organization in 2018, that there is “no Universal Health Coverage without access to quality medicines”. Medicine costs impose a significant economic burden on NCD households in countries at all levels of development, highlighting the need to include essential medicines for NCDs in universal health coverage benefit packages.

Key messages

To achieve the goal of improved financial risk protection for NCDs we need to understand drivers of out-of-pocket spending among households with NCDs. Medicines are by far the largest driver of OOP in countries at all levels of development and require urgent attention to ensure universal health coverage.

Cutaneous manifestations of diabetic peripheral neuropathy

There is a rise in number of people diagnosed with Diabetes Mellitus. The incidence is rising in modern Indian society because of Industrial development and drastically changing lifestyles. Diabetic neuropathies are microvascular disorders that are usually associated with the duration of Diabetes. Among the various forms, the most common is Diabetic Peripheral Neuropathy. The disease if neglected leads to chronic ulcer formation leading to amputations frequently. Hence the aim of this study is to document the early cutaneous changes and create an early awareness in the importance of controlling Diabetes. The study consisted of 205 patients with Type 2 DM. Participant's neuropathy status was determined based on Neuropathy Disability Score and Diabetic Neuropathy Symptom Score. Among the Skin changes documented, the common changes seen were: Peripheral hair loss in 185 (90.2%), Xerosis in 168 (82%), Anhydrosis in 162 (79%), Plantar Fissures in 136 (66.3%), Plantar Ulcer in 80 (39%), common nail changes documented were Onychomycosis in 165 (80.5%) and Onychauxis in 53 (25.8%) patients in relation to the occupation and duration of Diabetes mellitus. In conclusion, it is important to control glycemic levels in the all stages of Diabetes and institute foot care measures to prevent the complications of neuropathy.

Pharmacokinetics, clot strength and safety of a new fibrinogen concentrate: randomized comparison with active control in congenital fibrinogen deficiency

Essentials Congenital afibrinogenemia causes a potentially life-threatening bleeding and clotting tendency. Two human fibrinogen concentrates (HFCs) were compared in a randomized pharmacokinetic study. Bioequivalence was not shown for AUCnorm , which was significantly larger for the new HFC. Increases in clot strength were comparable, and no thromboses or deaths occurred in the study.

SUMMARY

Background Human fibrinogen concentrate (HFC) corrects fibrinogen deficiency in congenital a-/hypofibrinogenemia. Objectives To assess pharmacokinetics (PK), effects on thromboelastometry maximum clot firmness (MCF), and safety of a new double virus-inactivated/eliminated, highly purified HFC vs. active control. Patients/Methods In this multinational, randomized, phase II, open-label, crossover study in 22 congenital afibrinogenemia patients aged ≥ 12 years, 70 mg kg-1 of new HFC (FIBRYGA, Octapharma AG) or control (Haemocomplettan® P/RiaSTAP™, CSL Behring GmbH) were administered, followed by crossover to the other concentrate. Fibrinogen activity, PK and MCF in plasma were assessed. Results The concentrates were not bioequivalent for the primary endpoint, AUCnorm (mean ratio, 1.196; 90% confidence interval [CI], 1.117, 1.281). Remaining PK parameters (Cmaxnorm , IVR, t1/2 , MRT) reflected bioequivalence between concentrates, except for clearance (mean ratio, 0.836; 90% CI, 0.781, 0.895) and Vss (mean ratio, 0.886; 90% CI, 0.791, 0.994). Mean AUCnorm was significantly larger for the new HFC (1.62 ± 0.45 vs. 1.38 ± 0.47 h kg g L-1  mg-1 , P = 0.0001) and mean clearance was significantly slower (0.665 ± 0.197 vs. 0.804 ± 0.255 mL h-1  kg-1 , P = 0.0002). Mean MCF increased from 0 mm to 9.68 mm (new HFC) and 10.00 mm (control) 1-hour post-infusion (mean difference, -0.32 mm; 95% CI, -1.70, 1.07, n.s.). No deaths, thromboses, viral seroconversions or serious related adverse events occurred. Conclusions Bioequivalence was not demonstrated for AUCnorm , clearance and Vss . Larger AUCnorm and slower clearance were observed for the new HFC. Remaining pharmacokinetic parameters reflected bioequivalence to control. Safety profiles and increases in clot strength were comparable between concentrates.

Efficacy and safety of Nuwiq® (human-cl rhFVIII) in patients with severe haemophilia A undergoing surgical procedures

INTRODUCTION

Haemophilia A patients are at a high risk of excess bleeding during surgeries. The aim of haemostatic therapy during the perioperative period is to normalize FVIII level perioperatively and postoperatively to maintain normal haemostasis until wound healing is complete.

AIMS/METHODS

To examine the efficacy of Nuwiq^® (simoctocog alfa, human-cl rhFVIII), a 4^th generation recombinant FVIII produced in a human cell line, for surgical prophylaxis in patients with severe haemophilia A. This analysis assessed the efficacy of Nuwiq^® during surgical procedures and in the postoperative period in seven clinical studies of previously treated patients (PTPs) with severe haemophilia A.

RESULTS

Thirty-six patients, aged 3-55 years, received surgical prophylaxis with Nuwiq^® for 60 surgeries (28 major and 32 minor). Efficacy was evaluated for 52 surgeries (25 major and 27 minor). The success rate of Nuwiq^® treatment was 98.1% (51 of 52 evaluated surgeries); haemostatic efficacy was assessed as "excellent" or "good" in all but one major surgery (assessed as "moderate"). The number of infusions ranged from 1 to 19 for minor surgeries and from 3 to 76 for major surgeries. The median (range) daily doses were 42.0 (28.2-100.9) IU kg^-1 for minor surgeries and 69.3 (43.3-135.6) IU kg^-1 for major surgeries. There were no serious treatment-related adverse events, and none of the patients developed FVIII inhibitors.

CONCLUSIONS

The results of this pooled analysis show that Nuwiq^® was efficacious in maintaining haemostasis during and after major and minor surgical procedures in PTPs with severe haemophilia A.

Nonacog beta pegol in previously treated children with hemophilia B: results from an international open-label phase 3 trial

Essentials Nonacog beta pegol is a recombinant glycoPEGylated factor IX with an extended half-life. This phase 3 trial investigated its safety/efficacy in previously treated hemophilia B boys ≤ 12 years. A 40 IU kg(-1) dose provided effective once-weekly prophylaxis and hemostasis when used to treat bleeds. Nonacog beta pegol was well tolerated in previously treated boys ≤ 12 years with hemophilia B.

SUMMARY

Background Nonacog beta pegol is a recombinant glycoPEGylated factor IX with an extended half-life, developed to improve care for patients with hemophilia B. Objectives To investigate the safety, efficacy and pharmacokinetics of nonacog beta pegol for the prophylaxis and treatment of bleeds in previously treated children with hemophilia B. Patients/Methods This phase 3 trial, paradigm(™) 5, enrolled and treated 25 children (aged ≤ 12 years) with hemophilia B (FIX ≤ 2%). Patients were stratified by age (0-6 years and 7-12 years), and received once-weekly prophylaxis with 40 IU kg(-1) nonacog beta pegol for 50 exposure days. Results No patient developed inhibitors, and no safety concerns were identified. Forty-two bleeds in 15 patients were reported to have been treated; the overall success rate was 92.9%, and most bleeds (85.7%) resolved after one dose. The median annualized bleeding rates (ABRs; bleeds per patient per year) were 1.0 in the total population, 0.0 in the 0-6-year group, and 2.0 in the 7-12-year group; the estimated mean ABRs were 1.44 in the total population, 0.87 in the 0-6-year group, and 1.88 in the 7-12-year group. For 22 patients who had previously been receiving prophylaxis, the estimated mean ABR was 1.38 versus a historical ABR of 2.51. Estimated mean steady-state FIX trough levels were 0.153 IU mL(-1) (0-6 years) and 0.190 IU mL(-1) (7-12 years). Conclusion Nonacog beta pegol was well tolerated in previously treated children with hemophilia B; a 40 IU kg(-1) dose provided effective once-weekly prophylaxis and hemostasis when bleeds were treated.

Low frequency of elevated prothrombin times in patients with lupus anticoagulants when using a recombinant thromboplastin reagent: implications for dosing and monitoring of oral anticoagulant therapy

Many patients with lupus anticoagulants (LA) are treated with oral anticoagulation and monitored using the international normalised ratio (INR) derived from the prothrombin time (PT). Recent reports have produced conflicting conclusions about the extent to which LA interferes with PT determination. The degree of anticoagulation may be overestimated in a patient whose LA affects the PT. A number of reports conclude that specific thromboplastin reagents containing recombinant tissue factor are sensitive to the presence of LAs and should not be used to monitor oral anticoagulant therapy in these patients. These studies were performed on orally anticoagulated patients. The present retrospective study on 400 patients with LAs who were not receiving therapeutic anticoagulation was performed to ascertain the frequency of prolonged PT in these patients when using Innovin recombinant thromboplastin. Only 17 (4.3%) out of 400 had prolonged PT in the presence of LA. As this is a low prevalence, and not all patients with LAs will require anticoagulant therapy, it is concluded that baseline INR determination should be used to highlight the need to monitor individual patients with LA-insensitive reagents. As the use of moderate-intensity oral anticoagulation for patients with LAs and previous thrombosis is receiving wider acceptance, an informed approach to anticoagulant monitoring will reduce the possibility of under-anticoagulating patients receiving this therapy.

A Microfluidic Method for the Selection of Undifferentiated Human Embryonic Stem Cells and in Situ Analysis

Conventional cell-sorting methods such as fluorescence-activated cell sorting (FACS) or magnetic-activated cell sorting (MACS) can suffer from certain shortcomings such as lengthy sample preparation time, cell modification through antibody labeling, and cell damage due to exposure to high shear forces or to attachment of superparamagnetic Microbeads. In light of these drawbacks, we have recently developed a label-free, microfluidic platform that can not only select cells with minimal sample preparation but also enable analysis of cells in situ. We demonstrate the utility of our platform by successfully isolating undifferentiated human embryonic stem cells (hESCs) from a heterogeneous population based on the undifferentiated stem-cell marker SSEA-4. Importantly, we show that, in contrast to MACS or FACS, cells isolated by our method have very high viability (~90%). Overall, our platform technology could likely be applied to other cell types beyond hESCs and to a variety of heterogeneous cell populations in order to select and analyze cells of interest.

Psychosocial factors and obesity in 17 high-, middle- and low-income countries: the Prospective Urban Rural Epidemiologic study

Background/Objectives:

Psychosocial stress has been proposed to contribute to obesity, particularly abdominal, or central obesity, through chronic activation of the neuroendocrine systems. However, these putative relationships are complex and dependent on country and cultural context. We investigated the association between psychosocial factors and general and abdominal obesity in the Prospective Urban Rural Epidemiologic study.

Subjects/Methods:

This observational, cross-sectional study enrolled 151 966 individuals aged 35–70 years from 628 urban and rural communities in 17 high-, middle- and low-income countries. Data were collected for 125 290 individuals regarding education, anthropometrics, hypertension/diabetes, tobacco/alcohol use, diet and psychosocial factors (self-perceived stress and depression).

Results:

After standardization for age, sex, country income and urban/rural location, the proportion with obesity (body mass index ⩾30 kg m⁻²) increased from 15.7% in 40 831 individuals with no stress to 20.5% in 7720 individuals with permanent stress, with corresponding proportions for ethnicity- and sex-specific central obesity of 48.6% and 53.5%, respectively (P<0.0001 for both). Associations between stress and hypertension/diabetes tended to be inverse. Estimating the total effect of permanent stress with age, sex, physical activity, education and region as confounders, no relationship between stress and obesity persisted (adjusted prevalence ratio (PR) for obesity 1.04 (95% confidence interval: 0.99–1.10)). There was no relationship between ethnicity- and sex-specific central obesity (adjusted PR 1.00 (0.97–1.02)). Stratification by region yielded inconsistent associations. Depression was weakly but independently linked to obesity (PR 1.08 (1.04–1.12)), and very marginally to abdominal obesity (PR 1.01 (1.00–1.03)).

Conclusions:

Although individuals with permanent stress tended to be slightly more obese, there was no overall independent effect and no evidence that abdominal obesity or its consequences (hypertension, diabetes) increased with higher levels of stress or depression. This study does not support a causal link between psychosocial factors and abdominal obesity.

Comparison of Contamination of Low-Frictional Elastomeric Rings with That of Conventional Elastomeric Rings by Streptococcus mutans - An In-vivo Study

INTRODUCTION

The presence of brackets and ligatures has been shown to be related to an increase in gingival inflammation and increased risk of decalcification. The various measures were taken to reduce the plaque accumulation and also lot of efforts were made by manufacturers that reduced the binding friction between the ligature rings and arch wire that facilitated easy sliding of the tooth through the wire. The low frictional ligatures rings manufactured by different manufacturers presumed to attract fewer bacteria due to greater reduction in surface roughness. Our study aimed to evaluate whether the low frictional elastomeric rings accumulate fewer bacteria than conventional ligature rings.

MATERIALS AND METHODS

Thirty patients (15 males and 15 females) who underwent fixed appliance therapy were selected. The study was done using split-mouth design. In each volunteer, synergy low frictional elastomeric rings were tied to brackets bonded to the maxillary premolar on the right side and mandibular premolar on the left side. Conventional elastomeric rings that served as control group were tied to the contralateral teeth, with the same design. Samples were collected after four weeks (28 days) and cultured for bacteria Streptococcus mutans.

RESULTS

There was no statistical difference between Streptococcus mutans count in low frictional elastomeric rings with that of conventional rings.

CONCLUSION

We concluded that adherence of Streptococcus mutans is similar in both synergy low frictional elastomeric rings and conventional clear elastomeric rings and thus the manufacturer's claim of minimal bacterial adherence was discarded.

Pharmacokinetic and pharmacodynamic properties of plasma-derived vs. recombinant factor IX in patients with hemophilia B: a prospective crossover study

BACKGROUND

Effective treatment of acute bleeding episodes in patients with hemophilia B relies on factor IX recovery, with higher levels being more desirable, whereas prevention of bleeds with a prophylactic regimen depends on the half-life of the product. Lower recovery values have been reported following administration of recombinant FIX (rFIX) than following administration of plasma-derived FIX (pdFIX).

OBJECTIVES

To compare the pharmacokinetic and pharmacodynamic properties of rFIX and pdFIX in patients with hemophilia B.

METHODS

A prospective crossover study of nine patients with moderate to severe hemophilia B was performed. Following a washout period, 50 U kg(-1) FIX was administered, and blood samples were taken as per protocol up to 48 h postinfusion. Paired data were analyzed with the Wilcoxon signed rank test.

RESULTS

Mean peak recovery at 10 min postinfusion was 62.14 IU dL(-1) with pdFIX and 52.7 IU dL(-1) with rFIX (P = 0.08). Mean half-life was 16.6 h with pdFIX and 17.5 h with rFIX (P = 0.55). Maximum peak thrombin generation (PTG) was 35.9 nm with pdFIX and 28.9 nm with rFIX (P = 0.21). Administration of rFIX resulted in early PTG, whereas administration of pdFIX resulted in slightly later and sustained PTG. At 48 h, PTG was similar with pdFIX (19.0 nm) and rFIX (19.4 nm) (P = 0.91).

CONCLUSIONS

Patients experienced better recovery with pdFIX than with rFIX. pdFIX and rFIX had similar half-lives. Maximum PTG was higher for pdFIX; however, this difference did not reach statistical significance. The clinical impact of the slightly increased, delayed and sustained PTG with pdFIX requires further investigation.

Evaluation of hyoid bone position and its correlation with pharyngeal airway space in different types of skeletal malocclusion

Introduction:

The hyoid bone and its relation with the pharyngeal space in health and disease has been an intriguing subject for years.

Aim:

This study attempts to evaluate the hyoid bone position and to ascertain any correlations with pharyngeal airway space in skeletal class I, II, and III malocclusions.

Materials and Methods:

McNamara's airway analysis was carried out to assess the upper and lower airway widths and Hyoid triangle analysis by Bibby and Preston was carried out to determine the position of the hyoid bone.

Conclusion:

A positive correlation was found between the lower airway and horizontal distance from the hyoid bone to the retrognathion in class I skeletal pattern with average growth pattern.

Three dominant-negative mutations in factor XI-deficient patients

Factor XI (FXI) deficiency results from genetic defects of the F11 gene and is generally considered to be inherited in an autosomal recessive manner. However, the homodimeric structure of FXI allows, in some cases, the dominant-negative transmission of the disease. The aim of this study was to characterize novel missense mutations in three unrelated patients and verify the dominant-negative effects of these mutations on the secretion of wild-type FXI protein by expression studies. The F11 gene was PCR amplified, from genomic DNA extracted from peripheral blood, and sequenced on an ABI 3100 Genetic Analyzer. Human wild-type FXI and FXI mutants were expressed in BHK570 cells using Lipofectamin transfection reagents. Conditioned media and cell lysates were collected for the measurement of luciferase activity, FXI antigen and Western blot analysis. DNA sequencing revealed three novel missense F11 mutations; c.127G>A in exon 3 (Ala43Thr), c.723C>G in exon 7 (Phe241Leu) and c.1207G>A in exon 11 (Val403Met). In vitro expression studies showed that the mutation Ala43Thr, Phe241Leu or Val403Met remarkably decreased the extracellular secretion of mutant FXI, rather than reducing synthesis of the mutant proteins. Cotransfection of wild-type FXI with mutant FXI constructs indicated that the mutation Ala43Thr, Phe241Leu or Val403Met reduced the secretion of wild-type FXI by 75.9%, 68.6% or 71.4%, respectively. Our study suggests that dominant-negative mutations in FXI-deficient patients of non-Ashkenazi Jewish origin may be more prevalent than thought, resulting from FXI's unique dimeric structure.

Von Willebrand factor--two sides and the edge of a coin

Von Willebrand factor (VWF) has multiple functions in coagulation. It is a clotting protein and its deficiency causes a primary haemostatic bleeding disorder. Excess VWF, particularly high molecular weight multimers can cause thrombosis. There is also a debatable function of protecting factor VIII (FVIII) in circulation with the prevention of development of FVIII inhibitors. This commentary addresses these functions.