The impact of state paid sick leave policies on weekday workplace mobility during the COVID-19 pandemic

OBJECTIVES

This study aimed to evaluate whether the Families First Coronavirus Response Act (FFCRA) modified the association between pre-existing state paid sick leave (PSL) and weekday workplace mobility between February 15 and July 7, 2020.

STUDY DESIGN

This was a longitudinal, observational study.

METHODS

The 50 US states and Washington, D.C., were divided into exposure groups based on the presence or absence of pre-existing state PSL policies. Derived from Google COVID-19 Community Mobility Reports, the outcome was measured as the daily percent change in weekday workplace mobility. Mixed-effects, interrupted time series regression was performed to evaluate weekday workplace mobility after the implementation of the FFCRA on April 1, 2020.

RESULTS

States with pre-existing PSL policies exhibited a greater drop in mobility following the passage of the FFCRA (β = -8.86, 95% confidence interval: -11.6, -6.10, P < 001). This remained significant after adjusting for state-level health, economic, and sociodemographic indicators (β = -3.13, 95% confidence interval: -5.92, -0.34; P = .039).

CONCLUSIONS

Pre-existing PSL policies were associated with a significant decline in weekday workplace mobility after the FFCRA, which may have influenced local health outcomes. The presence of pre-existing state policies may differentially influence the impact of federal legislation enacted during emergencies.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

AB0896 Comparative Effectiveness of Guselkumab in Psoriatic Arthritis: Updates to a Systematic Literature Review and Network Meta-Analysis

Background

The efficacy of guselkumab (GUS), an interleukin (IL)-23 p19-subunit inhibitor, has been demonstrated for psoriatic arthritis (PsA) in two pivotal phase 3 trials (DISCOVER‑1&2). A third phase 3b trial (COSMOS) evaluated GUS in patients with PsA who had an inadequate response (IR) to tumor necrosis factor inhibitors (TNFi). GUS has previously been compared to targeted PsA therapies through network meta-analysis (NMA).

Objectives

This NMA update was to include data for GUS in TNFi-IR patients from COSMOS, as well as two additional key comparators, risankizumab (RIS), an IL-23 inhibitor, and upadacitinib (UPA), a Janus kinase inhibitor (JAKi).

Methods

A systematic literature review identified PsA randomized controlled trials up to February 2021. A subsequent hand-search identified data for newer agents, including congresses up to July 2021. Bayesian NMAs were performed to compare treatments on American College of Rheumatology (ACR) response, Psoriasis Area and Severity Index (PASI) response, modified van der Heijde-Sharp (vdH-S) score, and serious adverse events (SAEs). Analyses used fixed or random effects models and adjusted for placebo response via meta-regression on baseline risk when feasible. Multinomial models were used for ACR and PASI. Results were summarized by ranking treatments in league tables according to results derived from NMAs. Conclusions (ie, comparable or better/worse) for GUS 100 mg every 8/4 weeks (Q8W/Q4W) versus comparators were based on overlap of pairwise 95% credible intervals (CrIs) (ie, treatments are comparable if CrIs overlap 1 [dichotomous outcomes] or 0 [continuous outcomes]).

Results

Thirty-three phase 3 studies were included in the NMAs. Studies were placebo-controlled up to 24 weeks except for 2 head-to-head studies, and evaluated 15 targeted PsA therapies in TNFi naïve, IR, or mixed populations. For ACR 20 response, GUS Q8W and Q4W ranked 14th and 12th among 23 treatments and were comparable to most other active agents, including RIS and UPA, subcutaneous (SC) TNFi, and most IL-17A inhibitors (IL-17Ai), as demonstrated by overlap in pairwise 95% CrIs with unity. Results were similar for ACR 50 and 70 responses. For PASI 90, GUS Q8W and Q4W ranked 2nd and 1st among 23 treatments and were better than multiple agents, including all SC TNFi, JAKi, including UPA, and other small molecules, as demonstrated by nonoverlap in pairwise 95% Crls with unity. GUS Q8W and Q4W were similar to RIS and most IL-17Ai for PASI 90, but point estimates consistently favored GUS. For vdH-S score, GUS Q8W and Q4W ranked 8th and 3rd among 18 treatments; GUS Q4W was better than RIS, and both GUS Q8W and Q4W were comparable to most other agents, including UPA. SAEs were comparable across most agents.

Conclusion

GUS demonstrated better skin efficacy than most other targeted PsA therapies, including UPA. For vdH-S, both GUS dose regimens were comparable to most treatments, with both GUS dose regimens ranking higher than most, including UPA and RIS. Both GUS dose regimens demonstrated ACR responses that were comparable to most other agents, including UPA and RIS, and ranked favorably in the network for SAEs.

References

None

Disclosure of Interests

Philip J Mease Speakers bureau: AbbVie, Amgen, Boehringer Ingelheim, Bristol-Myers Squibb, Celgene, Eli Lilly, Galapagos, Gilead, GlaxoSmithKline, Janssen, Merck, Novartis, Pfizer, Sun Pharma, and UCB Pharma, Consultant of: AbbVie, Amgen, Boehringer Ingelheim, Bristol-Myers Squibb, Celgene, Eli Lilly, Galapagos, Gilead, GlaxoSmithKline, Janssen, Merck, Novartis, Pfizer, Sun Pharma, and UCB Pharma, Grant/research support from: AbbVie, Amgen, Boehringer Ingelheim, Bristol-Myers Squibb, Celgene, Eli Lilly, Galapagos, Gilead, GlaxoSmithKline, Janssen, Merck, Novartis, Pfizer, Sun Pharma, and UCB Pharma, Iain McInnes Consultant of: AbbVie, Bristol-Myers Squibb, Celgene, Eli Lilly, Gilead, Janssen, Novartis, Pfizer, and UCB Pharma, Grant/research support from: Bristol-Myers Squibb, Celgene, Eli Lilly, Janssen, and UCB Pharma, Lai-Shan Tam Grant/research support from: Novartis and Pfizer, Raji Rajalingam Employee of: EVERSANA, Steve Peterson Shareholder of: may own stock or stock options in Johnson & Johnson, Employee of: Janssen Global Services, LLC, Fareen Hassan Shareholder of: may own stock or stock options in Johnson & Johnson, Employee of: Janssen EMEA, Soumya D Chakravarty Shareholder of: may own stock or stock options in Johnson & Johnson, Employee of: Janssen Scientific Affairs, LLC, Christine CONTRE Shareholder of: may own stock or stock options in Johnson & Johnson, Employee of: Janssen Pharmaceutical Companies of Johnson & Johnson, France, Alison Armstrong Employee of: EVERSANA, Wolf-Henning Boehncke Speakers bureau: AbbVie, Almirall, Celgene, Eli Lilly, Janssen, Leo, Novartis, and UCB Pharma, Consultant of: AbbVie, Almirall, Celgene, Eli Lilly, Janssen, Leo, Novartis, and UCB Pharma, Grant/research support from: Pfizer, Christopher T. Ritchlin Consultant of: AbbVie, Amgen, Eli Lilly, Gilead, Janssen, Novartis, Pfizer, and UCB Pharma, Grant/research support from: AbbVie, Amgen and UCB Pharma

POS1099 QUALITY OF LIFE, WORK IMPAIRMENT, AND DAILY ACTIVITY IMPAIRMENT OF PATIENTS WITH PSORIASIS VERSUS PSORIATIC ARTHRITIS: A REAL-WORLD SURVEY IN US AND EUROPE

Background

Psoriasis (PsO) and psoriatic arthritis (PsA) and are chronic immune-mediated diseases characterised by joint inflammation and skin lesions which negatively impact patients’ health-related quality of life (HRQoL). Several previous comparative studies have focused on PsA patients with or without skin involvement. Better understanding of the impact of both PsO and PsA on HRQoL and work / activity impairment will improve understanding of the incremental burden of PsA compared to PsO, and may lead to more personalised treatment options.

Objectives

To compare HRQoL, work impairment, and daily activity impairment of patients with a PsO diagnosis (dx) only, PsO dx with musculoskeletal (MSK) symptoms (sx), PsA dx with active skin sx, and PsA dx without active skin sx.

Methods

Data were drawn from the Adelphi PsO & PsA Disease Specific Programmes™ (DSP), real-world point-in-time surveys of rheumatologists, dermatologists and their consulting patients in the United States and Europe (France, Germany, Italy, Spain and UK); conducted in 2018/19. Patients were grouped according to their symptoms and confirmed diagnoses, comprising four groups:

1. Patients with PsO dx only,

2. Patients with PsO dx and with MSK sx,

3. Patients with PsA dx and with active skin sx,

4. Patients with PsA dx with no active skin sx,

Multivariate linear regression analyses with marginal mean predictions examined differences in patient-reported outcome measures (PROMs) between the four groups. Measures included HRQoL (EuroQol 5-Dimension 5-Level [EQ-5D Utility] and EuroQoL Visual Analogue Scale [EQ-VAS]), work impairment, and daily activity impairment (Work Productivity and Activity Impairment Questionnaire [WPAI]). Analyses controlled for demographics (age, sex, BMI), comorbidities present in >10% of patients and current treatment class (biologics, csDMARDs, steroids & other).

Results

4491 patients were included: Group 1 (n=1833), Group 2 (n=91), Group 3 (n=2451), and Group 4 (n=116). 54% of patients were male, 89% of patients were white, with a mean age of 46.6 years. Demographics were consistent across all patient groups.

The model-predicted EQ-5D-Utility was lower in Groups 2, 3 and 4, compared with Group 1 (p=0.003, p<0.001 and p=0.004 respectively). Similarly, predicted EQ-VAS was lower in Group 3 compared with Group 1 (p=0.006), Table 1.

Table 1.

Predictions of PROMs for PsO-PsA patient groups

PRO toolGroup [n]*Predicted PRO valuePopulation norm (MCID)Regression model p-value (vs. reference group)EQ-5D Utility score (n=1839)1 (ref) [743]0.9220.88 (0.07)2 [32]0.8160.0033 [1023]0.810<0.0014 [41]0.8500.004EQ-VAS (n=1882)1 (ref) [763]78.7878.2 (n/a)2 [36]70.560.0573 [1040]73.890.0064 [43]75.230.248WPAI % overall work impairment (n=1015)1 (ref) [422]15.36n/a (15.0)2 [14]17.860.5603 [558]22.16<0.0014 [21]26.090.014WPAI % work time missed (n=1028)1 (ref) [424]0.91n/a (n/a)2 [14]3.570.4863 [569]4.460.0024 [21]10.430.003WPAI % impairment while working (n=1153)1 (ref) [486]14.90n/a (20.0)2 [18]13.890.8463 [626]19.63<0.0014 [23]17.390.435WPAI % activity impairment (n=1818)1 (ref) [732]18.02n/a (20.0)2 [32]26.250.1223 [1012]26.14<0.0014 [42]25.240.044

*n values provided for reference, but margins are predictions as a result of the model and not for the specific number of patients in each subgroup.

(1) patients with PsO dx only

(2) Patients with PsO dx and MSK sx

(3) Patients with PsA dx and with active skin sx

(4) Patients with PsA dx with no active skin sx

Overall work impairment increased in Groups 3 and 4, compared with Group 1 (p<0.001 and p=0.014 respectively). Furthermore, Groups 3 and 4 missed more work compared with Group 1 (p=0.002 and p=0.003 respectively). Group 3 patients exhibited an increase in presenteeism and activity impairment compared with Group 1 (p<0.001), Table 1.

Conclusion

Patients experiencing PsA dx or MSK sx experienced an additional disease burden compared to patients with PsO sx alone, as measured by worse HRQoL and work impairment.

Disclosure of Interests

Joseph F. Merola Consultant of: Merck Research Laboratories, Abbvie, Dermavant, Eli Lilly and Company, Novartis, Janssen, UCB, Samumed, Celgene, Sanofi Regeneron, GSK, Almirall, Sun Pharma, Biogen, Pfizer, Incyte, Aclaris, and Leo Pharma, Lars Erik Kristensen Speakers bureau: Pfizer, AbbVie, Amgen, UCB, Gilead, Biogen, BMS, MSD, Novartis, Eli Lilly, and Janssen Pharmaceuticals, Consultant of: Pfizer, AbbVie, Amgen, UCB, Gilead, Biogen, BMS, MSD, Novartis, Eli Lilly, and Janssen Pharmaceuticals, Grant/research support from: Novo, UCB, Eli Lilly; Novartis and Abbvie, Feifei Yang Employee of: Employee of Janssen Pharmaceuticals, Steve Peterson Employee of: Employee of Janssen Pharmaceuticals, Rachel Teneralli Employee of: Employee of Janssen Pharmaceuticals, Nicola Massey Employee of: Adelphi Real World, Soumya D. Chakravarty Employee of: Employee of Janssen Pharmaceuticals, Megan Hughes Employee of: Adelphi Real World, May Shawi Employee of: Employee of Janssen Pharmaceuticals, Sarah Weatherby Employee of: Adelphi Real World, Christine Contre Employee of: Employee of Janssen Pharmaceuticals, Iris Lin Employee of: Employee of Janssen Pharmaceuticals, Fareen Hassan Employee of: Employee of Janssen Pharmaceuticals, M Elaine Husni Consultant of: Abbvie, Amgen, Eli Lilly, Novartis, Janssen, UCB, Pfizer, Regeneron, and BMS

Osteocytes Influence on Bone Matrix Integrity Affects Biomechanical Competence at Bone-Implant Interface of Bioactive-Coated Titanium Implants in Rat Tibiae

Osseointegration is a prerequisite for the long-term success of implants. Titanium implants are preferred for their biocompatibility and mechanical properties. Nonetheless, the need for early and immediate loading requires enhancing these properties by adding bioactive coatings. In this preclinical study, extracellular matrix properties and cellular balance at the implant/bone interface was examined. Polyelectrolyte multilayers of chitosan and gelatin or with chitosan and Hyaluronic acid fabricated on titanium alloy using a layer-by-layer self-assembly process were compared with native titanium alloy. The study aimed to histologically evaluate bone parameters that correlate to the biomechanical anchorage enhancement resulted from bioactive coatings of titanium implants in a rat animal model. Superior collagen fiber arrangements and an increased number of active osteocytes reflected a significant improvement of bone matrix quality at the bone interface of the chitosan/gelatin-coated titan implants over chitosan/hyaluronic acid-coated and native implants. Furthermore, the numbers and localization of osteoblasts and osteoclasts in the reparative and remodeling phases suggested a better cellular balance in the chitosan/Gel-coated group over the other two groups. Investigating the micro-mechanical properties of bone tissue at the interface can elucidate detailed discrepancies between different promising bioactive coatings of titanium alloys to maximize their benefit in future medical applications.

AB0556 COMPARING EFFICACY OF GUSELKUMAB VERSUS USTEKINUMAB IN PATIENTS WITH PSORIASIS ARTHRITIS: AN ADJUSTED COMPARISON USING INDIVIDUAL PATIENT DATA FROM DISCOVER 1&2 AND PSUMMIT TRIALS

Background:

Guselkumab is an anti-interleukin (IL)-23 monoclonal antibody recently approved for a treatment of Psoriasis arthritis (PsA). In two large Phase III trials of patients with PsA (DISCOVER -1 & -2) guselkumab has shown to be superior versus placebo. In this indication no direct comparison is available between guselkumab and ustekinumab, a monoclonal antibody targeting IL-12 and IL-23. Indirect comparisons based on relative treatment effects versus a common comparator (placebo) only allow for analyses up to week 24 due to cross-over to active arms in available PsA trials.

Objectives:

To compare indirectly joint and skin efficacy of guselkumab versus ustekinumab up to week 52, using pooled patient-level trial data from DISCOVER 1&2 and PSUMMIT 1&2, adjusting for cross-trial population differences.

Methods:

Patient level data, including baseline characteristics and outcome data on American College of Rheumatology (ACR) response, Psoriasis Area Severity Index (PASI) response from the guselkumab arms of DISCOVER -1 & -2 were pooled with the data from the ustekinumab trials PSUMMIT -1&-2. Analyses were performed for bio-naïve and bio-experienced populations separately. Differences in patient characteristics across trial populations were adjusted for using multivariate logistic regression, including: gender, age, body mass index, previous TNF use, disease duration, PASI level, number of swollen and tender joints. This method of indirect comparisons allows for analysis of comparative efficacy beyond controlled induction period and odds ratios’ resulting from this model were translated into predicted response rates for ustekinumab, assuming same patient population, as enrolled in the guselkumab trial arms.

Results:

Majority of baseline characteristics for patients on guselkumab (100mg q8w; 100mg q4w) were comparable to patients on ustekinumab 45/90mg, in both in bio-naïve and bio-experienced group of patients. The probability of reaching a ACR 20 in both the bio-naïve & bio-experienced population was significantly higher for guselkumab vs ustekinumab at weeks 52 for both dosing regimens of guselkumab (bio-naïve ACR 20: q8w OR= 1.88 [1.28;2.76]), q4w (OR= 1.92 [1.29;2.86]; bio experienced ACR20 q8w OR= 2.72[1.17;6.31], q4w OR=4.77 [1.95;11.63]). Similarly guselkumab was superior over ustekinumab on PASI 90 outcome at week 52 in both bio-naïve & bio-experienced patients with BSA ≥3 % at baseline (bio-naïve: q8w OR= 2.59 [1.68;3.99]), q4w OR= 3.19 [2.03;5.00], and bio-experienced q8w OR= 3.96[1.39,11.27], q4w OR=13.10[4.18,41.04]). Figure 1 represents unadjusted pooled DISCOVER 1&2 trial results and estimated proportions of ustekinumab treated patient group achieving ACR 20 in bio-naïve patient group up to week 52 using the method described above.

Conclusion:

An adjusted comparison using patient level data from pivotal Phase III studies demonstrates both dosages of guselkumab to be significantly more effective versus ustekinumab in both skin and joint outcomes in both bio-naïve & bio experienced patients up to week 52.

Disclosure of Interests:

Joris Diels Shareholder of: Janssen, Employee of: Janssen, Pushpike Thilakarathne Employee of: Janssen, Agata Schubert Shareholder of: Janssen, Employee of: Janssen, Fareen Hassan Shareholder of: Janssen, Employee of: Janssen, Steve Peterson Shareholder of: Janssen, Employee of: Janssen, Wim Noel Shareholder of: Janssen, Employee of: Janssen.

DXA reference values of the humanoid sheep model in preclinical studies

Background

Merino land sheep are a popular pre-clinical large animal model in research on systemic skeletal diseases such as osteoporosis. Interpretation of studies is difficult because many reference parameters are missing or not established. This study aims to determine the reference parameters of the skeletal system (peak bone mass = PBM, T-Score). A defined standard allows an easier comparison of the study data of the animal model with human studies (T-Score).

Materials and methods

A total of 116 Dual Energy X-ray Absorptiometry DXA measurements were performed on 74 untreated sheep. The average age of the animals was 57 months. The BMD, BMC, and fat content of the sheep were determined by the relevant human region of interest (ROI). From this, the PBM and from this the T-score for each of the animals were calculated.

Results

Using 682 DXA measurements BMD and BMC were determined to provide an indication to PBM. For BMD a significant correlation to the age of the animals was observed (p = 0.043). A significant correlation was also seen for BMC (B) (p ≤ 0.001). In the age-dependent analysis, a widespread of values above the linear regression line was measured for both BMD and BMC between the 50th and 90th months of life. From an age of about 90 months, a wider spread of values below the linear regression line was found, although the average values continued to rise.

Discussion

The evaluation of the 116 DXA measurements allowed the determination of the PBM for merino land sheep. With the help of the PBM, a T-score was calculated for each animal. The statistical analysis shows significant differences in BMD values between the different animal groups in each of the four ROIs investigated. Individual control or sham groups per study are therefore not sufficient. To improve comparability, an independent reference group should be established.

Conclusion

An independent reference group for PBM and a T-score was established from four to six-year-old animals. The bone density increases with the age of the animals. Around the fourth year of life, a first peak could be observed. Also, after the seventh year of life, a further peak with the beginning plateau phase was observed. When compiling a group of animals for an osteoporosis model, animals from the age of seven years should, therefore, be used.

Effect of head covering on phototherapy induced hypocalcemia in term neonates with hyperbilirubinemia: A randomised controlled study

BACKGROUND

Phototherapy is the primary treatment for hyperbilirubinemia in neonates. Hypocalcemia is a lesser known but potential detrimental effect of phototherapy. It has been hypothesized that phototherapy inhibits pineal secretion of melatonin, which blocks the effect of cortisol on bone calcium. Therefore, unchecked cortisol increases bone uptake of calcium and induces hypocalcemia. Covering head during phototherapy in order to prevent light reaching to the pineal gland which eventually leads to the prevention of hypocalcemia is hypothesized to prevent hypocalcemia but it lacks sufficient evidence worldwide.

METHOD

It is a prospective, randomized controlled study. 112 neonates were randomized into two groups of 56 neonates. Group A underwent phototherapy without head cover and group B with head covered by a cap.

RESULT

The mean decline in serum ionic calcium after 48 hours of phototherapy in group A and group B was 0.57±0.37 mg/dl and 0.34±0.24 mg/dl respectively. This decline in serum ionic calcium was significantly higher in group A. (p < 0.001). 26.8% newborns from group A developed hypocalcemia while in group B only 14.3% developed hypocalcemia however it was not found to be statistically significant. Incidence of symptomatic hypocalcemia between the two groups was also not significant.

CONCLUSION

There was significant reduction in serum calcium in neonates undergoing phototherapy without head cover as compared to neonates with head cover but risk of hypocalcemia was not significant. Further studies with larger sample size including preterm are recommended.

Evidence of platelet dysfunction in congenital cyanotic heart disease: relevance to palliative systemic-pulmonary shunt and haemostatic parameters

Introduction

Platelets in congenital cyanotic heart disease (CCHD) were occasionally characterized by significantly enhanced expression of P-selectin in resting circulating platelets as well as their augmented activation in response to stimulating agents. P-selectin is present in the alpha granule membrane as well as Weibel-Palade body membrane of endothelial cells. It is translocated to platelet membrane after activation; thus, its expression on platelet surface is an indicator of platelet activation in vivo. The occurrence of the prothrombotic variant of GPIIIa in cyanotic children may be associated with enhanced activation of circulating platelets.

Purpose

To study the platelet functions in patients with CCHD by determination of Pselectin expression and the GPIIIa polymorphism and to correlate these findings with other clinical, radiological, and laboratory parameters in these patients.

Methods

This study included 47 patients, with cyanotic congenital heart disease with decreased pulmonary blood flow, attending the Pediatric Cardiology Clinic. They were divided into two groups: Group I: 31 patients with congenital cyanotic heart disease before cardio surgery Group II: 16 patients with congenital cyanotic heart disease 3–6 months after palliative or corrective cardio surgery, Group III: 12 age and sex matched normal children were included in the study as control group. They were subjected to Flow-cytometric evaluation of platelet activation by Pselectin expression: P-selectin expression was estimated using monoclonal antibody.-Typing of GPIIIa gene polymorphism was done.

Results

Statistically significant higher P-selectin levels were found in patients compared with controls being significantly higher in patients &lt;3 years of age. There was significant negative correlation between P-selectin level and O2 in patients. The incidence of prothrombotic variant A2 was described as phenotype positive. Statistically significant higher levels of P-selectine were found in positive phenotype patients than positive phenotype controls

Conclusion

Enhanced platelet activation may be an important contributor in the high thrombotic liability in congenital cyanotic heart disease. This may be attributed in part to genetic factors

Funding Acknowledgement

Type of funding source: None

1014 Relationship Between Lung Function and Obstructive Sleep Apnea in Cystic Fibrosis

Introduction

The frequency of obstructive sleep apnea (OSA) may be high among patients with cystic fibrosis (CF), a life-shortening, genetic respiratory disease that affects approximately 30,000 Americans. Yet, the potential relationship between OSA and lung function has not been thoroughly explored.

Methods

Single-center retrospective review of polysomnography (PSG) results from 2009-2017 in referred patients with CF and available pulmonary function data (PFTs) obtained at time of PSG and at 3, 6, 9, and 12-months prior.

Results

Mean ages were 11.1±3.9 (sd) and 37.1±14.1 years, among 18 children and 16 adults, respectively. Mean body mass index (BMI) was normal in both groups (62.5±26.6% in children; 25.1±6.4 kg/m2 in adults). Twenty-six subjects (76%) had OSA (apnea-hypopnea index &gt;1 in children, ≥5 in adults). Mean forced expiratory volume in 1 second percent predicted (FEV1 PPD) was higher among subjects with vs. without OSA at PSG and at each time-point in the year prior, independent of age and BMI at PSG (longitudinal mixed effects model, β=19.0, SE=8.1, p=0.028). While FEV1 PPD remained unchanged in the non-OSA group, FEV1 PPD at PSG was lower, in comparison to the year prior in subjects with OSA, with the greatest difference observed at 9-months prior to PSG (2-sample t-test, difference of -6.6% vs 0.6% in OSA vs. non-OSA groups respectively, p=0.078).

Conclusion

The PFTs, as daytime markers of CF lung disease severity, do not seem to reliably predict risk for OSA. In our sample, CF patients with vs. without OSA had better PFTs at baseline but they also showed a greater tendency for decline in PFTs over the year prior to OSA diagnosis. Larger sample size and longer duration of assessment may help, going forward, to assess any potential adverse impact of OSA on lung function decline.

Support

NIH Training Grant (T32NS007222, F32HL145915)

P1380 tissue Doppler and speckeled tracking of left ventricle post coarctation repair

Introduction

Left ventricular dysfunction was observed after repair of coarctation of the aorta (COA) before development of left ventricular concentric hypertrophy.

Aim

The aim of this study was to assess the the LV functions after COA repair.

Methods

Thirty pediatric patients with COA repair underwent echocardiographic examinations using Conventional echocardiography, tissue doppler image (TDI) and 2D-STE.

Results

The LV systolic functions assessed by TDI and 2-D-STE showed a significant reduction of (S׳׳LW LV, IVA at LW LV, IVA at the septum, longtudinal strain (LS) basal and global radial (GRS) in cases compared to control group . There is significant increase in GCS in cases compared to control group, the conventional Doppler derived MPI of LV in post coarctation repair cases was significantly prolonged compared to control. Analysis of mitral annulus velocities including E", A", E"/A" ratio and E/E′ ratio revealed worsening of the left ventricular diastolic mechanics in the post COA repair cases compared to healthy controls. The E" wave velocity (at the left ventricular lateral wall) was significantly lower in post COA repair in cases compared with controls , E"/A" ratio was significantly lower in post COA repair cases compared with controls . The E/E′ ratio was significantly higher in the post COA repair cases compared to the control group .

Conclusions

LV systolic and diastolic dysfunction was fount in patient after COA repair.

LV systolic function by 2-D-STE Cases Control P value Mean SD mean SD GLS -21.51 2.79 -22.63 2.99 .094 LS basal -19.94 2.83 -22.63 2.99 &lt;0.01 (S) LS Mid -21.08 2.75 -21.87 2.78 .273 LS apical -23.52 4.22 -21.74 4.23 .109 GRS 22.58 5.24 49.01 10.08 &lt;0.01 (S) RS basal 20.92 8.29 43.56 18.95 &lt;0.01 (S) RS mid 25.03 7.59 56.80 14.27 .223 RS apical 21.78 8.34 46.66 15.11 &lt;0.01 (S) GCS -20.09 2.66 -16.73 2.78 &lt;0.01 (S) CS basal -21.49 2.70 -16.98 4.69 &lt;0.01 (S) CS mid -21.27 4.09 -15.83 3.67 &lt;0.01 (S) CS apical -17.51 4.63 -17.39 4.57 .920

Computational segmentation of collagen fibers in bone matrix indicates bone quality in ovariectomized rat spine

Bone loss varies according to disease and age and these variations affect bone cells and extracellular matrix. Osteoporosis rat models are widely investigated to assess mechanical and structural properties of bone; however, bone matrix proteins and their discrepant regulation of diseased and aged bone are often overlooked. The current study considered the spine matrix properties of ovariectomized rats (OVX) against control rats (Sham) at 16 months of age. Diseased bone showed less compact structure with inhomogeneous distribution of type 1 collagen (Col1) and changes in osteocyte morphology. Intriguingly, demineralization patches were noticed in the vicinity of blood vessels in the OVX spine. The organic matrix structure was investigated using computational segmentation of collagen fibril properties. In contrast to the aged bone, diseased bone showed longer fibrils and smaller orientation angles. The study shows the potential of quantifying transmission electron microscopy images to predict the mechanical properties of bone tissue.

Lack of efficacy of transgenic pea (Pisum sativum L.) stably expressing antifungal genes against Fusarium spp. in three years of confined field trials

Fusarium root rot is a major pea disease in Canada and only partial tolerance exists in germplasm. Transgenic technologies may hold promise but the economic benefits of genetically modified (GM) pea will need to surpass the regulatory costs, time and labor involved in bringing a GM crop to market. European pea (Pisum sativum L.) cultivars expressing four antifungal genes, 1-3 β glucanase (G), endochitinase (C) (belonging to PR proteins family), polygalacturonase inhibiting proteins (PGIPs) (P) and stilbene synthase (V) have been transformed for disease tolerance and showed disease tolerance under laboratory conditions. Transgenic lines with four antifungal genes inserted either individually or stacked through crossing were tested for their efficacy against Fusarium root rot (Fusarium avenaceum) in confined trials over three years (2013 to 2015) in comparison with two parental German lines and three Canadian lines. Superior emergence, higher fresh weight or lower disease ratings above and below ground, of transgenic lines in presence of disease inoculum were not observed consistently in the three years of field experiments when compared to the parental and Canadian lines in the presence of disease inoculum. No indication of an advantage of stacked genes over single genes was observed. Most transgenic lines had lower relative gene expression in the roots than in the leaves in greenhouse trials suggesting a possible explanation for poor tolerance to Fusarium root rot. Field trials are necessary to verify the agronomic performance and ecological relevance of the promising effects detected under laboratory conditions.

Evaluation of RIDA®GENE norovirus GI/GII real time RT-PCR using stool specimens collected from children and adults with acute gastroenteritis

BACKGROUND

Norovirus is the leading cause of epidemic and sporadic acute gastroenteritis (AGE) in the United States. Widespread prevalence necessitates implementation of accurate norovirus detection assays in clinical diagnostic laboratories.

OBJECTIVE

To evaluate RIDA^®GENE norovirus GI/GII real-time RT-PCR assay (RGN RT-PCR) using stool samples from patients with sporadic AGE.

STUDY DESIGN

Patients between 14 days to 101 years of age with symptoms of AGE were enrolled prospectively at four sites across the United States during 2014-2015. Stool specimens were screened for the presence of norovirus RNA by the RGN RT-PCR assay. Results were compared with a reference method that included conventional RT-PCR and sequencing of a partial region of the 5'end of the norovirus ORF2 gene.

RESULTS

A total of 259 (36.0%) of 719 specimens tested positive for norovirus by the reference method. The RGN RT-PCR assay detected norovirus in 244 (94%) of these 259 norovirus positive specimens. The sensitivity and specificity (95% confidence interval) of the RGN RT-PCR assay for detecting norovirus genogroup (G) I was 82.8% (63.5-93.5) and 99.1% (98.0-99.6) and for GII was 94.8% (90.8-97.2) and 98.6% (96.9-99.4), respectively. Seven specimens tested positive by the RGN-RT PCR that were negative by the reference method. The fifteen false negative samples were typed as GII.4 Sydney, GII.13, GI.3, GI.5, GI.2, GII.1, and GII.3 in the reference method.

CONCLUSIONS

The RGN RT-PCR assay had a high sensitivity and specificity for the detection of norovirus in stool specimens from patients with sporadic AGE.

Efficacy and evaluation of environmental management system to control sandfly vector of Kala-azar

The established vector for visceral leishmaniasis, Phlebotomus argentipes (Diptera: Psychodidae) breeds inside the human dwellings and cattle shed under crevices at the base of the wall. P. argentipes was controlled by plastering the base of wall (9″height × 9″base). The study was conducted in two phases: (i) Screening of plastering materials (ii) validation of the most suitable material. During the first phase (2014); four intervention materials were evaluated in four different arms: (i) cement (ii) brick chimney fly ash (BCFA i.e. waste material from an oven for backing raw earthen brick in charcoal) mixed with lime (95:5) (iii) wire mesh (25 holes/cm²) and (iv) glazed tiles. Ten houses were selected as test and same as control in four different villages for each arm having similar ecotype and similar density of sandflies. The pre and post intervention density of sandflies were evaluated. Significant reduction in sandfly density was found with cement (46.2%) and BCFA (29.6%) plastering (P < 0.05). In the second phase of the study (2015); the two most effective interventions were validated at village level with one control. A significant reduction in the density of P. argentipes was found with cement; 60.2% (Mean ± S.D. = 2.48 ± 2.78, 95% CI = 1.93-3.02) and BCFA; 48.2% (Mean ± S.D. = 1.98 ± 2.20, 95% CI = 1.55-2.41) (P < 0.05). BCFA was found easily accessible, acceptable and cost effective that can be used in any type of wall materials at own cost. This can be implemented as one of the integrated vector control approach in the programme.

Metabolic engineering of apple by overexpression of the MdMyb10 gene

Flavonoids are low-molecular-weight phenolic compounds that are widely distributed in the plant kingdom. They have different roles in plant resistance to biotic and abiotic stresses. The transcription factor gene MdMyb10 (Gene Bank: DQ267896) was introduced into two apple (Malus domestica Borkh.) cultivars i.e. 'Holsteiner Cox (HC)' and 'Gala' via Agrobacterium-mediated transformation. The regenerated shoots were selected on kanamycin containing media. The presence of additional MdMyb10 gene in putative shoots was confirmed by PCR, RT-PCR and Southern blotting. Expression level of introduced MdMyb10 gene was analyzed by quantitative real time PCR. The results confirmed a dramatic increase in overexpression of MdMyb10 in the transgenic plants, up to 1261 and 847-folds for cultivars Holsteiner Cox and Gala, respectively compared to non-transformed negative control plants. HPLC-MS was used to determine the levels of different flavonoid compounds in both non-transgenic and transgenic plants. In MdMyb10 'HC' transgenic plants, some of the polyphenols analyzed were enhanced while others were reduced in comparison to their levels in the non-transgenic plants. On the other hand, all of the analyzed polyphenol classes were induced in MdMyb10 'Gala' transgenic plants in comparison to their levels in the non-transgenic plants. In the present study, the flavonoid pathway was successfully modified in apple by overexpressing the MdMyb10 transcription factor to validate the hypothesis of increased effect on plant disease resistance.

Molecular and functional characterization of cry1Ac transgenic pea lines

Transgenic pea lines transformed with the cry1Ac gene were characterized at molecular (PCR, RT-PCR, qRT-PCR and immunostrip assay) and functional levels (leaf paint and insect feeding bioassays). The results showed the presence, expression, inheritance and functionality of the introduced transgene at different progeny levels. Variation in the expression of the cry1Ac gene was observed among the different transgenic lines. In the insect bioassay studies using the larvae of Heliothis virescens, both larval survival and plant damage were highly affected on the different transgenic plants. Up to 100 % larval mortality was observed on the transgenic plants compared to 17.42 % on control plants. Most of the challenged transgenic plants showed very negligible to substantially reduced feeding damage indicating the insect resistance of the developed transgenic lines. Further analysis under field condition will be required to select promising lines for future uses.

Pharmaceutical Evaluation of Cefuroxime Axetil Tablets Available in Drug Market of Pakistan

Cefuroxime is a second generation cephalosporin antibiotic with a broad spectrum activity against Gram positive and Gram negative bacteria. The purpose of this research work was to evaluate the pharmaceutical quality standards of four different brands of cefuroxime axetil 125 mg tablets with different price ranges purchased from retail pharmacies of Pakistan. The brands were tested for physicochemical evaluation and in vitro dissolution studies in different medium like 0.07N HCl, distilled water, 0.1N HCl of pH 1.2 and phosphate buffers of pH 4.5 and pH 6.8. Statistical analysis, model dependent (zero order, first order, Korsmeyer-Peppas, Hixson-Crowell, Weibull) and model independent (Difference f1, similarity f2) approaches were applied to multiple dissolution profile of all brands. All brands were found to be similar with reference and meeting the compendial quality standard. Inter brand variation was observed in disintegration time and assay which was resulted in significant differences (P<0.05) in drug release data and Weibull was observed as best fill model.

Polymeric prodrug combination to exploit the therapeutic potential of antimicrobial peptides against cancer cells

The first targeted anticancer polymeric prodrug candidates of antimicrobial peptides, intended for combination therapy with another polymeric prodrug of an approved antineoplastic agent (doxorubicin) are reported.

Mitochondrial Neurogastrointestinal Encephalopathy: Clinical, Biochemical and Molecular Study in Three Egyptian Patients

BACKGROUND

Mitochondrial Neurogastrointestinal Encephalopathy syndrome is a rare autosomal recessive disorder. The disease is caused by mutations in the thymidine phosphorylase gene. This article reports the clinical, biochemical and molecular findings in three Egyptian patients with Mitochondrial Neurogastrointestinal Encephalopathy sundrome from two different pedigrees.

SUBJECTS AND METHODS

The three patients were subjected to thorough neurologic examination. Brain Magtnetic Resonance Imaging. Histochemical and biochemical assay of the mitochondrial respiratory chain complexes in muscle homogenate was performed (1/3). Thymidine Phosphorylase enzyme activity was performed in 2/3 patients and Thymidine Phosphorylase gene sequencing was done (2/3) to confirm the diagnosis.

RESULTS

All patients presented with symptoms of severe gastrointestinal dysmotility with progressive cachexia, neuropathy, sensory neural hearing loss, asymptomatic leukoencephalopathy. Histochemical analysis of themuscle biopsy revealed deficient cytochrome C oxidase and mitochrondrial respiratory chain enzyme assay revealed isolated complex 1 deficiency (1/3). Thymidine Phosphorylase enzyme activity revealed complete absence of enzyme activity in 2/3 patients. Direct sequencing of Thymidine Phosphorylase gene revealed c.3371 A>C homozygous mutation. Molecular screening of both families revealed heterozygous mutation in both parents and 4 siblings.

CONCLUSIONS

Mitochondrial Neurogastrointestinal Encephalopathy syndrome is a rare mitochondrial disorder with an important diagnostic delay. In case of pathogenic mutations in Thymidine Phosphorylase gene in the family, carrier testing and prenatal diagmosis of at risk members is recommended for early detection. The possibility of new therapeutic options makes it necessary to diagnose the disease in an early state.

Do diabetic patients receiving conventional dialysis solutions benefit from peritoneal dialysis?

AIM

The study aimed to evaluate the impact of glucose-based peritoneal dialysis solutions (GBPDS) on diabetic patients on maintenance peritoneal dialysis.

METHODS

In this cross-sectional study we compared the influence of long term use of GBPDS on sixteen parameters related to the peritoneal glucose load, hydration status, inflammation, blood pressure, lipid profile and left ventricular mass in 45 stable PD patients (20 diabetic and 25 non-diabetic) receiving GBPDS.

RESULTS

At 24 months HbA1c, peritoneal glucose load index (PGLI), fluid overload (FO), plasma BNP, hsCRP and IL-6 levels, WBC count, blood pressure, triglycerides, LDL-C and left ventricular mass index (LVMI) were higher in diabetic patients compared to non-diabetic subjects (P ≤ 0.04). Of 16 tested variables, 14 had deteriorated at 24 months in diabetic patients. PGLI values > 3 g/kg/day or FO > 1.0 L were associated with abnormal values of HbA1c, plasma BNP, CRP and plasma IL-6 levels. 60% of diabetic patients had PGLI > 3g/kg/day compared to 32% of non-diabetic patients (P < 0.001). Seventy per cent of diabetic patients had FO > 1.0 L compared to 28% of non-diabetic patients (P < 0.001). Only 12% of diabetic patients had nocturnal blood pressure dipping compared to 45% of non-diabetics (P = 0.03). 57.8% of the studied patients had increased LVMI. Diabetic patients had higher LVMI values compared to non-diabetics (P < 0.001). The presence of DM was found to be the most powerful predictor for the development of LVH (P < 0.001).

CONCLUSION

Utilization of GBPDS in diabetic PD patients may be associated with substantial adverse consequences affecting glycemic control, hydration status, lipid profile, inflammation, blood pressure control and LVM.

Coexistence of lobular granulomatous mastitis and ductal carcinoma: a fortuitous association?

A 77-year-old female patient with a medical history significant for hypertension and epilepsy presented with right breast pain of 6-months duration. Examination revealed a hard sub-areola tender mass with irregular borders associated with mild right nipple retraction. Mammography showed a 2.2 x 2.4 cm stellate mass of the right breast. Ultrasound-guided core biopsies of the tumour were performed. Pathological examination revealed a grade II infiltrating ductal carcinoma. The patient underwent right radical mastectomy with homolateral axillary lymphadenectomy. Histological examination of the surgical specimen revealed grade II infiltrating ductal carcinoma concomitant with granulomatous lobular mastitis. To the best of our knowledge, the coexistence of granulomatous lobular mastitis and ductal carcinoma has been described only twice in the English language literature. The theory that chronic inflammation leads to cancer is well documented. Whether our patient had developed cancer from granulomatous lobular mastitis or otherwise is a matter of debate until more cases are encountered and more research is done in the area of breast cancer pathogenesis with regards to it arising from granulomatous lobular mastitis.

Coexistence of xanthogranulomatous cholecystitis and gallbladder adenocarcinoma: a fortuitous association?

Xanthogranulomatous cholecystitis is a relatively uncommon variant of chronic cholecystitis, characterized by marked thickening of the gallbladder wall and dense local adhesions. Not only does xanthogranulomatous cholecystitis mimic malignancy, it can also be infrequently associated with gallbladder carcinoma in 0.2% to 35.4% of cases. Herein, the authors report a new case of xanthogranulomatous cholecystitis concomitant with gallbladder adenocarcinoma in a 65-year-old female patient. Because of its overlapping clinical, radiological and macroscopic findings with gallbladder cancer, definitive diagnosis of xanthogranulomatous cholecystitis relies on extensive sampling and thorough microscopic examination of the surgical specimen to exclude the possibility of coexisting tumour. It is still a matter of debate whether xanthogranulomatous cholecystitis is truly a precursor of gallbladder carcinoma or if it is just an incidental finding. This aspect needs to be explored in the future with further studies.

Pancreatic heterotopia in the gallbladder neck associated with chronic cholecystitis

The gallbladder is an unusual location of pancreatic heterotopia defined as the presence of pancreatic tissue lacking anatomical and vascular continuity with the main body of the gland. A 55-year-old previously healthy male patient presented with repeated attacks of right hypochondriac pain and vomiting. On physical examination, the right upper abdomen was tender to palpation with a positive Murphy's sign. Abdominal ultrasonographic examination showed multiple gallstones within a thin-walled gallbladder. Laparoscopic cholecystectomy was performed with uneventful recovery. Macroscopic examination of the surgical specimen revealed a yellowish intramural nodule measuring 7 mm close to the neck of the gallbladder. Histological examination revealed chronic cholecystitis and subserosal foci of heterotopic pancreas made up of exocrine acinar and ductal elements without islet cells corresponding to incomplete heterotopia. Heterotopic pancreas is usually detected as an incidental microscopic finding in a gallbladder specimen removed by cholecystectomy. Pre-operative diagnosis is difficult primarily due to its non-specific clinical features.

Effect of antifungal genes expressed in transgenic pea (Pisum sativum L.) on root colonization with Glomus intraradices

Pathogenic fungi have always been a major problem in agriculture. One of the effective methods for controlling pathogen fungi to date is the introduction of resistance genes into the genome of crops. It is interesting to find out whether the induced resistance in crops will have a negative effect on non-target organisms such as root colonization with the AM fungi.   The objective of the present research was to study the influence of producing antifungal molecules by four transgenic pea (Pisum sativum L.) lines expressing PGIP gene from raspberry, VST-stilbene synthase from vine, a hybrid of PGIP/VST and bacterial Chitinase gene (Chit30) from Streptomyces olivaceoviridis respectively on the colonization potential of Glomus intraradices. Four different experiments were done in greenhouse and climate chamber, colonization was observed in all replications. The following parameters were used for evaluation: frequency of mycorrhization, the intensity of mycorrhization, the average presence of arbuscules within the colonized areas and the presence of arbuscules in the whole root system which showed insignificant difference between transgenic and non-transgenic plants. The root/shoot ratio exhibited different values according to the experiment condition. Compared with negative non-transgenic control all transgenic lines showed the ability to establish symbiosis and the different growth parameters had insignificant effect due to mycorrhization. The results of the present study proved that the introduced pathogen resistance genes did not affect the mycorrhization allocations in pea.