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.

The prevalence of frailty and its relationship with sociodemographic factors, regional healthcare disparities, and healthcare utilization in the aging population across India

Objective

To estimate frailty prevalence and its relationship with the socio-economic and regional factors and health care outcomes.

Methods

In this study, participants from the harmonized Diagnostic Assessment of Dementia for the Longitudinal Aging Study in India (LASI-DAD) were included. The frailty index (FI) was calculated using a 32-variable deficit model, with a value of ≥ 25% considered as frail. Data on demographic (including caste and religion) and socioeconomic profiles and health care utilization were obtained. The state-wise health index maintained by the government based on various health-related parameters was used to group the participants' residential states into high-, intermediate-, and low-performing states. Multivariable and zero-inflated negative binomial regression was used to assess the relationship of frailty index with sociodemographic characteristics, health index, and health care expenditure or hospitalization.

Results

Among the 3953 eligible participants, the prevalence of frailty was 42.34% (men = 34.99% and women = 49.35%). Compared to high-performing states, intermediate- and low-performing states had a higher proportion of frail individuals (49.7% vs. 46.8% vs. 34.5%, P < 0.001). In the adjusted analysis, frailty was positively associated with age, female sex, rural locality, lower education level, and caste (scheduled caste and other backward classes). After adjusting for the socio-economic profile, FI was inversely associated with the composite health index of a state (P < 0.001). FI was also significantly correlated with total 1-year health care expenditure and hospitalization (P < 0.001 and 0.020, respectively).

Conclusion

There is a high prevalence of frailty among older Indian adults that is associated with sociodemographic factors and regional health care performance. Furthermore, frailty is associated with increased health care utilization and expenditure.

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

N/A

Prevalence of dementia in India: National and state estimates from a nationwide study

INTRODUCTION

Prior estimates of dementia prevalence in India were based on samples from selected communities, inadequately representing the national and state populations.

METHODS

From the Longitudinal Aging Study in India (LASI) we recruited a sample of adults ages 60+ and administered a rich battery of neuropsychological tests and an informant interview in 2018 through 2020. We obtained a clinical consensus rating of dementia status for a subsample (N = 2528), fitted a logistic model for dementia status on this subsample, and then imputed dementia status for all other LASI respondents aged 60+ (N = 28,949).

RESULTS

The estimated dementia prevalence for adults ages 60+ in India is 7.4%, with significant age and education gradients, sex and urban/rural differences, and cross-state variation.

DISCUSSION

An estimated 8.8 million Indians older than 60 years have dementia. The burden of dementia cases is unevenly distributed across states and subpopulations and may therefore require different levels of local planning and support.

HIGHLIGHTS

The estimated dementia prevalence for adults ages 60+ in India is 7.4%. About 8.8 million Indians older than 60 years live with dementia. Dementia is more prevalent among females than males and in rural than urban areas. Significant cross-state variation exists in dementia prevalence.

Intractable hiccups: How can chest X-ray help?

We describe the case of a young male presenting with hiccups refractory to antacids. Due to high index of suspicion was evaluated with a chest X-ray which revealed pericardial effusion. The effusion was drained, and the hiccups resolved. It is a teaching moment, to consider simple imaging, i.e., chest X-ray in patients with refractory hiccups to rule out more serious underlying causes.

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.

Deep phenotyping and genomic data from a nationally representative study on dementia in India

The Harmonized Diagnostic Assessment of Dementia for the Longitudinal Aging Study in India (LASI-DAD) is a nationally representative in-depth study of cognitive aging and dementia. We present a publicly available dataset of harmonized cognitive measures of 4,096 adults 60 years of age and older in India, collected across 18 states and union territories. Blood samples were obtained to carry out whole blood and serum-based assays. Results are included in a venous blood specimen datafile that can be linked to the Harmonized LASI-DAD dataset. A global screening array of 960 LASI-DAD respondents is also publicly available for download, in addition to neuroimaging data on 137 LASI-DAD participants. Altogether, these datasets provide comprehensive information on older adults in India that allow researchers to further understand risk factors associated with cognitive impairment and dementia.

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

Clinical features and outcomes of COVID-19 in older adults: a systematic review and meta-analysis

Background

Few studies have focused on exploring the clinical characteristics and outcomes of COVID-19 in older patients. We conducted this systematic review and meta-analysis to have a better understanding of the clinical characteristics of older COVID-19 patients.

Methods

A systematic search of PubMed and Scopus was performed from December 2019 to May 3rd, 2020. Observational studies including older adults (age ≥ 60 years) with COVID-19 infection and reporting clinical characteristics or outcome were included. Primary outcome was assessing weighted pooled prevalence (WPP) of severity and outcomes. Secondary outcomes were clinical features including comorbidities and need of respiratory support.

Result

Forty-six studies with 13,624 older patients were included. Severe infection was seen in 51% (95% CI– 36-65%, I²–95%) patients while 22% (95% CI– 16-28%, I²–88%) were critically ill. Overall, 11% (95% CI– 5-21%, I²–98%) patients died. The common comorbidities were hypertension (48, 95% CI– 36-60% I²–92%), diabetes mellitus (22, 95% CI– 13-32%, I²–86%) and cardiovascular disease (19, 95% CI – 11-28%, I²–85%). Common symptoms were fever (83, 95% CI– 66-97%, I²–91%), cough (60, 95% CI– 50-70%, I²–71%) and dyspnoea (42, 95% CI– 19-67%, I²–94%). Overall, 84% (95% CI– 60-100%, I²–81%) required oxygen support and 21% (95% CI– 0-49%, I²–91%) required mechanical ventilation. Majority of studies had medium to high risk of bias and overall quality of evidence was low for all outcomes.

Conclusion

Approximately half of older patients with COVID-19 have severe infection, one in five are critically ill and one in ten die. More high-quality evidence is needed to study outcomes in this vulnerable patient population and factors affecting these outcomes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02261-3.

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.

The changing perspective of clinical trial designs

Maintaining health and well-being of the population is a universal priority. Governments around the globe are therefore seeking greater efficiency and better outcomes from researches being held. Although large randomized trials or systematic review of several large trials provides the highest level of evidence, the intricate cost, time, and difficulties of conventional trials have led to questions about their sustainability commanding search for alternative approaches. Demands for improved competences in medical research have led to mounting interest in newer clinical trial designs. This article provides an insight into newer clinical trial designs, including cluster trials, adaptive designs, the master protocols along with their strengths, weaknesses, and which trials design should be opted for in different clinical scenarios.

Drooping shoulders: A rare manifestation of an uncommon disease

Primary systemic amyloidosis is an uncommon disease which presents with involvement of the kidney, heart, peripheral nervous system and liver. The involvement of skeletal muscles called amyloid myopathy is uncommon. We report a 74-year-old male who presented with progressively drooping shoulders followed by other muscular involvement without other organ involvement as a manifestation of amyloidosis. The patient was managed with melphalan, prednisolone and thalidomide with clinical improvement.

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.

Low one-repetition-maximum knee extension is significantly associated with poor grip strength, female sex, and various aging-related syndromes

OBJECTIVE

Muscle strength in older adults is usually measured according to grip strength, which demonstrates upper muscle strength only. In this study, we used one-repetition-maximum (1-RM) knee extension as a measure of lower limb strength and assessed its relationship with grip strength and various geriatric syndromes.

METHODS

One hundred outpatients over the age of 65 years were recruited from a geriatric medicine center in India. The 1-RM knee extension was measured along with grip strength. Various geriatric conditions were measured, such as: nutrition (using the Mini Nutritional Assessment), cognition (Hindi Mental State Questionnaire), depression (5-item Geriatric Depression Scale), frailty (Fried and Rockwood models), and osteoporosis (dual-energy X-ray absorptiometry scan). Sarcopenia was diagnosed using the Asian Working Group for Sarcopenia criteria.

RESULTS

The mean age of participants was 72.5 years with 69% of them male. Median values of 1-RM knee extension and grip strength were 2.29 (0.5-10.0) and 17.5 (0-78), respectively. The 1-RM knee extension had moderate correlation with grip strength (r = 0.491, P < 0.001). Among demographic details, only female sex (P < 0.001) was significantly associated with lower 1-RM values. Further, after adjusting for age and sex, lower value of log10 1-RM knee extension was found to be significantly associated with malnutrition (P = 0.001), dementia (P = 0.016), depression (P = 0.047), frailty (Rockwood: P = 0.049; Fried: P = 0.011), and sarcopenia (P < 0.001).

CONCLUSION

The 1-RM knee extension has only moderate correlation with grip strength. A lower 1-RM knee extension value is significantly associated with female sex and various geriatric conditions, such as malnutrition, dementia, depression, frailty, and sarcopenia.

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.

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.

Classification for esophagogastric junction (EGJ) complex based on physiology

We propose a new classification for esophagogastric junction (EGJ) incorporating both physiologic and morphologic characteristics. Additionally, we contrast it with the Chicago v 3.0 EGJ classification. With Institutional Review Board (IRB) approval, prospectively maintained database was queried to identify patients who underwent high-resolution manometry (HRM) and pH-study between October 2011 and October 2015. Patients with prior foregut intervention, pH study on acid suppression, esophageal dysmotility, or lower esophageal sphincter-crural diaphragm separation of >5 cm were excluded. We classified patients into three groups-Type-A: Complete overlap of lower esophageal sphincter-crural diaphragm (single high-pressure zone); Type-B: Double high-pressure zone with pressure inversion point (PIP) at or above lower esophageal sphincter; Type-C: Double high-pressure zone with PIP below lower esophageal sphincter. A total of 214 included patients were divided into Type-A (n = 101), Type-B (n = 32), and Type-C (n = 81). Abdominal lower esophageal sphincter length (AL), lower esophageal sphincter pressure (LESP), and lower esophageal sphincter pressure integral (LESPI) were significantly lower in Type-C than both Type-A and Type-B [AL(cm): 0.2 vs. 2(P < 0.001) vs. 1.6(P <0.001); LESP(mmHg): 20.1 vs. 32.1(P < 0.001) vs. 29.2(P < 0.001); LESPI(mmHg.cm.s): 187 vs. 412(P < 0.001) vs. 343(P < 0.05)] while overall lower esophageal sphincter length(OL) and Integrated Relaxation Pressure (IRP) were significantly lower in Type-C than Type-A [OL(cm): 2.9 vs. 3.6(P < 0.001); IRP(mmHg): 8.2 vs. 9.6(P < 0.05)]. Type-C patients had significantly higher positive pH score (>14.7) than Type-A and Type-B [72% vs. 47% (P < 0.05) vs. 41% (P < 0.001)]. In Type-C morphology, there is both anatomical and physiological deterioration, weakest lower esophageal sphincter function (abdominal length, lower esophageal sphincter pressure, and lower esophageal sphincter pressure integral) and is most likely to be associated with pathological reflux. This proposed classification incorporates both physiological and morphological derangements in a graded fashion.

A Cross-Cultural Study of Young Children's Understanding of Spatial Prepositions

Bengali-, English and Hindi-speaking children aged 5 to 9 years were asked to place an object 'in front of or 'behind' a frontedor nonfronted-object. All children responded on the basis of an inherent object cue when the fronted-object was used. When a nonfronted-object was used all children treated it as if it was a fronted-object facing towards themselves. These results were compared with those of Hausa-speakers who also use the inherent object cue for fronted-objects but treat nonfronted-objects as if they are facing away from themselves.

Wearable Sensor System Powered by a Biofuel Cell for Detection of Lactate Levels in Sweat

An NAD⁺-dependent enzymatic sensor with biofuel cell power source system for non-invasive monitoring of lactate in sweat was designed, developed, and tested. The sensor component, based on lactate dehydrogenase, showed linear current response with increasing lactate concentrations with limits of detection from 5 to 100 mM lactate and sensitivity of 0.2 µA.mM^-1 in the presence of target analyte. In addition to the sensor patch a power source was also designed, developed and tested. The power source was a biofuel cell designed to oxidize glucose via glucose oxidase. The biofuel cell showed excellent performance, achieving over 80 mA at 0.4 V (16 mW) in a footprint of 3.5 × 3.5 × 0.7 cm. Furthermore, in order to couple the sensor to the power source, system electronic components were designed and fabricated. These consisted of an energy harvester (EH) and a micropotentiostat (MP). The EH was employed for harvesting power provided by the biofuel cell as well as up-converting the voltage to 3.0 V needed for the operation of the MP. The sensor was attached to MP for chronoamperometric detection of lactate. The Sensor Patch System was demonstrated under laboratory conditions.

Comparison of follicular dynamics, superovulatory response, and embryo recovery between estradiol based and conventional superstimulation protocol in buffaloes (Bubalus bubalis)

Aim:

To evaluate the follicular dynamics, superovulatory response, and embryo recovery following superstimulatory treatment initiated at estradiol-17β induced follicular wave emergence and its comparison with conventional superstimulatory protocol in buffaloes.

Materials and Methods:

Six normal cycling pluriparous buffaloes, lactating, 90-180 days post-partum, and weighing between 500 and 660 kg were superstimulated twice with a withdrawal period of 35 days in between two treatments. In superstimulation protocol-1 (estradiol group) buffaloes were administered estradiol-17β (2 mg, i.m.) and eazibreed controlled internal drug release (CIDR) was inserted intravaginally (day=0) at the random stage of the estrous cycle. On the day 4, buffaloes were superstimulated using follicle stimulating hormone (FSH) 400 mg, divided into 10 tapering doses given at 12 hourly intervals. Prostaglandin F2α analogs (PGF2α) was administered at day 7.5 and day 8, and CIDR was removed with the second PGF2α injection. In superstimulation protocol - 2 (conventional group) buffaloes were superstimulated on the 10^th day of the estrous cycle with same FSH dose regimen and similar timings for PGF2α injections. In both groups, half of the buffaloes were treated with luteinizing hormone (LH) 25 mg and other half with 100 ug buserelin; gonadotrophin releasing hormone (GnRH) analog at 12 h after the end of FSH treatment. All buffaloes in both protocols were inseminated twice at 12 and 24 h of LH/GnRH treatment. Daily ultrasonography was performed to record the size and number of follicles and superovulatory response.

Results:

Significantly higher number of small follicles (<8 mm) was present at the time of initiation of superstimulatory treatment in the estradiol group compared to the conventional group (12.5±0.80 vs. 7.3±1.21, respectively, p=0.019), however, the number of ovulatory size follicles (≥8 mm) did not differ significantly between the respective groups (15.5±1.24 vs. 12.2±1.30; p=0.054). Total embryos and transferable embryos recovered were non-significantly higher in the estradiol group compared to the conventional group (5.83±0.86 vs. 4.67±1.16, p=0.328, and 3.67±0.93 vs. 2.67±0.68, p=0.437, respectively). The significant higher proportion of transferable embryos were recovered in buffaloes treated with LH compared to GnRH (73.3% vs. 48.5%; p=0.044).

Conclusion:

The average number of ovulatory size follicles (>8 mm), corpora lutea, and transferable embryos was higher in buffaloes superstimulated at estradiol-induced follicular wave compared to the conventional protocol: Further the percentage of transferable embryos was significantly higher in buffaloes administered with LH compared to GnRH.

Standardised extract of safed musli (Chlorophytum borivilianum) increases aphrodisiac potential besides being safe in male Wistar rats

The standardised extract of root of safed musli (Chlorophytum borivilianum) was evaluated for its aphrodisiac potential and safety profile on reproductive system. Wistar albino rats were trained to provide sexual experience under a dim red light (10 W) in a glass tank. Male and female rats were placed periodically in the glass tank in a particular order, that is male followed by introduction of the receptive female. Dosing of extract was carried out for 54 days at 125 and 250 mg kg^-1 p.o to male rats. On 14th and 28th days, the animals were observed from the cage side for sexual behaviours. Safed musli at both dose levels enhanced sexual vigour and libido which might be useful for treatment of sexual dysfunction in male till 28th day. Safety profile was assessed after 54 days of drug treatment, where both doses showed an increase in sperm count and increase in sperm motility. Thus, it can be stated that both doses possessed the spermatogenic potential, which would be highly beneficial in treating oligospermia or low sperm count. After 54 days of study, there was increase in sperm abnormality (%) at both doses, but not more than 10%, which indicated that this formulation will not induce infertility.